Physiotherapy in Rheumatoid arthritis

Rheumatoid arthritis (RA) is really a chronic and painful clinical condition leading to progressive joint damage, disability, deterioration in quality of life, and shortened life expectancy. Even mild inflammation may lead to irreversible damage and permanent disability. The clinical course based on symptoms may be either intermittent or progressive in patients with RA. In many patients, the clinical course is progressive, and structural damage develops within the first 2 years. The purpose of RA management is to achieve pain alleviation and prevent joint damage and functional loss. Physiotherapy and rehabilitation applications significantly augment medical therapy by increasing the management of RA and reducing handicaps in everyday living for patients with RA. Within this review, the application of physiotherapy modalities is examined, such as the use of cold/heat applications, electrical stimulation, and hydrotherapy. Rehabilitation treatment techniques for patients with RA for example joint protection strategies, massage, exercise, and patient education will also be presented.

Introduction
RA is really a chronic and progressive disease resulting in considerable physical functional loss and disability. Currently, there isn't any curative therapy for RA; therefore, patients are put through various life-long treatment modalities. Thus, an essential component of successful control over the disease is educating patients and informing them concerning the planned treatment modalities. Objectives of physiotherapy and rehabilitation applications in patients with RA will be to prevent disability, to improve functional capacity, to supply pain relief, and to provide patient education.
Before beginning therapy, the physiotherapy needs of patients are determined according to their incapacity, disability, and handicaps. Physical assessment will include these components:

 Functional assessment (ie, transfer status, analysis of gait, activities of everyday living);
 Range of joint motion (ROM) (for all joints);
 Muscle strength test (manual or by isokinetic equipment);
 Postural assessment; and
 Evaluation of respiratory function.

It ought to be remembered that presence of inflammation, instability, and contractures may modify the results of these evaluations and tests. Scales for example Arthritis Impact Measurement Scale I and II, Health Assessment Questionnaire, and Functional Independence Measure can be utilized for functional assessment.
Physiotherapy Modalities and Rehabilitation Treatment Approaches Rheumatoid Arthritis Patients..
Physiotherapy Modalities
Physiotherapy modalities are generally used in the treatment of RA. Included in this are cold/hot applications, electrical stimulation, and hydrotherapy.
Controlled studies performed with adequate amounts of cases and using validated objective measures to judge various physiotherapy and rehabilitation methods in RA are very rare. This is because the condition process may be impacted by various factors, and also the actual effectiveness from the investigated agents is tough to determine. However, various physiotherapy agents are generally used in daily practice; usually, their use is according to personal experiences.
Cold/Hot Applications
Cold/hot modalities would be the most commonly used physical agents in arthritis treatment. It's well known that cold application is mainly used in acute stages whereas hot can be used in chronic stages of RA.
By utilizing heat, analgesia is accomplished, muscle spasm relieved, and elasticity of periarticular structures obtained. Heat may be used before exercise for obtain the most. Thermotherapy may be applied like a superficial hot-pack, infrared radiation, paraffin, fluidotherapy, or hydrotherapy. Applications are recommended for 10-20 minutes a couple of times a day. Caution is essential in patients with sensorial deficits and impaired vascular circulation in feet and hands because of burn risk. Cold application is preferred in active joints where intra-articular heat increase is undesired. Cold-pack, ice, nitrogen spray, and cryotherapy will vary methods of applying cold-therapy.
Cartilage-destroying enzymes are made within the inflamed joints of patients with RA. Amounts of destructive enzymes for example collagenase, elastase, hyaluronidase, and protease are affected by the temperature of local joints. With temperatures of 30° Celsius or lower, results of these enzymes are negligibly small. Normal intra-articular temperatures are 33° Celsius, whereas it may rise to 36° Celsius in patients with RA. Increasing intra-articular temperatures are also related to a rise in collagenase activity and cartilage damage. Regardless of the inhibition of cell proliferation and metabolic activation inside the synovial fluid at 41-42° Celsius, it can't be used as a therapeutic method due to irreversible joint damage. Various research has investigated the changes within joints upon use of heat. Intra-articular temperature increased by superficial heat application. Within the first 5 minutes, the joint temperature decreased but subsequently, not surprisingly, it began to rise. It's been suggested that inside the first few minutes, superficial vessels become dilated and circulation moves from the inflamed synovial tissue. The alternative of this occurs throughout the cold application. Results of heat application change between normal healthy subjects and patients with inflamed joints. Accordingly, skin temperature rises with paraffin at most and intra-articular joint temperature with diathermy application. Temperature increase with short-wave diathermy application continues for 40 minutes. However, it's been observed that increased intra-articular temperature doesn't have beneficial effect on clinical prognosis or radiologic progression. Skin temperature decreases probably the most by cold air application, whereas intra-articular temperature decreases probably the most by ice application. Increased intra-articular temperature by cold-pack application might be explained by reactional temperature rise with short-term application, that was previously mentioned.
