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. ) Decem ber, 1967 P H Y S I O T H E R A P Y Page 7 C A R P A L T U N N E L T E N O S Y N O V IT IS and T E N O V A G IN IT IS V T R I G G E R T E N D O N S S T R E T C H IN G O F C A P S U L E a n d L IG A M E N T S T E N D O N 1 D IS P L A C E M E N T O F T E N D O N A R T H R I T I S A n o th e r effect o f effusion m ay be to stre tc h th e jo in t cap su le a n d ligam ents so th a t te n d o n h a v in g pulley a tta c h ­ m en ts will have its line o f pull shifted. P ro life ra tin g synovium m ay a lso cause d iste n tio n . S om e c apsules a re stre tc h ed o th e rs m ay be th ic k e n e d , re su ltin g in a loss o f jo in t m obility. P a n n u s invades a n d e ro d e s a rtic u la r c artila g e at the jo in t m argins, a t th e ju n c tio n o f c artila g e a n d sy n o v iu m a n d a t the a tta c h m e n ts o f c o lla te ral ligam ents b one e ro sio n occurs. M uscle, tendon and nerve M uscle w eakness is p o stu la te d to be d ue to in h ib itio n , disuse a n d reflex v a sc u la r c hanges. It is c o n sid ere d th a t b o th m uscle spasm a n d in h ib itio n m ay be m ed ia te d o n a n eural reflex basis by stim u la tio n o f th e p ro p rio ce p tiv e nerve en dings in th e in fla m m a to ry process. T e n d o n lesions interfere w ith th e m uscle a ctio n . Dynamic aspects o f deformity (a) S tru c tu ra l re la tio n s h ip s a re c h an g e d . A n ta g o n istic m uscle p u ll is n o t o p p o se d a n d force is exerted a g ain st ligam ent a n d c apsule re su ltin g in a shift. (b) A new j o in t e q u ilib riu m is th u s estab lish e d . A S S E S S M E N T O F P A T IE N T Emotional factors A s w ith a n y c o n d itio n it is necessary fo r th e th e ra p is t to u n d e rsta n d th e effect a c h ro n ic d e fo rm in g illness h as u pon a p a tie n t. E m o tio n a l fa c to rs c a n n o t be identified as real cause, how ever, lo n g p e rio d s o f c o n tin u a l p a in , a n d disability re n d e r p a tie n ts less a ble to c o p e w ith th e ir disease. An e d u c a tio n p ro g ra m m e is e ssential as th e p a tie n t u sually feels a n ta g o n istic a n d resentful. Functioning o f the patient T h e p a tie n t is c arefully q u e stio n e d a b o u t his a b ility to cope in th e w ork, hom e a n d leisure situ a tio n s, e.g. a b ility to c o p e w ith physical re q u ire m e n ts a t w o rk , a b ility to cope w ith stairs, get in a n d o u t o f c h airs, bed, cars, etc. Individual joint assessment E ac h jo in t is ex am in ed for ten d e rn ess, te m p e ra tu re , sw elling defo rm ity , active ra n g e o f m o v em e n t, forces re q u ire d to c o u n te ra c t d e fo rm in g forces. T o ta l lim b fu n c tio n is carefully n o te d a n d difficulties observed. M uscle strength G r o u p m uscle stre n g th a n d c o m p o n e n t s tre n g th a re b oth assessed, e.g. grip s tre n g th — a b o m a n o m e te r bag is u se d ; q u a d ric e p s se ttin g ability. T R EA TM EN T P R O G R A M M E (a) E ducation B o th fam ily a n d p a tie n t m ust be e d u c a te d as to the n a tu re o f th e disease. T h e follow ing to p ic s sh o u ld be discussed: i. D e sc rip tio n o f jo in t stru c tu re . ii. A ffect rh e u m a to id a rth ritis has o n jo in ts . E m phasis th a t th e re is as yet no cure. iii. C o m m o n d e fo rm itie s e.g. flexion o f th e knees. P re ­ ven ta tiv e tre a tm e n t sh o u ld be discussed. iv. R e a s o n for rest, exercise a n d the b a la n ce betw een these. v. If p o ssible films a b o u t th e disease sh o u ld be show n. W o rk in g o n a rh e u m a to id u n it I fo u n d th a t m axim um c o -o p e ra tio n from th e p a tie n ts w as o b ta in e d if the a bove d iscussions w ere h e ld ; also th e p a tie n ts b e nefitted greatly from g ro u p discussion. (b) R e s t R e st is in d ividually p rescribed as a tre a tm e n t in th e acute p hase. I n th e later stages a b a la n ce o f rest a n d exercise is estab lish e d . M a n y p a tie n ts try to k eep as a ctiv e as possible to p re v en t d e fo rm ity a n d loss o f fu n c tio n . A t c e rta in stages in th e disease excess use o f jo in ts k eep th e m in a sta te o f su sta in ed a n d c o n tin u o u s in fla m m a tio n so accelerating d e stru ctio n . L ig h t rem oveable sp lin ts a re w o rn in te rm itte n tly d u rin g day a n d night. i. R est during the acute phase R e st m ea n s te m p o ra ry n o n w eight o r n o n use o f a jo in t, k e eping it in a n o p tim u m p o sitio n o f fu n c tio n . W h e n the 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 8 P H Y S I O T H E R A P Y December, 1967 join ts demonstrate acute sym ptom s total body rest and splinting o f specific jo in ts is valuable resulting in decreased inflam m ation and so increased m obility and function. T otal im m obilisation is not the answer, the patient must AC TIV E L Y m ove each joint through as full a range as possible O N C E daily. R est is decreased progressively with improvement and