The University of Toronto Rheumatic Disease Unit Page 2 P H Y S I O T H E R A P Y December, 1967 APPROACH TO THE M ANAGEM ENT O F RHEUMATIC ARTHRITIS By D . A . G O R D O N and M . A . O G R Y Z L O The m odern medical m anagem ent o f the rheumatic diseases dem ands a collaboration o f m any persons with w idely differing skills, and involves political, econom ic, ethical, social and educational, as well as m edical respon­ sibilities. U n til the early part o f this century, there was no concept o f special R h eum atic D isease Units being created for the treatment o f rheum atoid arthritis and other forms o f arthritis. H owever, real stim ulus cam e with the post-war success o f newly created rheum atic disease centres at Edinburgh, M anchester and Taplow in the U n ited K ingdom , in the Scandinavian countries and in N orth American Veterans’ H ospitals, which clearly dem onstrated that a great deal could be don e for sufferers from these diseases. In Canada, the m agnitude o f the problem o f arthritis was recognized by the C anadian Arthritis and R heum atism Society at a time when the speciality o f rheum atology had virtually no status, physicians trained in this specialty were scarce, and hospital services for the general arthritic popula­ tion were at a m inim um . From the Society’s inception in 1948, its m ain effort was directed at correcting these deficien­ cies. In its “Plan for A ttack” , one o f its m ain objectives was the provision o f centralized units designed for exemplary care o f arthritis, to be com bined in certain instances with extended research programmes (L). D u e to the cost involved, the programme could not be im plem ented prior to the establishm ent o f governm ent-sponsored hospitalization. In its subm ission to the R oyal C om m ission on H ealth Services in 1961, the Society recom m ended the establishm ent o f 25 or m ore centres in relation to regional teaching hospitals across Canada. B y dem onstrating high standards o f diag­ n osis and treatment, by stim ulating research and by their educational activities, it was envisaged that these units would exercise a profound and beneficial influence on the care o f arthritis patients far beyond the confines o f the units them ­ selves, and thus w ou ld contribute to a significant reduction in the incidence and severity o f permanent physical disa­ bility. T raditionally, patients with arthritis have been at a disadvantage in the com petition for adm ission to hospital. The usual organization o f medical services has tended to accentuate the difficulties in com m unication betw een the m edical, nursing, physiotherapy, occupational therapy and social work members o f the therapeutic team, particularly w hen these members have been pre-occupied with the problems o f the m ost seriously ill patients, n o t necessarily those suffering from arthritis. These treatment shortcom ings and the lack o f com m unication between the various dis­ ciplines have been further com pounded because rheumatic disease patients have usually been scattered throughout the hospital. This random distribution o f patients has com pli­ cated, rather than facilitated, the adm inistration o f a rheumatic disease programme. F or m any years it had been apparent that the com plex needs o f the arthritic patient were n o t being m et in T oronto by our teaching hospitals, and that a radical revision in our concept o f treatment for these patients was required. Som e m eans was necessary to rem ove the arthritic from com peti­ tion with m ore acute illnesses, and at the sam e tim e provide a programme o f “ total care” for these patients. In recent years the situation changed dramatically so that this pro­ gramme could be implemented. The m ost im portant factor was that universal governm ent hospital insurance became a reality in Canada in 1961. Im m ediately, the financial burden o f hospitalization was eliminated, and the prospect o f being able to admit all patients in need o f hospital care became a reality. A n other im portant factor was the form ation in 1959 o f a com m ittee*, under the late D r. W allace Graham , whose task was to draw up specific proposals for the establishm ent o f an exemplary R heum atic D isease U n it in T oronto. The recom m endations o f this com m ittee were outlined in the follow in g proposals: 1. to establish a U n it for the study o f the rheumatic diseases, as well as the prolonged active treatment and rehabilitation o f patients suffering from these diseases. 