Electrical Stimulation
Electrostimulation can be used in patients with RA to alleviate pain. Transcutaneous electrical nerve stimulation (TENS) treatments are the most commonly used method. TENS at various frequencies and reported the highest frequency TENS was the most effective, with an analgesia that persisted as much as 18 hours. Various research has reported an increase in hand grip strength after daily use of 15 minutes of TENS along with a decrease in pain after using TENS once per week for 3 weeks. Levy and colleagues observed decrease in synovial fluid and inflammatory exudate following TENS application in acute arthritis and suggested that pain alleviation may be partially explained with this effect. Postoperative pain control by TENS therapy following knee joint arthroplasty reduces need for analgesic drugs and hospital stays. Because of the variations between the materials and techniques of the studies, it is not easy to interpret TENS applications. Nevertheless, TENS generally is a short-acting therapy (6-24 hours), and also the most beneficial frequency is 70 Hz. Additionally, it has a high 'placebo effect'. It cannot be used in each and every painful joint simultaneously, the industry disadvantage in patients with polyarticular involvement. Interferential current may also be used for analgesia. Studies have shown its efficacy on pain alleviation, swelling, and improvement in ROM. Also, no difference was discovered between interferential current and TENS within the magnitude of analgesia.
Hydrotherapy
There's been widespread use of balneotherapy by patients with rheumatic diseases because the old times looking for a cure for their ailment. Therefore, there are several suggestions that the science of rheumatology continues to be developed in balneotherapy. Initially, the word “balneotherapy” was used to discriminate thermal and standard water therapy from hydrotherapy, however nowadays these terms in many cases are used interchangeably. In recent years, balneotherapy has served among the therapeutic alternatives in other rheumatoid diseases, specifically in chronic degenerative diseases. Objectives of balneotherapy will be to increase ROM, to bolster muscles, to relieve painful muscle spasms, and also to improve the patient's well-being.
Balneotherapy in arthritis treatment is really a disputed issue. O'Hare and colleagues have reported a rise in diuresis, hemodilution, and a reduction in rheumatoid factor levels. In comparison, Becker has attributed the primary effect to a reduction in joint loading, relaxation, as well as an increase in general physical conditioning. There has been studies showing benefits of balneotherapies on several factors for example reduction in pain and grip strength. Effectiveness of balneotherapy isn't just associated with hot water but additionally with the minerals included in the water. It has been claimed that mineral waters possess some positive effects in balneotherapy. Water has mechanical, chemical, and physical action mechanisms. Its mechanical action occurs throughout the bath when the body weight decreases by 50% to 90% with respect to the type of bath. In cases of muscle weakness or widespread painful joint inflammation, this course of action allows the patients to do their exercise programs. Additionally, various studies have shown that balneotherapy results in muscle, tendon, and ligament relaxation along with a feeling of well-being. Here the experience mechanism provides exponential benefits. Decreasing thought of pain by enhancing the pain thresholds at free nerve endings, relieving muscle spasm by effecting gamma muscle tissue, peripheral vasodilatation, and elimination of painful mediators are of these mechanisms. In addition, balneotherapy includes a sedating effect by increasing acetylcholine release in the central nervous system through activation of parasympathetic central nervous system. Endorphin release throughout the therapy also plays a role in improved action mechanisms.
Results of balneotherapy on the immune system recently become a subject of great interest. There are some speculations about its immunostimulatory and inhibitory effects. Particularly, alterations in release of interleukin-1 and interleukin-6, tumor necrosis factor-alpha, and gamma-interferon, that have a role in etiopathogenesis of inflammatory arthritis, happen to be reported.
Environmental changes while at balneotherapy ought to be considered. Physical and mental comfort, cessation of home duties, and vacation atmosphere are among positive factors that could also contribute to the recovery process.
In conclusion, although the results of balneotherapy are currently not clarified, it's a palliative treatment in rheumatoid diseases through various mechanisms. There's need for further appropriately designed studies encompassing assessment of quality of life being an outcome measure.
Rehabilitative Treatment
Physiotherapy treatment is essential in helping patients with RA manage their disease. Along with occupational therapists, physiotherapists educate patients in joint protection strategies, utilization of assistive devices, and performance of therapeutic exercises.
Joint Protection Strategies
Joint protection strategies, for example rest and splinting, using compressive gloves, assistive devices, and adaptive equipment, have benefits in managing RA symptoms and deformities.
Rest and Splinting
The joints ought to be put into rest throughout the acute stage from the disease. Bed rest relieves the pain sensation in cases of extensive joint involvement. It is important, at this stage, to put the joints into rest in a functional position. Rest position ought to be as follows: shoulder joint in 45° abduction, both wrist joints in 20° to 30° dorsal flexion, fingers slightly in flexion, hips at 45° abduction with no flexion, knees totally extended, and feet inside a neutral position.[ Splints enables you to give desired position resting and functional positioning towards the involved active joints. Increased compliance could be gained by offering the individual splints made of soft materials. Orthosis and splinting are utilized for the following objectives to decrease pain and inflammation, to prevent growth and development of deformities, to prevent joint stress, to aid joints, and to decrease joint stiffness.