subsidence o f pain. ii. Sub acute phase R est periods are interspersed with periods o f physical therapy. The rest splints are worn at night and durmg rest periods. iii. Chronic phase R ehabilitation is very active— the patient sets the pace. Periods o f strenuous exercise are follow ed by rest. Positions o f rest In bed. Every patient must lie P R O N E for at least one hour daily to prevent hip flexion contractures. P a tie n t in Supine (а) 1 in. plyw ood bed board to prevent flexion o f hip while supine. (б) F o o t board. (c) N o pillow or very sm all p illow under head. (d ) N o pillow under knees. (e) 6 in. blocks under casters to elevate bed— this permits the patient to get in and out o f bed with minimal joint strain. P rone Position (а) H ips fully extended. (б) If possible feet at right angles. In a chair. I f possible chairs are raised 4 in. so as to prevent the hips being flexed to an angle greater than 90°. S P L IN T IN G I f possible aluminium splints or prenyl splints are used— if this is not possible p .o.p . splints serve this function equally. . Splinting aiming at: reduction o f pain. prevention o f deformity, im provem ent o f function, correction o f deformity— as. in serial splints. Leg splints. Extend from m id thigh to M /P join ts o f foot. The knee must not be hyperextended, ankle in the mid position with the foot at right angles. I f the patient dem on­ strates a tendency to external rotation at the hip a rotator bar can be attached to the splint. Velcro strapping is used to attach the splints— one strap is mid thigh, one directly over the patella (avoid pressure o n the tibial tubercle as the tibia tends to sublux on the femur due to the laxity o f the cruciate ligaments). Arm splints. It has been stated that on e quarter o f patients suffering from rheum atoid arthritis dem onstrate major deformity o f the hands. A lthough types o f deformity are varied there is frequently a wrist flexion deformity with volar subluation o f the ulna, radial deviation o f the carpus and ulnar drift o f the fingers. T he wrist being the key joint in functional balance o f the hand. W hen flexion deformity occurs at this level an im balance o f long flexors and extensors to the digits occurs leading to finger deformity. C om m on hand deform ities include flexion deformities o f M .C .P. join ts with volar subluxation, ulnar deviation o f the P .I.P. join ts o f the fingers. A t the level o f the phalanges there m ay be swan neck deformities with hyperextension o f P.I.P. join ts and flexion o f D .I.P . join ts or the Boutenniere deformity with hyperextension o f D .I.P . join ts and flexion o f P.I.P. jo in ts— this deformity is caused by the lateral slips o f the E xtensor D igitoru m slipping toward the volar side o f the finger and so acting as flexors. A hand splint m ust therefore be m ade to accom plish the follow ing: i. The wrist in the m id position (the patients com plained o f increased pain if wrist put into any degree o f extension). ii. Splint must control radial deviation at the carpus. iii. Support heads o f meta-carpals and lim it flexion at M .C .P . join ts to 30°. iv. Splint must n o t extend beyond mid shaft o f proximal phalanges so as to allow flexion o f phalanges with support under metacarpal heads. v. Ulnar deviation o f the fingers m ust be controlled. vi. Velcro strapping is used— one directly over the wrist, one directly over the M .C .P . joints. EX E R C ISE TH E R A P Y M uscle weakness and atrophy is a constant factor. Individual attention is given to m uscles and joints. Applicable principles Passive m ovem ents are never given to a rheum atic joint. Static exercise given where severe bon e o n bon e crepitus is present. Resistance through range given if pain not to o severe. Specific therapy as well as class work should be given. A n exercise routine should be established. Class work— should be given with the aim o f putting each jo in t through as full a range as possible. A hand and foot class given daily follow in g wax as well as a general ward class should be given. The ward class should include postural exercises, quadriceps drill, hip exten sion exercises as well as general m obilising and strengthening exercises should be given. These classes were typed out and supervised w hile the patient was in hospital so that a similar routine could be follow ed at hom e. P .N .F . techniques proved m ost valuable when com bined with ice especially in reduction o f pain, spasm and increase in strength. R ou tin e exercises such as straight leg raising using sandbags were taught. R heum atic shoulders and knee joints responded exceptionally well to ice plus static con ­ tractions in various parts o f the range later progressing to m ovem ent through range in all P .N .F . diagonals. P O O L T H E R A PY This proved m ost beneficial when individual supervision o f each patient was given. The technique which was m ost successful was dem onstrated to m e by a physiotherapist from Bad R agaz in Switzerland. N o individual m uscle was exercised but m ovem ent patterns were used. R e-ed ucation o f walking in the p ool post surgery (e.g. after synovectom y, osteotom y, cup replacements in the hip joint) allow ed patients to weight bear correctly and so retrain their pattern o f walking. R esisted walking in the p ool was given to re-educate, strengthen and increase endurance o f the patient. This can be done by giving direct resistance to the patient or by altering the speed o f m ovem ent in the water. 