Arthritic Patient

(1)

R h bilit ti f th Rehabilitation of the A th iti P ti t

Arthritic Patient

謝霖芬醫師

Outlines Outlines

 Introduction of arthritis

 Common arthritis in clinical practice

 Evaluation of joint function

 Goals of rehabilitation

 Rehabilitation management

 Conclusion

Rehabilitation of the Arthritic Patient-謝霖芬 2

Introduction of arthritis Introduction of arthritis

3

Definition of arthritis

 Inflammation of the joint

4

(2)

Symptoms and signs of arthritis

 Pain  Fatigue

 Stiffness

 ROM limitation

 Tenderness

 Crepitation

 ROM limitation

 Swelling

 Crepitation

 Deformity g

 Weakness

y

 Instability

 Functional impairment

Classification of arthritis Classification of arthritis

 Inflammation

 inflammatory, noninflammatory

 Number of joints

 monoarticular, polyarticular , p y

 Symmetricity

 symmetrical, asymmetrical

 Etiology

 autoimmune (RA AS SLE) degeneration

 autoimmune (RA, AS, SLE), degeneration (OA), infection, metabolism (gout)

Common arthritis in clinical practice

Rh t id th iti (RA)

 Rheumatoid arthritis (RA)

 Osteoarthritis (OA)

 Ankylosing spondylitis (AS)

Etiology & pathology of RA Etiology & pathology of RA

 Autoimmune

Ch i iti

 Chronic synovitis

 joint

 tendon sheath

 bursa

(3)

Clinical feature in RA Clinical feature in RA

 Progressive or persistent (P) I fl t (I)

 Inflammatory (I)

 Symmetric (S)

 Arthritis (A)

 Extrarticular manifestations

Joint involvement in RA Joint involvement in RA

 Wrist and hand (MCP, PIP)

 Foot (MTP, subtalar)

 Knee, hip, elbow, shoulder

C i l i

 Cervical spine

1987 ARA revised criteria for RA

 Morning stiffness

 Arthritis in 3 or more joint areas

 Arthritis of hand joints S t i th iti

 Symmetric arthritis

 Rheumatoid nodules

 Serum rheumatoid factor

 Radiographic changes

11

Common deformities in RA Common deformities in RA

Ul d i ti (MCP)

 Ulnar deviation (MCP)

 Button-hole deformity (PIP) y ( )

 Swan-neck deformity (PIP)

 Toe deformity (hallux valgus

 Toe deformity (hallux valgus, clawed-toes)

 MTP subluxation

 Flat-foot Flat foot

12

(4)

Specific problems in RA Specific problems in RA

 Rupture of tendons (4th, 5th finger extensors)

extensors)

 C-spine involvement (C1-2, subaxial)

 Nerve entrapment (median n.)

’ f

 Baker’s cyst with rupture or calf dissection

dissection

Rehabilitation of the Arthritic Patient-謝霖芬 15 Rehabilitation of the Arthritic Patient-謝霖芬 16

(5)

Osteoarthritis (OA) ( )

Degenerative Joint Disease (DJD)

P i

 Primary

 Secondary

19

Pathology of OA Pathology of OA

 Cartilage destruction S b h d l l i

 Subchondral sclerosis

 Secondary changes

synovial hypertrophy y yp p y osteonecrosis

b t

bone cyst

20

(6)

Etiology of OA Etiology of OA

 Aging T

 Trauma

 Occupation

 Hormone

 Genetic defect

 Racial difference

Joint involvement that leads to

f ti l i i t i ti t

functional impairment in patients with OA

with OA

 Large weight-bearing joints

 Spines

 First CMC

 Erosive DIP & PIP

Clinical feature of knee OA Clinical feature of knee OA

P i

 Pain

 Stiffness

 Swelling

 Tenderness

 Crepitation

 Deformity (varus)

 Instability

Clinical feature of AS Clinical feature of AS

 Chronic arthritis mainly attack whole spine p

 25% involve peripheral joints

 Enthesopathy

 Extraskeletal involvement: iritis

 Familial tendency

 Rheumatoid factor: negative

 High HLA-B27 positive rate

g p

(7)

Modified New York Criteria for AS (1984)