Various reports show benefits of wrist splints to managing pain and inflammation and preventing the introduction of deformities. Flexible wrist orthosis increases hand grip strength by 20% to 25%. Various ring orthoses happen to be developed to prevent finger deformities. Major factors determining patient compliance towards the orthosis are size of the orthosis, heat generated at the skin through the orthosis, hardness of the parts in touch with the skin, and whether or not this interferes with functions from the hand. Joint stress within the feet may be alleviated by medial arc supporting pad in the sole of the foot by metatarsal pad. Viscoelastic soles may decrease shock loading occurring at proximal tibia throughout the gait, by as much as 40%. Philadelphia corset may be recommended if atlantoaxial involvement exists. Orthosis provides better immobilization and could be used in the presence of cervical instability.
Compression Gloves
Patients using compression gloves have reported reduced joint swelling and increased well-being. However, there isn't any positive evidence regarding improved grip strength or hand functions by using gloves. Improvement might be provided by using compression gloves for hour intervals or limited to night in patients with inflammation within their hands or fingers. Gentle compression is helpful because of the containment of joint swelling and subsequent loss of pain.
Assistive Devices and Adaptive Equipment
Occupational therapy improves functional ability in patients with RA. Occupational therapy interventions for example assistive devices and adaptive equipments have benefits on joint protection and energy conservation in arthritic patients. Assistive products are used in order to lessen functional deficits, to decrease pain, and to keep patients' independence and self-efficiency. Loading within the hip joint might be reduced by 50% by holding a cane. Actually, most of these instruments are originally designed for patients with neurologic deficits; therefore, certain adaptations may be required for them to be used in patients with arthritis. Elevated toilet seats, widened gripping handles, arrangements related to bathrooms, etc. might all facilitate the daily life. The procedures required to increase compliance from the patient with the environment and also to increase functional independence mostly are determined by the occupational therapist. Catalogues introducing various assisting equipment models designed for every type of requirement should be given to patients.
Massage Therapy
Massage is really a commonly used treatment tool that improves flexibility, enhances a sense of connection with other treatment modalities, improves general wellness, and can help to diminish swelling of inflamed joints. that pain thresholds both in the massage site and also at the knee and ankle have decreased after applying oscillatory manual massage towards the intervertebral paraspinal region. Massage is located to be effective on depression, anxiety, mood, and pain. This finding results in the question of whether there are several changes in peripheral nociceptive perception and central information in RA. Also, massage decreases stress hormonal levels.
Therapeutic Exercise
Muscle weakness in patients with RA may occur due to immobilization or reduction in activities of everyday living. Maintenance of normal muscle strength is essential not only for physical function but additionally for stabilization of the joints and protection against traumatic injuries. It might be proposed that exercise therapy has benefits on increasing physical capacity instead of reducing the activity from the disease.
Prior to establishing a workout program for patients with RA, the next characteristics should be considered: if the involvement of the joints is local or systemic, stage from the disease, age of the individual, and compliance from the patient with the therapy. Duration and harshness of the exercise are adjusted based on the patient. ROM exercises, stretching, strengthening, aerobic conditioning exercises, and routine daily activities can be utilized as components of exercise therapy.
Tthere shouldn't be straining exercises during the acute arthritis. However, every joint ought to be moved in the ROM at least one time per day in order to prevent contracture. When it comes to acutely inflamed joints, isometric exercises provide adequate tone of muscle without exacerbation of clinical disease activity. Moderate contractures ought to be held for 6 seconds and repeated 5-10 times every day. It should be remembered when isometric exercises are performed in a magnitude in excess of 40% of maximum voluntary contraction, they might lead to impairment in blood flow and fatigue following the exercise. If the disease activity is low, then isotonic exercises ought to be performed by using really low weights. Low-intensity isokinetic knee exercises (by 50% from the maximum voluntary contraction) were considered to be safe and effective in patients with RA. If pain persists a lot more than 2 hours or an excessive amount of fatigue, loss of strength, or rise in joint swelling occurs after a workout program, then it ought to be revised. Also, walking doesn't lead to intra-articular pressure rise in healthy subjects but achieves this in a knee with inflammation and effusion. Thus, patients with active arthritis should particularly avoid activities for example climbing stairs or lifting weights. Producing excessive stress within the tendons during the stretching exercises ought to be avoided. In sudden stretches, tendons or joint capsules might be damaged. Finally, in chronic stage with inactive arthritis, conditioning exercises for example swimming, walking, and cycling with adequate resting periods are recommended. They increase muscle endurance and aerobic capacity and improve functions from the patient in general, and in addition they make the patient feel good.