Rehabilitacion Reumatologica

31
Rheumatologic
Rehabilitation
LIN-FEN HSIEH, HUI-FEN MAO, CHUAN-CHIN LU, AND
WEI-LI HSU
Introduction to Rheumatic Diseases effusion), contracture of soft tissues, or irreversible damage to the
articular cartilage or subchondral bone.
Rheumatology is a branch of medicine devoted to the evaluation, Clinical examination of patients with rheumatic diseases should
diagnosis, and treatment of immune-related and nonimmune- involve observation of the entire person, including movement and
related musculoskeletal disorders or other connective tissue dis- posture, and then examination of each region. The procedure of
orders including different types of arthritis, lesions of soft tissues local regional examination includes look, feel, move, and strength.
(such as muscle, tendon, cartilage, bursa, and fascia), vasculitis, For “look,” pay attention to swelling, deformity, skin change, and
and hereditary connective tissue disorders. Arthritis may occur muscle. For “feel,” one first evaluates warmth by using the backs of
due to immunologic dysfunction (e.g., rheumatoid arthritis [RA], the fingers, palpates tenderness, and determines the precise loca-
ankylosing spondylitis [AS], and psoriatic arthritis); degeneration of swelling. For detection of joint effusion, techniques such
tion (e.g., degenerative arthritis or osteoarthritis [OA]); metabolic as the bulge sign (Video 31.1) and patellar ballottement (Video
problems (e.g., gout and other crystal-related arthritis); and bacte- 31.2) may be used. For “move,” both active and passive move-
rial or microbial infection. Arthritis and soft tissue disorders may ments are assessed. Active movement is observed mainly to screen
cause pain, impairment, physical disability, dependence on others for possible lesion location. Pain or limited ROM are criteria for
for activities of daily living (ADLs), occupational disability, and abnormality.
psychosocial problems, leading to the loss of wages and socioeco- During passive movement, pain, reduced ROM, and abnormal
nomic burdens. “end feel” (sensation of the examiner’s hand at end ROM) should be
Since 2000, a burst of biologic agents and synthetic antirheu- recorded. “strength” is usually examined for the contractile tissues
matic drugs has changed the treatment and clinical outcomes of (i.e., muscle and tendon). It is usually tested with maximal isometric
rheumatic diseases; however, pain and physical disability persist contraction at the neutral position. If pain and/or weakness during
in patients with rheumatic diseases. Although physiatrists are not or after the test is reported, a lesion of contractile tissues including
much concerned regarding immunology and new biologic and the muscle, tendon, tendon sheath, musculotendinous junction,
synthetic drugs, they pay considerable attention to the biome- and tenoperiosteal junction (enthesis) is likely. The exact location
chanical problems of rheumatic diseases and act as leaders in the of contractile tissue lesions may be determined through palpation
rehabilitation team for most musculoskeletal disorders. Because or accessory tests mentioned further on. An accessory test is some-
soft tissue lesions are discussed in detail in other chapters, this times required for lesion localization (e.g., passive shoulder hori-
chapter focuses mainly on arthritis and related disorders. zontal adduction to detect an acromioclavicular lesion and passive
A diarthrodial or synovial joint is composed of the ends of forearm pronation to provoke pain and thus to detect biceps brachii
bones, synovium, cartilage, and a joint capsule, which encloses tendinopathy at the distal insertion [radial tuberosity]). In addition,
the joint. The joint capsule is surrounded by ligaments and other joint stability should be evaluated by stressing a joint.
periarticular structures such as bursae, tendons, and muscles. The If indicated, imaging studies and laboratory tests should be
joint capsule contains a joint cavity, which is filled with a lubricat- conducted. In the recent decade, musculoskeletal ultrasound
ing synovial fluid. Diarthrodial joints allow a large range of move- has become popular. The benefits of ultrasound examination
ment and are the most common joints in the extremities, such as are that it is radiation free and is useful for the detection and
the shoulders, elbows, wrists, hips, knees, and ankles. Arthritis is grading of synovitis, joint effusion, and bony erosion. Labora-
the inflammation of a joint or joints and is clinically characterized tory tests include screening for erythrocyte sedimentation rate
by pain, tenderness, swelling, warmth, and redness. In the chronic (ESR), C-reactive protein (CRP), complete blood count (CBC),
stage, joint damage may occur, and deformity, crepitus, reduction uric acid, rheumatoid factor (RF), anticitrullinated protein anti-
in the range of motion (ROM) of the joint, or abnormal move- body (ACPA), or anticyclic citrullinated peptide (anti-CCP),
ment pattern may develop. Reduction in the joint ROM may be antinuclear antibody, human leukocyte antigen (HLA)-B27, and
caused by joint inflammation (synovial hypertrophy and possible synovial fluid analysis. A combination of history taking, physical
606
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CHAPTER 31 Rheumatologic Rehabilitation 607
examination, imaging studies, and laboratory tests is usually used muscle contraction. The quadriceps can work as shock absorb-
to arrive at the correct diagnosis or disease classification. For ers and stabilizers and hence protect the joint surfaces during
rehabilitation evaluation of rheumatic diseases, the International loading and movement. For this reason quadriceps weakness
Classification of Functioning, Disability and Health (ICF) model should be specifically managed in the course of a rehabilitation
is suggested. program.
Osteoarthritis Symptoms and Signs

OA, the most common joint disorder worldwide, can lead to dis- Pain at and around the knee joint is the most common chief com-
ability and decreased quality of life. It is characterized by cartilage plaint. It usually occurs after activity and is relieved by rest. Other
degradation, subchondral bone alteration, meniscal degeneration, symptoms include stiffness, joint swelling, deformity, crepitus, and
synovial inflammatory response, and accompanying periarticular impaired function. The different pain characteristics always indi-
bone response. It often affects knees, hips, hands, spine, and feet. cate different underlying mechanisms. Pain predominantly during
OA is known to be caused by multiple factors, including genetic usage indicates faulty mechanical loading or enthesopathy; pain at
predisposition, joint integrity, mechanical forces, and cellular bio- rest indicates inflammation; and pain at night indicates increased
chemical processes. intraosseous pressure. Persisting rest and night pain occurring in
advanced OA is an indicator of severe damage. Disability due to
knee OA usually results from pain, reduction of knee joint ROM,
Knee Osteoarthritis and poor control of movement.
Clinically, knee OA is characterized by usage-related joint pain The signs indicative of knee OA include crepitus, reduced
and restricted movement. It generally presents with focal cartilage ROM, bony enlargement and the presence of joint effusion. Other
loss and new bone formation, affecting all joint tissues. Structural features may include deformity, instability, periarticular or joint-
tissue changes are reflected in radiographic findings. line tenderness. In addition, muscle weakness and wasting may be
The prevalence of knee OA is estimated to be 12.5% world- apparent. The presented signs can occur in any combination and
wide. It is more common in women and older adults, and its primarily reflect altered knee joint structure. Crepitus reflects an
prevalence increases with age.28 Its increasing prevalence makes it irregular articular surface; bony enlargement reflects osteophyte
important to understand knee OA and its treatment. and subchondral bone remodeling; restricted movement reflects
joint space narrowing.
The three major symptoms (persistent knee pain, limited
Risk Factors morning stiffness, and reduced function) and three indicative
Identification of the risk factors for knee OA is crucial because signs (crepitus, restricted movement, and bony enlargement) are
early identification of the underlying mechanism can allow phy- the central features of knee OA.40 Knee pain is, in fact, a con-
sicians to initiate adequate and prompt treatment and hence to sequence of structural deterioration and also contributes to its
avoid the exacerbation of OA. The commonly identified risk fac- progression. Persistent knee pain over 1 year can predict acceler-
tors include older age, being female, being overweight, muscle ated loss of cartilage, which increases the risk of progressing radio-
weakness, prior knee injury, and malalignment. graphic changes.
Aging is the most important risk factor. The prevalence of
symptomatic knee OA continues to increase with age. Various Imaging
aging-related processes contribute to the development of OA,
including increased susceptibility to cell death, leading to the loss Clinical OA is defined by typical symptoms and signs from a
of chondrocytes, increased destruction of joint tissue, and defec- detailed medical history and physical examination, whereas radio-
tive repair of damaged matrix. Female gender is also a risk fac- logic OA focuses on structural changes within the joint (Fig.
tor. Women have a greater prevalence of knee OA compared with 31.1). The Kellgren and Lawrence Grading Scale is the most com-
men. Women with radiographic knee OA are more likely to have monly used system (Table 31.1). It defines the severity of knee
symptomatic OA than are men. OA and its effect on joint space narrowing, osteophytes, sclero-
Being overweight, the most common modifiable risk factor, sis, and bony deformity. This grading scale must be evaluated
promotes the development and progression of knee OA. It does together with clinical assessment. Although imaging can reflect
so not only by increasing mechanical load but also by factors the joint structure and is strongly related to clinical symptoms, the
related to adipose tissues. The lifetime risk for knee OA will radiographs of middle-aged or older adults without complaints
increases as body mass index (BMI) increases. A person with a of knee pain always show some joint space narrowing and osteo-
BMI greater than 30 has a threefold greater risk of developing phyte formation. Moreover, knee symptoms can appear before any
early OA than a person of normal weight. By contrast, weight radiographic change (Grade 0). The presence of abnormal x-ray
loss can reduce the risk of developing knee OA. Moreover, mod- findings does not appear to be a reliable identifier for the assess-
erate exercise can be a protective factor. Any factor that alters ment of knee pain. Therefore the diagnosis of symptomatic knee
proper joint biomechanics can trigger the onset and acceler- OA should not be made by radiography but by typical clinical
ate the progression of the degenerative process. Subsequently, findings.40
clinical symptoms may occur. Any injuries affecting the knee According to the recommendations of the European League
ligaments may also decrease joint stability and can contribute to Against Rheumatism (EULAR) in 2017, imaging is not required
joint degeneration. to make the diagnosis in patient with typical symptoms of OA. If
Muscle weakness is an independent risk factor for knee OA26 imaging is needed, as in patients with an unexpected rapid dete-
and can also participate in the progression. Quadriceps weakness rioration in symptoms or signs, plain radiography should be used
can be due not only to disuse but also arthrogenous inhibition of first. In patients with suspicious additional diagnoses, soft tissues
608 SE C T I O N 3 Common Clinical Problems
A B
• Fig. 31.1(A) Typical clinical finding of varus deformity, bony enlargement, and quadriceps muscle wast-
ing. (B) Weight-bearing view of the knee joints shows definite osteophyte and moderate space narrowing
at the medial tibiofemoral compartment. The radiographic feature reflects the altered appearance of the
knee joints.
TABLE Kellgren-Lawrence Radiographic Grading Scale