 Low back pain > 3 months

 Limitation of lumbar spine ROM

D d h t i

 Decreased chest expansion

 Sacroiliitis (X ray)

 Sacroiliitis (X-ray)

Evaluation of joint function Evaluation of joint function

 Pain (VAS) F ti

 ADL

G it l i

 Fatigue

 Tenderness

 Gait analysis

 Articular index

 Swelling  ACR20, 50, 70

 ROM

 Strength

 ASAS20.50, 70

 Lequesne index

 Strength

 Hand function

 Lequesne index

 WOMAC

27

WHO International Classification of Functioning, Disability and Health

Disability and Health

Health condition (disorder or disease)

Body functions Body functions

and structures

Activities Participation

Environmental Personal

Environmental factors

Personal

factors

(8)

Impairment: problems in body function or structure

 Pain

 Tender joint count j

 Swollen joint count

 ROM

 Deformities

 Muscle strength

 X rays: erosion joint space

 X rays: erosion, joint space narrowing, osteophytes, etc.

Activities: execution of a task or action

R hi

 Reaching

 Manipulation

 Timed button test

 6-min walking test

 HAQ AIMS ACR20 50 70 (RA)

 HAQ, AIMS, ACR20, 50, 70 (RA)

 WOMAC, Lequesns index (OA) q ( )

 BASFI, BASDI, BAS-G, ASAS20, 50, 70 (AS)

70 (AS)

Participation: involvement in life situations

 Self care D ti lif

 Domestic life

 Occupation

 Education

 Leisure

Environmental factors: external feature of physical and social world

 Home physical environment

 Work station set up

 Broad handle utensils

 Assistive devices and mobility aids

 Interpersonal environment

 Social support

 Societal policies and regulations

(9)

Personal factors Personal factors

 Personal identity

O ti

 Occupation

 Goals

 Beliefs about arthritis

 Coping style p g y

 Self-efficacy

 Religious and spiritual beliefs

Goals of rehabilitation Goals of rehabilitation

S f

 Symptom relief

 Improve or maintain mobility &

strength

 Maximal functional ability

M i l i d d

 Maximal independence

 Improve sense of self worth

 Improve sense of self-worth

Rehabilitation management Rehabilitation management

35

Pain management Pain management

R t & th ti ( li t )

 Rest & orthotics (splints)

 Medication

 NSAIDs, analgesics, local injection, DMARD, biologic agents , g g

 Physical modalities

 Manual therapy

 massage, mobilization, manipulation

 Therapeutic exercise

36

(10)

Mobility exercise Mobility exercise

 Types

ROM (acti e acti e assisti e

 ROM (active, active-assistive, passive)

p )

 Stretching (static, PNF, ballistic)

 Joint mobilization

Clinical consideration Clinical consideration

F ti f t t

 For prevention of contracture

 full ROM, low repetition , p

 For increasing ROM

 heat and stretch

 Splint or cast may be applied after stretch

 Avoid forceful passive ROM or stretching in acute arthritis

Strengthening exercise Strengthening exercise

I i

 Isometric

 Isotonic

 concentric

 eccentric

 Isokinetic

 concentric

 eccentric

Clinical consideration Clinical consideration

I t i i b d i t

 Isometric exercise may be used in acute condition

I t i i ld b d i

 Isotonic exercise could be used in subacute or chronic stage

I ki ti i i t ll

 Isokinetic exercise is not usually recommended for arthritic patients;

training should be performed in pain free training should be performed in pain-free range or crepitation free range

S bma imal intensit is safer than

 Submaximal intensity is safer than maximal intensity

F tl it j i t diti

 Frequently monitor joint conditions

(11)

Aerobic exercise Aerobic exercise

M d i i bi l

 Mode: swimming, bicycle

ergometry, walking, low impact g y, g, p aerobics, 太極拳

F 3 5 ti / k

 Frequency: 3~5 times/week

 Duration: 20~60 min

 Duration: 20 60 min

 Intensity: 55~90% HR max, 40~85%

VO . ₂ R, 40~85% HRR, RPE: 12~16.

