The chronic progressive nature of arthritis dictates a plan of care (POC) that includes patient education and self-management beyond the initial presentation. Although RA is systemic and OA is a more localized condition, both diseases can significantly affect health, function, participation, and quality of life. The rehabilitation of persons with arthritis requires comprehensive and coordinated efforts of a team of health professionals, including physical therapists, and ensures that the patient is first and foremost in treatment planning. The patient's ability to self-manage successfully is a major predictor of better health outcomes.75 The physical therapist plays a pivotal role in helping the patient with minimal disability gain confidence and experience in using self-management skills to deal with the condition. The general goals and outcomes for persons with RA and OA are similar (see Box 23.4).
Box 23.4 Examples of General Goals and Outcomes for Patients with Arthritis
Impact of impairments is reduced.
Pain is decreased.
ROM of all joints is maximized sufficient for functional activities.
Muscle activation and strength is maximized sufficient for functional activities.
Joint stability is maximized and biomechanical stress on all affected joints are decreased, deformity prevented.
Endurance is increased for all functional activities and desired leisure activities.
Ability to perform physical actions, tasks, or activities is improved.
Independence in ADL is promoted, including dressing, transfers, and self-care.
Efficiency and safety of gait pattern and balance are improved.
Patterns of adequate physical activity or exercise to maintain or improve musculoskeletal and cardiovascular fitness and general health are established.
Health status and quality of life are improved.
Patient, family, and caregivers are educated to promote the individual's capacity for self-management, including joint protection.
Adapted from Guide to Physical Therapist Practice.
The remainder of this chapter will discuss physical therapist examination and interventions for people with RA and OA of the hip and knee. Although OA also presents at other joints, these two are the most common and disabling sites for OA and are most frequently seen by a physical therapist.
Physical Therapy Examination
A comprehensive and multisystem examination and history is an essential component of physical therapy management. Whether the patient is a direct access client or seen in a system-based clinical setting, collaboration and communication with other care providers working with the patient is imperative. As with all patient-centered care, the patient is the primary stakeholder and should be actively engaged in goal setting and in the development of the POC.
Careful observation of the patient during the initial meeting and history can help inform the process. For example, observation of the patient's gait, ability to remove outerwear, and transfer into a chair for the history will provide the therapist with a quick assessment of functional ability.
The medical and social history will direct and inform the examination and provide insight into the development of a POC and need for potential resources. Ascertaining the patient's understanding of the disease and the implications of the disease is an important component of the interview process. In particular, the therapist should be concerned with identifying "red flag" signs and symptoms that indicate the need for immediate medical follow up (Table 23.5).76 Pain assessment questions should include location, duration, pattern, quality, and intensity. Specific details regarding joint inflammation such as joint heat, swelling, and erythema should be recorded and confirmed during the physical examination. A determination of joint stiffness (morning versus after prolonged static posture), previous activity level, pattern and degree of fatigue, presence of co-morbidities, and current medication is also essential. Use and effectiveness of previous therapeutic interventions and complementary approaches should be noted. Although many physical therapy tests and measures are used during the examination, specific adaptations may be made to tailor the examination to the person with RA or OA. Especially in RA, the tender and swollen joint count appears to be a sensitive measure of systemic disease activity and guides the exercise prescription.16
Table 23.5"Red Flags" Suggesting the Need for Urgent Evaluation and Management ||Download (.pdf) Table 23.5 "Red Flags" Suggesting the Need for Urgent Evaluation and Management
|Flag ||Differential Diagnosis |
|History of significant trauma ||Soft tissue injury, internal derangement, or fracture |
|Hot, swollen joint ||Infection, systemic rheumatic disease, gout, pseudogout |
|Constitutional signs (e.g., fever, weight loss, malaise) ||Infection, sepsis, systemic rheumatic disease |
|Focal nerve lesion (compartment syndrome, entrapment neuropathy, mononeuritis multiplex, motor neuron disease, radiculopathya) Myositis, metabolic myopathy, paraneoplastic syndrome, degenerative neuromuscular disorder, toxin, myelopathy,a transverse myelitis |
(burning, numbness, paresthesia)
Radiculopathy,a reflex sympathetic dystrophy, entrapment neuropathy
Myelopathy,a peripheral neuropathy
|History of significant trauma ||Soft tissue injury, internal derangement, or fracture |
|Claudication pain pattern ||Peripheral vascular disease, giant cell arteritis (jaw pain), lumbar spinal stenosis |
Tenderness and subjective reports of pain on passive range of motion (PROM) are highly indicative of inflammation; thus, gentle pressure and appropriate hand position is paramount during examination. Goniometric measurement of PROM is indicated and necessary at all affected joints after a gross joint screening to assist in monitoring treatment effectiveness. Standardized procedures are essential for reliable and valid measures. Otherwise, potential variations in intrarater and inter-rater reliability will reduce the accuracy of data comparison throughout the disease course.77 If joint pain or poor activity tolerance prohibits measurement of PROM, the therapist may consider substituting a functional ROM test by asking the patient to touch various body parts (e.g., the top of the head and small of the back) to determine the available ROM for performing self-care activities. The therapist should note any tenderness, crepitus, or pain during examination of ROM.
Regardless of whether the patient has OA and monoarticular involvement or RA with polyarticular involvement, the impact of an involved joint on the kinematic chain or on the contralateral side should not be overlooked.78 When there is OA in a hip or knee, active motion in functional positions should be examined in all joints of both lower extremities (LEs). It is important to observe motion for symmetry and smoothness during gait, stair climbing, and rising from a chair. Ascending stairs requires the greatest amount and velocity of knee flexion and may be one of the best activities to determine knee function.79 Decreased ROM at the hip and knee increases the risk for injury and falls. Approximately 50° hip flexion and 90° knee flexion are required to recover balance from a stumble during walking.80
Pain and joint effusions impede muscle contraction, limiting examination of strength. A patient may be able to generate force in the pain-free range but unable to completely contract in the painful range secondary to reflex inhibition. Traditional strength tests (e.g., manual muscle tests) are not appropriate in the presence of severely deformed and/or deranged joints. Functional strength assessments are more appropriate and will provide sufficient data to formulate treatment goals. Individuals who demonstrate a lag phenomenon will have limited active range and will not be candidates for traditional grading systems, because these are not sensitive to changes in the quality and quantity of muscle contraction. When documenting strength, it is important to include information on required modifications made to preferred testing positions, grade of strength exhibited in that arc of motion, and the method of strength testing used (e.g., break test, isometric holding at the end of range, or resistance throughout the ROM). Modifying the test protocol to include an isometric break test at midrange or most comfortable joint position generally yields higher grades than would be received if full range testing were done. Any modifications to standardized test protocols must be carefully documented. It is also important to document the time of day the patient was tested, as well as the use and timing of medications that might alter performance or exercise tolerance.
The functional threshold for LE strength has yet to be determined. However, reports from studies that have examined knee strength as a percentage of body weight suggest that isokinetic strength measured at velocities between 60° and 180° per second should be 20% to 30% body weight for knee extension and 20% to 25% for knee flexion.78,79 Isometric knee extension below 10 kg (22 lb) of force (measured with the hip at neutral and knee at 90°) corresponded to marked disability in a study of persons with OA of the knee.81 It is also important to perform strength testing of the muscle groups proximal to the affected joints to detect deficits that can affect function and contribute to abnormal biomechanics.
Joint stability is essential for normal biomechanics, function, and independence. Inflammatory aspects of RA can lead to joint instability and eventual deformity. Intra-articular ligaments are highly susceptible to inflammatory and erosive changes in RA. Thus, ligamentous laxity of any affected joint should be fully investigated. Pseudolaxity, often detected in unicompartmental knee OA, should be differentiated from true ligamentous laxity.
