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Rheumatology: 9. Physical and occupational therapy in the management of arthritis
Clinical basics · Principes cliniques The case Mr. P is a 53-year-old man who, when younger, was actively involved in a number of sports including football, skiing and tennis. At the age of 22 years, he had a meniscectomy for a torn medial meniscus of the left knee. This knee became painful 5 years ago, especially at the end of the day. Over the past year, the episodes of pain have increased to the point where he has curtailed all recreational activity and is finding it increasingly difficult to walk long distances. Due to his pain and the resultant inactivity, he has gained 20 kg. Weight-bearing radiographs of his knee show moderate loss of joint space involving the medial joint compartment. Physical therapy, which is also known as physiotherapy, and occupational therapy are integral components of the management of many forms of arthritis (Table 1). Physical and occupational therapists will establish a therapeutic home program and educate patients about the disease and its management. Although this article focuses on the prescription of these services in the management of osteoarthritis, physical therapy will also benefit patients with chronic inflammatory conditions, such as ankylosing spondylitis, and patients with connective tissue disease may also require these disciplines if their disease affects the musculoskeletal system. Patients with rheumatoid arthritis, psoriatic arthritis, systemic lupus erythematosus or other chronic polyarthritic rheumatic diseases will follow a similar process and may be best referred to therapists familiar with these specific problems who have the time and resources to devote to patient education. In all of the chronic arthritides, treatment will ideally be multidisciplinary and education will be a major component. Limited problems such as tendinitis or bursitis are usually well managed in the community without specific referral. Role and function of the physical therapist
The physical therapist will assess the musculoskeletal status of the patient by taking a history and examining ranges of motion, muscle strength, joint status (e.g., stability, alignment), posture and gait. Physical therapists who have additional training in rheumatic diseases will also evaluate the acuteness of the disease. This is necessary in inflammatory diseases, such as ankylosing spondylitis and rheumatoid arthritis, because it relates directly to the extent of physical activity that the patient can tolerate. Exercise can exacerbate the acuteness of disease if it is not delivered at a level consistent with the condition of a particular joint. An appropriate level of exercise may be followed by a short period (up to 2 hours) of moderate discomfort; however, significant exacerbation of the condition for a longer duration may occur if the assessment of the disease stage was inadequate or the patient has been overzealous or is exercising incorrectly. Physical therapists trained in the evaluation of rheumatic diseases can be located in some provinces through the Arthritis Society. A single toll-free number (800 321-1433) allows people to contact their local Arthritis Society office for referrals to community care providers.
Physical therapy consists of exercises to improve muscle strength, joint mobility and cardiovascular function. Heat, cold, electrical treatments or hydrotherapy may also be used to achieve temporary relief of pain and reduction of muscle spasm, but these techniques are used to prepare the patient with arthritis for exercise and should not be viewed as the treatment. The emphasis should be on exercise and education, with the goal of enabling the patient to continue an independent home program after discharge.
Gait training may be required to change poor habits, identify muscle weakness and imbalance and increase strength and walking range. For example, following total hip arthroplasty, patients often have a "Trendelenburg gait" with a lateral shift toward the operated leg in stance phase. This may be because of shortness of the leg, weak hip abductors or habit. An assessment of the strength of the hip and knee musculature, measurement of leg length and observation of gait will allow the therapist to identify which problems need to be corrected and how to do so.
A physical therapist uses posture training and counselling to help patients reduce stress on joints or soft tissue during regular movement, work and recreational activities. For example, a dentist with ankylosing spondylitis who spends a large part of his or her day stooped over the chair is increasing the likelihood of fixed postural deformities. It may be possible to encourage this patient to work from a sitting position, so that the spine is maintained in a more erect position for most of the workday. A person with osteoarthritis of the hip may not want to use a cane held in the opposite hand unless the therapist spends time demonstrating leverage and how forces on the hip joint can be unloaded when a cane is used properly.
As most forms of arthritis are chronic, the patient will usually be instructed in a program of exercise that can be carried out at home. In addition to learning the exercises, the patient should also understand the rationale behind them and be given guidelines for progression. Long-term adherence to a regimen, particularly one as time-consuming as an exercise program, will only occur if the patient understands the reasons for doing the exercises and believes that they will be useful. Role and function of the occupational therapist
The occupational therapist's role is to improve patients' ability to perform daily tasks, help them adapt to disruptions in lifestyle and prevent loss of function. Principles of energy conservation and joint protection, as well as techniques for stress management, are taught to minimize fatigue, reduce stress on joints, reduce pain and increase performance in the activities of daily life.