31.1 for Osteoarthritis of the Tibiofemoral Joint
Grade of
Osteoarthritis Description
0 No radiographic findings of osteoarthritis
1 Doubtful narrowing of joint space and possible
osteophytic lipping
2 Definite osteophytes with possible narrowed joint
space
3 Definite osteophytes with moderate joint space
narrowing and some sclerosis
4 Definite osteophytes with severe joint space A
narrowing, subchondral sclerosis, and definite
deformity of bone contour

are best imaged by ultrasound (Fig. 31.2) or magnetic resonance

imaging (MRI) and bone by computed tomography (CT) or
MRI. For knee OA, radiography of weight-bearing and patello-
femoral views are to be considered.32
Prognosis
Knee OA progresses slowly. However, if untreated, it can even-
tually cause various degrees of disability, usually with difficulty
in rising from a seated position, walking, climbing stairs, and B
performing housework. Varus deformity of the knee joints, early • Fig. 31.2 (A) Normal femoral trochlear cartilage in a young man. (B)
onset, and female gender were the three main factors pointing to Severe diffuse focal thinning of femoral trochlear cartilage at the medial
a poor prognosis. side in a 67-year-old female with osteoarthritis of the knee.
to modify the disease course are still not approved by most evi-
Hip Osteoarthritis dence-based guidelines. Before treatment, a holistic assessment
Hip OA is less common than knee OA. Hip joint symptoms do of people with OA is an essential management strategy. In addi-
not obviously match radiographic findings. The risk factors for hip tion to detailed physical examination of the affected joints, the
OA can be divided into joint level and person level. The former following crucial items should be addressed: severity and loca-
includes hip joint morphology, muscle function, and joint shape. tion of joint involvement; causes, frequency, and severity of pain;
The latter includes age, sex, weight, genetics, ethnicity, and occu- impact of symptoms on gait and ADLs, impact of participation;
pation. The most important risk factor for developing hip OA psychological effects of OA (e.g., loss of self-esteem, feeling
is the presence of abnormal hip joint morphology—for example, old, sleep disturbance, and depression), assessment of the risk
following trauma or congenital dislocation of the hip, leading to for falls, presence of comorbidities, presence of social support,
abnormal loading on the hip joint. As in the case of other joints, expectations of treatment, previous treatments, and modifiable
hip OA is strongly related to increasing age. For symptomatic hip risk factors (e.g., obesity, malalignment of joint, and exercise
OA, the difference between men and women is not significant. habit). Treatments should be individualized to patients’ needs,
The association of gender with OA appears weaker at the hip joint values, and goals; medical personnel should assist patients in
compared with other joints, where female gender is a vital risk decision-making, with prioritization of patients’ safety. Success-
factor. ful treatment depends on patients’ adherence, behavior modifi-
Being overweight is associated with an increased risk of hip OA, cations, and optimal implementation of recommendations from
although this association is less marked than the strong association medical personnel.
between BMI and knee OA. Genetic factors are very important OA management includes nonpharmacologic intervention,
in the development of hip OA. They contributed approximately pharmacologic treatment, and surgical options.19,23 Nonpharma-
60% to hip OA risk in twin studies. Different hip morphology is cologic intervention comprises patient education, self-manage-
a likely contribution to genetic differences between races. Also, ment, exercise, weight loss management, bracing or splinting, and
high-impact exercise can predispose to the development of hip acupuncture.8 For pharmacologic management, acetaminophen,
OA. The underlying mechanism is obviously too much biome- topical or oral nonsteroidal antiinflammatory drugs (NSAIDs),
chanical stress to the joint. Hip pain, morning stiffness, painful intra-articular corticosteroids, opioids, and duloxetine are com-
internal rotation, hip flexion less than 115 degrees, and an ESR monly used.
below 20 mm/h are the main predictive factors for the develop-
ment of hip OA.28 Pharmacologic Management
Acetaminophen was previously recognized as a safe medication;
Hand Osteoarthritis however, regular use of this medication may cause gastrointes-
Hand OA, which commonly occurs in women, is a highly preva- tinal blood loss, and its efficacy is not as high as that of other
lent joint disease with often slow progression. The most frequently medications. Thus, conservative dosing and treatment duration is
affected joint is the distal interphalangeal (DIP) joint. The preva- recommended.
lence of hand OA is estimated to be higher than that reported for Because of the many side effects of NSAIDs (particularly gas-
hip and knee OA. According to the various definitions of hand trointestinal, cardiovascular, and renal disorders), treatment with
OA, the prevalence of radiographic hand OA ranges from 21% NSAIDs should initially be started on as-needed basis or be pre-
to 92% but that of symptomatic hand OA ranges from only 3% ceded by a trial of topical agents. In addition, to reduce the gas-
to 16%. trointestinal side effects, the use of cyclooxygenase 2 (COX-2)
The most common symptom of hand OA is pain in the inhibitors or addition of misoprostol or proton pump inhibitors
affected joint. Other symptoms include stiffness, decreased hand to oral NSAIDs may be suggested. The most common side effect
muscle strength, and restricted hand movement. The indica- of COX-2 inhibitors is the risk of thrombosis, especially coronary
tive signs include nodes at the DIP joints and proximal inter- artery thrombosis.10
phalangeal (PIP) joints, called Heberden and Bouchard nodes, Intra-articular corticosteroid injection (Videos 31.3 and 31.4)
respectively, and deformities such as squaring of thumb base. can reduce inflammation and angiogenesis within the synovium.
The presence of nodes is a hallmark of hand OA. Involvement of In randomized clinical trials, intra-articular corticosteroids have
first carpometacarpal joint is also common and often causes sig- been proven effective in the treatment of knee and hip OA; how-
nificant joint pain, impairment of hand function, and reduced ever, their effectiveness is not long lasting. The use of oral or intra-
grip strength. muscular corticosteroid injections for the management of OA is
unproven.
Management of Osteoarthritis Opioids reduce pain by binding to opioid receptors in the cen-
tral and peripheral nervous systems. The pain-reducing effect of
OA-related pain and functional impairment are the hallmarks opioids is modest, and considering their many side effects (e.g.,
of OA. The sources of OA-related pain are the bone, synovium, constipation, sedation, psychological effects, and dependence),
joint capsule, and periarticular structures, including the mus- the use of opioids in OA management is limited. For OA patients
cles, tendons, ligaments, and bursae. In addition to local factors, with pain sensitization or chronic widespread pain, duloxetine,
the pain may be influenced by psychosocial and environmental which is a selective serotonin and norepinephrine reuptake inhibi-
factors, and peripheral and central sensitization of nociceptive tor antidepressant, may be effective.5
pathways may perpetuate the pain and play a role in the chronic- Although oral use was postulated to incorporate glucos-
ity of the disease. Management of OA aims to reduce or elimi- amine and chondroitin into the articular cartilage and animal
nate pain, minimize functional impairment and disability, and studies have suggested that they may have antiinflamma-
improve quality of life. Despite numerous efforts, interventions tory effects, in the past few years many non-industry-funded
studies have demonstrated negative results. Thus glucos- Clinical Characteristics