Fatigue is one of the systemic manifestations of RA and frequently unappreciated. Individuals with OA also report fatigue. To best ascertain the impact of fatigue on patient functioning and independence, assessments should be made over the course of a single day and over several days. The increased incidence of asymptomatic cardiovascular disease, elevated risk for ischemic heart disease, and decreased cardiovascular fitness of individuals with RA demands specific attention.24 Heart rate, respiratory rate, blood pressure and ratings of perceived exertion should all be measured during a functional activity that is reasonably stressful for the patient's current level of fitness. Excessive increases in perceived exertion may indicate the presence of inflammation or impairment of pulmonary and cardiac function that requires more extensive and formal evaluation. It is also important to determine cardiovascular fitness in individuals with OA, because cardiovascular deficits and increased risk for coronary artery disease are clearly associated with long-standing or severe disease.24,82
Functional examination measures provide a rich and patient-centered approach to assessment. Functional measures may include ADL, work, and leisure activities (see Chapter 8, Examination of Function). The selection of a functional measure is based on the demographic features of the patient (e.g., age, gender), the level and depth of information required, and the measure's sensitivity/responsiveness in gauging the efficacy of treatment.83,84,85 As with goniometric measurement, the reliability and validity are important for individual and comparative purposes. The Functional Status Index (FSI), a valid and reliable measure, was designed for use in outpatient rheumatologic settings to assess an individual's function in a sample of typical ADL. FSI parameters include pain, level of difficulty, and dependence (Appendix 23.A).86,87 The Health Assessment Questionnaire (HAQ) is a generic measure consisting of the following five domains or subscales: disability, discomfort, pain, drug side effects (toxicity), and costs of care (Appendix 23.B).88 The HAQ is a component of the ACR core of measures for rheumatoid arthritis89 and has been shown to correlate highly with measures of disease progression in RA (x-ray changes).17 The modified HAQ, an abbreviated version of the HAQ, is a quick, easy to complete and score instrument that assesses the impact of disease activity on function and disability. Both versions are available for free online. Another arthritis-specific instrument, the revised Arthritis Impact Measurement Scales 2 (AIMS2), expands the concept of function to include performance in psychological and social domains as well as physical function. The AIMS2 also measures the patient's satisfaction with current functional status and individual preferences for outcome.90 The AIMS2 is not well suited for program evaluation or research purposes due to its complicated scoring algorithm and associated costs. The WOMAC is a widely used, valid, and reliable self-report instrument of 24 items in three categories specific to OA of the hip and/or knee (pain, stiffness, and function). The WOMAC takes about 10 minutes to administer and is easily scored by hand. It is available in either Likert form (0–4) or visual analogue scale.91 Both the AIMS2 and the WOMAC are sensitive to clinical intervention and provide excellent clinically feasible, standardized measures in the domains of function and disability to monitor change over time. The Knee Injury and Osteoarthritis Outcome (KOOS) measure was developed using the WOMAC as a base and includes sports, recreation, and leisure items. This measure is readily accessible, is relatively easy to score, and demonstrates strong validity, reliability, and responsiveness in adults.92 A modified version of the KOOS was developed for persons with hip osteoarthritis (HOOS).93
Mobility, Gait, and Balance
A complete and detailed gait examination is one of the most important contributions of the physical therapist to the rehabilitation team's understanding of the individual's functional abilities and serves to identify additional areas for examination and intervention.94,95 (See Chapter 7, Examination of Gait, for a complete discussion.) Substantial differences in fall risks,56 knee ROM, and gait velocity between patients with either OA or RA and their peers without arthritis have been demonstrated.95,96
With RA, alternations in sensation may be evident with the presence of Raynaud's disease or with compression of nerves due to inflammation or joint derangement. Any indication of peripheral neuropathy or nerve involvement should be investigated using standard examination procedures (see Chapter 3, Examination of Sensory Function). Sensory changes resulting from other co-morbidities or from the normal aging process should be considered when appropriate.
Individuals with chronic arthritis experience years of functional and social loss that would stress any person's ability to cope and adapt.97 Although pain is significantly correlated with self-reports of depression, no firm association with function has been identified.98 The overall psychological status of the individual with RA is generally similar to those individuals with other chronic diseases that threaten a severe change in body image and disruption of social integration (see Chapter 26, Psychosocial Disorders). Individuals respond to these threats with various coping strategies to maintain psychological well-being. No single strategy can be deemed definitely better than another, although for individual patients some strategies will lead to better coping and more positive outcomes than others. Exploration of the patient's attitude toward rehabilitation and readiness to make health behavior changes, as well the availability of social support, can assist the therapist in shared goal setting and identifying realistic expectations of future functional ability. Persons with RA face the additional challenges of living with a chronic disease that is characterized by a fluctuating disease course and must learn to adapt their lifestyle, activity level and medication and sleep schedule according to their disease activity. Thus, it is paramount that the therapist works with the patient to set realistic, achievable goals and educate the patient about warning signs of flares to help the patient self-manage.
Anxiety and depression are also common in patients with OA and may alter the pain experience, function, and response to treatment interventions.99 Chronic pain, fatigue, loss of function, and reduced activity levels can all contribute to emotional distress. It is therefore important to recognize the signs of anxiety and depression and, if indicated, refer to appropriate screening services and resources to help individuals manage their psychological symptoms through improved coping skills.100 Participation in the Arthritis Self-Management Program has been shown to improve coping.
Therapists should be aware of environmental factors in the home, work, and leisure environments that might serve as facilitators or barriers to functioning and warrant specific identification, examination, and recommendations to address (see Chapter 9, Examination of Environment.) A discussion about the home and work environments may reveal conditions that threaten independence that can be addressed through ergonomic and environmental modifications and school or workplace accommodations. The costs of such changes may be a limiting factor for implementing these recommendations. The work environment affects employment and disability in more ways than the physical setting and task requirements. Acceptance and understanding by supervisors and co-workers of the disease and self-management requirements of the worker with arthritis are important determinants of maintaining employment and income. Other environmental factors common to both the RA and OA ICF Core Sets include technology and assistive devices for ADL, mobility, transportation, and employment; design and access to buildings; climate; and attitudes of family, friends, and health professionals.62,63,101,102
Physical Therapy Intervention
The development of specific goals and expected outcomes for the individual with arthritis is based on the following general goals and expected outcomes developed in conjunction with the patient (Box 23.4).
The specific goals and outcomes identified for each patient will depend on the type of arthritis, disease activity level, the clinical presentation, and patient preferences in line with patient-centered care. Mutual goal setting promotes patient participation in treatment. It is the physical therapist's responsibility to document the POC, implement that plan safely and effectively, and delegate responsibility appropriately to ensure that the patient's goals can be reached. The therapist should ensure that treatment goals and objectives are measurable, attainable, and documented, with specific timeframes included (e.g., increase left shoulder flexion ROM by 10° in 2 weeks, and independent ambulation with platform crutches on level surfaces for at least 250 feet without fatigue within 1 month). Failure to achieve goals within the stated timeframe indicates the need for reevaluation and reformulation of the goals. Goals and outcomes should be revised to reflect changes owing to both personal and environmental factors that may affect progress or alter the proposed time frames (see Chapter 1, Clinical Decision Making).
Modalities for Pain Relief
A variety of physical agents are available to relieve pain and prepare the patient for passive and dynamic stretching and other exercise interventions. The most common form is thermotherapy.
Superficial heat, heat that penetrates only a few millimeters, produces localized analgesia and increases circulation in the vicinity where it is applied. Types of superficial heat include moist hot packs; dry heating pads; and lamps, paraffin, and hydrotherapy. The evidence supporting the effectiveness of these modalities is weak, but patients often report that they gain comfort from moist heat. Paraffin is particularly useful in delivering superficial heat to irregularly shaped joints or to individuals who cannot tolerate the weight of a moist hot pack. Hydrotherapy allows the therapist to combine heating of tissues with exercise, and provides the patient the experience of aquatic therapy, although it is expensive. Systematic reviews of heat and cold therapy in arthritis suggest small to modest effects.103,104
Deep heating modalities, such as ultrasound, may affect the viscoelastic properties of collagen and increase the plastic stretch of ligaments, providing modest improvements in pain and function in individuals with knee OA.105 However, their efficacy in RA is not demonstrated.106 Their use in treating individuals with RA during the acute stage of inflammation is contraindicated because they may stimulate collagenase activity within the joint, furthering its destruction.107,108 Furthermore, modalities that do not readily translate to home use foster a dependency on clinical care and do not promote self-management.