Recreational exercise Recreational exercise

I t th d ROM &

 Improve strength, endurance, ROM &

aerobic capacity

 Social contact

 Increase self-esteem

 Increase self esteem

 Antidepressant effect f

 Avoid high-force activities

 Avoid recreational activities in acute arthritis

43

Orthoses (splints) Orthoses (splints)

U i h j i t

 Unweigh joints

 Stabilize joints j

 Decrease joint motions

 Improve joint motion

 Prevention of deformity?

44

(12)

Assistive devices Assistive devices

 Compensate for lost function

 Alleviate joint stress

 Decrease energy demands

 Increase safety

Guidelines for footwear selection

 Cushion sole

 Low heel

 Arch support

 Firm counter

 Pressure relief

 Adequate width and depth S ft t i l i th

 Soft material in the upper

 Foot orthotics, custum-made shoes

oot o t ot cs, custu ade s oes

Patient education Patient education

 Work simplification

E ti

 Energy conservation

 Body mechanics

 Joint protection

Rehabilitation for RA or other inflammatory polyarthritis

(13)

Acute stage Acute stage

 Rest (systemic, local) C ld th

 Cold therapy

 Pain management (TENS laser)

 Pain management (TENS, laser)

 ROM exercise (active-assistive)

 ROM exercise (active assistive)

 Isometric exercise if indicated

 Muscle massage or hot pack

Subacute Subacute

H ld h

 Heat or cold therapy

 Hydrotherapy

 ROM exercise (active-assistive, ti )

active)

 Strengthening exercise (isometric

 Strengthening exercise (isometric, isotonic)

J i t t ti

 Joint protection

Chronic stage Chronic stage

H t th

 Heat therapy

 Hydrotherapy y py

 Orthoses

 Assistive devices

 Joint protection

 Exercise (stretching, strengthening, conditioning, recreation)

conditioning, recreation)

51

Rehabilitation for knee OA Rehabilitation for knee OA

 Identify pain mechanism

 Tap effusion if present

St id ( B t ) i j ti if i di t d

 Steroid (or Botox) injection if indicated

 Viscosupplementation with hyaluronic acid

 Avoid flexion contracture

 Strengthening exercise, balance and i ti t i i

proprioceptive training

 Shoes modification and bracing for d f it

deformity

 Cardiorespiratory fitness training

52

(14)

Rehabilitation for

Ankylosing Spondylitis

 Spine extension and ROM of neck, shoulder and hip

shoulder, and hip

 Chest expansion exercise

 Assistive devices

 prism glasses

 long-handled devices

 canes

 Modalities for pain relief

Rehabilitation of the Arthritic Patient-謝霖芬 55 Rehabilitation of the Arthritic Patient-謝霖芬 56

(15)

Conclusion Conclusion

T h

 Team approach

 Individualized program

 Early treatment

 Practical

 Economical

 Compliance of patients p p

 Periodic reevaluation and adjustment

Physician Physician

Nurse Psychologist

Social worker PT

Patient

Social worker PT

Patient

Family OT

O th ti t Orthotist Bioengineer

P d thi t

Pedorthist

(16)

Therapeutic Physical Agents and Clinical

A li ti Application

新光吳火獅紀念醫院復健科謝霖芬醫師謝霖芬醫師

1

Physical Modality (Physical Agent)

 Various forms and means of applying of applying of energy and materials to patients

patients

2

Categories of Physical Agent

Category Types Clinical examples

Thermal Deep-heating agents Superficial heating

t

Diathermy Hot pack agents

Cooling agents Ice pack

Mechanical Traction Compression

Mechanical traction Elastic bandage Compression

Water Sound

Elastic bandage Whirlpool Ultrasound

3

Electromagnetic Electromagnetic fields Electric currents

Ultraviolet TENS

History of the Use of Physical History of the Use of Physical Modalities

 400B.C. electric shocks (torpedo fish) treat th iti

arthritis

 Ancient Greeks and Romans used heat and water to treat musculoskeletal problems

 17 ^th century: spa in Europe y p p

 17 ^th century: use amber(琥珀) to generate static electricity for the treatment of inflammation

electricity for the treatment of inflammation

 Sunlight for bone and joint disease

4

(17)

Modes of Heat Transfer

 Conduction(傳導): Hot pack, cold pack

 Convection(對流): Whirlpool, fluidotherapy

 Conversion(轉換): Ultrasound diathermy

 Radiation(輻射):Infrared

 Evaporation(蒸發):Vapocoolant spray

5

General Uses of Cryotherapy in General Uses of Cryotherapy in Physical Medicine y

 Musculoskeletal conditions

acute sprains, strain, arthritis….