2. to dem onstrate the highest standards o f m edical care for patients requiring such treatment and to restore or m aintain their state o f personal self-sufficiency. 3. to provide the resources necessary for continuin g an intensive clinical investigation and research. “ Other members o f the com m ittee included the late D r. A . A . Fletcher, D r. M . A . Ogryzio D r. D . C. Graham, D r. J. S. Crawford and Mr. Edward D u n lop , Secretary. F rom the U niversity o f T oronto R heum atic D isease U n it, The W ellesley H ospital, T oronto, Canada. D . A . G ordon, M .D ., F .R .C .P . (C): Clinical Teacher in M edicine, C onsultant in Arthritis, U niversity o f T oronto Rheum atic D isease U n it, The W ellesley H ospital. M . A . Ogryzio, M .D ., F .R .C .P . (C): A ssociate Professor o f M edicine, D irector, U niversity o f T oronto R heum atic D isease U nit, The W ellesley H ospital. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) D e c e m b e r, 1967 P H Y S I O T H E R A P Y Page 3 4. to supplem ent and enhance facilities for under­ graduate and graduate instruction in medicine, physical and occupational therapy, public health and social work. These proposals were wholeheartedly accepted and in 1961 the University o f T oron to R h eum atic D isease U n it was established ( 2). T hroughout all these developm ents, the Ontario H ospital Services C om m ission, in charge o f the hospital insurance plan, furnished much theoretical and practical encouragem ent. A n exam ple o f this was the recognition that these special units require an increased number o f physiotherapists com pared with general hospitals. The ratio o f one physiotherapist for every 30 or more patients, usual in general hospitals, was recognized to be inadequate in the rheum atic disease setting. Thus, one physiotherapist for every six patients was authorized. N o w housed in the new W ellesley H ospital, the U nit consists o f 40 beds in a segregated area on the 6th floor, having at its disposal facilities o f a well-equipped 650-bed general hospital, including a m odern Rehabilitation D epart­ ment under the direction o f D r. C. M . Godfrey. F acilities for basic research in the rheum atic diseases com prise 4 m odules with a total o f 3,000 square feet o f laboratory space on the main floor o f the hospital. Adjacent to the rheumatic disease patients, space has been provided for physiothera­ pists and social workers, as well as for a Clinical Investigation U nit o f 10 beds, associated with 1,200 square feet o f additional laboratory space for clinical and m etabolic investigations. The concept and organization o f a m odern rheumatic disease unit is depicted schem atically in Fig. 1. A ll phases o f the programme are now functioning, and the diagram is intended to illustrate the dynam ic inter-relationship between the treatment, education and research functions o f the U nit. Patients have generally been adm itted o n an elective basis by application. In cases where the patient is not known to the staff, and where inadequate inform ation is provided by the referring physician, a pre-adm ission assessm ent is usually requested through the agency o f the Canadian Arthritis and R heum atism Society. This involves a visit to the patient by a physiotherapist and social worker o f the field staff o f the Society and the subm ission o f a detailed Program E v a lu a t io n ^ » Follow-Up Fig. 1.