Patients are trained in alternative methods and the use of adaptive equipment for performing daily self-care, work, school, leisure and recreational tasks. Emphasis is placed on evaluating the patient within the context of his or her home, work or school setting so that appropriate, acceptable interventions will enhance the patient's capabilities. Environmental modifications may be necessary to promote independent functioning. For example, a grab rail fixed to the wall or bathtub can facilitate entry and exit from the tub. The toilet is often the lowest seat in the house and may be difficult for patients with hip or knee problems to use; a raised toilet seat may mean the difference between independence and institutional care for some patients. Ergonomic positioning of desks, chairs and computer monitors may be important for patients in sedentary jobs (Fig. 1).1,2 An occupational therapist may also help the patient adjust to new or changed roles in the family or community. Symptom management for patients with osteoarthritis Osteoarthritis is perhaps the most common rheumatology problem that the family physician sees, and physical and occupational therapy play an important role in relieving the symptoms associated with this disease.
Education
Pain relief
Physical therapy
Occupational therapy
Physical therapy
Cane use
Physical therapy
Occupational therapy
Weight control
Physical therapy
Joint protection
Occupational therapy
Splinting
Occupational therapy
Physical and occupational therapy for an inflammatory form of arthritis
The principles outlined here also apply to inflammatory forms of arthritis but require closer patient adherence to instruction because the potential for loss of mobility, flexion contractures and deformity are even greater in chronic inflammatory polyarthritis.
Exercise should become part of the daily routine, but the patient should focus on the joints in which the inflammation and pain are most severe. Each active joint should be taken through its full range of motion daily. Isometric exercise may maintain muscle strength without exacerbating the condition of the joint. Exercise should stop short of increasing inflammation in the joint (as observed by an increase in pain and warmth or swelling in the joint). Any activity that increases inflammation in the joint should be avoided.
It is important to note that exercises for spondylitis are often the reverse of those recommended for mechanical back pain. Flexion exercise regimens are commonly used for mechanical back pain to improve abdominal strength and flatten the lumbar spine. In spondylitis, pain and inflammation promote a stooped posture with potential deformity in a position of flexion. Therefore, exercise is aimed at maintaining spinal extensor mobility and increasing the strength of the spinal extensor muscles. As spondylitis is less common than mechanical low-back pain (e.g., disc lesions, sprains), there is a danger of applying the standard mechanical treatment rationale to the inflammatory back problem.
Custom-fitted or store-bought splints may rest an active joint or provide support to a damaged joint, and patients are willing to wear these when they are well fitted.
Of paramount importance is the patient's understanding of the need to adhere to a regimen over a long period. Education, delivered when the patient is receptive, is effective; this is rarely at the time of diagnosis. Typically, denial and anger precede the optimum teaching moment. Conclusion
Physical and occupational therapists expect to be provided with the primary diagnosis for the problem they are going to treat. They do not expect specific instructions or treatment recommendations but generally prefer to be allowed some discretion in developing a treatment plan based on their findings.
These therapists also expect the primary care physician or specialist to have achieved control of inflammation and pain through pharmacologic means where possible. A patient with ankylosing spondylitis, for example, is less likely to adhere to a daily exercise regimen if he or she has not achieved some degree of pain management with an appropriate anti-inflammatory medication.
The services of physical and occupational therapists will be enhanced if supporting information is forwarded to them at the time of referral. Copies of radiologic reports or radiographs, for example, can help them tailor treatment and education to the individual patient. As the primary care physician, the general practitioner should also determine what treatment is being carried out by the therapist and whether it is successful. Regular communication will facilitate the development of a rapport between physician and therapist and will improve treatment for the patient. Treatment for Mr. P Mr. P, who has moderate osteoarthritis of the knee, has every reason to expect significant improvement in his symptoms with a program of analgesic or anti-inflammatory medication combined with the therapy outlined in Table 1. He is using a heating pad at home for pain relief and has made good progress with daily quadriceps exercises. These exercises include static quadriceps contractions, but the main exercise involves extending the knee over a shallow block (in this case a rolled-up cushion) with a 3-kg weight attached to his foot. He does 2 sets of 10 repetitions, holding each for 5 seconds. He is progressing by increasing the weight as his strength improves. He swims 3 times a week and participates in a program of deep-water jogging for weight loss. Over the last 6 weeks, he has lost 4.5 kg. He has stopped using an exercise bicycle, because the activity aggravated the condition of his kneecap and has opted for isometric exercise. His therapist has reinforced the rationale for the use of medication and has discussed the common side effects with him. His physician is supportive of the these interventions, enhancing the likelihood of compliance with the treatment regimen and, thus, an excellent outcome. Competing interests: None declared.
Mr. Clark is in private practice. This article has been peer reviewed. This series has been reviewed and endorsed by the Canadian Rheumatology Association. The Arthritis Society salutes CMAJ for its extensive series of articles on arthritis. The Society believes that this kind of information is crucial to educating physicians about this devastating disease. Series editor: Dr. John M. Esdaile, Professor and Head, Division of Rheumatology, University of British Columbia, and Scientific Director, Arthritis Research Centre of Canada, Vancouver, BC. Reprint requests to: Mr. Bruce M. Clark, 206-888 West 8th Ave., Vancouver BC V5Z 3Y1; fax 604 877-0736; bclark@istar.ca Supplementary reading
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