 Following certain orthopedic surgeries

 Spasticity management

 Emergency treatment of minor burns

6

Types of Cooling Agents

 Cold packs or ice packs

I f i

 Ice cups for ice massage

 Controlled cold compression units

V l t b i f i i

 Vapocoolant spray or brief icing

 Frozen towels

 Ice water immersion

 Cold whirlpool

 Contrast bath

7

Contraindications for the Contraindications for the Application of Cryotherapy pp y py

 Cold hypersensitivity C ld i t l

 Cold intolerance

 Cryoglobulinemia

 Paroxysmal cold hemoglobinuria

 Raynaud’s disease or phenomenon

 Over regenerating peripheral nerves

 Over an area with circulatory compromise or Over an area with circulatory compromise or PVD

8

(18)

Precautions for the Application of Precautions for the Application of Cryotherapy y py

 Over a superficial main branch of a nerve

 Over an open wound

 Hypertension

 In patients with poor sensation or poor mentality

 Very young or very old patients

9

Effects of Heat

 Hemodynamic effect - vasodilation

 Neuromuscular effect

- changes in nerve conduction velocity and firing rate

and firing rate - increase pain threshold - changes in muscle strength - changes in muscle strength

 Metabolic effect

- increase metabolic rate - increase metabolic rate

 Alter tissue extensibility

- increase collagen extensibility

10

increase collagen extensibility

Effects of Cryotherapy and Effects of Cryotherapy and Thermotherapy py

Effect Cryotherapy Thermotherapy

Pain 　　

Muscle spasm Blood flow

　　

　 +

Edema formation +

Edema formation

Nerve conduction velocity Metabolic rate

　　　

+ + + Collagen extensibility

Joint stiffness

　 +

11

Spasticity 　 0

General Uses of Heat in Physical General Uses of Heat in Physical Medicine

 Musculoskeletal conditions

 Pain control

 Arthritis

 Contracture

 Muscle relaxation

 Chronic inflammation

12

(19)

Classification of Heat Therapy

 Superficial- depth to 1 cm

 Deep - depth more than 1 cm (3~5 cm)

13

Superficial Heat Superficial Heat

 Hot packs (70~80 ^o C)

 Paraffin baths(45 54 ^o C)

 Paraffin baths(45-54 C) mineral oil to paraffin=1:7 I f d

 Infrared

 Fluidotherapy

 Hydrotherapy

 Contrast baths

 Balneotherapy (Spa)

14

General Contraindications and General Contraindications and Precautions for Therapeutic Heat p

 Acute inflammation, trauma, or hemorrhage Bl di di d

 Bleeding disorders

 Cutaneous insensitivity

 Inability to communicate or respond to pain

 Malignancy

 Edema

 Ischemia Ischemia

 Impaired circulation

15

Hydrotherapy

 Whirlpool, Hubbard tank, pool Temperature: 33 45°c

 Temperature: 33~45 c

 Decrease weight bearing

 For water-based exercise

 Massage effect (whirlpool) Massage effect (whirlpool)

16

(20)

Applications of Hydrotherapy in Applications of Hydrotherapy in Musculoskeletal Disorders

 Chronic arthritis (RA, OA, AS, LBP)

 Muscle spasm

 Fibromyalgia y g

 Joint stiffness

 For exercise

17

Contraindications for Hydrotherapy

W d i f i

 Wound or infection

 Cardiac instability Cardiac instability

 Bladder or bowel i ti

incontinence

 Epilepsy p p y

 Disturbance of consciousness consciousness

 Tendency to suicide

18

Contrast Bath

 Alternate immersion in hot (38 ^o C-44 ^o C) &

cold (13-16 ^o C )water

 Local edema reduction

 Pain relief and desensitization

 For RA, complex regional pain syndrome, ankle sprain (subacute stage)….,etc.

ankle sprain (subacute stage)….,etc.