— Organization and functions o f the Rheumatic D isease U nit depicted schematically. report to the referring physician and to the Rheum atic D isease U nit. The evaluation can usually be com pleted during the waiting period for adm ission, which varies from one to six weeks. Where the patient has been know n to the staff o f the U n it this pre U n it evaluation is usually unneces­ sary and adm ission has been expedited in rotation as beds have becom e available. These procedures have been effective in avoiding the unnecessary adm ission o f patients for whom the real intention m ay merely have been the provision of nursing and dom iciliary care on a continuing basis. T he conceptual aim has been to develop a U n it primarily for the purposes of: com plete investigation o f patients with rheumatic disorders; early, accurate diagnosis; intensive application o f accepted therapeutic procedures and rehabili­ tation o f those disabled patients w ho are capable o f res­ ponding. Our experiences and impressions to date confirm that the advantages to be gained from the establishm ent of a rheum atic disease U n it are legion. A s em phasized pre­ viously, all patients requiring hospitalization for diagnosis and m anagem ent o f arthritis are eligible and, because adm issions are controlled, these patients d o n o t have to com pete directly with patients with other general medical problems o f a m ore acute nature. The patient pop ulation com prises all types o f rheumatic diseases, including the collagen diseases. H ow ever, as might be expected, the majority suffer from rheum atoid arthritis. A lthough rheum atoid arthritis is a symmetrical polyarthritis affecting in particular peripheral join ts, there is an increasing appreciation that this is a disease o f the patient as a whole. For this reason m any prefer the term “rheum atoid disease” instead o f “rheum atoid arthritis” (3). Figure 2 schem atically depicts m any o f these non-articular features which can affect the patient systematically. Systemic Feotures of RA Fig. 2.— Schematic depiction o f certain systemic features and complications o f rheumatoid arthritis. In the past tw o years we have studied 106 patients with classical rheum atoid arthritis4 adm itted to the University o f T oronto R heum atic D isease U n it5. The characteristic female predom inance o f 65 per cent and the m ean age o f 54 for rheum atoid arthritis were confirm ed (see Table I). R h eum atoid factor detected by m eans o f the latex test was found in 96 per cent o f these patients with a titration level o f 1 :1280 or greater in 84 per cent o f cases, and the pathog- R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 4 P H Y S I O T H E R A P Y December, 1967 Fig. 3.— Ward rounds at the University o f Toronto Rheumatic D isease Unit, The W ellesley Hospital. n o m o n ic f e a tu r e o f s u b c u t a n e o u s n o d u l a t i o n w a s p r e s e n t in 59 p e r c e n t o f p a t i e n t s . S y n o v ia l e f fu s io n s w e re n o te d in 51 p e r c e n t o f p a t i e n t s . T a b l e I I d e p ic ts t h e p r e v a le n c e o f v a r i o u s s y s te m ic f e a tu r e s in th e s e p a t i e n t s w h ic h h ig h lig h ts th e n e e d f o r o p t i m u m in v e s tig a tiv e se rv ic e s t o b e f o u n d o n ly in a n a c tiv e g e n e r a l h o s p i t a l r a t h e r t h a n a c h r o n i c c a r e o r c o n v a le s c e n t h o s p ita l. T A B L E I F e a t u r e s o f 1 06 p a t i e n t s w i t h c l a s s i c a l r h e u m a t o i d A RTH RITIS C h a r a c t e r i s t i c s N u m b e r P e r C e n t F e m a le s ......................................... 67 65 M e a n A g e ......................................... 54 y e a r s J o i n t E ff u s io n P r e s e n t 57 5J S u b c u t a n e o u s N o d u l a t i o n 65 59 R h e u m a to i d F a c t o r P o s itiv e 102 94 T it r e o f 1 :1 2 8 0 o r G r e a t e r 90 84 B e fo re t r e a t m e n t c a n b e in s t i t u t e d p r e c is e m e d ic a l d ia g n o s e s m u s t b e e s ta b lis h e d in a s s o c i a t i o n w ith c a r e f u l f u n c tio n a l a n d s o c ia l a s s e s s m e n ts . T h e s e a s s e s s m e n ts a r e c a r r ie d o u t a n d r e c o r d e d in e a c h p a t i e n t ’s c h a r t by U n it p h y s i o t h e r a p i s ts , o c c u p a t i o n a l t h e r a p i s t s a n d s o c ia l w o r k e rs . E d u c a t i o n o f t h e p a t i e n t is b a s ic t o t h e su c c e s s fu l m a n a g e ­ m e n t o f t h e p a t i e n t s u f f e rin g f r o m r h e u m a t o i d a r t h r i t i s . T h is a p p r o a c h is c o u p le d w ith a c le a r a p p r e c i a t i o n o f th e p a t i e n t ’s e m o t i o n a l r e a c t i o n a n d r e q u ir e m e n ts . A s a c o n ­ s e q u e n c e , a d m is s io n o f p a t i e n t s e a r ly in t h e c o u r s e o f th e ir T A B L E I I F e a t u r e s o f 106 p a t i e n t s w i t h c l a s s i c a l r h e u m a t o i d A r t h r i t i s S y s te m ic C o m p l i c a t i o n s N u m b e r P e r C e n t C a r d i o v a s c u l a r ............................... 