Local applications of cold will also produce local analgesia, increase superficial circulation at the site of application following an initial period of vasoconstriction, and decrease intra-articular temperature.109 Cold is particularly useful around joints that are inflamed and swollen, a condition that usually worsens with the application of superficial heat modalities. Therapists may use either wet or dry application techniques. Superficial cold is contradicted in patients with Raynaud's phenomenon or cryoglobulinemia, linked to an abnormal protein (cryoglobulins) in the blood that gels at low temperatures. Both may be associated with RA.
Therapists may also wish to consider using other modalities for pain relief in treating the individual with RA, including transcutaneous electrical nerve stimulation (TENS), although the value of TENS as reported in the literature is inconsistent.110,111 A meta-analysis of studies investigating TENS for knee OA pain concluded that the mode of TENS applied did affect results, repeated use was more effective than a single application, and use for at least 4 weeks was the most effective.111
Orthoses, Splints, and Braces
In RA, hand and wrist orthoses may be used to immobilize specific joints and help reduce pain and swelling by providing local rest and support. There are three primary types of splints: functional (used to restore or improve function), corrective (used to improve alignment), and resting (used to maintain joint alignment and reduce pain). Resting splints are worn at night or periodically during the day. There is evidence of small benefits for pain reduction and increased function with the use of functional splints. Hand splints may improve grip and pincher strength.112 There is evidence that wearing functional wrist splints decreases grip strength and does not affect pain, morning stiffness, pinch grip, or quality of life with regular wear.113 A study that investigated the effect of functional wrist splint wear on task performance reported that wearing a commercially available elastic wrist orthosis resulted in some decrement in performance speed on a number of common tasks, though pain was significantly reduced for all tasks.114 There is consistent evidence supporting the use of splints for short- and long-term pain relief in hand OA.115
Foot orthoses also may be used to alleviate pain through biomechanical support or correction for individuals with knee OA. A lateral wedge insole designed to reduce medial compartment stress appears to reduce pain and NSAID use in some individuals with knee OA.116 Other methods that show promise in treating knee OA pain are patellofemoral taping,117 and load shifting or unloader knee braces (stress shifted away from most involved area).116 All orthotic interventions require professional evaluation, selection, education, and monitoring of use.
Complete bed rest is rarely recommended. Adequate quality and quantity of sleep at night and short rests during the day are preferred. General recommendations include 8 to 10 hours of sleep per night and brief 30-minute rest periods during the day. Inactivity is a common problem for people with arthritis and may lead to deconditioning, depression, lower pain thresholds, diminished bone and soft tissue health, and increased risk for other serious health conditions. Thus, a major goal of therapy is to assist the person to maintain or regain adequate levels of physical activity and avoid the unnecessary consequences of inactivity.16
Range of Motion and Flexibility Exercise
A major factor affecting joint mobility in individuals with RA is the level of inflammation and resting position in which specific joints are maintained. For example, intra-articular pressure is reduced when the knee is slightly bent. Although helpful in reducing joint pain, this flexed position may lead to capsular and musculotendonous shortening and eventual contracture. Patients should be taught proper positioning when resting and should be encouraged to perform daily, active ROM as tolerated to maintain motion. Active-assisted, passive, and proprioceptive neuromuscular facilitation (PNF) techniques may also be applied to shortened muscles.118 Pain should be respected at all times and should be minimal during and after exercise. Evoking a pain response during stretching may lead to a reflex contraction of the agonist muscle as opposed to creating a relaxation response. Stretching exercises to lengthen shortened muscles should be performed slowly, held for 20 to 30 seconds two to three days a week or more often if indicated. It is important to educate the patient not to do stretching exercises that involve inflamed, swollen joints because they are at risk for capsular stretching and rupture.119 Common wisdom recommends that exercise-induced pain should subside within 1 hour. If the patient reports discomfort lasting longer than 1 hour, it may indicate that either the technique, intensity, or duration of the exercise was too great and should be reduced or modified at the next exercise session. Patients should be encouraged to exercise on their own during those times of the day when they feel best. Local pain relieving modalities before or immediately after exercise may be useful and increase exercise adherence.
In hip and knee OA, manual therapy may offer some additional benefit within a comprehensive treatment program that includes exercise.118 Manual therapy is not generally recommended for individuals with RA who have joint inflammation or resultant laxity.
Decreased muscle function (strength, endurance, power) in persons with arthritis arises from both direct and indirect effects of the disease. These include intra-articular and extra-articular inflammatory disease elements, side effects of medication, disuse, reflex inhibition in response to pain and joint effusion, impaired proprioception, and loss of mechanical integrity around the joint. A variety of conditioning programs can be effective for improving strength, endurance, and function without exacerbation of pain or disease activity.
Initially, isometric exercise may be indicated to improve muscle tone, strength, and static endurance; to recruit or activate specific muscles; and to prepare joints for more vigorous activity. Although isometric exercise does avoid dynamic joint stress and mechanical irritation, it can produce other unwanted effects. Isometric exercise performed at more than 50% of maximal voluntary contraction constricts blood flow through the exercising muscle, leading to post-exercise muscle soreness, and the increased peripheral vascular resistance produces increased blood pressure.119 In the knee and hip, high-intensity isometric contractions are associated with significant increases in intra-articular pressure and reduce synovial circulation.120,121,122 Patients with cardiovascular disease should perform these exercises with caution and be sure to breathe during the contraction because holding one's breath can increase intra-abdominal pressure (Valsalva maneuver). Patient instructions for isometric exercise should include the cautions to (1) maintain the contraction for no more than 6 seconds; (2) avoid maximal effort because it is neither necessary nor desirable; (3) exhale during the contraction and inhale during a similar time period of relaxation; and (4) not contract more than two muscle groups at a time.
Dynamic exercise includes both shortening (concentric) and lengthening (eccentric) contractions. Strength and endurance may be improved through resistance (physiological overload) supplied by weight of the body part or external resistance in the form of free weights, elastic bands, or a variety of resistive exercise equipment. A cautious approach to resistance training is recommended to protect unstable or inflamed joints from damage.16,119 Strengthening exercise should be performed within the pain-free range. Maximum benefit and maintenance can be achieved by incorporating functional movements and body positions in the recommended exercise routine. The use of well-controlled smooth movement toward the end part of the range is advised, and modifications to resistance, repetitions, or frequency are recommended as needed. Gradual progression of resistance and repetition is recommended. Reduce exercise intensity, frequency, or motion if increased joint swelling or pain occurs (local inflammatory response).
Individuals with RA benefit from maintaining or restoring muscular fitness. A number of well-controlled studies have reported on strengthening programs that provide overload with results indicating positive adaptations in muscle and functional performance with no exacerbation of disease symptoms. Data from selected RA exercise studies are presented in Box 23.5 Evidence Summary.123-135 Loads of up to 70% one repetition maximum (1RM) used in a circuit training resistance program for persons with controlled RA demonstrated no exacerbation in joint symptoms and significant improvements in strength and function.123,124,126,128
Box 23.5 Evidence Summary Therapeutic Exercise in the Management of Rheumatoid Arthritis (RA)
|Author (yr) ||Design and Sample ||Intervention ||Adherence ||Outcomes |
|Hakkinen et al123 (2001) || |
RCT. 70 pts w/recent onset RA. 24 month study. No pt had taken glucocorticoids or DMARDs previously.
Random assignment to 2 groups. Randomization performed by clustering pts according to age (<50, >50 yo) and sex to keep groups comparable.
Strength training group: all major ms @ 50-70% 1RM. 8-12 reps x 2. ∼45' per session 2x/wk. (intensity re-evaled every 6 months) Total mins/wk: 90' ROM group: no resistance, only ROM and stretching 2x/wk.
All encouraged to participate in recreational activities 2-3x/wk (30-45' ea.) Training diaries examined @ 6-month intervals. All treated w/meds to achieve disease remission.
62 pts completed study.
Strength group compliance = 1.4-1.5x/wk.
Sig incr ms strength (19-59%).
Sig improvements in clinical disease activity parameters, HAQ scores, and walking speed in the strength group.
Improvements in ms strength, disease activity parameters, and phys funx in control group but < strength group.
