The Role of Physical Therapy in Management of Patients with Osteoarthritis and Rheumatoid Arthritis
The Role of Physical Therapy in Management of Patients with Osteoarthritis and Rheumatoid Arthritis
surBrenda Greene, PT, PhD, OCSDivision of Physical TherapyEmory University School of MedicineAtlanta, GA
S. Sam Lim, MDDivision of Rheumatology Emory University School of MedicineAtlanta, GA
Summary Points
The overall goals of physical therapy are to prevent and minimize impairments, functional limitations, and disability resulting from arthritis.
Intervention by physical therapists is appropriate at all stages of the care continuum, from primary and secondary prevention through postsurgical rehabilitation.
Physical therapists use thermal and electrical agents, exercise, assistive devices, and patient education to achieve patient goals.
Introduction
The overall goals of physical therapy are to prevent and minimize impairment, functional limitations, and disability resulting from arthritis. Physical therapy goals are accomplished through the examination, assessment, and development of individual treatment plans by a physical therapist to address each person's functional limitations. Once individual problems are identified, physical therapists use their understanding of pathomechanics to design and implement interventions to prevent or improve the patient's impairments. Physical therapist intervention is appropriate at all stages of the care continuum, from primary and secondary prevention through post- Therapeutic Exercise
Therapeutic exercise is the systematic implementation of planned physical movements, postures, or activities designed to: 1) remediate or prevent impairments; 2) enhance function; and 3) enhance fitness and well-being (12). In both RA and osteoarthritis (OA) patients, common impairments to be addressed by therapeutic exercise are decreased strength, range of motion, and cardiovascular endurance (13).
By understanding the pathophysiologic process of arthritis and the biomechanics of joint function, physical therapists develop exercise programs that not only address specific patient impairments and goals, but they also develop exercise programs that protect vulnerable joints in an attempt to prevent anticipated sequelae of the disease process. For example, if a patient with OA of the knee presents with a varus deformity and Grade I laxity of the lateral collateral knee ligament, the therapist would expect increased compression and muscle shortening on the medial side of the joint and increased tension on the lateral side of the joint. To protect the vulnerable lateral collateral ligament when strengthening exercises for the hip abductor muscles are performed, resistance will be applied above the knee rather than at the ankle. To prevent or improve shortening in muscles and tendons, stretching exercises will be emphasized for the hip adductor and hamstring muscles. In addition to appropriate exercise program planning, the physical therapist monitors the patient's response to exercise, re-assesses initial findings, and modifies the exercise program when necessary.
The therapeutic exercise program must be designed with the specific stage of the disease process in mind, the number of joints involved, and the degree of inflammation. RA is characterized by a variable course of exacerbations and remissions, and OA may present with acute intra-articular or extra-articular swelling. Conventional wisdom dictates that during an acute flare the goals of therapeutic exercise are to decrease pain and inflammation and to maintain range of motion and strength without aggravating the inflamed joints (14,15). Appropriate exercises at this stage are isometric exercises at multiple joint angles to slow the atrophy associated with rest and or active range-of-motion (ROM) exercises to prevent contractures and maintain nutrition to the cartilage. Although the described exercises represent the current standard of care, some have suggested that even in the acute stage of RA a more intensive, dynamic exercise program has greater benefit than the current standard without deleterious effects (16).
During the subacute and chronic stages of the disease process, the goals of therapeutic exercise are to progressively increase muscle strength, range of motion, and function (14,15). Appropriate exercises at these stages are aquatic exercises, dynamic isotonic exercises, and passive range of motion. Once the joints symptoms have subsided, aerobic exercises are a necessity.
The research evidence supporting the effectiveness of aerobic and strengthening exercises in people with OA and RA is moderately strong. A systematic review of 6 randomized clinical trials using aerobic conditioning exercises, such as stationary bicycling, walking, or aquatic exercise, in people with RA was conducted by the Cochrane Group (17). The conclusions were that conditioning exercises were effective in improving aerobic capacity, muscle strength, and joint mobility. In people with knee OA, aerobic exercise has been shown in an 18-month randomized clinical trial to decrease pain and self-reported disability and improve objectively assessed functional performance (18). Strengthening exercises in people with OA have also been shown to have the same beneficial effects of decreased pain and disability and improved function (18). Improvements in joint range of motion also have been reported following conditioning exercises (19).
The evidence suggests that supervised exercises of moderate to high intensity properly performed do not exacerbate joint pain or disease progression (17,19). Some patients may be safer and more likely to initiate an exercise program if they first receive individualized exercise instruction from a health care professional. Two of the factors that have been shown to consistently influence exercise behavior are the confidence one feels for being able to exercise (self-efficacy) and the belief that exercise results in positive benefits (20,21). The physician is in a unique position to positively influence a patient's beliefs about exercise.
Physical activity is defined as "any bodily movement produced by skeletal muscles that results in energy expenditure" (22). Low levels of physical activity are associated with increased mortality rates from a variety of causes (23,24). The Centers for Disease Control and Prevention and the American College of Sports Medicine recommend every U.S. adult, including those with disabilities, should have at least 30 minutes or more of moderate-intensity physical activity on most days of the week (25). The 30 minutes can be accumulated from shorter multiple bouts of physical activity dispersed throughout the day. The level of physical activity in the population of people with arthritis is not known. Based on physical impairments common in this population, it is probable that physical activity is lower in people with arthritis than in the general population.