28 25 P u l m o n a r y ................... 23 21 S p le n o m e g a ly ............................ 10 9 D ig ita l a n d S k in V a s c u litis 29 26 N e u r o p a t h y ......................................... 14 12 A t l a n t o - a x i a l S u b l u x a t i o n 2 1 /6 0 35 P o s itiv e L E T e s t ............................... 18 16 illn e ss h a s b e e n e m p h a s iz e d s o t h a t th e y m a y be b e tte r e d u c a t e d a b o u t th e ir c o n d i t i o n , a n d in o r d e r t o p r e s c r ib e a p r o p e r re g im e n c a lc u l a t e d to p r e v e n t d is a b ility a n d m a i n t a i n f u n c tio n a l c a p a c ity . T h is e m p h a s is o n p a t i e n t e d u c a t i o n a t t h e U n i t is i l l u s t r a t e d b y t h e d a ily w a r d e x e rc is e s, h a n d c la s se s a n d r e g u l a r p a t i e n t m e e tin g s f o r d is c u s s io n o f o t h e r a s p e c ts o f a r t h r i t i s . I t is n o t s u r p r i s i n g t h a t p a t i e n t s le a r n a g o o d d e a l a n d p r o f it g r e a tly f r o m th e i r a s s o c ia tio n w ith t h e o t h e r p a t i e n t s in th e U n it. O u r p o lic y o f a llo w in g a m b u l a t o r y p a t i e n t s h o m e - le a v e o n th e w e e k e n d s h a s a ls o b e e n a n i m p o r t a n t f a c t o r in m a i n t a i n i n g p a t i e n t m o r a le , a n d h a s n o t i n te r f e r e d w ith t h e p h y s i o t h e r a p y p r o g r a m m e . I n a d d i t i o n to g e n e ra l a n d s p e c ia l e x e rc is e s t h e p h y s io th e r a p y m e a s u re s e m p lo y e d a t t h e U n i t in c lu d e h y d r o t h e r a p y , v a r io u s f o rm s o f h e a t a n d c o ld to re d u c e j o i n t i n f la m a tio n a n d m u s c le s p a s m , a s w ell a s v a r i o u s r e s tin g a n d f u n c tio n a l s p lin tin g m e th o d s . O t h e r m e a s u re s t o c o n t r o l r h e u m a t o i d d is e a s e a c tiv ity in c lu d e th e u s e o f v a r i o u s m e d ic a tio n s (se e T a b l e I I I ) . S a lic y la te s a s e n t e r i c c o a t e d p r e p a r a t i o n s w e re m o s t c o m ­ m o n ly p r e s c r ib e d in 93 p e r c e n t o f p a t i e n t s , a n d th e a d e q u a c y o f th is th e r a p y w a s e n s u r e d by p e r io d ic m e a s u r e m e n t o f b lo o d s a lic y la te lev els. C h l o r o q u i n e o r g o ld t h e r a p y h a d b e e n u s e d a t s o m e tim e o r o t h e r in 91 p e r c e n t o f p a t i e n t s in th is se rie s (se e T a b l e I I I ) in a t t e m p t s t o i n d u c e d ise a se r e m is s io n in th o s e n o t r e s p o n d in g t o th e m e a s u re s o u tlin e d a b o v e . T h e s e a g e n ts h a v e b e e n f o u n d t o b e o f g r e a te s t v a lu e in e a r ly a c tiv e d is e a s e r a t h e r th e n in l o n g s t a n d i n g r h e u m a t o i d a r t h r i t i s . C o r t i c o s t e r o i d s w e re u s e d in 38 p e r c e n t o f c a se s. M o s t o f th e s e in d iv id u a ls h a d b e e n t a k i n g p r e d n is o n e p r io r to a d m is s io n a n d o u r u s u a l e f fo r ts h a v e b e e n d ir e c te d to g r a d u a l r e d u c t i o n o f th is m e d ic a tio n r a t h e r t h a n to th e ir in s t i t u t i o n . T h e lo n g - te rm c o m p l i c a t i o n s o f c o r tic o s te r o id s a r e w ell k n o w n a n d o n ly in t h e m o s t se v e re o r e ld e r ly ca se s a r e w e te m p te d t o u se th e s e a g e n ts in th e lo w e s t p o s s ib le d o s a g e . I n t r a - a r t i c u l a r s te r o id in je c tio n s u se d in 39 p e r c e n t o f p a t i e n t s a r e m u c h p r e f e r r e d to s y s te m ic m e d ic a tio n , b u t in r a r e in s ta n c e s w h e re is o la te d a r t i c u l a r a r e a s o f s y n o v itis fail t o r e s p o n d , s u r g ic a l s y n o v e c to m y is p e r f o r m e d b y o u r o r t h o p a e d i c c o lle a g u e s . I n o t h e r s e le c te d c a s e s w ith lo n g R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) December, 