"Regular dynamic strength training combined w/endurance-type PA improves ms strength and phys funx, but not BMD∗, in pts w/early RA, w/out detrimental effects on disease activity."
|Baillet et al 124 (2009) || |
RCT. Data collected at 1, 6, and 12 months. 50 patients. All pts treated with DMARD before enrollment. ECG performed on every pt, all had consultation w/cardiologist (pts > 45 yo, + CVD risk factors or abnorm ECG).
Exclusion criteria: tx w/>10 mg glucocorticoid/day, no/unstable DMARD regimen, disease activity score 28 variation >1.2 past 3 months, an age <18 >70 yo and global funx status RA class III or IV. Pts unable to follow the programme (complete ex, follow-ups, educational programme or complete questionnaire) excluded.
Needed: 38 pts in DEP group. 76 pts in control group (conventional jt rehab). But sample size limited to 50.
1st week = educational/testing meetings
2nd week = occupational therapy - RA on ADLs
3rd week = OT skill ex and ADLs w/incr intensity (against resistance).
4th week = ex focused on office tasks.
Training programme: improve ms strength, flex, endurance, balance. 5x/wk in gym (45'/day) and pool (60'/day). Cycling activity = HR 60-80% HRM.
Resistance/intensity ex designed indivi dually. Scheduled breaks and relaxation sessions for p! tolerance/psycho-soc. "warm-up" and "cool-down" for each session. Pts kept a diary.
Multidisciplinary prog -3 day intervention (∼20H) designed to incr knowledge of disease, management, jt protection. Hydrotherapy (45' @ 35°C) 1st day, relaxation 45' 2nd day, phys ex (45 min/day) to prevent atrophy and tension.
25 randomly placed on DEP. 25 into control group.
2 individuals left after randomization. No pts lost to follow-up.
1 not assessed for NHP and AIMS2-SF @ 1 month.
3 pts not assessed @ 6 months. 4 not assessed @ 12 months.
|HAQ (primary outcome) improved throughout length of trial in the DEP group∗∗ improvement > DEP than standard joint rehab group @ 1 month but not 6 months or 12. DEP improved NHP (Nottingham HealthProfile) and aerobic fitness @ 1 month but not after. DEP improved DHI, SODA, DAS 28, AIMS2-SF, but not sig. |
|de Jong et al126 (2003) || |
RCT. Testing effectiveness and safety of a 2-yr intensive ex program (RAPIT) w/those of PT - aka UC-usual care.
309 RA pts assigned to RAPIT or UC. Primary end points funx ability (MACTAR), Pt preference disability questionnaire, and HAQ and effects on x-ray progression in large joints.
Stratified for age (<50 and >50) and sex put into random digit generator.
2x/wk ex prog 1.25 hrs/session. 2.5 hrs/week.
3 parts per session: bike training (20'), ex circuit (20') and sport/game (20'). Each session had "warm-up" and "cool-down".
Bike settings based on 1) HR during ride 2) RPE (0-10). HR kept @ ∼70-90% HRM and RPE @ 4-5.
Ex circuit: 8-10 ex for ms strength, endurance, jt mobility, ADLs. Ex: rest→90 sec/60 sec 1st weeks - 90 sec/30 sec after 6 months. Each ex repeated 8-15x.
Sport/game section: impact-delivering sport activities. Impact loading also during "warm-up" and "ex circuit" portions. UC group:
Tx by PT only if regarded as necessary by MD. All pts MDs had choice for med selection and other tx strategies (except high-intensity WB ex).
Needed 119 pts/group for statistical sig. planned to enroll @ least 150/group. Used 309 pts. RAPIT group slightly younger 45 yo vs 47 yo mean. > proportion of females - 79% vs 72%.
9 pts randomized but refused participation.
Lost 5 pts in UC and 14 in RAPIT over the 2 yrs. 14 other RAPIT pts failed to attend ex classes but were reg evaled. Median % of sessions attended was 74%. 65% had high attendance rate first 6 months, 49% second 6 month period and stable thereafter.
After 2 yrs RAPIT > improvement in funx ability than UC. Mean difference in change of MACTAR was 2.6 1st year and 3.1 2ndyear. 2 yr mean HAQ change -0.09. Median x-ray damage didn't incr in either group.
Both groups w/considerable baseline damage showed progression in damage (more obvious in RAPIT group). RAPIT effective in improving emotional status. No detrimental effects on DA were found.
"Long-term high-intensity ex program is more effective than UC in improving funx ability of RA pts. Intensive ex does not incr x-ray damage of the lrg jts, except possibly in pts w/considerable baseline damage of the lrg jts."
|Eversden L, et al127 (2007) || |
RCT. Hydrotherapy vs Land Ex. Effects on overall response to tx, phys funx, and QOL.
115 pts randomly assigned.
Men and woman 18 yo+ w/RA in funx classes 1-3 in Birmingham clinics Required to understand and follow simple instructions in English.
Stable dose of DMARDs for 6 weeks and NSAIDs for 2 weeks before entry. No injections of corticosteroids allowed in 4 wks before study.
Excluded pts w/sx 3 months prior or scheduled, pts who'd received PT or hydrotherapy in 6 months before study. Pts w/chlorine sensitivity, infected open wound, incontinence of faeces, poorly controlled epilepsy, HTN, DM, and fear of water were excluded from hydroptherapy.
Excluded: pregnant women, pts w/co-morbid conditions preventing safe use of hydrotherapy, known carries of staph in the URT and weighing >102 kg b/c of safety procedures for the pool.
30' session 1x/wk for 6 weeks (both water and land groups).
Pts allowed to default up to 3 sessions as long as 6 were completed. HEP given to all pts - not required to do ex b/n tx but could if desired. Group sizes 1-4 for hydro and 1-6 for land ex @ a time.
Ex tailored to each pts ability. "Warm up" = mobilizing and stretching. Core ex focused on jt mobility, ms strength, and funx activities.
Degree of difficulty reviewed weekly to ensure progress.
"Cool down" phase after each session.
|11 pts did not complete tx in land ex. 4 pts did not complete in hydrotherapy. Goal to recruit 60 pts into each of the groups. 115 pts were randomized. 57 pts in hydrotherapy (46 had data collection-primary outcome). 58 pts in land (40 pts had primary outcome data). || |
Primary outcome: self-rated global impression of change -7pt scale.
Secondary outcomes: EuroQol health related QOL, EuroQol health status valuation, HAQ, 10m walk time, p! scores-collected @ baseline, after tx, 3 months later.
Hydrotherapy pts sig "much better" or "very much better" than land ex. 10m walk test improved in both groups. No sig diff b/n groups in HAQ, EQ-5D utility score EQ VAS and pain VAS.
"Pts w/RA treated w/hydrotherapy are more likely to report feeling much better or very much better than those w/land ex immediately on completion of the tx programme. This perceived benefit was not reflected by differences b/n groups in 10m walk times, funx scores, QOL measures and pain scores.
|Lemmey et al128 (2009) ||RCT. "Efficacy of high-intensity progressive resistive training (PRT) in restoring ms mass and funx in pts w/RA" also to "investigate the role of the insulin-like growth factor (IGF) system in ex-induced ms hypertrophy in the context of RA." 28 pts w/est controlled RA. Conducted July 2004-January 2007. || |
2 groups: 2x/wk PRT (n=13) or range of mvt home ex control group (n=15).
Dual x-ray absorptiometry-assessed body comp; objective phys funx; disease activity; and ms IFG's assessed @ weeks 0 and 24.
Stratified by age, sex and estrogen status.
Assessments done @ baseline and immediately following 24 wk training period. Pts required to fast and refrained from ex for 24 hrs.
24 wks, 2x/wk. 3x8 @ load of 80% 1RM per ex. 1-2' rest b/n ex. leg press, chest press, leg ext, seated row, leg curl, triceps ext, standing calf raises, and bicep curl. Goal to achieve hypertrophy.
1 set completed in 1st week
2 sets 2nd week
15 reps/set @ 60% of 1RM wks 1-4.
12 reps/set @ 70% 1RM 5-6 wks.
8 reps/set @ 80 % max weeks 7-24 1RM reassessed every 4 wks.