Assistive Devices
When a joint is painful, swollen, or weak, a goal of physical therapy is to decrease the compressive forces through the joint by use of an assistive device, such as a cane. A major contributor to hip joint compressive forces during walking is the activity in the hip abductor muscles (26). In order to get the benefit of decreased hip joint compression, the cane must be used in the contralateral hand (27). During stance phase of gait when the hip abductor muscles are active in maintaining a relatively level pelvis, a cane in the contralateral hand produces torque in the same direction as the hip abductor muscles and reduces the demand on these muscles. Proper fit and placement of the cane is necessary to get the desired benefit. Even if the knee joint is the target of decreased compressive forces, the cane should be placed on the contralateral side to maintain normal arm and leg swing and to allow the device to work at its greatest mechanical advantage.
A variety of other assistive devices may be used to improve function. For example, if a person has weak knee extensor or hip extensor muscles, extenders may be placed on the chair legs to elevate the seat. From an elevated seat position a person has a better mechanical advantage in the knee and hip joints and a smaller distance to travel. Another example is the use of reachers to provide an extended reaching arm so that objects can be grasped with less range of motion. Assistive devices should be used when they improve function and are accepted by the patient.
Patient Education
Due to the chronic nature of arthritis, self-management is essential. Most theories about why people engage in health behaviors identify some or all of the following factors as important contributors to health behavior: an individual's knowledge, beliefs, and skills; the psychosocial environment; and the physical environment (28). Knowledge about the disease process and beneficial health behaviors is considered necessary, but not sufficient, to lead to positive behavior change. Patient education should also focus on helping patients to gain confidence in new skills such as exercise or functional activities.
One of the most important ideas a patient can learn is his or her role in life-long self-management. Although physical therapists have a role in patient education, helping people with arthritis find community programs also is a goal. Examples of community programs are the Arthritis Foundation's Arthritis Self-Help Course (ASHC) and People with Arthritis Can Exercise (PACE) course. The evidence supporting the effectiveness of these community education programs to increase self-efficacy for self-management, improve function and quality of life is relatively strong (29).
Conclusions
The link between the pathology of arthritis and disability is not a direct one. Many factors can positively or negatively impact patient functional outcomes. Physical therapists work to prevent and minimize impairments, functional limitations, and disability resulting from arthritis through the use of thermal and electrical agents, exercise, assistive devices, and patient education.
gical rehabilitation.
surBrenda Greene, PT, PhD, OCSDivision of Physical TherapyEmory University School of MedicineAtlanta, GA
S. Sam Lim, MDDivision of Rheumatology Emory University School of MedicineAtlanta, GA
Summary Points
The overall goals of physical therapy are to prevent and minimize impairments, functional limitations, and disability resulting from arthritis.
Intervention by physical therapists is appropriate at all stages of the care continuum, from primary and secondary prevention through postsurgical rehabilitation.
Physical therapists use thermal and electrical agents, exercise, assistive devices, and patient education to achieve patient goals.
Introduction
The overall goals of physical therapy are to prevent and minimize impairment, functional limitations, and disability resulting from arthritis. Physical therapy goals are accomplished through the examination, assessment, and development of individual treatment plans by a physical therapist to address each person's functional limitations. Once individual problems are identified, physical therapists use their understanding of pathomechanics to design and implement interventions to prevent or improve the patient's impairments. Physical therapist intervention is appropriate at all stages of the care continuum, from primary and secondary prevention through post- Therapeutic Exercise
Therapeutic exercise is the systematic implementation of planned physical movements, postures, or activities designed to: 1) remediate or prevent impairments; 2) enhance function; and 3) enhance fitness and well-being (12). In both RA and osteoarthritis (OA) patients, common impairments to be addressed by therapeutic exercise are decreased strength, range of motion, and cardiovascular endurance (13).
By understanding the pathophysiologic process of arthritis and the biomechanics of joint function, physical therapists develop exercise programs that not only address specific patient impairments and goals, but they also develop exercise programs that protect vulnerable joints in an attempt to prevent anticipated sequelae of the disease process. For example, if a patient with OA of the knee presents with a varus deformity and Grade I laxity of the lateral collateral knee ligament, the therapist would expect increased compression and muscle shortening on the medial side of the joint and increased tension on the lateral side of the joint. To protect the vulnerable lateral collateral ligament when strengthening exercises for the hip abductor muscles are performed, resistance will be applied above the knee rather than at the ankle. To prevent or improve shortening in muscles and tendons, stretching exercises will be emphasized for the hip adductor and hamstring muscles. In addition to appropriate exercise program planning, the physical therapist monitors the patient's response to exercise, re-assesses initial findings, and modifies the exercise program when necessary.
