Rehab programs for rheumatoid arthritis
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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Information from the National Institutes of Health, the American Physical Therapy Association, and the Arthritis Foundation
A comprehensive rehabilitation program is critical for the management of rheumatoid arthritis. The two major areas where a patient will receive assistance are Physical and Occupational Therapy.
The goals for patients with RA include pain relief, increased range of motion (ROM), increased strength and endurance, and prevention and correction of deformities. Numerous non-drug methods are available to assist patients in achieving these goals. These methods include therapeutic modalities, splints and orthotics, assistive device equipment, joint protection and energy conservation techniques, as well as education and therapeutic exercise programs.
Superficial or deep heat is effective for relieving joint pain and stiffness due to RA. In addition, it is also used to treat joints in preparation for ROM, stretching, and muscle strengthening exercises. Heat may be administered via moist hot packs, electric mittens, a hot shower, spas, ultrasound, diathermy, or paraffin. Both superficial and deep heating methods have been shown to raise the intra-articular temperature in patients with RA.
Cold is the preferred treatment for an acutely inflamed joint. Application of cold results in decreased pain and decreased muscle spasm. Cold may be delivered via ice packs, ice sticks, topical sprays, or ice water.
Orthotic devices are used to decrease pain and inflammation, improve function, reduce deformity, and correct biomechanical malalignment.
Lower extremity orthoses are prescribed to provide stability and proper alignment or to shift weight bearing off the affected limb. The most common orthoses used for the lower extremity apply to the foot and ankle joints. Approximately 80% of patients affected with RA have significant foot involvement. These problems are easily accommodated by providing a deep, wide, soft leather shoe. A metatarsal pad or bar is used to remove weight from painful MTP joints, and a rocker-bottom sole can be used to facilitate roll-off. Hind foot pronation abnormalities should be addressed with custom inserts. Finally, knee orthoses may be used to control edema, pain, patellar alignment, hyperextension, or collateral or cruciate ligament instability.
Fatigue and decreased endurance are frequent symptoms in patients with RA. When comparing these patients to age-matched subjects without RA, a reduction in aerobic capacity and muscular strength is noted. This reduction is due both to the disease itself and to the lack of physical activity in these patients. Exercise is an integral part of the rehabilitation management of RA.
Aerobic conditioning in patients with RA improves maximum oxygen uptake and decreases perceived exertion at sub maximal workloads. In addition, patients undergoing long-term endurance training feel less isolated, have fewer days of sick leave, and have improved function in activities of daily living (ADL). Thirty minutes of daily aerobic exercise, several times each week, should be encouraged in patients with well-controlled RA.
Muscle atrophy often accompanies RA and is exacerbated by inactivity, bed rest, splints, and medications. Isometric exercises restore and maintain strength in patients with RA without producing pain. Resistance exercises may be initiated when the isometric program has been well established and when the patient is free of pain.
Occupational therapy also can be very useful for patients with RA. An occupational therapist may work in conjunction with the physical therapist to ensure that the patient is able to meet his or her goals. An occupational therapist may also assist in the recommendation and use of splints and orthotics, especially when the upper extremity is affected. Upper extremity orthoses may be classified as either static or dynamic. Static splints are used to support a weak or unstable joint, to rest a joint for pain relief, or to maintain functional alignment. Dynamic splints traditionally have been used to manage the postoperative hand, but they also may be used to increase manual dexterity. The most commonly used splints for the hand are the finger-ring splints and the thumb post splint. The functional wrist splint and the resting hand splint are commonly used for wrist splinting.
Many assistive devices are available to patients with RA and are used to provide maximal function, maintain independence, reduce joint stress, conserve energy, and provide pain relief. Equipment is available to assist patients with transfers, dressing, feeding, toileting, cooking, and ambulation.
Joint protection education provides the patient with techniques and recommendations of how to prevent overuse of a joint and how to avoid biomechanical torques that excessively bend the joint. The use of adaptive equipment is important. In addition, other components of a good joint protection program include maintenance of good posture, avoiding overuse during inflammation, modification of tasks to decrease joint stress, and use of appropriate splints.
Fatigue is a major component of RA and is due to the systemic nature of the disease, as well as the decreased cardiovascular endurance observed in patients with this inflammatory disease.
The goal of energy conservation techniques is to save energy while maximizing function. Adaptive equipment is an essential part of this program. Other elements include the maintenance of joint ROM and strength, the improvement of cardiovascular fitness, and taking short rest periods during the day. Every individual with RA should implement joint protection and energy conservation programs into their lifestyle.
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