19

Deep Heat (Diathermy)

 Ultrasound

 Shortwave

 Microwave

20

(21)

Ultrasound

 Frequency >20000 H

Hz

 Common frequency range:0.7~3.3 MHz

 Energy absorption 2 gy p to 5 cm

21

Effects of Ultrasound

 Thermal effects

 high absorption coefficient (high collagen)

collagen)

 low absorption coefficient (high water)

 Non-thermal effect

h i l t

 mechanical events

22

Cli i l A li ti f Ult d Clinical Application of Ultrasound

Soft tiss e shortening

 Soft tissue shortening

 Reduce pain and muscle p spasm

 Tendon injuries

 Tendon injuries (tendinitis, bursitis)

 Resorption of calcium deposits

deposits

 Phonophoresis

23

C t i di ti f th U f

Contraindications for the Use of Ultrasound

Ultrasound

 Malignant tumor ^ Pacemaker

 Malignant tumor

 Pregnancy

 Pacemaker

 Thrombophlebitis

 CNS tissue

 Joint cement

 Eyes

 Reproductive

 Joint cement

 Plastic component

 Reproductive organs

24

(22)

Precaution for the Application of Precaution for the Application of Ultrasound

 Acute inflammation (pulsed USD)

 Epiphyseal plates

 Fracture

 Breast implants

25

Extracorporeal Shock Wave Therapy

 First introduced into medicine 20+yrs ago

 First treatment: kidney stone

 Treatment of musculoskeletal conditions in recent yrs: lateral epicondylitis, plantar fasciitis, calcifying tendinopathy, pseudoarthrosis, y g p y, p ,

nonunion fractures, etc.

 Can decrease pain and promote tissue

 Can decrease pain and promote tissue regeneration

26

Physical Characteristics of ESWT

 A sonic wave

 High peak pressure (50-100MPa)

 Fast initial rise in pressure (< 10nsec)

 Low tensile amplitude

 Short half life

Broad frequency spectrum

 Broad frequency spectrum

27

ABOUT ABOUT

SHOCKWAVE

 Main fields of application

 Rehabilitation

 Orthopedics

 Sport medicine p

Oth li ti

The course of the pressure induced by the shockwave in the tissue

 Other application:

 Veterinary (race horses)

The course of the pressure induced by the shockwave in the tissue

 Aesthetics medicine – anti-cellulite treatment

28

(23)

Applicators – EMS, STORZ, Applicators EMS, STORZ, BTL

29

Diathermy

 Application of electromagnetic energy to produce heat

 Shortwave:10-50MHz (27 12MHz)

 Shortwave:10 50MHz (27.12MHz)

 Microwave:2450MHz

 Continuous or pulsed mode

 Heat deeper tissues & large areas

30

31

Clinical Indications for the Use of Clinical Indications for the Use of Diathermy y

 Pain control

 Accelerated healing

 Decreased joint stiffness

 Increased ROM

32

(24)

33

Contraindications for Thermal Level Contraindications for Thermal Level Diathermyy

 Metal implants or pacemaker

 Malignancy

 Pregnancy

 Eyes

 Testes

Growing epiphyses

 Growing epiphyses

34

Laser

 Light amplification Light amplification by stimulated

emission of radiation

35

Characteristics of Laser

 Monochromatic: same ffrequency

 Coherence: in phase

 Directional: minimal divergence g

36

(25)

Lower Power Laser (Cold Laser)

 Power density:<500 mW (usually

<50mW/cm ² )

 Energy density:<35 J/cm ²

 Energy density:<35 J/cm

 For acute condition: 0.05-1 J/cm ²

 For chronic condition: up to 40 J/cm ²

37

Penetration and Absorption of Cold Penetration and Absorption of Cold Laser

 HeNe(632.8nm)

 direct penetration=0.8mm

 indirect penetration=10-15mm

 indirect penetration 10 15mm

 GaAs(904 nm )

 direct penetration=15mm

 indirect penetration=5cm

38

Effect of Cold Laser

 Celluler effect

 Increased ATP and nucleic acid production

 Stimulation of macrophages

 Stimulation of fibroblast to increase collagen production

production

 Altered nerve conduction and regeneration

 Vasodilation

39

Clinical Use of Cold Laser in Clinical Use of Cold Laser in Rehabilitation Medicine