"warm up" and "cool down" periods - 10' ea. Low-intensity ROM ex. asked to perform these 2x/wk at home (ROM ex). ROM was control condition b/c most commonly prescribed for Pts w/RA.
All completed training diary to check for compliance and adverse effects. Control pts phoned every 2 weeks.
Needed sample size for each group = 5 subjects. Aimed for 18 subjects to cover drop out. (36 total) 36 individuals were randomized into 2 groups. 28 attended baseline assessment and commenced training.
PRT: 48 scheduled sessions - completed avg 34.6 sessions. (73%) ROM ex group: good compliance avg 25.9 sessions (54%).
PRT incr LBM and ALM (appendicular lean mass); reduced trunk fat mass by 2.5 kg (not sig); and improved training-specific strength by 119%, chair stands by 30%, knee ext strength by 25%, arm curls by 23%, and walk time by 17%.
Body comp and phys funx remained unchanged in control patients. Changes in LBM and regional lean mass assoc w/changes in objective funx.
Coinciding w/ms hypertrophy, previously diminished ms levels of IGF-1 and IGF binding protein 3 both incr following PRT
"In an RCT, 24 weeks of PRT proved safe and effective in restoring lean mass and funx in pts with RA. Ms hypertrophy coincided w/sig elevations of attenuated ms IGF levels, revealing a possible contributory mechanism for rheumatoid cachexia. PRT should feature in disease management."
|Smidt et al129 (2005) || |
Summarize available evidence on effectiveness of ex therapy for pts w/disorders of ms, nervous, respiratory, and cv systems. Systematic reviews. OA: 7 reviews for hip/knee OA. 3 reasonable/good quality reviews: ex therapy, consisting of strengthening, stretching and funx ex is effective for pt with knee OA compared to no tx. Indications that ex therapy is effective for pts w/hip OA - based on 1 large RCT. Insufficient evidence to support/refute the effectiveness of a specific type of ex therapy (individual, group, hydro tx) for pts w/knee or hip OA.
(Fransen et al 2002, Mc-Carty and Oldham 1999, Pendleton et al 2000, Petrella 2000, Philadelphia Panel 2001a, Puett and Griffin 1994, van Baar et al 1998a, Van Baar et al 1999, van Baar et al 2001)
"Ex therapy, consisting of strengthening, stretching, and functional exercises, is effective for patients with knee OA, compared to no tx" - Fransen, Philadelphia panel, van Baar 1998a, Van Baar 1999, and 2001.
One large RCT stated "ex therapy is effective for pts w/hip OA" - van Baar et al 1998b.
"Insufficient evidence to support or refute the effectiveness of a specific type of exercise therapy (individual, group therapy, or hydrotherapy) for pts with knee or hip OA."
Used overview of each systematic review (>60 pts) was made. Categorized according to quality score: good (>80), reasonable quality (60-79), mod quality (40-59), poor (20-39) and very poor (<20). Used reasonable (60-70) and good (>80).
Conclusions were discussed with panel of experts and categorization of conclusion based on 2 research questions:
A) What is the effectiveness of ex therapy, compared to no tx, a placebo, or a wait-and-see policy? B) What is the effectiveness of ex therapy, compared to other tx (steroid injections)? Is one specific type of ex therapy more effective than others?
104 sys reviews selected. 45 = good quality. Overall inter-rater agreement for quality assessment was (86%). Most disagreements caused by differences interpretation when discussing the power of RCT and heterogeneity of RCT and outcomes.
RA: 2 systematic reviews investigated the effectiveness of ex therapy for pts with RA.
(Augustinus et al 2000, van den Ende et al 1998, van den Ende et al 2002). One systematic review → conclusion there is insufficient evidence to support or refute the effectiveness of ex therapy for patients w/rheumatoid arthritis. (van den Ende 1998 and 2002).
|Ex therapy effective for pts w/knee OA, sub-acute (6-12 wks) and chronic (>12 wks) lbp, therapy is effective for pts w/ankylosing spony, hip OA, Parkinson's disease, pts w/stroke. Insufficient evidence to support/refute effectiveness for neck pain, shld pain, repetitive strain injury, RA, asthma, and bronchiectasis. NOT effective for pts w/acute LBP. Effective for wide range of chronic disorders. |
|Ottawa Panel 130 (2004) ||Create guidelines for the use of ther ex and manual therapy in the management of adult patients (.18 yo) w/a dx of RA. Evidence from comparative controlled trials ID and synthesized using Cochrane Collaboration methods. || |
Set inclusion/exclusion criteria with a panel of 9 experts. Performed Lit search for RCTs-expanded to case-control, cohort, and non RCTs.
Rehab interventions: IDed as specific funx strengthening ex, whole-body funx strengthening ex, and PA. comparators = placebo, untx or use of ed pamphlets or written instructions for self-management.
16 studies out of 2,280 potential articles.
862 articles for manual therapy -4 had potential-none included. Concluded: ther ex - including specific funx strengthening and whole-body funx strengthening are a beneficial intervention for pts with RA - benefit may vary according to disease acuity and the time frame during which the outcomes are measured. Clinical benefits: pain relief, upper-limb (grip) and lower-limb force, and funx status
Other benefits: improved overall funx, and decr number of sick leaves.
6 + recommendations clinical benefit were developed on therapeutic ex. The efficacy of manual therapy intervention could not be determined for lack of evidence.
6 + recommendations of clinical benefit were developed on ther ex. efficacy of man therapy interventions could not be determined for lack of evidence.
Panel recommends use of ther ex for RA. Further research is needed to determine efficacy of manual therapy in the management of this disease.
Recommend: knee funx strengthening, whole-body funx strengthening, general PA, and whole-body, low-intensity ex, for the management RA. Evidence is lacking for shld/hand strengthening ex and whole-body, high-intensity ex or manual therapy.
|Bearne 131 (2002) || |
Compare quadriceps sensorimotor funx, lower limb funx performance and disability in pts w/RA and healthy subjects and to investigate the efficacy and safety of a brief rehab regime.
Quad strength, voluntary activation, proprioceptive acuity and the aggregate time to perform 4 common activities - compared b/n 103 RA pts w/lower limb involvement and 25 healthy subjects.
Quad strength/voluntary activation: strain gauge system attached to specially constructed chair - seated w/hip/knee flex 90 deg. Used percutaneous estim on voluntary isometric contraction. Recorded 3 max voluntary contractions and analyzed. Weakest leg = "index leg". Recorded ms strength and voluntary activation using strongest MVC of the index leg for analysis.
Rehabilitation: 47 pts randomized to begin immediately, 41 pts delayed. 10 ex sessions (2 x/wk x 5 wks) - simple, progressive, individually prescribed ex designed to incr quad strength, address each pt's disabilities and improve balance and coordination, using inexpensive and unsophisticated equip. Each ex session had warm-up ex (i.e., 5 mins cycling), 24 isometric MVCs (4 sets x 6 contractions -1 min rest between each) @ 90 deg knee flex to incr quad strength, 3 individually prescribed funx ex (sit-to-stand, step-ups etc) and 3 balance ex - 1-5 min and # reps recorded. Pts were encouraged and given feedback on performance.
Each ex session = 30-40 mins.
|Measured: Health Assessment Questionnaire, clinical disease activity and plasma concentration of proinflammatory cytokines were measured in the RA pts. || |
RA pts had weaker quads, poorer activation, and proprioceptive acuity and took longer to perform AFPT.
Rehab incr quad strength and voluntary activation and subjective disability w/out exacerbating disease activity.
All improvements maintained @ 6 month follow-up.
No change during control period.
|Brorsson et al132 (2009) || |
"To eval the effects of hand ex in pts with RA, and to compare the results with healthy controls."
40 women (20 w/RA and 20 healthy) performed hand ex programme. Results evaluated after 6 and 12 wks w/hand force measurements. Hand funx was evaluated with Grip Ability Test (GAT) and with patient relevant questionnaires-Disability of the arm, Shoulder, and Hand-DASH and Short Form-36. US measurements performed on EDC for analysis of ms response to ex programme.
Study period: 18 wks-examined @ 6 wk intervals. 2 baseline exams completed before ex regimen began. (week 0).