amine and chondroitin are no longer recommended for OA
treatment. Typically the disease’s onset is insidious, with pain, stiffness, and
Hyaluronic acid (HA) intra-articular injection (Videos 31.5 swelling of the joints being the predominant symptoms. Morning
to 31.8) is believed to increase the viscosity and elasticity of stiffness, or stiffness after prolonged inactivity, often lasts more
the OA joint, and previous studies have shown that HA exerts than an hour in the active inflammatory stage. Up to one-third
antiinflammatory and antinociceptive effects. HA has been of patients with RA experience an acute onset of polyarthritis
approved by the regulatory agency for use in the treatment of associated with systemic symptoms including fatigue, myalgia,
knee OA; however, metaanalyses have shown that HA injection depression, low-grade fever, and weight loss. The most common
provides either no efficacy or only minimal efficacy. HA injec- joints involved in the early stage of the disease are the metacarpo-
tion may also increase the risk of adverse effects (e.g., crystal phalangeal (MCP) and PIP joints of the fingers, the interphalan-
arthropathy, pseudoseptic joints, and flaring of pain). There- geal joints of the thumb, the wrists, and the metatarsophalangeal
fore recent OA-related academic organizations have either not (MTP) joints of the toes. Other joints—such as the shoulders,
recommended HA injections for OA management or reported elbows, hips, knees, and ankles—are also frequently affected. Over
uncertain efficacy. the whole course of the disease, the facet and atlantoaxial joints of
Prolotherapy, also called proliferation therapy, is an the cervical spine and the acromioclavicular, sternoclavicular, tem-
injection-based therapy for chronic musculoskeletal pain. poromandibular, and cricoarytenoid joints may also be involved.
Although the application of prolotherapy can be traced back to The DIP joints are rarely involved in RA, perhaps resulting from
the 1950s, it has become increasingly popular internationally less synovium than the MCPs and PIPs. In addition to involve-
over recent years. Prolotherapy usually involves the injection ment of the joints, tenosynovitis is also common in patients with
of hypertonic dextrose (15% for soft tissues, 25% for joints), RA and may cause trigger finger, de Quervain disease, carpal tun-
morrhuate sodium, phenol-glycerin-glucose (P2G), platelet- nel syndrome, tendon rupture, and even compression of the cer-
rich plasma (PRP), or stem cells into the tendon and ligament vical cord due to narrowing of the space available for the upper
insertions and intra-articular structures. It has been hypoth- cervical cord.
esized to cause local irritation and subsequent inflammation, In the late stages of RA, joint deformities commonly occur.
followed by tissue healing, although the mechanism of action Buttonhole (or bouttonnière) deformity is flexion of the PIP
remains unknown. Prolotherapy (including PRP injection) has joints with extension of the DIP joints (Fig. 31.3A). Because
shown short- and long-term improvement in pain, function, the central extensor tendon is destroyed by tenosynovitis, the
and even radiologic features, but its application in OA has still PIP joints pop up dorsally, resulting in lateral and ventral dis-
not been recommended by most OA-related academic orga- placement of the lateral bands of the extensor tendon. In this
nizations. Ultrasound-guided prolotherapy has been shown to condition, the lateral bands of the extensor tendon act as flexors
improve the accuracy of medicine delivery and clinical out- of the PIP joints; with tendon shortening, hyperextension of
comes of treatment.18 the DIP joints develops. In contrast, the swan-neck deformity
is the opposite of the buttonhole deformity, with hyperexten-
sion of the PIP joints and flexion of the MCP and DIP joints
Surgical Procedures (see Fig. 31.3B). Shortening of the intrinsic muscle exerts ten-
These include total joint replacement, arthroscopic meniscus sur- sion on the dorsal tendon sheath, leading to hyperextension of
gery, osteotomy, and lavage and debridement. Among them, only the PIP joints. The lateral bands of the extensor tendon sublux
total joint replacement has been proven effective for OA. Recently dorsally as the PIP joints herniate in the ventral direction. In
unicompartmental knee replacement has been shown to be effec- addition, shortening of the deep flexor tendons causes flexion of
tive for end-stage unicompartment knee OA. the DIP joints. Other deformities include ulnar deviation (see
In summary, patients with mild or intermittent pain are likely Fig. 31.3C) of the MCP joints, palmar subluxation of the wrists,
to require only nonpharmacologic treatment and possibly topical arthritis mutilans, hammer-toe deformity, claw-toe deformity,
NSAIDs, oral analgesics, and intra-articular injection; for patients flat feet, hallux valgus (see Fig. 31.3D), metatarsal joint sub-
with frequent pain and more functional limitations, oral NSAIDs, luxation, and “Z” deformity of the thumb (hyperextension of
duloxetine, and bracing may also be required; and for patients the interphalangeal joint, flexion, and subluxation of the MCP
with prolonged moderate-to-severe pain and more ADL limita- joints).
tions, stronger pain medications (e.g., opioids) or even surgery Owing to the extra-articular foci of the immune response,
may be indicated. patients with RA may have different types of extra-articular
manifestations during the course of the disease. Common extra-
articular features include fatigue, mild normocytic normochro-
Rheumatoid Arthritis mic anemia, rheumatoid nodule (subcutaneous nodule, which
RA is a chronic, systemic inflammatory disease of unknown occurs in 15% to 20% of patients with RA), scleritis, episcleritis,
etiology that primarily involves the joints. It also often involves myositis, vasculitis, neuropathy, pericarditis, interstitial pneu-
soft tissues, such as tendon sheaths and bursae. In addition, it monitis and fibrosis, nodular lung disease, myocarditis, cardiac
may present with extra-articular manifestations. Inflammation conduction defect, Felty syndrome (RA with neutropenia and
and destruction of the joint and soft tissue may lead to joint splenomegaly), Sjögren syndrome, and amyloidosis. Vasculitis is
deformity and loss of physical function. This can happen if a serious condition; it can present in five different clinical ways:
the disease is left untreated or when it becomes unresponsive distal arteritis, cutaneous ulceration, palpable purpura, arteritis of
to treatment. The prevalence of RA varies from 0.3% to 1.5% the viscera, and peripheral neuropathy (mononeuritis multiplex or
of the population, with a female-to-male ratio of around 3 distal sensory neuropathy). Extra-articular features may be associ-
to 1. ated with poor prognosis, particularly vasculitis and rheumatoid
A B
C D
• Fig. 31.3 Typical deformities of the hands and foot in patients with rheumatoid arthritis. (A) Buttonhole (the
third finger) deformity. (B) Swan-neck (the second finger) deformity. (C) Ulnar deviation. (D) Hallux valgus
and toes overriding.
lung disease. The presence of RF and ACPA or anti-CCP is also 1987 Revised American Rheumatism
• BOX 31.1
common in patients with RA. Association Criteria for the Classification
of Rheumatoid Arthritis
Classification Criteria Morning stiffness: Morning stiffness in and around the joints, lasting at
Until 2010, the classification criteria for RA had been based on the least 1 h before maximal improvement.
Arthritis of three or more joint areas: Soft tissue swelling or fluid (not
1987 American Rheumatism Association (ARA) revised criteria,
bony overgrowth alone) observed by a physician in at least three joint
which included four clinical criteria (morning stiffness, arthritis of areas simultaneously. The 14 possible areas are right or left PIP, MCP,
three or more joint areas, arthritis of hand joints, and symmetric wrist, elbow, knee, ankle, and MTP joints.
arthritis), positive RF, the presence of rheumatoid nodules, and Arthritis of hand joints: At least one area swollen (as defined previously) in
radiographic changes (Box 31.1). The four clinical criteria must have a wrist, MCP, or PIP joint.
been present for 6 weeks.4 These criteria may be useful for clinical Symmetric arthritis: Simultaneous involvement of the same joint areas (as
study and can rule out some varieties of transient polyarthritis (e.g., defined previously for criterion 2) on both sides of the body (bilateral
acute viral polyarthritis). However, a major drawback of these cri- involvement of PIP, MCP, or MTP joints is acceptable without absolute
teria is their ineffectiveness in identifying some patients with early symmetry).
disease who subsequently have typical RA because rheumatoid nod- Rheumatoid nodules: Subcutaneous nodules over bony prominences, on
exterior surfaces, or in juxta-articular regions observed by a physician.
ules and radiographic erosive changes are usually not present in the
Serum rheumatoid factor: Demonstration of abnormal amounts of serum
early stage of disease. In addition, ACPA testing (which has a similar rheumatoid factor by any method for which the result has been positive
sensitivity for RF but is much more specific for RA) was not previ- in less than 5% of normal controls.
ously available. In contrast, the ARA criteria did not require any Radiographic changes: Radiographic changes typical of rheumatoid
exclusion, thus a patient could initially fulfill the diagnostic crite- arthritis on posteroanterior hand and wrist radiographs, which must
ria of RA but evolve into other diagnoses later, particularly Sjögren include erosion or unequivocal bony decalcification localized in or most
syndrome, scleroderma, psoriatic arthritis, crystalline arthritis, and marked adjacent to the involved joints (osteoarthritis changes alone do
systemic lupus erythematosus (SLE). To facilitate earlier diagnosis not qualify).
of RA and thus early effective treatment, The Joint Working Group MCP, Metacarpophalangeal; MTP, metatarsophalangeal; PIP, proximal interphalangeal.
of the American College of Rheumatology (ACR) and the EULAR
TABLE 2010 American College of Rheumatology/ education, relative rest with appropriate exercise, physical
31.2 European League Against Rheumatism modalities, occupational therapy, proper orthoses, appropriate
shoes, and durable medical equipment. Nutritional counseling,
Classification Criteria for Rheumatoid Arthritis
psychosocial interventions, vocational training, and measures
Score–Based Algorithm for Classification in an to prevent complications of drug therapy are also an integral
Eligible Patient [Cutpoint for RA: ≥6/10]) part of treatment. Most of these measures are covered in the
Joint Involvementa (0–5) domain of rehabilitation management, which is discussed later
in this chapter.
1 medium to largeb joint 0 Sustained remission or low disease activity is the pharmaco-
2–10 medium to large joints 1 logic treatment target in patients with RA. The goal is to achieve
more than 50% improvement by 3 months and is typically
1–3 smallc
joints (with or without involvement of 2
large joints)
attained by the sixth month.37 Three classes of drugs are com-
monly used in treating patients with RA: NSAIDs, glucocorti-
4–10 small joints (with or without involvement of 3 coids, and disease-modifying antirheumatic drugs (DMARDs).
large joints) NSAIDs can reduce acute inflammation, thereby reducing pain
>10 joints (at least one small joint) 5 and improving function. However, NSAIDs alone cannot pre-
vent the progression of joint damage and the resultant irrevers-
Serology (0–3) ible disability. Therefore patients with RA should be treated early
Negative RF AND negative ACPA (or anti-CCP) 0 with DMARDs.
DMARDs are a class of drugs that can change or modify
Low-positive RF OR low-positive ACPA (or anti-CCP) 2 the disease course and hence inhibit the progression of joint
High-positive RF OR high-positive ACPA (or anti-CCP) 3 damage. The DMARDs currently available for RA treatment
are categorized into synthetic and biologic agents (Table 31.3).
Acute Phase Reactants 1 Among the conventional synthetic DMARDs (csDMARDs),
Normal CRP AND normal ESR 0 methotrexate (MTX) should be the preferred drug for RA.
If patients are intolerant to MTX or have contraindications,
Abnormal CRP OR abnormal ESR 1
leflunomide or sulfasalazine should be included in the first-
Duration of Symptoms (0–1) line therapy.3 csDMARDs may be combined with NSAIDs and
glucocorticoids.
<6 weeks 0
Glucocorticoids are also potent antiinflammatory drugs. They
≥6 weeks 1 are particularly useful at the onset of disease. Glucocorticoids
aJoint
are used as a bridging strategy; they are then tapered while the
involvement refers to any swollen or tender joint on examination or evidence of syno-
DMARDs take effect. They can also be used during a disease flare
vitis on magnetic resonance imaging or ultrasonography. Distal interphalangeal joints, first
carpometacarpal joint, and first metatarsophalangeal joint are excluded from assessment. or as local injection agents when one or two joints or soft tissues
bMedium to large joints refers to shoulders, elbows, hips, knees, and ankles. are more inflamed.
cSmall joints refers to the metacarpophalangeal joints, proximal interphalangeal joints, meta- In 2015, the ACR recommended oral administration of low
tarsophalangeal joints 2 through 5, thumb interphalangeal joints, and wrists. doses of glucocorticoids (≤10 mg/day of prednisolone or equiva-
ACPA, Anticitrullinated protein/peptide antibody; anti-CCP, anticyclic citrullinated peptide lent) for less than 3 months.
antibody; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; RF, rheumatoid fac- When patients exhibit little response to MTX monotherapy
tor; ULN, upper limit of normal.
and even to two or more csDMARDs, it is time to start a bio-
Modified with permission from Aletaha D, Neogi T, Silman AJ, et al: 2010 rheumatoid arthritis
logic DMARD (bDMARD) or a targeted synthetic DMARD
classification criteria: an American College of Rheumatology/European League Against Rheu-
matism collaborative initiative, Ann Rheum Dis 69:1580–1588, 2010. (tsDMARD) in addition to MTX. All bDMARDs are adminis-
tered via the intravenous or subcutaneous routes, but tsDMARDs
are administered orally. Biologic therapy must be used in com-
bination with MTX because the response to this combination is
superior to that with biologic therapy alone. When the treatment
developed new criteria for RA in 2010 (Table 31.2).2 The 2010 cri- target is not achieved with the use of a first-line bDMARD or
teria comprise four domains: (1) type and number of affected joints, tsDMARD, switching to another agent with a different mode of
(2) RF and ACPA, (3) acute-phase reactants (CRP and ESR), and action is recommended. When a patient is in persistent remission,
(4) the duration of symptoms. For the evaluation of a patient with tapering of a bDMARD may be considered; however, complete
suspected RA, the highest category within each domain is taken discontinuation of the bDMARD or tsDMARD is not necessary
and the four respective numbers are added. The maximal possible because it can lead to disease recurrence.34,36
score is 10, where a score of 6 or more indicates the presence of RA. The drawbacks of biologic DMARDs are their high cost, pos-
The new criteria place a greater emphasis on serology and imaging sible side effects, and sometimes serious adverse events (infection,
studies (ultrasound and MRI), which can also be used to evaluate tuberculosis, demyelinating syndromes, increased risk of certain
synovitis. malignancies, and drug-induced lupus). With regular assessment
of disease activity and tight control of treatment strategies, many
Management of Rheumatoid Arthritis patients with RA remain in remission or in a state of low-dis-
ease activity wherein joint destruction and physical disability are
The comprehensive management of RA requires a combina- avoided. In patients with intractable pain, severe joint destruc-
tion of nonpharmacologic measures, medical interventions, tion, or poor response to long periods of medical treatment and
and surgery. Nonpharmacologic measures include patient rehabilitation, surgery may be considered. Common surgeries for
TABLE Disease-Modifying Antirheumatic Drugs TABLE Differentiation of Inflammatory Versus