1967 P H Y S I O T H E R A P Y Page 5 standing disease and deform ity various reconstructive surgical procedures are carried out. O ne measure to the success o f the foregoing program me has been obtained from a functional assessm ent o f 243 patients with rheum atoid arthritis evaluated at the tim e o f adm ission to the U n it and at the time o f discharge8. T hese results are sh ow n in T able IV where it can be seen that at the tim e o f discharge there has been a substantial reduction in the proportion o f patients in class III and IV. T A B L E III F e a t u r e s o f 106 p a t i e n t s w i t h c l a s s i c a l r h e u m a t o i d ARTHRITIS Treatment N um ber Per Cent S a l i c y l a t e s ...................................... 103 93 Chloroquine ............................. 35 32 Gold ............................................... 65 59 Systemic Steroids .................... 42 38 Duration o f Steroids— less than 1 y e a r .................... 10 23 less than 5 y e a r s .................... 20 46 more than 5 years 10 23 Intra-articular Steroids 43 39 T A B L E IV T h e r a p e u t i c r e s p o n s e o f 243 p a t i e n t s w i t h RHEUMATOID ARTHRITIS F unctional Capacity* A d m ission Discharge I C om pletely normal 5 16 II Adequate ............................. 34 131 III Limited ............................. 133 77 IV Incapacitated .................... 71 19 •Am erican R heum atism A ssociation Classification. Possibly the greatest advantage arising from the creation o f such a U n it has been the m ore effective app lication o f treatment m ethods, resulting from im proved com m unication between the various m embers o f the team , including the medical staff, nurses, physiotherapists, occu pational thera­ pists and social workers. A ll representatives o f these treat­ ment disciplines are based on the R h eum atic D isea se U n it, and m ake rounds regularly together, in add ition to their individual professional relationship with patients. (See figure 3). A s a consequence, all U n it personnel now obtain a more com plete and intensive experience in the investigation and management o f the rheum atic disease patient than previously and they develop an appreciation o f the inter­ disciplinary approach. Furtherm ore, there has been an increased facilitation in the education o f the various Unit staff m em bers from their association at rounds, seminars and the out-patient follow -u p clinic. A s noted, each patient has a thorough m edical investigation by the clinical staff, including a social history and an assessm ent by a ph ysio­ therapist assigned to the patient. On discharge from the U nit, the fam ily physician is given not only the usual sum m ary o f m edical investigations and recom m endations as to future m anagem ent, but also a com plete physiotherapy, occu pational therapy and social work report. In add ition to the pre-adm ission evalu ation referred to above, the physiotherapists and social workers o f the C anadian Arthritis and R h eum atism Society carry ou t a regular evalu ation o f patients in their hom e setting follow in g discharge7. T his has been an im portant and successful aspect o f the program me. A s evidenced by the im provem ent m aintained by 75 per cent o f patients discharged from the U n it during three years o f follow -up evalau tion 8. Further­ m ore, continued liaison with the Arthritis Society p h ysio­ therapists and social workers is m aintained by the regular attendance o f their representatives at the R h eum atic D isease U n it teaching rounds and conferences. T he treatment program m e is under the direct supervision o f 3 geographic full-tim e physicians. Participating in the treatment program m e are a num ber o f part-time consultants including on e in physical m edicine, 2 in orthopaedic surgery* one in clinical psychiatry, on e in research psychiatry and one in m icrobiology. A t the h ou se physician level, provision ■s m ade for on e resident physician or senior clinical fellow , assisted by 2 or 3 assistant residents or clinical fellow s. T he full-tim e physicians participate in active research program mes in the various m etabolic, im m unologic, m icrobiologic or p ath ologic aspects o f the rheum atic