Ex prog performed for 12 wks. Designed according to Flat (reference 12) and performed: 5x/wk, each task x 10 and position of max effort held 3-5 sec with 20 sec rest b/n reps. Ex sessions separated by @ least 1 day.
Ex program took 10 min to complete - used therapeutic putty (85g). pts chose soft, medium, or firm putty. Pts kept diaries during training period to declare all ex.
|40 subjects recruited - 2 control and 2 RA pts withdrew = 36 completed the study. || |
"The ext and flex force improved in both groups after 6 wks. Hand funx (GAT) also improved in both groups. The RA group showed improvement in the results of the DASH questionnaire. The cross-sectional area of the EDC incr significantly in both groups measured with US."
Conclusion: "A sig improvement in hand force and hand funx in pts with RA was seen after 6 weeks of hand training; the improvement was even more pronounced after 12 wks. Hand ex is thus an effective intervention for RA pts, leading to better strength and funx."
|Crowley 133 (2009) || |
"Review of literature….evaluate the effectiveness of HEP for pts w/RA."
Searched 7 databases.
| || |
8 papers out of 18 were included. All had high risk of bias.
"Results show that HEP are effective in improving ms strength, jt mobility, shld funx, and self-efficacy and reducing morning stiffness, number of tender/swollen jts, and p! w/out incr inflammation or disease activity"
|"The results of this review highlight the benefits of HEP for pts w/RA, when encompassed physical, funx, and QOL domains. Further research is needed to confirm these findings." |
|Hsieh et al 134 (2009) || |
"Compare the effectiveness and safety of supervised aerobic ex and home aerobic ex in female Chinese pts with RA".
30 patients w/RA assigned to group.
Supervised aerobic ex prog supervised by PT, home program done @ home after 1 instructional session.
|1 hr ex: 3 x/wk x 8 wks. Aerobic capacity and disease-related variables, including p! intensity, funx ability, psychological status and jt funx were measured. 10 min stretching, 10 min warm-up, 30 min pool ex, 10 min cool down. Objective to allow target HR of 50-80% VO2 peak for @ least 30 mins. Multiple short sessions were allowed for total of 30 mins. Used daily logs for self-monitoring of duration intensity and freq of ex. called every 2 wks and checked ex log @ end of 8wk prog. || |
38 patients recruited → 30 pts randomized into 2 groups. All completed study.
Most pts ACR class II.
"An 8 wk supervised aerobic ex prog induced sig improvement in aerobic capacity of female Chinese patients w/RA, and was superior to a home aerobic ex prog. Both prog of aerobic ex were safe for female Chinese pts with RA."
Compliance in SAE = 100%, HAE = 52% ranging 32-75%. No sig diff in baseline data b/n groups.
Within-group: variables of ex tolerance test (VO2, MET, work, O2 pulse, SBP @ peak CV response and VO2, MET @ ventilator threshold) = sig improvement found in SAE group but not HAE.
Stat sig diff observed for b/n group comparisons b/n SAE and HAE w/changed score b/n baseline data and post-ex data in Vo2, MET, work, O2 pulse, and SBPT @ peak CV response.
Sig diff b/n group comparison in changed score of VO2 and MET @ vent threshold. SAE induced mean improvements of 20%, 16%, 14% in VO2 peak, peak workload, and O2 pulse respectively. No sig difference b/n groups for disease-related measures except global self-assessment and global MD assessment.
Within group SAE = sig diff for global p! intensity, ADL p! scale, grip strength, walking time, and global self-assessment. HAE group = sig ex effect in global p! intensity, ADL pain scale, and walking time. No sig b/n group diff regarding changed score b/n baseline data and post-ex data for disease-related measures.
|Kennedy135 (2006) ||Eval the outcome of intensive ex prog for pts with RA on bone mineral density and disease activity. Searched 6 databases. Included: papers investigating the effect of aerobic and/or strengthening prog on pts w/RA. 11 papers out of 30 returned were included; 4 of 11 had low risk of bias. 1999-2004. || |
van den Ende et al 2000–20 female pts. Sample size 64. Isometric and isokinetic ms strength + bicycling for 15 min, 3x/wk @ 60% age predicted max + usual care vs usual care (ROM + isometric).
Outcome measures: disease activity, ms strength, jt mobility, funx ability.
Results: Incr ms strength and physical funx w/no incr disease activity in intensive ex group.
de Jong et al 2003 - 237 female pts, n = 309. RAPIT prog: 2x/wk: (i) bike training (20 in @ 70-90% max HR); (ii) ex circuit (20 min)p (iii) sport/game (20 min) vs usual care.
Outcome measures: Disease activity, funx ability, physical capacity, emotional status, radiographic damage.
Results: No detrimental effects on disease activity. Funx ability improved more than "usual care" group. Emotional status improved in RAPIT group. Pts w/baseline jt damage showed more progression of jt damage.
de Jong et al 2004 - 237 female, n = 309. Intervention same as above.
Outcome measures: Disease activity, physical capacity, funx ability, radiological damage of small and lrg jt x-rays, BMD of hip and lumbar spine.
Results: Decr in BMD in femoral head only both groups, smaller decr in RAPIT groups.
de Jong et al 2004 - 237 female, n = 309. Intervention per de Jong 2003.
Outcome measures: Rate of radiographic progression of damage in hands and feet (Larsen score)
Results: sig less radiological damage in small jts.
30 articles = RCTs of ex in RA. Used a total of 11 papers. Only
4 studies had low level of bias. Review focused on results
of the 4 low biased studies.
|"Ex prog for pts w/RA don't incr disease activity, are safe, and slow down the loss of bone mineral in the hip. Results of this review highlight the safety and benefits of aerobic and dynamic strengthening ex prog for pts w/RA." |
|Williams et al136 (2010) ||"To evaluate the feasibility and gait stability and balance outcomes of a 4-month individualized HEP for women w/arthritis." Pre-post interventional study. || |
Initial assessment, then all participants received home balance ex from PT based on assessment findings and ex available from commercially available kits. All measures repeated 4 months later.
Main outcome measures: Falls risk and balance measures. Intervention: Pts visited @ home by PT to start prog. Complete ex 5x/wk for 4 months. Balance, strengthening and walking ex were selected from Otago ex prog and Visual Health Information Ex Prescription Kits - Balance & Vestibular Rehab set.
Participants received an ex folder including: description, graphics and dosage of each ex, ex calendar for each moth of prog. If ex weights were required = provided by PT.
Given b/n 4-8 ex (∼20-30 mins including rests) as well as recommendation to walk in the community @ least 3x/wk. Reviewed ex @ home on 2 occasions. 4 and 8 wk marks.
Modifications made as needed.
N = 49, females. LL OA or LL RA. Only 39 were eligible and completed study.
66.7% adherence to prog.
"At baseline, 64% of participants reported falling in the preceding 12 months, avg falls risk-Falls Risk of Older People-Community Setting - score was 14.5 w/42% rated as moderate risk.
Pts achieved and improved performance on most balance and related measures after ex prog including falls risk, activity levels, fear of falling, funx reach test, rising index for sit to stand, step width in walking, and body mass index."
"An individualized balance training hEP is feasible for older women with OA and RA and may improve stability during walking and other funx activities."