31.3 Currently Available for Rheumatoid Arthritis 31.4 Mechanical Low Back Pain
Type Target Drugs Inflammatory Pain Mechanical Pain
Synthetic Conventional Methotrexate Age of onset <40 years Middle to old age
synthetic Leflunomide Type of onset Insidious Acute or insidious
(csDMARD) Sulfasalazine
Hydroxychloroquine Symptom duration >3 months Mostly <3 months
Targeted JAK Tofacitinib Night pain Common Rare
synthetic Baricitinib
(tsDMARD) Effect of exercise Improved Usually worse (acute
pain)
Biological Biological TNF Adalimumab
(bDMARD) Certolizumab Sacroiliitis Positive Negative
Etanercept Low back mobility Limited in all Limited in one or some
Golimumab motions motions
Infliximab
Neurologic deficits Unusual Possible
B cell Rituximab
CRP or ESR Increase in active Normal
T cell Abatacept stage
IL-6 Tocilizumab
CRP, C-reactive protein; ESR, erythrocyte sedimentation rate.
IL-1 Anakinra
DMARD, Disease-modifying antirheumatic drug; IL, interleukin; JAK, Janus kinase; TNF,
tumor necrosis factor. however, within a few months, the pain becomes bilateral and per-
sistent, and the lower back becomes stiff. Gradually pain and stiff-
ness may ascend from the lower back to the middle back and then
patients with RA are artificial joint replacement, synovectomy (for to the upper back and neck region.
the hand, wrist, elbow, knee, and tendon sheath), tendon repair, Patients with AS may experience arthritis outside of the spine,
osteotomy, and arthrodesis (for the wrist, ankle, or cervical spine). and peripheral arthritis occurs in approximately 35% to 50% of
patients with AS over the course of the disease.31 The most com-
Ankylosing Spondylitis monly affected joints, in order of frequency, are the shoulders,
hips, and knees. Involvement of the ankles, sternoclavicular joints,
Seronegative spondyloarthropathy is a type of chronic inflammatory and temporomandibular joints is also reported. Hip involvement
arthritis involving the axial structures; it is manifested by chronic is present in 25% to 35% of patients with AS and is associated
back pain and progressive stiffness of the spine.38 It can also involve with a high degree of physical disability and a poor prognosis.
the shoulders, hips, and other peripheral joints. Its manifestations Enthesitis occurs in approximately 40% to 70% of patients with
include AS, reactive arthritis, arthropathy of inflammatory bowel AS at some time during the course of the disease.38 The most com-
disease, psoriatic arthritis, undifferentiated spondyloarthropathy, and mon location of enthesitis in patients with AS is the calcaneal
juvenile-onset AS. In addition to inflammation of the spine (includ- attachments of the Achilles tendon. Other locations include the
ing the sacroiliac joint), this disease is characterized by the absence calcaneal attachments of the plantar fascia, shoulders, costochon-
of an RF, the tendency for familial aggregation, an association with dral junctions, sternoclavicular and manubriosternal joints, and
the HLA-B27, inflammation around the entheses (the site of tendon superior iliac crest. Dactylitis (or “sausage digits”) is characterized
insertion into bone), uveitis, urethritis, and psoriatic skin lesion. AS by diffuse swelling of the toes or fingers and is present in 6% to
is the prototypic form and is frequently encountered by physiatrists. 8% of patients with AS.
The prevalence of AS has been estimated to be 0.1% to 1.4% Patients with AS may have extra-articular comorbidities
of the population (0.2% to 0.5% in the United States), and the including anterior uveitis, inflammatory bowel disease, psoriasis
male-to-female ratio is approximately 2 to 3. The prevalence of AS skin lesions, aortic regurgitation, cardiac conduction disturbance,
generally mirrors the frequency of HLA-B27 in the population; it restrictive lung disease, apical pulmonary fibrosis, immunoglobu-
is approximately 5% to 6% in people who test positive for HLA- lin nephropathy, or renal amyloidosis. Among these conditions,
B27.38 The peak age of onset is between 20 and 30 years. anterior uveitis (or iritis) is the most common, occurring in 25%
to 40% of patients with AS.41 Anterior uveitis presents as acute
eye pain, redness, photophobia, increased lacrimation, and blur-
Clinical Characteristics ring of vision. Treatment of acute uveitis should begin as early as
The most common presentation is chronic inflammatory back possible to avoid complications such as glaucoma or vision loss.
pain. The pain usually starts at the buttock or lower back level, with Recent data suggest that the prevalence of osteoporosis and ver-
possible radiation to the posterior thigh. It is a dull pain, insidi- tebral fractures in patients with AS is 25% and 10%, respectively.
ous in onset and chronic (lasting >3 months). The pain is worse Approximately 65% of fractures are associated with a neurologic
in the later part of the night and the early morning, with morn- deficit. Spinal cord injury is 11 times more common in patients
ing stiffness lasting more than 30 minutes and often hours. It can with AS than in the general population and affects the cervical
be relieved with exercise or activity and worsened with rest (Table spine more often than the thoracic and lumbar spine. Spontane-
31.4). It is usually improved with the use of NSAIDs. At first, ous subluxation of the atlantoaxial joint and cauda equina syn-
buttock or lower back pain may be unilateral and intermittent; drome may also occur in patients with AS.
Radiographic Grading of Sacroiliitis

• BOX 31.2
Grade 0: Normal
Grade 1: Suspicious changes
Grade 2: Minimal abnormality—small localized areas with erosions or
sclerosis without alteration in the joint width
Grade 3: Unequivocal abnormality—moderate or advanced sacroiliitis with
erosions, sclerosis, widening, narrowing, or partial ankylosis
Grade 4: Total ankylosis
Laboratory findings are generally nonspecific for AS. An ele-

vated ESR or CRP is present in approximately 50% to 70% of
patients who have AS with active disease. Normochromic normo-
cytic anemia is occasionally seen, and HLA-B27 is present in 90%
to 95% of patients of European ancestry with AS.
• Fig. 31.4 Anteroposterior view of the pelvis in a patient with ankylosing
Imaging spondylitis shows grade 3 sacroiliitis bilaterally (arrows).
Plain radiography and MRI are the principal imaging techniques

used to evaluate patients with AS, especially for sacroiliac joints.
In general, radiographic changes take a few years to develop.
Radiographic findings of sacroiliitis (pelvis, anteroposterior view)
include narrowing of the joint space, sclerosis, erosion, and bony
ankylosis. These have been divided into five grades (Box 31.2, Fig.
31.4). Other findings on plain radiograph of the pelvis include
erosions and osteitis at the ischial tuberosity, femoral trochanter,
iliac crests, and symphysis pubis. Radiographic changes of the
spine may include squaring of the vertebral bodies, syndesmoph-
ytes (Fig. 31.5), ankylosis of the facet joints, and calcification of
the anterior longitudinal ligament.
If a plain radiograph of the pelvis does not fulfill the criteria for
sacroiliitis but the suspicion of AS remains high, the next step is
MRI. In the case of active sacroiliitis, MRI can show bone marrow
edema in the bones adjacent to the affected joints, as shown in short
tau inversion recovery (STIR) images (Fig. 31.6) or T2-weighted
images with fat suppression (not seen in T1-weighted images). MRI
has been shown to be more sensitive than conventional radiography,
bone scintigraphy, and CT scans in the detection of sacroiliitis.38
Diagnosis Criteria
Diagnosis (or classification) of classic AS is based on the 1984
modified New York criteria, which requires the symptoms of lower
back pain, limited lumbar spine motion and chest expansion,
and plain radiographs showing sacroiliitis (Box 31.3).15 A stage
at which the clinical symptoms and signs of patients fulfill the
• Fig. 31.5Lateral view of the thoracolumbar spine in a patient with anky-
clinical criteria of AS but do not suggest sacroiliitis on radiographs losing spondylitis shows syndesmophytes (arrow) and a bamboo spine.
and may reveal sacroiliitis on MRI is called nonradiographic axial
spondyloarthritis (nr-axSpA). The proportion of patients with nr-
axSpA who experience disease progression is unknown; however, (discussed later), medication, and surgery. Patients should be edu-
factors related to disease progression include male sex, HLA-B27, cated about the nature of AS and encouraged to perform regular
disease duration, the extent of inflammation on MRI, and per- exercise and to quit smoking. NSAIDs should be used for the ini-
sistent systemic inflammation.31 Current treatment strategies for tial therapy. Continuous NSAID use is suggested for patients who
patients with nr-axSpA with high disease activity (symptoms and have AS with persistent active symptoms to lower the rate of radio-
signs) are the same as those for patients with established AS.39 graphic progression in the spine. NSAIDs can be supplemented
with a simple analgesic (acetaminophen) or low-potency opioid.
Management of Ankylosing Spondylitis For patients with axial disease who are not responsive to NSAIDs,
a tumor necrosis factor (TNF) inhibitor (or an anti-TNF agent)
The goals of management of patients with AS are (1) symptom relief, is recommended.39 TNF inhibitors are very effective for symptom
(2) maintenance of function, (3) prevention of spinal disease com- relief, can stop bony destruction, and may have potential for dis-
plications, and (4) minimization of extraspinal and extra-articular ease modification. A reduction in acute spinal infiammation can
comorbidities. Management includes a rehabilitation program be revealed on MRI with TNF inhibitors. Interleukin-17 (IL-17)
SERONEGATIVE SPONDYLOARTHROPATHY, SACROILIITIS

X-ray MRI STIR
• Fig. 31.6 Comparison of anteroposterior view of the pelvis (left) and magnetic resonance imaging (MRI; short
tau inversion recovery [STIR], right) of the sacroiliac joint in a patient with early ankylosing spondylitis. MRI shows
left sacroiliitis (white arrows), which is not shown on the plain film (black arrow). (Courtesy Dr. Hung-Ta Wu.)
1984 Modified New York Criteria for

• BOX 31.3 or evidence of spinal cord compression resulting from atlantoaxial
subluxation is observed. Spinal manipulation with high-velocity
Ankylosing Spondylitis
thrust should be avoided in AS patients who have spinal fusion or
Clinical Variables advanced spinal osteoporosis.6
• Inflammatory back pain >3 months
• Limitation of motion of the lumbar spine in both the sagittal and frontal Psoriatic Arthritis
planes
• Limitation of chest expansion relative to normal values Psoriatic arthritis is a member of the seronegative spondyloar-
thropathy family and is defined as an inflammatory arthritis
Radiologic Variables (Plain Radiographs)
associated with psoriasis. It is usually negative for RF and affects
• S acroiliitis grade ≥2 bilaterally
women and men equally. The prevalence of psoriatic arthritis is
• Sacroiliitis grade 3–4 unilaterally
approximately 1 to 2 per 1000, and the incidence is approximately
Definite Diagnosis 6 per 100,000 per year. It is estimated that 4% to 30% of patients
• At least one clinical variable plus at least one radiologic variable with psoriasis have psoriatic arthritis.
Patients with psoriatic arthritis present with symptoms and signs
of joint, entheseal, and spinal inflammation. They usually complain
of pain and stiffness in the affected joints. Morning stiffness often lasts
inhibitor, a fully human monoclonal antibody (secukinumab) that for longer than 30 minutes; it is accentuated by prolonged immobil-
targets IL-17A, has recently been found to be effective in relieving ity and is relieved by physical activity. Moll and Wright have described
symptoms of AS and to have the potential for disease modifica- five clinical patterns of psoriatic arthritis: (1) asymmetric oligoarthritis
tion. Currently NSAIDs, TNF inhibitors, and IL-17 inhibitors are (Fig. 31.8), (2) polyarthritis, (3) predominant DIP joint involvement,
the only effective drugs for the spinal manifestations of AS. For (4) destructive arthritis (arthritis mutilans), and (5) predominant
AS patients with predominantly peripheral arthritis who are not spondyloarthritis. Polyarthritis is the most common (63%), followed
responsive to NSAIDs and for whom TNF inhibitors are unsuit- by oligoarthritis (13%), and predominant DIP involvement (<5%).
able, sulfasalazine is suggested. Local corticosteroid injections may Although spinal involvement is found in 40% to 70% of patients
be indicated for persistent peripheral arthritis, sacroiliitis pain, or with psoriatic arthritis, spinal involvement alone occurs in only 2%
enthesitis; they should not be used at sites of the Achilles, patellar, to 4% of patients with psoriatic arthritis. Some patients present with
and quadriceps tendons because they may cause tendon rupture. more than one pattern, and the classification is not fixed. The pat-
Short-term use of systemic corticosteroids may be helpful for symp- tern of disease may fluctuate. Other musculoskeletal features include
tomatic control; however, their long-term use should be avoided.6 dactylitis (sausage digit, resulting from inflammation of the soft tissue
In AS patients whose joints are destroyed, total joint replacement and joints), enthesitis, tenosynovitis, nail lesions (pits and onycholy-
may be necessary. Wedge osteotomy of the spine is reserved for AS sis), and pitting edema in the hands or feet.
patients with severe spinal deformities (Fig. 31.7). Fusion of the The most typical radiologic finding is the coexistence of erosive
atlantoaxial joint is required if considerable neck or occipital pain changes and new bone formation in the DIP joints. Other changes
A B
• Fig. 31.7 Severe deformity of the spine in a 29-year-old patient with ankylosing spondylitis. (A) Before
surgery. (B) After surgery. Substantial improvement after spinal osteotomy (90-degree correction) and total
hip replacement (60-degree correction). (Courtesy Dr. Ing-Ho Chen.)
• BOX 31.4 Classification for Psoriatic Arthritis