diseases, assisted by 3 or m ore research fellow s. T he para­ m edical personnel include 5 physiotherapists, 2 occupational therapists and 3 social workers, assisted by 4 graduate students from the U niversity o f T oron to S ch ool o f Social W ork. A ll o f these individuals spend their w orking day with their patients on the U n it. T he success o f this program me and the ease o f co-ord in ation o f various basic and clinical research studies has been self-evident. M any o f the ad­ ministrative difficulties encountered in m anaging an ou t­ patient rheum atic disease program me, as described by Engelm an e t a la, appear to have been elim inated. A t the present tim e, similar units are in operation in 5 other C anadian m edical centres. M ore are in the planning stage although not all are provided with research facilities. M eanw hile, the concept o f the University o f T oronto R h eu m atic D ise a se U n it is being expanded to other U n iver­ sity o f T oron to teaching hospitals. T he success o f the University o f T oron to R heum atic D isease U n it at T he W ellesley H ospital w ould appear to support the recom m endations o f the Canadian Arthritis and R heum atism Society in its su bm ission to the R oyal C om ­ m ission on H ealth Services. V isualized as “ focal poin ts for specialized diagnosis, treatm ent, research and m edical education, in order to provide a truly balanced rheumatic disease control program m e,” the creation o f such U nits has enabled the com plex needs o f the patient with arthritis R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 6 P H Y S I O T H E R A P Y December, 1967 to be m et in a c o m p re h en siv e way. A t the sa m e tim e the tre a tm e n t p ro g ra m m e facilitate s a n d c o m p le m e n ts in every way th e e d u c a tio n a n d re sea rc h fu n c tio n s o f th e U nit. It is e v id e n t th a t th e re sp o n sib ility fo r de v elo p in g R h e u m a tic D isease U n its will fall u p o n v a rio u s pa rties, in clu d in g U n iv e rsity D e p a rtm e n ts o f M e dicine, T ea ch in g H o s p ita ls a n d G o v e rn m e n t H o s p ita l In su ra n c e C o m m issio n s, as well as local M edical Societies. H ow ever, th e effort o f p lan n in g a n d seeking o u t m e th o d s o f a ch ieving th e d esired goal in e ach a re a , is a re sp o n sib ility to be m et, if a t all, only by in te rested lay g ro u p s such as the C a n a d ia n A rth ritis a n d R h e u m a tis m Society. I n su m m a ry , th e ra tio n a le fo r a n d a im s o f th e R h e u m a tic D ise a se U n it c o n c e p t as well as o u r U n it a p p ro a c h to the m a n a g e m e n t o f r h e u m a to id a rth ritis have been described. W e h a v e b e en g reatly h e a rte n e d by o u r experiences to d a te a n d h o p e th a t th e e sta b lish m e n t elsew here o f sim ila r u n its will lead n o t only to b e tte r m e th o d s fo r c o n tro llin g the v a rio u s fo rm s o f a rth ritis , b u t will also e n h an c e e d u c a tio n a b o u t th e rh e u m a tic diseases, a n d lead to new know ledge a b o u t them . T h e a u th o rs wish to th a n k M iss R o se m ary J a c o b s o n o f Jo h a n n e s b u rg , a re ce n t p h y sio th e ra p ist w ith th e U nit (see F ig u re 3, th ird fro m th e rig h t) for e n c o u ra g in g us to w rite th is a cc o u n t. R e f e r e n c e s 1. T h e C a n a d ia n A rth ritis a n d R h e u m a tis m Society: ‘A rth ritis — p la n fo r a tta c k .’ Canad. M e d . A ss. J. 62:34, 1950. 2. O g r y z l o , M . A ., G o r d o n , D . A. a n d S m y t h e , H . A. ‘T h e R h e u m a tic D isease U n it (R .D .U .) C o n c ep t A rth ritis a n d R h e u m a t.’ in press. 3. ‘H a r t , F . D . ‘C o m p lic a te d R h e u m a to id D ise a se,’ B rit. M e d . J., 2, 131, 1966. 4. R o p e s , M . W ., B e n n e t t , G . A ., C o b b , S ., J a c o x , R . F . a n d J e s s a r , R . A. ‘1958 R e v isio n o f D ia g n o stic C rite ria for R h e u m a to id A rth ritis ,' Bull. R heum . D is., 9:175, 1958. 5 . B e l l , D . A ., G o r d o n , D . A., R a u m a l , R . a n d B r o d e r , I ‘C o rre la tio n betw een th e R h e u m a to id B iologically Active F a c to r (R B A F ) a n d C linical F e a tu re s o f R h e u m a to id A rth ritis (R A ) A rth ritis a n d R h e u m a t.’ 10:266, 1967. 