Designing exercise interventions for individuals with RA requires careful consideration of the patient's disease activity, disease severity, and systemic disease features. Persons with RA in an active flare-up should limit their exercise to daily ROM exercises incorporated into ADLs to promote adherence to active joint movement and isometric exercises to promote strength. Walking as tolerated is encouraged together with daily periods of rest and a full night of sleep to manage fatigue. When the disease activity subsides, the exercise program can be progressed by adding dynamic strengthening exercises, with caution to avoid stress on deranged joints or cysts, and greater repetitions of isometric exercises as well as greater engagement in physical activity. When the disease is in remission, aerobic exercises and dynamic exercises with resistance should be considered to promote cardiovascular health and improve strength and conditioning.16
In persons with knee OA, the evidence is strong and consistent that LE exercise that includes neuromuscular and functional training reduces pain and improves function. Interventions have included isometric, isotonic, and functional exercise, as well as proprioceptive and balance training. Interventions have been tested in both clinically supervised and self-directed settings with positive results and acceptable adherence.97,136 Evidence supporting the use of exercise in the management of knee and hip OA is presented in Box 23.6 Evidence Summary.137,138,139,140,141,142 Physical therapists should routinely incorporate strategies to enhance patient motivation and adherence to the therapeutic exercise and home exercise programs (HEPs) including exercise booster sessions (periodic follow-up appointments), goal setting, and other self-efficacy enhancing practices.119
Box 23.6 Evidence Summary Therapeutic Exercise in the Management of Knee and Hip Osteoarthritis (OA)
|Reference ||Subjects ||Methods ||Duration/Dosage ||Results/Comments |
|Bartels et al 137 (2007) ||Patients with OA in one or both knees or hips. 800 subjects in total with mean reported age ranging from 66 to 71 years. ||Systematic review of 6 RCTs or quasi-experimental studies up to May 2006, compared aquatic-exercise interventions to land-based exercise. ||Aquatic exercises ranged from 6 weeks to 3 months and 2 to 3 sessions/week. || |
Mixed findings, with small to moderate short-term improvements in function and HRQoL, and minimal to large reduction in pain immediately following intervention. No changes in stiffness or walking ability.
Authors commented that aquatic exercise may be a beneficial first step in an exercise therapy program to get particularly disabled patients introduced to training.
|Pisters et al 141 (2007) ||Patients with OA of the hip or knee. 1721 subjects in total. No mean ages provided. ||Systematic review of 11 RCTs or controlled clinical trials up to Nov 2005 in Dutch, German, or English languages. Compared long term (≥ 6 month follow-up) effects of exercise therapy compared to a control intervention. ||Exercise therapy ranged from 1 to 12 months and follow-up period from 6 to 15 months. ||Significant small to moderate benefits for pain that weren't maintained at long-term follow-up. Nonsignificant effects on self-reported function and conflicting evidence for performance-based function. Moderate evidence that additional post-treatment booster sessions had a positive influence on maintenance of the post-treatment effects in the long term. Authors comment that better adherence was associated with better patient outcomes and future research should focus on how exercise behavior can be stimulated and maintained in the long term. |
|Fransen and McConnell 138 (2008) ||Adults with established diagnosis of knee OA or self-reported knee OA. 3719 subjects in total with mean age ranging from 61 to 74 years. ||Systematic review of 32 RCTs up to Dec 2007, compared land-based, therapeutic exercise to non-exercise control group. ||Exercise intervention ranged from 4 weeks to 12 months and <1 to 3x/week ||Small to moderate short-term beneficial treatment effects for pain and self-reported physical function. Benefits, however, are comparable to reported estimates for current simple analgesics and NSAIDs taken for knee pain. Authors also noted that it is clear that most people with knee OA need some form of ongoing monitoring or supervision to enable an exercise program to provide optimal clinical benefits. |
|Fransen et al139 (2009) ||Adults with established hip OA. 204 subjects in total with mean age ranging from 65 to 70 years. ||Systematic review of 5 RCTs up to Aug 2008, comparing some form of land-based therapeutic exercise with non-exercise control group. ||Exercise intervention ranged from 6 to 12 weeks and 1 to 3x/week. ||Small short-term beneficial treatment effect for pain, but no benefit for self-reported physical function. With most studies including people with either hip or knee OA, authors raise the question as to whether a non-joint specific exercise program can maximize treatment benefit. |
|McNair et al140 (2009) ||Patients with clinically and/or radiographic confirmed hip OA only. 356 subjects in total with mean age ranging from 66 to 72 years ||Systematic review of 6 RCTs and quasi-experimental studies up to June 2008, compared a minimum of 3 weeks of exercise therapy to comparison intervention. ||Exercise interventions ranged from 5 to 8 weeks and 1 to 2 sessions/week ||Only 1 high quality trial, "insufficient evidence" to support exercise as treatment to reduce pain, improve function, and limited evidence for enhanced HRQoL. Exercise programs in included studies did not meet current exercise guidelines (intensity, volume, progression). Authors commented that this was insufficient description of progression of training regimens, a fundamental requirement of successful exercise programs. The authors further commented that there remains a paucity of articles addressing the effects of exercise on hip OA specifically. |
|Jansen et al142 (2011) ||Adults with knee OA ||Systematic review of 12 RCTs; compared strength training alone, exercise therapy alone and exercise therapy plus manual therapy compared to non-exercise control. ||Variable durations ||Small to moderate beneficial effects of each intervention type for pain. Exercise plus manual mobilization improved pain significantly more than exercise alone. Each intervention also improved physical function significantly. |
Individuals with RA or OA are usually deconditioned compared to their age-matched peers. A number of systematic reviews and well-controlled trials have reported improvements in aerobic capacity and activity levels through regular cardiovascular conditioning without aggravating joints and other disease symptoms.16,24,125,130 Programs and guidelines appropriate for healthy adults or older individuals can be instituted following the Centers for Disease Control and Prevention (CDC) recommendations for exercise, which suggest 30 minutes of moderate-intensity exercise five times per week143 or the more recent guidelines to accumulate 150 minutes each week.144 If weight-bearing is a barrier to exercise, low– or non–weight-bearing activities such as stationary cycling, pool-based aerobics, or deep water running may be options.16,127,145 For most people, walking and stationary bicycles are a safe and effective means of aerobic exercise.16,145 Furthermore, patients who have engaged in such a program often report an increase in self-esteem and improved emotional status.16 Medical screening as appropriate for age and medical condition (e.g., Revised Physical Activity Readiness Questionnaire [PAR-Q]) should be performed before beginning an aerobic exercise program.
Functional training for the individual with arthritis proceeds in the same fashion as for other individuals with similar deficits. Therapists may choose to reduce the functional demands of an activity either temporarily, such as under conditions of acute inflammation, or permanently by incorporating a variety of adaptive equipment into ADL that substitute for lost ROM and strength. These modifications can include long-handled appliances and devices with built-up handles for easier grasp. There are aids for dressing and grooming, as well as personal hygiene. By breaking down functional tasks, such as rising from a chair or climbing stairs, into smaller movements, the therapist can help the patient identify faulty movement patterns and address specific components of the movement that are causing difficulty.
UE involvement in RA, particularly of the wrist and hands, may complicate the choice of an ambulatory assistive device by precluding any weight-bearing on these affected joints. In these instances, platform attachments can be used to transform the forearm into a weight-bearing surface. Rearranging the home or work environment also can improve a person's functional abilities. Raising beds or chairs can reduce the effort needed to stand up. Railings placed around the bed, bath, and along stairways also can help increase an individual's independence.
Gait and Balance Training
Specific deviations will be evident throughout the gait cycle. These may include gait asymmetries, decreased velocity, cadence and stride length, prolonged period of double support, inadequate initial contact and push-off, and diminished joint excursion through both swing and stance. Gait deviations in the patient with RA, specifically owing to foot pain or deformities, may also be evident (Table 23.6).146,147 Therapists should address the underlying joint and muscle impairments that contribute to these deviations in the gait training program with persons with any type of arthritis.
Table 23.6Analysis of Gait Deviations, Physical Examination Findings, and Treatment Goals ||Download (.pdf) Table 23.6 Analysis of Gait Deviations, Physical Examination Findings, and Treatment Goals
|Gait Deviations ||Physical Examination Findings ||Treatment Goals |
|Pronated Foot |
Decreased step length
Initial contact with medial
border of foot
Late heel rise
Plantarflexion of ipsilateral
ankle in swing
Genu valgus with
Tenderness over subtalar midtarsal area
Limited inversion range
Weak and painful posterior tibialis
Pronated weight-bearing posture
Lax medial collateral ligament of knee
Relieve subtalar and midtarsal joint stresses
Increase ankle inversion
Strengthen posterior tibialis muscle
Stabilize hypermobile joints with rigid orthosis
Maintain neutral alignment in stance by foot
|Hallux Valgus |
|Lateral and posterior weight shift Late heel rise Decreased single-limb balance || |
Lateral deviation of great toe Swelling of first MTP joint Shortening of flexor hallucis brevis muscle
Tenderness of great toe Weakness of great toe abduction
|Accommodate foot with wide toe box shoe Increase extension of great toe Relieve weight-bearing stresses |
|Metatarsophalangeal Joint Subluxation |
|Diminished roll off Decreased single-limb stance Apropulsive progression Decreased single-limb balance ||Painful MTP heads with weight-bearing Callus formation over MTP heads Ulcerations over MTP heads Limited MTP flexion Prominent MTP heads ||Redistribute pressure with metatarsal bar Relieve pressure with soft cutout shoe insert Increase flexion mobility of MTP joints Accommodate foot with extra-depth shoe |
|Hammer or Claw Toes |
|Diminished roll off Decreased single-limb stance Apropulsive progression Decreased single-limb balance || |
Posture of MTP joint hyperextension with proximal and distal interphalangeal joint flexion
Posture of MTP and distal interphalangeal joint hyperextension with proximal interphalangeal flexion Callus formation at plantar tips and dorsum of proximal interphalangeal joint Limited MTP flexion
Improve toe alignment with metatarsal bar Accommodate foot with extra-depth shoe
Diminish pressure with soft insert Increase toe mobility
|Painful Heel |
|Toe-heel pattern No heel contact in stance Decreased stride length Decreased velocity Plantarflexion of ankle in swing Increased hip flexion in swing Decreased step length of contralateral limb || |
Painful active plantarflexion
Painful passive and active dorsiflexion
Swelling and pain at Achilles insertion
Tenderness over spur
Decreased ankle dorsiflexion range
Decrease inflammation with steroid injection or modalities
Relieve weight-bearing stress
Decrease pressure over spur with soft shoe insert
Maintain ankle mobility
The degree to which the gait of an individual with arthritis should, or can, approximate normal is one of the most difficult questions in designing a therapeutic program. Some "abnormalities" such as antalgic limping may in fact reduce joint loading. Joint destruction may necessitate the introduction of assistive devices as simple as a standard cane or as cumbersome as platform crutches or rolling walkers with platform attachments. The gait of the individual with RA or OA should be safe, functional, and cosmetically acceptable to the patient rather than an unattainable idealized version of the norm. Use of a properly fitted, standard cane in the contralateral hand is associated with decreased joint loading and pain in individuals with both hip and knee OA.
Decreased walking speed in arthritis is common, and there is general agreement that increased speed is a meaningful measure of functional improvement. For example, a person's ability to walk fast enough to cross the street with the timing of the traffic light is important for functional and safe community locomotion. However, increased walking speed without attention to joint biomechanics may be undesirable. In a clinical trial of a nonsteroidal drug for persons with knee OA, all with a varus deformity, gait variables were included as outcome measures. The researchers found that self-reported pain diminished and walking speed increased in the active therapy group. At the same time, kinetic analysis of joint forces showed the increased speed was accompanied by increased adductor moment at the knee and greater loading of the medial compartment.148 This additional loading of the joint and increased stress on lateral supporting tissue may not be worth the gains of increased speed. Attention to biomechanical factors thus should be considered in comprehensive management, even when drug therapy decreases pain and improves gait speed.
Decreased proprioceptive input, impaired neuromuscular reflexes, altered joint biomechanics, pain, and muscle weakness contribute to static and dynamic balance problems in the individual with LE arthritis. Balance training may include progression from static postures moving from double- to single-limb support, stable to unstable surfaces, and adding perturbations where safe. Dynamic balance activities include maintaining postural alignment while shifting weight from one limb to the other in various directions and walking on different surfaces to challenge the vestibular and proprioceptive systems (see Chapter 10, Strategies to Improve Motor Function). Table 23.7 provides a summary of outcome measures for RA and OA organized by ICF Categories.
Table 23.7Outcome Measures for RA and OA Organized by ICF Categories ||Download (.pdf) Table 23.7 Outcome Measures for RA and OA Organized by ICF Categories
| ||Body Structure and Function ||Activity and Participation ||Quality of Life and Personal Factors |
|RA || |
VAS or NPRS for pain
Active joint counta or Simplified Disease Activity Index (SDAI)
Strength (manual or myometry) including grip strength
Visual gait assessment
Multidimensional Assessment of Fatigue (MAF)
Balance (e.g., single leg stance)
HAQ-DI or Modified HAQ
Patient Specific Functional Scale (PSFS)
Arthritis Hand Function Test
Dynamic/functional balance (e.g., Berg Balance Scale, Timed Up and Go)
6-Minute Walk Test
|OA || || |
Hip disability and osteoarthritis outcome score (HOOS)
Knee injury and Osteoarthritis Outcome Score (KOOS)
Lower Extremity Functional Scale (LEFS)
Patient Specific Functional Scale (PSFS)
Disabilities of the Arm, Shoulder and Hand (DASH)
Arthritis Hand Function Test
Dynamic/functional balance (e.g., Berg Balance Scale, Timed Up and Go, sit-to-stand test)
6-Minute Walk Test
Joint protection is a key component of arthritis management, due to the impact of the disease on the joint and supportive structures. A randomized controlled trial for persons with hand OA compared the effects of a 3-month education-behavioral joint protection program to standard education (each consisting of a 20-minute session and provision of a piece of Dycem [nonslip matting] to use when opening jars). This single-blinded study demonstrated that patients in the joint protection and exercise group increased grip strength by 25% and both groups reported better hand function with the joint protection information.16,149 Patients should be encouraged to incorporate joint care into all ADL to minimize pain and conserve energy (see Appendix 23.C, Joint Protection, Rest, and Energy Conservation).
In addition to reducing pain and improving function, orthoses also may provide support and protection for vulnerable and painful joints. Foot orthotics or specially designed shoes can serve the dual purpose of relieving biomechanical stresses and enhancing function for the person with RA foot involvement.150,151 The cost of special shoes may not be reimbursable under many insurance programs. A good shoe will provide support and eliminate unnecessary joint motion in the talocalcaneal joint with a firm and wide heel counter. It should also help to maintain normal bony alignment and accommodate all existing foot deformities within a toe box of adequate dimensions. Pressure should be evenly distributed along the plantar surface of the foot during weight-bearing. Commercially available gel inserts may be helpful and are inexpensive; however, with more advanced biomechanical changes in the foot, the fabrication of orthoses may be required. A rocker sole (shoe sole that is curved at the toe) can be used to facilitate push-off with limited ankle motion. A controlled trial was conducted of the effect of off-the-shelf extra-depth orthopedic footwear for people with RA and at least 1 year of foot pain. Outcomes were measures of pain, gait, and physical function after 2 months of wearing the extra-depth shoes. The footwear group improved significantly on self-reported disability, weight-bearing and non–weight-bearing pain, and gait. In addition to extra depth in the shoe toe box, the shoes provided greater rear foot stability, an arch support, a stiff shank, and a padded heel collar above the counter for improved fit. This study reported that walking pain accounted for 75% of the variability in physical function level of the subjects.152
Education and Self-Management
Patient education in the rheumatic diseases has been shown to result in positive changes in knowledge, health behaviors, beliefs, and attitudes that affect health status, quality of life, and health care utilization. A recent review of the literature documented the well-established benefits of self-management programs on mental health.75 As in any chronic illness, education should include information needed to deal with the condition (taking medications, exercise), self-management skills necessary to carry out important social and vocational roles, and resources needed to deal with the emotional consequences of chronic illness such as depression, fear, and frustration. The evidence is overwhelming that education designed to teach self-management skills and increase client self-efficacy for these tasks is the most effective.75,153 The Arthritis Foundation (1330 West Peachtree Street, Atlanta, GA 30309, www.arthritis.org) can supply the clinician or the individual with a variety of educational materials, pamphlets, and self-help courses that will increase cognitive understanding of the disease process and self-management skills. Many local chapters of the Arthritis Foundation hold individual and family support groups to increase psychosocial adaptation, as well as conduct aquatic and land exercise programs in public facilities. The Association of Rheumatology Health Professionals, a division of the American College of Rheumatology (www.rheumatology.org), can provide the therapist with scientific and clinical resources for enhanced practice, as well as a network of professional colleagues who work in rheumatology. See Appendix 23.D for additional Web-based resources.