(CASPAR) Criteria
• Inflammatory musculoskeletal disease (peripheral arthritis, spondylitis,
or enthesitis) and
• At least 3 points from the following:
• Current psoriasis (2 points), a personal history of psoriasis (1 point),
or a family history of psoriasis (1 point)
• Typical nail lesions (1 point): onycholysis, pitting
• Dactylitis (1 point): present or past, documented by a rheumatologist
• Negative rheumatoid factor (1 point)
• Juxta-articular bone formation (1 point): on hand or foot radiographs
From Taylor W, Gladman D, Helliwell P, et al: Classification criteria for psoriatic arthritis:
development of new criteria from a large international study, Arthritis Rheum 54:2665–2673,
2006.
• Fig. 31.8 Swelling of right wrist and left third metacarpophalangeal joint
in a patient with psoriatic arthropathy.
after 3 months of treatment, a TNF inhibitor may be added, usu-
ally etanercept, adalimumab, or infliximab. TNF inhibitors have
include fluffy periostitis with new bone formation at the site of been demonstrated to reduce the radiographic progression of
enthesitis, lysis of the terminal phalanges, gross destruction of iso- disease, their effect is superior to that of MTX. In case of intol-
lated joints, “pencil in cup” appearance, and the presence of both erance or inadequate response to TNF inhibitors or in patients
joint lysis and ankylosis. MRI may be more sensitive than con- with severe skin involvement, IL-17 inhibitors or even IL-12/23
ventional radiography in detecting articular, periarticular, and soft inhibitors may be considered.35 The use of oral corticosteroids in
tissue inflammation. In recent years, the Classification of Psoriatic patients with psoriatic arthritis should be avoided. Joint replace-
Arthritis (CASPAR) study developed new criteria for patients with ment may be suggested when psoriatic arthritis causes damage
psoriatic arthritis (Box 31.4). A patient with inflammatory mus- that limits movement and impairs function.
culoskeletal disease can be classified as having psoriatic arthritis if
he or she has a total of at least three of the five categories. Gout and Other Crystal-Related
Treatment for psoriatic arthritis includes therapy for both skin Arthropathies
and joint disease. The treatment usually starts with NSAIDs. If
the arthritis is not well controlled by the NSAIDs, the next step Crystal-related arthropathies represent disorders in which minerals
is a nonbiologic DMARD, preferably MTX, leflunomide, or sul- are deposited in the musculoskeletal tissue. These crystals include
fasalazine. For patients whose joint condition does not improve monosodium urate (MSU), calcium pyrophosphate dihydrate
A B
• Fig. 31.9 (A) Acute gouty arthritis, marked by an abrupt onset of pain, erythema, swelling, and warmth
in the right first metatarsophalangeal joint. (B) Chronic tophaceous gout of hands with resultant deformity.
(CPPD), hydroxyapatite, and others. Intra-articular crystals can