6. O g r y z l o , M .A . U n iv e rsity o f T o ro n to R h e u m a tic D ise a se U n it F iv e Y e a r R e p o r t 1960-65. 7. C o h e n , B . S. B a u m , J . , L o g g i n s , B . a n d T e r r y , E. ‘H o m e c are p ro g ra m m e in th e m a n a g e m e n t o f a rth r itis .’ J. Chronic Dis. 19:631, 1966. 8. E n g e l m a n , E . T ., S e l l i n g e r , E . a n d M e t t i e r , S. R . ‘P ro b le m s in th e A d m in is tra tio n o f a n E xem p lary A rth ritis C linic in a T ea ch in g C e n tre ,’ A rth ritis an d R heum at. 6:78, 1963. Place of Physiotherapy in the Treatment of Rheumatoid Arthritis By R. JA C O B S O N , B .S c .,P h y s.(R an d ) In 1964 T h e A m erican R h e u m a tis m A sso c ia tio n e s ta b ­ lished 6 -4 p e r c en t o f th e p o p u la tio n w ere re p o rte d to have A rth ritis a n d R h e u m a tism . T h e S ocio -ec o n o m ic im p a c t o f the rh e u m a tic diseases c an be a p p re c ia te d from d a ta o b ta in e d from the U .S. N a tio n a l H e a lth Survey (1964)— th is show ed th a t o f th e one m illion p e rso n s c o nfined to th e house 17 per c ent a ttrib u te d th e ir re stric tio n to a rth ritis a n d rh e u ­ m atism a n d the sam e c o n d itio n s w ere blam e d fo r a w ork loss o f a p p ro x im a te ly 27 m illion days an n u ally . T h e m an a g em e n t o f rh e u m a to id a rth ritis is o f necessity so m e w h a t p ra g m a tic a n d the care o f e ach p a tie n t m u st be a d a p te d to his ow n needs. T h is a rtic le is a d e sc rip tio n o f th e general p rinciples e m ployed by the p h y sio th e ra p ist in the tre a tm e n t o f rh e u m a to id a rth ritis . T h e ideal s itu a tio n for such p a tie n ts is a u n it w here all the th e ra p is ts a re g e are d to th e e d u c a tio n a n d effective tec hniques o f m an a g em e n t. T Y PES O F PA T IE N T S A D M IT T E D T O T H E U N IT Ur) F irst tim ers— these p a tie n ts d e m o n s tra te th e active stage o f th e disease. (b) F la re u p ’s— reassessm ent o f the c o n d itio n a n d re ­ o rg a n is a tio n o f tre a tm e n t. (c) A d v a n ce d cases— these re q u ire m a in te n a n c e o f stre n g th a n d m axim al usage o f re m a in in g jo in t fu n c tio n . (cl) P o st surgical m an a g em e n t. Before c o n sid erin g th e a p p ro a c h e s a v ailab le in th is c o n d itio n , it is e ssential to c o m p re h e n d th e forces p ro d u c in g th e p a in a n d d e fo rm ity . (See T a b le 1). J O IN T D E F O R M IT Y J o in t fu n c tio n d e p en d s on th e a rc h ite c tu ra l in te g rity o f bones b e arin g surfaces a n d re stra in in g ligam ents, on m uscle p ow er a n d n e u ral re g u la tio n a n d free d o m fro m a dverse e x te rn al c irc u m s ta n c e s ; in th e rh e u m a to id all o f these m ay be involved. Movement In th e n o rm a l p e rso n activities o f daily living re su lt in m ain ta in in g m uscle s tre n g th a n d a n a d e q u a te b lo o d su p p ly ; the n u tritio n o f th e c a rtila g e is d e p e n d e n t o n jo in t m o v em e n t a n d th e m o st effective stress on b o n e p re v en tin g disuse o ste o p o ro sis is fro m m uscle c o n tra c tio n . In th e p e rso n with changes c h a ra c te ris tic o f th e rh e u m a tic ty p e exercise c a n n o t be left to c h an c e b u t is re g u la te d by a th e ra p e u tic regim e c o n tro lle d for lo ad , d ire c tio n , d u ra tio n a n d frequency. Capsule, ligament, cartilage and bone E ffusion in a jo in t will p ro d u c e a ra ised in tra -a rtic u la r pressure. T h is m ay re su lt e ith e r from a ctive disease process o r tra u m a tic in fla m m a tio n . D e A n d ra d e , G r a n t a n d D ixon suggested th a t stim uli from th e k nee jo in t reflexly in h ib it low er m o to r n e u ro n s su p p ly in g th e q u a d ric e p s . I n p a tie n ts w ith a rtic u la r disease p a in precedes w eakness. T h e highest pressures n o te d in th e knee a re d u rin g full k n e e b e n d w hereas th e low est p re ssu re n o te d w as w ith th e k n e e in a p o sitio n o f slight flexion. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )