Rehabilitation of patients

with rheumatic diseases

& arthritis

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 General information
 Rheumatic conditions adversely affect patients’ lives.
Dealing with chronic pain, stiffness, and fatigue,
limitations in daily activities and restricted participation
in society are some of the challenges that these patients
face.

 Rheumatic diseases are a burden for the health care

system and society and lead to decreased productivity
and financial loss.

 Pharmacological means alone rarely offer long-term

remission for these chronic disorders and rehabilitative
measures are incorporated in treatment protocols.
.
Rheumatic diseases
Adversely affect
patient’s wellbeing

Rheumatic Burden for society

and health care system
and
Musculoskeletal
Diseases Lead to financial loss
and productivity

Require
multidisciplinary
approach

.
 Medical rehabilitation
• Rehabilitation manages disease consequences, the most
important being pain, fatigue, joint stiffness, deformity and
aims alongside medical treatment to restore completely the
physical, medical, emotional, social, economic and vocational
potential of the individual.

• Rheumatologists, having a key position in patient management

need to know the advantages and limitations of rehabilitation
modalities.

• The majority of rehabilitative interventions require time and

changes in patient’s behavior and level of motivation.

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Rheumatologic multidisciplinary team
 Rheumatologists
 Physiotherapist
 Occupational therapist
 Nurse specialist
 Social worker
 Orthopedist
 Internalist
 Podiatrist
 Ophtalmolog
 Psychiatrist etc.
.
 Rehabilitation structured approach
• Goal of intervention and appropriate measures must be
defined.
• Rehabilitation plan should be developed in cooperation with
the patient.
• The World Health International Classification of Functioning,
Disability and Health (ICF) is a very good tool for measuring
health and disability at both individual and population level.
It has two parts with two components each :
Functioning and disability part which contains - body
functions and structures; activities and participation
Contextual factors part with - environmental factors and
personal factors.

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 Evolution of rehabilitation in
rheumatology
 Splinting and mobilization with assistive devices to promote
function were applied frequently in the forties after steroids
introduction.
 Joint replacements and post-operative rehabilitation
protocols bloomed in the sixties and seventies
 Incorporation of dynamic exercises and functional activities
earlier in the disease process occurred the eighties; the impact of
isometric and low-intensity isotonic exercise on immune
response and function was also evaluated.
 Increase of research in evaluation of various intensities,
frequencies, and modes of exercises on patient outcomes
ensued arrival of DMARD-s in the market

1940 1950 1960 1970 1980 1990

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Rehabilitation in rheumatology
• In the twenty first century the public health
perspective of promoting physical activity for
improving the quality of life, function, and
participation of patients is embraced.
• Research focus is on investigating the impact of
weight-bearing activities of various intensities on joint
integrity in light of radiological advancements and
advent of modern biologic therapies.

.
 Rehabilitation modalities in
rheumatology
 Total/Local body rest. Bed rest is practical but should not
be applied for more than four days especially in the
elderly.

 Manual therapy

 Massage

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Rehabilitation modalities in rheumatology
 Exercise therapy
Range of motion (RoM) and flexibility exercises– help preserve joint
movements and are passive when performed by the physiotherapist
or active when there’s patient involvement.
Isometric/static exercises – muscle contractions here are achieved
without joint movement and lengthening or shortening of muscle
fibers; they can be generated with the help of a fixed object like the
hand of the therapist, a belt, small ball or elastic band. Isometric
exercises increase strength and resistance and are easy and safe to
be performed by patients with inflammatory arthritis.
Isotonic/dynamic exercises – involve changes in the muscle fiber
length through their lengthening (essentric) or shortening
(concentric); nearby joints move through full RoM.
Aerobic conditioning / strengthening exercises – moderate intensity
exercises are effective (70-80% max heart rate = 220- age) and
include walking, running, cycling, swimming and stair climbing.
Aquatic exercises
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 Exercises in rheumatology
• Exercise therapy represent the foundation of rheumatic
conditions rehabilitative management.
• Involves repeating planned and structured physical
activities in order to improve or preserve components of
physical fitness.
• Exercise programs for patients with rheumatic diseases
usually involve the combination of exercises which
increase cardio pulmonary fitness, strengthen muscles
and enhance flexibility with training for specific
movement patterns or daily activities, education and
spare time activities.

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Exercises in rheumatology
Cardiopulmonary fitness exercises:
Public health recommendations for older adults can be utilized. They involve
completing moderate intense aerobic activities (cardiac and respiratory rate is
increased, with or without sweating, while the person can talk normally ) like
walking, running, aerobic dancing for at leas 30 min/5 days per week, or high
intensity exercises (higher heart and respiratory rate, sweating and the person
can speak only short sentences) for 20 min/3 days per week.
Exercises for increasing muscle strength
8-10 exercises to increase muscle strength with 8-12 repetitions each should to
be performed at least 2 times per week. Exercises should focus on damaged
structures and should be proceeded by a 5-10 min warm up with RoM exercises.
Flexibility and balance exercises
Flexibility exercises aim to keep RoM within physiologic limits. They should
involve the most used joints and are especially important when local
inflammation in present or for contracture prevention. They should be
performed preferentially every day or minimally three times per week. Balance
exercises reduce falling risk.

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Exercises
 Can be performed under the supervision of a
physical therapist

 By patients themselves after instruction

 Using community resources

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Reabilitation modalities in rheumatology
 Physical modalities
Superficial heat/cold therapy,
Electrotherapy - uses electricity transmitted
through surface electrodes to stimulate
nerves and muscles and alleviate pain.
Deep tissue heating/Ultrasound/
diathermy
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 Reabilitation modalities in
rheumatology
 Occupational therapy (learning joint
protection and energy conservation methods)
 Making architectural changes
 Vocational rehabilitation and self
management.

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 Reabilitation modalities in
rheumatology
 Orthoses (braces, splints,
corsets, collars, and
shoe modifications)

 Assistive devices (long-

handled reaches, sock aids,
modified eating utensils,
bottle openers etc)
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 Most important rehabilitative
modalities
 Exercise, patient education programs, and
self-management interventions are the best
studied and the most effective measures
producing moderate improvements in
patients’ strength, pain, function, and modest
(small to moderate improvements) results in
mood, quality of sleep, sleep patterns, and
psychological well-being.

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 Patient evaluation
 First step in every rehabilitation program is patient’s
problem identification and correct diagnosis based on a
comprehensive history, physical examination, laboratory
and diagnostic evaluation.
 Patients’ evaluation includes : measuring RoM (through
simple observation or goniometry), muscular strength
(through observation or hand held dynamometers), gait,
mobility and balance.
 There is primary, secondary and tertiary rehabilitation and
different strategies are applied for specific pathologies.

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 Arthritis Rheumatoid
Rheumatoid Arthritis is a chronic, systemic, autoimmune
disease which:
 Affects 1-2% of the population and results from
the interplay of genetic and environmental factors
 It is 2-3 times more common in women than in men and the
highest incidence rate is observed between ages 40 and 60;
autoantibodies are detected.
 Arthritis is erosive, symmetric, involving multiple peripheral
joints, (mainly PIP,MCF, MTF joints and wrists); extra-articular
manifestations are observed
 Causes pain, disability and loss of function
 Unresolved pathogenesis

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 Syndromes associated with RA

• Caplan’s syndrome: This is an occupational lung disease

with nodular lesions in the lung
• Sjögren’s syndrome: The patient complains of drying up
of lacrimal and salivary glands, consequently there is
dryness in the mouth and eyes.
• Felty’s syndrome: The components are
hepatosplenomegaly, lymphadenopathy,
and anemia
 Criteria for Classification of
Rheumatoid Arthritis
• Morning stiffness: Early morning stiffness in and around the joints,
lasting at least one hour.
• At least three joint areas affected having soft tissue swelling or
fluid.
• Arthritis of hand joints: At least one joint area swollen; from
among the wrist, metacarpophalangeal MCP joints and proximal
interphalangeal PIP joints
• Symmetric and simultaneous involvement of same small joint
areas on both sides of body
• Rheumatoid nodules: Subcutaneous nodules over bony
prominences or extensor surfaces, typically at the elbow.
• Serum rheumatoid factor positive Demonstration of abnormal
amounts of serum rheumatoid factor
• Radiographic changes: Typical rheumatoid arthritic lesions at the
hand and wrist must include erosions or decalcification localized in
these involved joints.
 Deformity

Swan Neck Deformity

Boutonnière Deformity:
 Deformity
Thumb Deformity: Three types of deformity occur at the
thumb.
• Type 1 – Boutonniere deformity at the interphalangeal
joint
• Type 2 – Subluxation of carpometacarpal joint during
adduction
• Type 3 – Exaggerated adduction of first carpometacarpal
joint, flexion at the metacarpophalangeal joint and
hyperextension at distal interphalangeal joint
 Rheumatoid Arthritis medical treatment
 Treatment should start as soon as possible, aggressive management is
preferred. Most utilized pharmacological agents include:
 NSAIDs are used to relieve pain and reduce minor inflammation but do not
induce long term remission. Analgesics relieve pain.
 Glucocorticosteroids – are potent anti inflammatory drugs and are used to
suppress the autoimmunity. Oral, intramuscular and intra-articular preparations
are used.
 Disease Modifying Anti–rheumatic drugs/DMARDs (methotraxate + folic acid,
hydroxychloroquine, sulfasalazine and leflunomide ) constitute the foundation
of RA therapy and can be used alone or in combination.
 Biologics target molecules on cells of the immune system, joints, and the
products that are secreted in the joint. Biologics used in RA include : TNF- α
blockers: etanercept, adalimumab, infliximab, certolizuma; toclizumab, an IL-6
receptor monoclonal antibody, Rituximab (Rituxan) a B cell inhibitor; Abatacept
a recombinant molecule which binds to CD80 / CD86 and prevents CD28
mediated costimulation, Anakinra an IL-1 inhibitor, and Tofacitinib a JAK 1 and 3
.
inhibitor
 Surgical Management