cause acute and chronic inflammation.
Among these crystal-related arthropathies, gout is the most crucial
and most common form. Gout, caused by the deposition of excessive
MSU crystals in the synovial fluid and other tissues, is the most com-
mon type of inflammatory arthritis worldwide, where its prevalence
ranges from 0.9% to 6.1%. Gout is more prevalent in men than in
women. In women, gout attacks usually occur after menopause.
Patients with gout are usually not diagnosed early, particularly
within the first few episodes, because gout can occur at the Achilles
tendon and can be elicited by trauma and often be misdiagnosed
as tendinitis and traumatic arthritis, respectively. Thus physiatrists
should be familiar with the clinical characteristics of gout.
Clinical Characteristics
Gout occurs after long-term hyperuricemia, characterized by a • Fig. 31.10Monosodium urate crystals from a joint with acute gouty arthri-
serum urate (sUA) level of greater than 7.0 mg/dL. It is the most tis, viewed under polarized light microscopy. Note that both intra- (arrow)
dominant factor for gout development. The possibility of gout and extracellular (arrowhead) crystals are present (×1000, with a first-order
development is related to sUA levels as well as the duration of red compensator).
sUA elevation. However, most people with hyperuricemia are and
remain asymptomatic throughout their lives; only some 10% of diabetes mellitus, dyslipidemia, obesity, and renal disease. Patients
them eventually develop gout. with early-onset gout or with tophi are more likely to exhibit
An acute gout attack is characterized by an abrupt onset of comorbidities. These comorbidities are markers of gout severity
pain, erythema, swelling, and warmth overlying the joint or bursa and prompt earlier treatment.21
(Fig. 31.9A). Initially it often affects a single joint of the lower
limbs. The first MTP joint is most commonly affected. The pain
is so severe that patients cannot tolerate touch or pressure to the
Management of Acute Gout
affected joint. They may experience great difficulty in walking or Patients with gout should be informed of the associated comor-
be unable to use the affected joint. A typical episode reaches its bidities and should be advised to follow a healthy lifestyle, includ-
peak in less than 24 hours and resolves in 14 days or less. No ing avoidance of alcohol intake and heavy meals, control of body
symptoms are observed between episodes. The presence of MSU weight, and maintenance of regular exercise.
crystals in the synovial fluid from the symptomatic joint or bursa The screening and treatment of associated comorbidities must
or the presence of tophus (see Figs. 31.9B and 31.10) is a sufficient be considered an integral part of gout management.21 Acute flares
criterion for the diagnosis of gouty arthritis.24 should be treated as early as possible, and NSAIDs should be pre-
If gout is uncontrolled or suboptimally treated, tophi may scribed at high doses if not contraindicated. Different types of
develop later (see Fig. 31.9B). Tophi occur most frequently in sub- NSAIDs do not have significantly different effects. Colchicine at
cutaneous tissues and joints, resulting in joint deformity and even 0.5 mg once or twice daily is recommended if not contraindicated.
restricted movement in severe cases. The most critical determinant Colchicine is contraindicated in patients with severely impaired
of tophi development is the sUA level, followed by gout duration.24 renal function, and the dose must be reduced in patients with
an estimated glomerular filtration rate (eGFR) of 10 to 50 mL/
Comorbidities min/1.73 m2. Colchicine should be used at lower doses in older
adults. If a patient does not respond well or NSAIDs are contrain-
Gout is an independent risk factor for mortality resulting from dicated, an intra-articular or oral corticosteroid is recommended.
coronary heart disease and renal disease. In addition, gout is Diet therapies have no effect on symptomatic outcomes.21 Dur-
highly associated with comorbidities such as hypertension, ing the acute attack, drugs that affect sUA concentration should
usually not be stopped (if already being used) or started (if not Musculoskeletal Manifestations
being used) for fear of prolonging or worsening an inflammatory
reaction.24 Joint pain is the most common and among the first manifes-
tations of SLE. It typically presents as symmetric polyarthritis
involving the MCP, PIP, and knee joints. Any young female
Prophylaxis patient with arthritis should be evaluated for a possible diagno-
For patients first presenting with acute gout, urate-lowering therapy sis of SLE. Unlike the case in RA, in SLE the joints are rarely
(ULT) should be considered and discussed. ULT should particularly erosive or deforming. SLE may present with swan-neck deformi-
be advised in patients with gout attacks over twice a year, the pres- ties of the hand resulting from recurrent synovitis and inflam-
ence of tophi, renal impairment (eGFR <60 mL/min/1.73 m2), a mation of the joint capsule, tendons, and ligaments. Unlike RA,
history of urolithiasis, onset at a young age (<40 years), higher sUA these deformities, known as Jaccoud arthropathy, are usually
levels (>8 mg/dL), and/or comorbidities. Delaying ULT initiation reducible.14
will expose the patients to a higher and long-standing crystal load, Another important consideration is the increased possibility of
which is harmful to the cardiovascular and renal systems. avascular necrosis, which is caused by SLE pathogenesis and/or
In patients on ULT, the sUA level should be maintained at concomitant large doses of glucocorticoids. The femoral head is
less than 6 mg/dL to prevent recurrent attacks. In a patient with the most commonly affected site.
tophi, the sUA level should be maintained at less than 5 mg/dL to
promote faster dissolution of crystals. An sUA level of less than 3 Neurologic Manifestation
mg/dL over the long term is not recommended.
All ULTs should be initiated at a low dose and then titrated Neurologic and psychiatric (NP) features of SLE (NPSLE) are
upward until the sUA target is reached, and this target should be severe but potentially treatable. NPSLE may be the first clinical
maintained lifelong.24 Allopurinol, a xanthine oxidase inhibi- manifestation of SLE, with a 10-fold increase in the mortality rate;
tor, is indicated in the following conditions: (1) hyperuricemia therefore clinicians should be aware of this disease.
associated with increased uric acid production (urinary uric acid The pathogenesis of NPSLE is multifactorial, involving isch-
excretion of ≥1000 mg in 24 hours), (2) uric acid nephropathy, emic and inflammatory mechanisms. Autoantibodies play a key
(3) nephrolithiasis, (4) prophylaxis before cytolytic therapy, (5) role in mediating both mechanisms. Patients with SLE may have
allergy to or intolerance of uricosuric agents. Allopurinol should various neuropsychiatric symptoms, which are less specific and
be started at a low dose (50 to 100 mg daily) and then increased less helpful for diagnosis. These include seizures, psychosis, mono-
in 100-mg increments every 2 to 4 weeks until the sUA tar- neuritis multiplex, myelitis, peripheral or cranial neuropathy,
get has been achieved. In patients with renal impairment, the and acute confusional state. It may sometimes not be possible to
starting dose and increments should be lower (50 mg) and the determine whether the neuropsychiatric findings are due to SLE
maximal dose to reach the target also lower. However, the target or other causes. Therefore, even if these neuropsychiatric symp-
sUA level is the same. The side effects of allopurinol are skin toms are present, other known causes should be considered for
rash and gastrointestinal discomfort; however, their incidence diagnosis. The ACR created standardized case definitions for 19
is low. Although allopurinol is well tolerated, potentially life- neuropsychiatric syndromes observed in SLE, including 12 cen-
threatening events, including severe cutaneous adverse reac- tral and 7 peripheral nervous system syndromes.
tions and liver and renal toxicity, have been reported, although The most common presentation of NPSLE is cognitive impair-
rarely. Allopurinol should not be used in patients carrying the ment, and the most vital correlate of cognitive impairment is
HLA-B*5801, which greatly increases the risk of adverse events. depression. NPSLE commonly occurs early, within the first or
When allopurinol is contraindicated or not tolerable, febuxo- second year after SLE diagnosis, in up to 50% of the patients.
stat can be used as an alternative second-line xanthine oxidase Approximately 28% to 40% of NPSLE-related manifestations
inhibitor.24 develop before or at the time of SLE diagnosis.
Uricosuric agents (including sulfinpyrazone, probenecid, and Transverse myelitis with paraplegia and sensory impairment is a
benzbromarone) can be used in patients who are resistant to or rare but severe complication of SLE or antiphospholipid antibody
intolerant of allopurinol. The most preferred drug is benzbro- syndrome. Stroke and transient ischemic attacks are also related to
marone, which can be used when the GFR is as low as 20 mL/ SLE vasculitis or antiphospholipid antibody syndrome. The three
min/1.73 m2. Treatment with a combination of allopurinol and major risk factors for NPSLE are SLE disease activity, previous or
benzbromarone was found to be more effective in lowering sUA concurrent major NPSLE events, and the presence of antiphos-
than either of the agents alone. ULT does not reduce the risk of pholipid antibodies. Patients with NPSLE (stroke, seizure, and
acute flares in the first 6 months.24 Thus colchicine at 0.5 mg cognitive dysfunction) are more likely to exhibit elevated serum
once or twice daily should be considered as prophylaxis against levels of lupus anticoagulant, antiphospholipid antibody, anticar-
acute attacks and continued up to 6 months. When a patient diolipin antibody, and increased levels of antineuronal antibody in
cannot tolerate colchicine, an NSAID at a low dose can be used cerebrospinal fluid (CSF).
as an alternative.21
Septic Arthritis
Systemic Lupus Erythematosus
Septic arthritis, also known as infectious arthritis, is a bacterial,
SLE is a chronic autoimmune disease that can affect many organ viral, mycobacterial, or fungal joint infection. Of these, bacterial
systems. It predominantly affects women of childbearing age, with infection is the most common. It usually occurs in older adults
the peak age of onset being between 15 and 40 years. The classic and very young children. Bacterial arthritis can lead to severe mor-
triad of fever, joint pain, and rash in a woman of childbearing age bidity and mortality. Delayed or inadequate treatment can cause
should prompt investigation into an SLE diagnosis.14 irreversible joint destruction, severe disability, and even death.17
The most robust risk factor is preexisting joint disease. Other Rehabilitation Goals for Rheumatic
• BOX 31.5
factors are RA, OA, gout, recent trauma, prior joint surgery, SLE, Diseases
and receipt of TNF inhibitor therapy. Of these, RA is the most
common factor and is related to worse outcomes. Any conditions 1. To increase or maintain functional performances
causing loss of skin integrity and those associated with compro- • Including to develop problem-solving skills related to joint protection
mised immunity present a risk for septic arthritis. and energy conservation
2. To keep proper joint alignment and to prevent joint deformities
3. To relieve pain and inflammation
Clinical Presentation 4. To increase or maintain mobility, strength, and endurance
5. To facilitate successful adaptation
The most common symptom is acute onset of joint pain, ery- • To help the patient cope with the unpredictable nature of the disease
thema, heat, and restricted joint mobility. Fever is detected in 6. To achieve sense of self-efficacy and well-being
only approximately 40% to 60% of patients with septic arthritis,
indicating that an elevated body temperature is not a prerequisite
for diagnosis.17
Septic arthritis usually affects a single joint; in only 20% of
cases, two or more joints are affected. The knee is the most com-
monly affected joint, followed by the shoulder, wrist, hip, and antibiotics are usually warranted until culture data are available.
ankle, whereas the hip joint is the most commonly affected joint Vancomycin is the initial antibiotic.17 For immunocompromised
in children. Infections of axial joints, such as the sternoclavicular patients or intravenous drug abusers, vancomycin plus a third-
or sacroiliac joints, are more common in patients with a history of generation cephalosporin should be administered. Treatment is
intravenous drug abuse. often continued up to 6 weeks, with intravenous administration
The most common causative organism in adults is Staphylococ- of the antibiotic for the first 2 weeks and then a switch to oral
cus aureus, followed by groups B and A streptococci, which are administration.
especially prevalent among older adults and those with chronic Aggressive rehabilitation is crucial in preventing muscle wast-
diseases. Gram-negative organisms are less common. Intravenous ing and joint contractures. Patients should be mobilized once their
drug abusers are susceptible to mixed bacterial infections, fungal pain has decreased.
infections, and infections by unusual organisms.
Rehabilitative Management of Rheumatic
Diagnosis
Diseases
Positive synovial fluid culture is the key to a definitive diagnosis.
Synovial fluid analysis can reveal a highly elevated white blood The rehabilitation of the patient with a rheumatic disease can
cell (WBC) count above 50,000/μL and a polymorphonuclear pose a challenge because he or she will probably have comor-
cell count above 90% in most cases. Gram staining can yield an bidities that need to be considered. The goal setting will have
immediate result and is often positive. A lower WBC count, a to accommodate those special considerations (Box 31.5). In
negative Gram stain, or a subsequently negative synovial fluid cul- addition to the medical treatments mentioned previously, the
ture cannot exclude the diagnosis but makes the condition less rehabilitative interventions should include patient education,
likely. Although the WBC count, ESR, and serum CRP concen- improvement or maintenance of functional mobility, assessing
tration are nonspecific, they can be used for monitoring responses the need for orthoses and durable medical equipment, appropri-
to treatment. ate physical modalities, and exercise.
Infection can be introduced into a joint by the hematogenous
route or by direct inoculation, such as penetrating trauma or
therapeutic joint injection. Penetrating trauma is the most com- Rehabilitation Evaluation of Patients With
mon means of introducing septic arthritis at the small joints of Rheumatic Diseases
the hands and feet. Because pathogenesis may be hematogenous,
blood culture is positive in 25% to 50% of these patients. To achieve the rehabilitation goals requires an understanding of
The most mandatory differential diagnosis for bacterial arthritis the disease process, specific conditions, potential deformities, how
is gout. Gout can present with similar symptoms and can coexist the arthritic condition has affected the individual’s functioning,
with bacterial arthritis. Gout can be diagnosed through polarizing and the patient’s individual needs. Holistic examination assists the
microscopic visualization of MSU. Other diagnostic clues include professionals in appropriate goal setting and treatment planning.
the presence of tophi and involvement of the first MTP joint in The key components of the rehabilitation evaluation of patients
gouty arthritis. with rheumatic diseases are described in Box 31.6. In addition to
the medical treatments mentioned earlier, the rehabilitative inter-
ventions should include the following.
Management
The key treatment is prompt removal of intra-articular pus and Patient Education
appropriate antibiotic treatment. Needle aspiration should be
repeated daily until effusions resolve and cultures are negative. Patients must understand that joint deformities cannot be pre-
Arthroscopic drainage can provide rapid recovery with low morbid- vented if the disease progresses without antiinflammatory or
ity. Because septic arthritis is rapidly destructive, broad-spectrum disease-modifying medication. Therefore all interventions require
• BOX 31.6 Key Components of the Rehabilitation Principles of Joint Protection for
• BOX 31.7
Evaluation of Patients With Rheumatic Rheumatic Diseases
Diseases
1. Respect pain as a signal to stop the activity.
2. Maintain muscle strength and joint range of motion.
Disease and Comorbidities Self-care
Domestic life • Maintaining daily activities within the limitations of the patient’s pain
Current diagnosis helps to prevent disuse atrophy.
Current disease activity Education
Leisure • Strengthening around an unstable joint can increase stability and
Cardiovascular comorbidities reduce pain.
Depression Subscales of HAQ and AIMS
WHODAS 3. Use each joint in its most stable anatomic and functional plane.
Other 4. Avoid positions of deformity and forces in their direction.
CHART
• For example: Turning resistive round doorknobs in an ulnar direction
Body Function and Structure Other
when the finger metacarpophalangeal joints are subluxed volarly
Pain and ulnarly should be avoided by use of a lever door opener.
Tender joint count Environmental Factors:
External Features of the 5. Use the largest, strongest joints available for the job.
Swollen joint count • For example: Using a belted waist pack rather than holding purse
Nodules and nodes Physical, Social, and
Attitudinal World with hook grasp.
Range of motion 6. Ensure correct patterns of movement.
Deformities Occupation
Home physical environment • For example: Cutting meat by holding the knife like a dagger.
Muscle strength 7. Avoid staying in one position for long periods.
X-ray, ultrasound, or MRI: Workstation setup
Broad-handle utensils 8. Avoid starting an activity that cannot be stopped immediately if it
erosions, loss of joint spaces, proves to be beyond your capability.
osteophytes Assistive devices and mobility
aids 9. Balance rest and activity.
10. Reduce the force.
Activities: Execution of a Task Interpersonal environment
• Building up handles to avoid tight grasp.
or Action Social support
Societal policies and regulations • Use of assistive devices, such as jar openers to reduce the stress of
Reaching the hand and wrist joints.
Manipulation • For osteoarthritis, the cartilage is too thin to protect against
Timed button test Personal Factors: Features
of Individual and Not Part of repetitive use of force.
Hand function • Use alternative methods to accomplish the task. For example, using
Six-minute walking test Health Condition
Personal identity the handrail to reduce the impact load to involved knee joints while
HAQ going up and downstairs.
AIMS Occupation
DAS 28 Goal Modified from Cordery J, Rocchi M: Joint protection and fatigue management. In Melvin J,
WOMAC Beliefs about arthritis Jensen G, editors: Rheumatologic rehabilitation series, volume 1: assessment and management,
Coping style Bethesda, MD, 1998, American Occupational Therapy Association, pp 279–322.
Participation: Involvement in Self-efficacy
Life Situations Religious and spiritual beliefs
Daily routines
process to reduce loading to vulnerable joints, develop strate-
gies with assistive devices and alternative movement patterns of
AIMS, Arthritis impact measurement scale; CHART, caring handicap assessment reporting affected joints to perform daily activities help preserve the pres-
technique; DAS 28, disease activity score calculator for rheumatoid arthritis; HAQ, health
ent integrity of joint structures, relieve joint pain during activities,
assessment questionnaire; MRI, magnetic resonance imaging; WHODAS, World Health
Organization Disability Assessment Schedule; WOMAC, Western Ontario and McMaster and relieve local inflammation.9,11
Universities Osteoarthritis Index. Systematic review studies have found that the use of various
Modified from Toledo SD, Trapani K, Feldbruegge E: Rheumatic diseases. In Braddom RL, editor: psychoeducational interventions such as general patient education,
Physical medicine and rehabilitation, ed 4, Philadelphia, 2010, WB Saunders, pp 769–784. self-management, cognitive–behavioral approaches, and individu-
alized joint protection yielded long-term improvements in func-
tion, pain, depression, and self-efficacy for 6 months to as much
as 4 years after the intervention. Research has provided strong
teaching the patient and family about the disease, its symptoms, evidence for the efficacy and long-term effect of joint protection
and how chronic synovitis can lead to irreversible destruction. programs.16,22,25,30 Traditional teaching methods such as the use
They must also know how to use adaptive skills and environmen- of written information, demonstrations, supervised practice, and
tal modifications and continue meaningful occupational function- visual aids have been successful in providing knowledge and skills.
ing (Videos 31.9 to 31.15). In addition, exercises, weight loss (in However, the behaviors of patients did not change, and the efficacy
cases of obesity), stress management/relaxation, and social support was not significant. Following this, researchers have emphasized
are usually included in the educational program. Fostering the that these principles require occupational therapists to apply teach-
patient’s self-efficacy to follow treatment at home is important.25,33 ing-learning techniques (i.e., skills practice, goal setting, and home
programs) that will lead to these behavioral changes.
Energy conservation principles are important to incorporate
Improve or Maintain Functional Mobility into the treatment intervention. Contributors to fatigue are mul-
Joint protection is a self-management technique widely taught to tifactorial and include physiologic, behavioral, and environmen-
people with rheumatic diseases, especially RA (Box 31.7). Joint tal factors. To control the effects of fatigue on everyday activities,
protection principles are ideally initiated early in the disease the therapist teaches the patient to analyze daily activities to
A B
• Fig. 31.11 (A) Assistive devices with built-up handles to avoid tight grasp. (B) Easy-to-hold utensils.
on the hands. Generally, selection of these products requires pro-