The therapeutic exercise program must be designed with the specific stage of the disease process in mind, the number of joints involved, and the degree of inflammation. RA is characterized by a variable course of exacerbations and remissions, and OA may present with acute intra-articular or extra-articular swelling. Conventional wisdom dictates that during an acute flare the goals of therapeutic exercise are to decrease pain and inflammation and to maintain range of motion and strength without aggravating the inflamed joints (14,15). Appropriate exercises at this stage are isometric exercises at multiple joint angles to slow the atrophy associated with rest and or active range-of-motion (ROM) exercises to prevent contractures and maintain nutrition to the cartilage. Although the described exercises represent the current standard of care, some have suggested that even in the acute stage of RA a more intensive, dynamic exercise program has greater benefit than the current standard without deleterious effects (16).
During the subacute and chronic stages of the disease process, the goals of therapeutic exercise are to progressively increase muscle strength, range of motion, and function (14,15). Appropriate exercises at these stages are aquatic exercises, dynamic isotonic exercises, and passive range of motion. Once the joints symptoms have subsided, aerobic exercises are a necessity.
The research evidence supporting the effectiveness of aerobic and strengthening exercises in people with OA and RA is moderately strong. A systematic review of 6 randomized clinical trials using aerobic conditioning exercises, such as stationary bicycling, walking, or aquatic exercise, in people with RA was conducted by the Cochrane Group (17). The conclusions were that conditioning exercises were effective in improving aerobic capacity, muscle strength, and joint mobility. In people with knee OA, aerobic exercise has been shown in an 18-month randomized clinical trial to decrease pain and self-reported disability and improve objectively assessed functional performance (18). Strengthening exercises in people with OA have also been shown to have the same beneficial effects of decreased pain and disability and improved function (18). Improvements in joint range of motion also have been reported following conditioning exercises (19).
The evidence suggests that supervised exercises of moderate to high intensity properly performed do not exacerbate joint pain or disease progression (17,19). Some patients may be safer and more likely to initiate an exercise program if they first receive individualized exercise instruction from a health care professional. Two of the factors that have been shown to consistently influence exercise behavior are the confidence one feels for being able to exercise (self-efficacy) and the belief that exercise results in positive benefits (20,21). The physician is in a unique position to positively influence a patient's beliefs about exercise.
Physical activity is defined as "any bodily movement produced by skeletal muscles that results in energy expenditure" (22). Low levels of physical activity are associated with increased mortality rates from a variety of causes (23,24). The Centers for Disease Control and Prevention and the American College of Sports Medicine recommend every U.S. adult, including those with disabilities, should have at least 30 minutes or more of moderate-intensity physical activity on most days of the week (25). The 30 minutes can be accumulated from shorter multiple bouts of physical activity dispersed throughout the day. The level of physical activity in the population of people with arthritis is not known. Based on physical impairments common in this population, it is probable that physical activity is lower in people with arthritis than in the general population.
Assistive Devices
When a joint is painful, swollen, or weak, a goal of physical therapy is to decrease the compressive forces through the joint by use of an assistive device, such as a cane. A major contributor to hip joint compressive forces during walking is the activity in the hip abductor muscles (26). In order to get the benefit of decreased hip joint compression, the cane must be used in the contralateral hand (27). During stance phase of gait when the hip abductor muscles are active in maintaining a relatively level pelvis, a cane in the contralateral hand produces torque in the same direction as the hip abductor muscles and reduces the demand on these muscles. Proper fit and placement of the cane is necessary to get the desired benefit. Even if the knee joint is the target of decreased compressive forces, the cane should be placed on the contralateral side to maintain normal arm and leg swing and to allow the device to work at its greatest mechanical advantage.
A variety of other assistive devices may be used to improve function. For example, if a person has weak knee extensor or hip extensor muscles, extenders may be placed on the chair legs to elevate the seat. From an elevated seat position a person has a better mechanical advantage in the knee and hip joints and a smaller distance to travel. Another example is the use of reachers to provide an extended reaching arm so that objects can be grasped with less range of motion. Assistive devices should be used when they improve function and are accepted by the patient.
Patient Education
Due to the chronic nature of arthritis, self-management is essential. Most theories about why people engage in health behaviors identify some or all of the following factors as important contributors to health behavior: an individual's knowledge, beliefs, and skills; the psychosocial environment; and the physical environment (28). Knowledge about the disease process and beneficial health behaviors is considered necessary, but not sufficient, to lead to positive behavior change. Patient education should also focus on helping patients to gain confidence in new skills such as exercise or functional activities.
One of the most important ideas a patient can learn is his or her role in life-long self-management. Although physical therapists have a role in patient education, helping people with arthritis find community programs also is a goal. Examples of community programs are the Arthritis Foundation's Arthritis Self-Help Course (ASHC) and People with Arthritis Can Exercise (PACE) course. The evidence supporting the effectiveness of these community education programs to increase self-efficacy for self-management, improve function and quality of life is relatively strong (29).
Conclusions
The link between the pathology of arthritis and disability is not a direct one. Many factors can positively or negatively impact patient functional outcomes. Physical therapists work to prevent and minimize impairments, functional limitations, and disability resulting from arthritis through the use of thermal and electrical agents, exercise, assistive devices, and patient education.
gical rehabilitation.
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