• Joint replacements
• Osteotomy
• Soft tissue procedures
– Synovectomy
– Arthrodesis
– Tendon transfer
Multidisciplinary Approach

 Appropriate pharmacologic therapy

 Pain control
 Management of osteoporosis
 Physiotherapy when inflammation is suppressed

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 Rehabilitation of Rheumatoid Arthritis
 During theactive phase of Rheumatoid Arthritis or
other inflammatory arthritis, measures to be taken
include:
Total body rest, splints and self management.
Active and passive RoM exercises
Isometric exercises
Physical modalities - Cold therapy (ice packs, ice chips, ice
massage, cryowraps) is applied to manage acute inflammation
diminish swelling and lessen pain.
Orthotics may also help in improving function and reducing
pain.
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 Rehabilitation of Rheumatoid Arthritis
 Interventions on the subacute phase include:
Increased repetitions of RoM exercises Progression
from isometric to isotonic/dynamic exercises.
Heat therapy and/or massage before stretching
may limit muscle spasm and improve tissue
flexibility.
Ergonomic changes.
Orthosis/ splinting.
Aquatic therapy.

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Rehabilitation of Rheumatoid Arthritis
 With stable disease patients should:

Integrate dynamic strengthening exercises with

resistance ones. Dynamic exercises can increase
muscle strength, physical and aerobic capacity.
Aerobic exercises (with 70%-80% max heart rate)
should be started. Low-impact exercise, such as
walking programs, aquatics, dance, and cycling, and
dynamic exercises with resistance are the most
commonly used exercises.

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Osteoarthritis
 Osteoarthritis (OA) is a very common, slowly
progressive joint disorder, whose symptoms typically
start after age 40; women are more often affected
by OA than men.
 It is called a degenerative joint disease or “wear and
tear” arthritis. OA results from degenerative changes
in the cartilage of weight-bearing joints (knee, hip
and spine) and hands.

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 Osteoarthritis
• OA likely begins with the
breakdown of articular cartilage,
which becomes ineffective, leaving
the bones to rub against one
another during movement.
• This process may be stimulated by
high circulating levels of pro-
inflammatory cytokines and cells.
• As OA progresses, the joint space
narrows, causing bone-on-bone
contact and spurring, ligament
laxity and decreased strength
around the joint can occur.

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Osteoarthritis Rehabilitation
 Dynamic strengthening exercises
Whole body strength training
Patient education
Aerobic exercises – cycling, swimming
Thermotherapy
Parafin application for hand OA

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 Knee Osteoarthritis Rehabilitation
 Open-chain isometric exercises, such as quadriceps
exercises, are used with progression to closed-chain
weight-bearing exercises, such as mini-squats and
step-ups. These exercises are effective and help
reduce pain and improve function.
 Patients benefit from joint mobilization and
manipulation procedures.
 Bracing, gait training, use of orthotics, and
appropriate footwear.
 Thermotherapy may alleviate pain, enhance tissue
extensibility, and reduce stiffness.

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Systemic lupus erythematosus
 Studies of exercise in SLE are limited. Considering
the fact that symptomatic coronary heart disease is a
major cause of mortality a comprehensive
cardiovascular pulmonary system review should be
done along with exercises that enhance cardiovascular
performance, such as biking, walking, and dynamic
exercises at moderate intensity.

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Ankylosing Spondylitis
 Ankylosing spondylitis is a systemic
inflammatory disease of the sacroiliac and axial
joints.
 It affects males more than females
 Starts in early adulthood
 Systemic features include fatigue, malaise and
osteopenia. Patients have back pain.
 It results in reduced physical activity engagement,
ankylosis, deformity and disability.
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Ankylosing Spondylitis management
 Medical therapy
 Physical modalities, such as thermal therapy to relax
soft tissues and prepare the patient for flexibility
exercises,
 Manual therapy,
 Assistive and ambulatory devices, orthoses
 Exercise therapy
 Patient education

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 Exercise therapy in Ankylosing
Spondylitis
• Posture/ core muscle strengthening exercises
• RoM exercises
• Flexibility & stretching exercises
• Exercises for strengthening hip – knee – spine
muscles
• Exercises for pulmonary fitness
• Strengthening of Extensor muscles
• Aquatic therapy

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Exercises for spine muscles

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Ankylosing Spondylitis rehabilitation
• Life style modification
• Exercises should be conducted on a regular basis
(more than 3 times per week)
• Posture awareness
• Swimming
• Quit smoking
• Ergonomics
• Secondary osteoporosis evaluation

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Conclusion
 Rehabilitation interventions comprise a large
range of interventions. Selection of
rehabilitation modalities for rheumatological
disorders is influenced primarily on the
disease state but is also dependent on other
variables like disease severity, medication
latency periods, comorbidities, disease
severity, and patient preferences.

.
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