fessional advice.
Exercise
The purposes of exercise programs for patients with arthritis are to
(1) increase and maintain ROM, (2) improve muscle strength and
endurance, (3) increase aerobic capacity, (4) increase bone den-
sity, (5) improve functional ability, and (6) improve psychologi-
cal function. In addition, through exercise programs, the joints
of patients with arthritis can be made to function better biome-
chanically. With improvements in aerobic capacity, cardiovascular
morbidity and mortality are reduced.27
Before exercise therapy is recommended, it is important to
evaluate the patient’s joint and periarticular conditions as well as
his or her cardiopulmonary function and other systemic features.
• Fig. 31.12 Writing aid to reduce dexterity demands and stress on hand
Common exercise interventions for patients with arthritis include
joints.
mobilization exercise, strengthening exercise, aerobic (or condi-
tioning) exercise, and recreational exercise.7
determine what causes increased pain and fatigue. Taking short Mobilization exercise can be performed by ROM exercise,
rest periods during a prolonged activity is often advised and is stretching exercise, proprioceptive neuromuscular facilitation
sometimes referred to as pacing. (PNF) technique, or joint mobilization. In actively inflamed
Many devices and types of equipment can be applied to assist joints, gentle active or active-assistive ROM through the possible
patients with rheumatic diseases, especially RA and OA. They are range should be performed. Passive stretching should be applied
designed to limit stress to joints and to further achieve functional with extreme caution because it may be associated with rupture of
independence. For patients with limited ROM or pain in the the joint capsule with large effusion or may induce an inflamma-
hands, assistive devices with built-up handles and other modifica- tory response in otherwise controlled joints. While inflammation
tions to avoid tight grasp—such as a broad key holder, buttoning subsides, the joint should be moved through the full range, pos-
and zipping aids, and easy-to-hold utensils (Fig. 31.11)—have sibly with assistance (active-assistive exercise). PNF techniques,
been designed with increased leverage or decrease effort and dex- such as the hold-relax and slow reversal-hold-relax technique, may
terity demands.11 Some devices, such as a writing aid (Fig. 31.12), be applied to improve exercise efficiency.
may enhance functional performance. Extended handle devices Aquatherapy is also useful for mobilizing joints because buoy-
may be helpful for patients with limited ROM at shoulder, elbow, ancy in water reduces the effect of gravity and thus unloads the
hip, or knee joints, such as a long-handled comb, reacher (Fig. joints. Mobilization exercise should commence in the early stages
31.13), and sock aid. For patients with ambulation difficulties, of arthritis, when just a few repetitions through the full ROM are
mobility aids such as a walker, crutch, wheelchair, or scooter can sufficient; if contracture or ankylosis of joints develops, it is dif-
be prescribed to accommodate different levels of difficulty or envi- ficult to restore the full ROM.20
ronmental requirements. An arthritic crutch with hand grip and The objective of strengthening exercise is to restore and main-
forearm support is highly recommended for patients with arthritis tain optimal muscle strength and endurance. There are three types
to reduce the stress on hand or wrist joints during ambulation. of muscle contraction: (1) isometric (static) contraction, (2) iso-
Appropriate footwear or insoles may be considered to enhance tonic (dynamic) contraction, and isokinetic (dynamic) contraction.
comfort during ambulation. Some equipment can reduce the During isometric contraction, there is no change in the muscle
effort on the lower extremities (e.g., a lift chair, a shower chair, or length and joint position. The advantage of isometric contrac-
elevated toilet seat) and may also help to reduce the stress placed tion is minimal joint stress during muscle contraction; thus it is
A B
C
• Fig. 31.13 Extended handle devices to decrease the demands of range of motion at the shoulder and hip
joints. (A) Long-handled comb. (B) Reacher. (C) Sock aid.
suited to sufferers of arthritis with mechanically deranged joints. patient’s condition. Both land- and water-based aerobic exercise
It may also be used in an acute inflammatory joint or immediately programs of 6 weeks’ to 3 months’ duration can have a positive
after surgery. During isotonic contraction, the load is fixed, but effect on aerobic capacity, muscle strength, or functional ability.20
muscle length and joint position are changed. If the muscle length During acute flares and periods of inflammation, strenuous exer-
is shortening during isotonic contraction, it is concentric contrac- cises should be avoided. If joint pain persists for 2 hours after exer-
tion while the muscle length is lengthening for eccentric contrac- cise and exceeds pain severity before exercise, the intensity and/or
tion. Isotonic contraction is suited for training of isotonic tasks and duration of exercise should be reduced.
for patients without acute inflamed or biomechanically deranged Recreational exercise is often a combination of mobilization
joints; it should be avoided in patients with active arthritis because exercise, strengthening exercise, aerobic exercise, and also fun to
isotonic contraction stresses the joint through its ROM. During do. It is usually a group exercise—that is, patients with a similar
isokinetic contraction, the velocity of muscle contraction is con- disease often exercise together.
stant, but the muscle contraction force is changeable (accommo- Exercise programs may comprise a combination of land- and
dative resistance). Isokinetic contraction usually requires maximal water-based activities (Fig. 31.14). Through recreational exercise,
force of contraction, which in most cases is not recommended for patients may improve muscle strength, aerobic capacity, as well as
patients with arthritis (unless the joints are in very good condition). psychosocial well-being. It may provide social contact and thus
The purpose of aerobic exercise is to increase aerobic capacity; have an antidepressant effect.
it increases work capacity and promotes optimal function; as such
it may reduce cardiovascular morbidity and mortality. Previous Orthoses
studies have shown that aerobic exercises increase aerobic capacity
and functional ability in patients with RA, OA, AS, and fibromy- Orthotic positioning, especially hand splints, is usually consid-
algia. Before the initiation of aerobic training, joint swelling and ered and may have different benefits (decreasing inflammation
disease activity should be controlled. For patients with arthritis, and pain, function improvement, and minimizing deformity)
the type of exercise should involve only low joint stress, such as for patients at different stages (Videos 31.16 to 31.22).1,11,13 For
walking, cycling, swimming, water aerobics, or low-impact aer- example, it is very common to prescribe a resting hand splint to
obic dance. The exercise intensity, duration, and frequency can provide support and reduce pain for patients at the acute stage
be adapted to those of cardiac rehabilitation. For water exercise, of their disease (Fig. 31.15). During the postinflammatory pro-
the temperature should be 83°F to 88°F (28°C to 31°C). Tai-Chi cess, an orthosis (e.g., the thumb-post splint) (Fig. 31.16) is used
exercise can also be used but should be modified according to the for external support to enhance stability of unstable or subluxed
• Fig. 31.14 A group pool exercise for patients with rheumatoid arthritis. • Fig. 31.17 Orthotic positioning of a swan-neck deformity. Inset, The oval-8
splint prevents proximal interphalangeal hyperextension and allows flexion.
There are findings suggesting that splints are effective in reduc-

ing pain both immediately after provision of the splint and after
splinting over a period of time. A systematic review also indicates
that grip strength is temporarily increased while a splint is worn.
However, there is insufficient evidence to show that wearing a
splint for a long time can decrease the severity of hand deformities
or preserve the hand function.1,13,33
A kinesiotape (KT) (Fig. 31.18) is a therapeutic elastic tape
that can be applied on the skin to reduce pain, increase ROM,
reduce swelling, and provide mechanical support. The hypoth-
esized therapeutic mechanism of the KT is improvement in the
local circulation in the taped area by increasing the cutaneous and
subcutaneous interstitial area and facilitation of lymphatic drain-
age. Moreover, the KT provides sensory feedback to patients who
have fear of movement and facilitates small muscle contraction
• Fig. 31.15 Resting splints (night splint). by generating a pull on the fascia, which may increase muscle
strength. Therefore the KT can be used for treating arthritis to
alleviate pain and improve joint function.
Physical Modalities
Physical modalities such as thermotherapy (heat and cold ther-
apy), electrical therapy, and low-power laser are commonly used
in rehabilitation practice to relieve pain and increase the flexibility
of joints and soft tissues in patients with rheumatic disorders.29
Heat
Heat therapy (including superficial or deep heat) can increase
both skin and joint temperature and the viscoelastic properties of
collagen. Clinically, these two effects can relieve stiffness of joints
and soft tissue, thus enhancing the efficacy of stretching. In addi-
tion, both superficial and deep heat can raise the pain threshold,
producing analgesia and a sedation effect by acting on A-delta
• Fig. 31.16 Thumb post splint for arthritis of the first carpometacarpal joint. and C fibers and muscle spindles. Conversely, heat therapy can
increase joint swelling, elevate leukocyte counts in the joint fluid
joints. To prevent undesirable displacement or movement, a three- of patients with arthritis, and may cause ischemic necrosis of the
point oval-8 splint (Fig. 31.17) may be recommended for wear synovium by increasing its metabolic demand.
during activities, allowing flexion but preventing hyperextension The most commonly used heat modalities in rheumatic dis-
of the finger PIP joints (swan-neck deformity).The MCP joint eases are moist heating pads, paraffin (Video 31.23), electrical
ulnar deviation orthosis may permit continued use of the IP joints heating pads, infrared heat, ultrasound, and shortwave diathermy.
of the hand without aggravating the deformity of the MCP joints. Most studies conclude that heat modalities do not alter the dis-
The orthosis can be made of lightweight thermoplastics, or soft ease process. There is also concern about the use of paraffin in
materials can be used to counteract the deforming forces. systemic sclerosis, because microvascular pathology may create
• Fig. 31.19 Transcutaneous electrical nerve stimulation for arthritis of the

knee. (Reprinted with permission of Archives of Physical Medicine and
Rehabilitation.)
evidence of the efficacy of electrical therapy for rheumatic diseases

is still lacking, electrical therapy can reduce joint and soft tissue
• Fig. 31.18 Kinesiotape. pain and may thus reduce the dosage of pain medications.
Low-Level (or Low-Power) Laser Therapy

heat dissipation impairments. However, paraffin baths are recom- Low-level laser therapy has been used in the treatment of rheu-
mended for short-term benefits in arthritic hands. matic diseases including RA, OA, lower back pain, and carpal
tunnel syndrome for more than 20 years. Six studies of medium
Therapeutic Ultrasound quality tested over 220 patients with RA and showed that low-
The thermal effects of ultrasound include an increase in metabolic level laser therapy decreased pain and morning stiffness more than
activity and blood flow, a decrease in subacute and chronic inflam- placebo laser therapy. No side effects were reported.
mation and muscle spasm, and an increase in the extensibility of col-
lagenous structures. The analgesic effect might be a result of increased Rehabilitation Intervention for Knee or Hip
microvascular permeability and cell metabolism.7 Continuous-mode
ultrasound generates the thermal effect, which increases nerve conduc- Osteoarthritis
tion and elevates the pain threshold. Pulsed-mode ultrasound stimu- Knee or hip OA may cause pain, swelling, limitation of the ROM,
lates cartilage repair and increases antiinflammatory and analgesic walking difficulty, and ADL dependence. If moderate effusion is
effects.29 Ultrasound has been applied for treatment of tennis elbow, observed, joint aspiration is indicated. Intra-articular corticoste-
OA, calcific tendinopathy of the shoulder, and other disabilities; how- roid injection may follow if the joint fluid is clear (see Videos 31.3
ever, scientific evidence for its usefulness is still not well recognized. to 31.8) Physical modalities such as cold therapy, electrical ther-
apy, and local massage to muscles in spasm may also be applied
Cold during the acute stage of arthritis.
The effects of cold therapy are to reduce skin and joint temperature, A short course of oral NSAIDs may also be administered in
reduce joint swelling and cell count in synovial fluid, decrease the patients with mild knee pain; local NSAID patches or gels may
metabolic demand of the synovium, and inhibit collagenase activity. also be applied, especially in patients with gastrointestinal prob-
It can also raise the pain threshold and inhibit muscle spindle activ- lems. Patient education on joint protection and exercise is cru-
ity. Therefore it can provide pain relief and reduce inflammation in cial once acute arthritis is under control. If a patient is obese or
patients with acute arthritis. Common cold modalities include a overweight, weight reduction programs including nutrition con-
cold pack, cold air, ice pack, or cold bath. Cold should not be used sultation and aerobic exercise are strongly suggested. The use of a
in patients with cold hypersensitivity, Raynaud phenomenon, cryo- cane on the less affected side can relieve joint force up to 20%. In
globulinemia, or paroxysmal cold hemoglobinuria. patients with unilateral tibiofemoral OA of moderate severity, a
valgus knee brace may be suggested for medial compartment knee
Electrical Therapy OA, and a varus knee brace may be suggested for lateral com-
The purposes of electrical therapy are pain control and muscle partment knee OA12; however, this condition is less common.
stimulation. There are different types, including transcutaneous Theoretically, a lateral wedge insole may be helpful for medial
electrical nerve stimulation (TENS)8 (Video 31.24) and middle- compartment knee OA; however, recent clinical guidelines no
frequency interferential therapy. These modalities are commonly longer recommend the use of the insole. Patellar taping may help
used in the treatment of rheumatic diseases. Electrical therapy has to relieve knee pain in patients with patellofemoral OA. In addi-
been shown to have a clinically beneficial effect on grip strength for tion, a structured exercise program (Video 31.25) that includes
patients who have RA with hand atrophy. Another study showed flexibility, strength, aerobic, balance, and proprioceptive training
that TENS may be more effective than the intra-articular injection or even Tai-Chi exercise is strongly suggested, and compliance
of HA in patients with OA of the knee (Fig. 31.19). Although with exercise regimens is essential. In patients with contracture
of the affected joint, heat therapy, hydrotherapy (Video 31.26), involved peripheral joints (especially the hips). The characteristic
and diathermy may be applied, followed by joint mobilization and posture of patients with AS is loss of lumbar lordosis, increased
stretching exercises. The rehabilitation process of hip OA is similar thoracic kyphosis, compensatory extension of the cervical spine,
to that of knee OA; however, well-controlled studies on hip OA and flexion of hip and knee joints. The center of mass of the trunk
are few. In addition, topical medications are less effective for hip in the sagittal plane shifts forward and downward. The main aims
OA, and intra-articular injection into the hip joint may depend of management for patients with AS are pain relief, improvement
more on imaging (e.g., ultrasound) guidance. of posture and mobility, and maintenance or improvement of
respiratory function.
Pain relief may be achieved with the use of antiinflammatory
Rehabilitation Intervention for Rheumatoid drugs and physical modalities including hot or cold packs, hot
Arthritis baths, hydrotherapy, spa therapy, diathermy, electric therapy,
and mobility exercise. Maintenance of good mobility of the
Acute Stage spine and peripheral joints not only relates to physical func-
In the acute stage, patients with RA often have arthritis involving tion but also affects relief of pain and stiffness. Before mobility
multiple joints; this may be accompanied by fever, weight loss, exercise, a hot pack, or hot bath (shower), followed by 5 to
anemia, and fatigue. In this stage, complete bed rest for a few 10 minutes of warmup exercise is suggested. The target areas
days may help relieve joints and systemic symptoms. If one or for stretching are the suboccipital muscles, pectoral muscles,
two joints are more severely affected, resting splints are recom- hamstrings, hip flexors, and spinal rotators. The ROM exercise
mended. Application of a cold pack or TENS over the inflamma- should include extension of all segments of the spine as well as
tory joints may help reduce joint swelling and relieve joint pain. full ROM of the neck, shoulders, and hips. It is advisable for
If there is severe spasm and pain in the nearby muscles, local patients to perform the exercises at the time of a day when they
hot packs or gentle massage would be beneficial. Bed rest should feel the least pain or fatigue. PNF techniques provided by ther-
be as short as possible, because prolonged bed rest may lead to apists are also suggested if available. Strengthening exercises for
deconditioning. the major muscle groups including back extensors, shoulder
For prevention of joint and soft tissue contracture, actively retractors, hip extensors, and other postural muscles are also
inflamed joints should be moved gently through the possible range recommended (Videos 31.27 and 31.28). In addition, aerobic
by the patient (active ROM) or with assistance from another per- training with brisk walking, cycling (with upright handlebars),
son (active-assisted ROM). Three repetitions for each joint once swimming, or other aquatic therapy can help to increase muscle
or twice daily are suggested. As joint inflammation subsides, the endurance and reduce cardiovascular morbidity and mortality.
range may be increased gradually to the full range, possibly with Inflammation of the costochondral joints or costovertebral
assistance. A PNF technique could be applied early on for selected joints or entheses may cause chest pain and inhibit deep breath-
muscle groups. Passive stretching is usually not performed in an ing. Treatment with antiinflammatory drugs and heat therapy
inflammatory joint; if performed, it should be done with extreme may help relieve pain and improve breathing patterns. Daily deep-
caution because it may worsen or prolong the inflammatory pro- breathing exercises with an emphasis on full rib cage expansion are
cess or lead to subluxation or rupture of a joint. encouraged.
For minimizing muscle atrophy, isometric exercise at submaxi- Education about correct posture is very important for
mal effort is recommended in the inflammatory condition. At first patients with AS. They should be instructed how to check
a few nonresistive repetitions should be performed with a gradual their postural alignment (e.g., measure body height, touch the
increase in repetition and resistance. Isotonic exercise is not rec- occipital protuberance to the wall while standing), and avoid
ommended in the acute inflammatory stage. Patient education positions that encourage a stooped posture or spinal flexion
(including joint protection and energy conservation techniques) for prolonged periods. A firm mattress and a small pillow or
should also commence. neck support are desirable for sleep. Lying on the side in a
curved position should be avoided. Daily prone lying for 10 to
Subacute and Chronic Stages 15 minutes or more is recommended.16 Because patients with
After the acute stage subsides, joint pain, morning stiffness, and AS often have a fragile and osteoporotic spine, contact sports,
joint swelling diminishes. Isotonic exercise (Video 31.27) can be cervical traction, or spinal manipulation should be avoided.
added to the exercise program gradually, with increases in rep- Minor trauma that results in fracture or dislocation of the spine
etition and resistance. Local cold therapy can be changed to hot with spinal cord compression is not uncommon. For enhancing
therapy if swelling of the joint subsides. Splints, foot orthoses, or independence in ADLs, prism glasses, long-handled devices, or
assistive devices can be prescribed if indicated. a cane may be needed.
A forearm support crutch or cane is preferable to a traditional
wrist support device. If a patient’s condition improves, endurance Summary
training, aerobic exercise, and recreational exercise can be added
to the exercise program. In view of the growing number of patients presenting with rheu-
matic diseases, research on prevention and treatment is evolving.
Less invasive surgical options and expanding conservative treat-
Rehabilitation Intervention for Ankylosing ments to combine allopathic and naturopathic medicine is the
current trend. Physiatrists will continue to be an integral part of
Spondylitis the management. The chronicity and disabling nature of these
The main symptoms of AS include chronic back pain, spinal defor- diseases will continue to challenge physiatrists toward innovation
mity, limited chest excursion, and pain and contracture of the and creativity.
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cise is more effective than home exercise in female patients with recommendations for the diagnosis of knee osteoarthritis, Ann
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626.e1

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31

Osteoarthritis Symptoms and Signs

TABLE Kellgren-Lawrence Radiographic Grading Scale

are best imaged by ultrasound (Fig. 31.2) or magnetic resonance

studies have demonstrated negative results. Thus glucos- Clinical Characteristics

TABLE Disease-Modifying Antirheumatic Drugs TABLE Differentiation of Inflammatory Versus

Radiographic Grading of Sacroiliitis

Laboratory findings are generally nonspecific for AS. An ele-

Plain radiography and MRI are the principal imaging techniques

SERONEGATIVE SPONDYLOARTHROPATHY, SACROILIITIS

1984 Modified New York Criteria for

• BOX 31.4 Classification for Psoriatic Arthritis

(CPPD), hydroxyapatite, and others. Intra-articular crystals can

on the hands. Generally, selection of these products requires pro-

There are findings suggesting that splints are effective in reduc-

• Fig. 31.19 Transcutaneous electrical nerve stimulation for arthritis of the

evidence of the efficacy of electrical therapy for rheumatic diseases

Low-Level (or Low-Power) Laser Therapy

You might also like

Rehabilitacion Reumatologica

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

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Rehabilitacion Reumatologica

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Copyright:

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31

Osteoarthritis Symptoms and Signs

TABLE Kellgren-Lawrence Radiographic Grading Scale

are best imaged by ultrasound (Fig. 31.2) or magnetic resonance

studies have demonstrated negative results. Thus glucos- Clinical Characteristics

TABLE Disease-Modifying Antirheumatic Drugs TABLE Differentiation of Inflammatory Versus

 Radiographic Grading of Sacroiliitis

Laboratory findings are generally nonspecific for AS. An ele-

Plain radiography and MRI are the principal imaging techniques

SERONEGATIVE SPONDYLOARTHROPATHY, SACROILIITIS

 1984 Modified New York Criteria for

• BOX 31.4  Classification for Psoriatic Arthritis

(CPPD), hydroxyapatite, and others. Intra-articular crystals can

on the hands. Generally, selection of these products requires pro-

There are findings suggesting that splints are effective in reduc-

• Fig. 31.19 Transcutaneous electrical nerve stimulation for arthritis of the

evidence of the efficacy of electrical therapy for rheumatic diseases

Low-Level (or Low-Power) Laser Therapy

You might also like

TABLE Kellgren-Lawrence Radiographic Grading Scale

TABLE Disease-Modifying Antirheumatic Drugs TABLE Differentiation of Inflammatory Versus

Radiographic Grading of Sacroiliitis

1984 Modified New York Criteria for

• BOX 31.4 Classification for Psoriatic Arthritis