 Rheumatoid arthritis O t th iti

 Osteoarthritis

 Lateral epicondylitis

 Carpal tunnel syndrome

 Neck or back pain

 Myofascial pain syndrome

 Chronic pain Chronic pain

 Wound healing

40

(26)

雷射治療範例-治療前

October 15, 2000, Condition before discharged from hospital

資料來源:www.avicennalaser.com 1-888-AVI-LASER41

雷射治療範例-治療4個月後

The scars after a series of laser irradiation - 4 months after injury

雷射治療範例-治療1年後

Condition 1 year after the injury

Contraindications for the Use of Contraindications for the Use of Laser

 Direct irradiation of the eyes

 Within 4 to 6 months after radiotherapy

 Hemorrhaging regions

 Locally to the endocrine glands

 Precautions: fever, epilepsy, malignancy, pregnancy gonads decreased sensation pregnancy, gonads, decreased sensation, confused patient, infected tissue,

t i t di i

44

autonomic system, cardiac region

(27)

Classification of Electrotherapy

 Low frequency: <1000Hz

 Medium frequency: 1000 100000 Hz

 Medium frequency: 1000-100000 Hz

 High frequency: > 100000 Hz

45 46

Uses of Electric Currents

 Neuromuscular electric stimulation

 Denervated muscle stimulation

 Pain control (TENS)

 Tissue healing

 Iontophoresis

47 48

(28)

Transcutaneous Electrical Nerve Transcutaneous Electrical Nerve Stimulation (TENS) ( )

 Low frequency: usually <200Hz

 Current : <100 mA

 Variable wave forms, modes, and Variable wave forms, modes, and electrodes

 Cheap portable

 Cheap, portable

 Gate control theory or endorphin release

 For acute or chronic pain

49 50

Medium Frequency Interferential Medium Frequency Interferential Current

 2 sinusoidal current differing by 20-100Hz

 Medium frequency→

low frequency C f t bl

 Comfortable

 More muscle More muscle stimulation

51

Parameters of Electrical Parameters of Electrical

Stimulation-Effects of Manipulation on Neurophysiological Responses

C t lit d d l d ti

 Current amplitude and pulse duration

 Strength-duration curve

O ti l l lit d d l d ti

 Optimal pulse amplitude and pulse duration selection

 Frequency

 Modulation

 Ramps

 On and off times

 Other timing modulations

52

 Other timing modulations

(29)

53 54

Contraindications and Precautions Contraindications and Precautions for Electrical Stimulation

 Demand pacemaker or arrhythmia

 Carotid sinus

 Thrombosis or thrombophlebitis Thrombosis or thrombophlebitis

 Pregnancy C di di

 Cardiac disease

 Impaired mentality or sensation

 Skin irritation or open wound

55

Adverse Effects of Electric Adverse Effects of Electric Stimulation

 Electrical burns

 Skin reactions to the electrodes

 Pain

56

(30)

Effect of Spinal Traction

 Joint distraction

 Reduction of disc protrusion

 Soft tissue stretching

 Muscle relaxation

 Joint mobilization Patient immobilization

 Patient immobilization

57

Contraindications and Precautions Contraindications and Precautions for Use of Traction

 Where motion is contraindicated

 Acute injury or inflammation

 Joint hypermobility or instability

 Peripheralization of symptom with traction

 Structural diseases or conditions affecting the spine p

 Pregnancy, hernia, osteoporosis

Di l f di f

58

 Displacement of disc fragment

Clinical Indications for the Spinal Clinical Indications for the Spinal Traction

 Disc bulge or herniation

 Nerve root impingement

 Joint hypomobility yp y

 Subacute joint inflammation inflammation

 Paraspinal muscle spasm

spasm

59

Advantages of Physical Modalities Advantages of Physical Modalities over Other Pain-modifying

Interventions

ff

 Fewer and less severe side effects

 Adverse effects: localized, easily avoided Adverse effects: localized, easily avoided

 Risk of further injury: minimal

 No dependence

 Not cause sedation

 Easy self application (some)

60

(31)

謝謝

61

謝謝