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 9 P A IN M axim um increase in m uscle strength is gained when the patient is pain free. Each patient responds to each technique o f pain relief differently. (а) D rug therapy: The drugs vary with each group o f physicians supervising the patients therapy. (б) R est: Described above. (c) H eat: Can be used in either the dry or the m oist form. I did not find any dramatic relief o f pain when using S .W .D . or infra-red. H ow ever patients reported relief o f sym ptom s in the sub acute and chronic stage o f the disease w hen m oist heat was used: wax baths to hands and feet, p ool therapy, hydrocolator packs. In m any patients sym ptom s were aggravated by the application o f heat in any form even in the chronic stage o f the disease. (d ) Ice: “In spite o f the fact that som e rheumatoid patients hate the cold weather, their natural prejudices against it have to be tactfully handled when introducing them to the treatment” (K n ott 1964). The application o f ice tow els proved m ost useful in com bination with isom etric exercise in the reduction o f pain in all the large joints. M any patients have obtained relief o f painful hands when immersing them in ice for few short repeated applications. N o t only was ice beneficial in reduction o f pain but g ood fast results were obtained when joint deformity was present the flexion contractures o f th e knees— ice packs applied to the hamstring group com bined with “ hold relax” to the contracted group with strength­ ening to the quadriceps mechanism. (e) Exercise: Described above. ( / ) W alking aids: W alking frames used in patients who are severely disabled. C anadian gutter crutches (fore­ arm support crutches) are preferable to canes for m any reasons: A patient invariably demonstrates pathology at the wrist— with the continuou s flexion and exten sion required at the wrist when using canes an increase in pain results as well as possible rupture o f extensor tendons o f the digits. A lso hand deformity does n o t allow patient to use cane efficiently. Gutter crutches tend, if correct height to prevent flexion at the hip when walking. R E H A B IL IT A T IO N A ll activities o f daily living m ust be checked and if necessary a dom iciliary visit sh ould be m ade to check height o f stairs etc. the patient must therefore be taught the easiest manner o f clim bing these stairs and the necessary adjustments to hom e made. Discharge o f patients Total re-assessment performed. Regular reports to the arthritic clinic m ust be m ade. All patients m ust continue their hom e programme o f exercise. C O N C L U S IO N In this paper I have only discussed the very general treatment o f the arthritic patient, also there has been no discussion o f the post-surgical approach to these patients. A physiotherapist can m ake a vital contribution to the habilitation o f the rheum atoid patient, especially when such therapy is supplem ented and com plem ented by all treating the patient. A c k n o w l e d g e m e n t (а) Support and encouragem ent from Mrs. M . Kirschbaum, Lecturer, Departm ent o f physiotherapy o f the University o f the W itwatersrand. (б) The co-operation and instruction given to m e by the R heum atic D iseases U n it expecially from Dr. D . G ordon and D r. J. Stein. B i b l i o g r a p h y 1. B l a n d , J. H . ‘Arthritis— M edical treatment and hom e care.’ 2 . B r o w n , M . E . ‘R h eum atoid Arthritic H and s,’ American Journal O ccupational Therapy, 1966, V ol. X X . 3. E y r i n g , E . J. A rth ritis and Rheumatism, 1963, V ol. 6. 4. H o l l a n d , Arthritis. 5 . H a i n e s , J.- ‘A survey o f recent developm ent in cold therapy,’ P hysiotherapy, July, 1967. 6. R heum atic D iseases, Am erican Journal o f Occupational Therapy, Sept., 1965. 7. R o b b , J. and R o s e , B. S. ‘R h eum atoid Arthritis and M aternal D epravation,’ British M e d ica l Journal o f M e dical Psychology, 1965. 8 . S h a l i t , I. and D e c k e c k e r , J. Lancet, 16 Jan., 1965. A. C. MILLER & CO. ORTHOPAEDIC MECHANICIANS M anufacturers and Suppliers of: O R T H O P A E D IC A P P L IA N C E S, A R T IF IC IA L LIM B S, T R U S S E S , S U R G IC A L CO RSETS, U R IN A L S , A R C H SU PP O R T S, C O L O ST O M Y BELTS, E L A ST IC ST O C K IN G S, A N K L E G U A R D S , W R IST G U A R D S , ELBO W G U A R D S , K N E E G U A R D S , L IG H T D U R A L C R U T C H E S F O R C H IL D R E N , W O O D E N C R U T C H E S , A N D M E T A L ELBO W C R U T C H E S. • Phone 23-2496 P.O. Box 3412 312 Bree Street, Johannesburg 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. )