Rehabilitation of Common Rheumatological Disorders

Rehabilitation of Common Rheumatological Disorders

Summary Pearls

· Rheumatic diseases include immune-related and nonimmune-related musculoskeletal disorders. Physiatrists should learn evaluation and treatment of rheumatic diseases.

· Pain, limited morning stiffness, reduced function, crepitus, restricted movement, and bony hypertrophy are the central features of osteoarthritis.

· Treatment of osteoarthritis includes nonpharmacological intervention, pharmacological treatment, and surgical options, and recently prolotherapy with intraosseous injection and transarterial microembolism has shown promising results.

· Rheumatoid arthritis is a chronic, systemic, inflammatory disease of unknown etiology that primarily involves the joint, especially small joints.

Introduction to Rheumatic Diseases

Rheumatology is a branch of medicine devoted to the evaluation, diagnosis, and treatment of immune-related and nonimmune-related musculoskeletal disorders or other connective tissue disorders, including different types of arthritis, lesions of soft tissues (such as muscle, tendon, cartilage, bursa, and fascia), vasculitis, and hereditary connective tissue disorders. Arthritis may occur because of immunological dysfunction (e.g., rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis); degeneration (e.g., degenerative arthritis or osteoarthritis); metabolic problems (e.g., gout and other crystal-related arthritis); and bacterial or microbial infection. Arthritis and soft tissue disorders may cause pain, impairment, physical disability, dependence on others for activities of daily living, occupational disability, and psychosocial problems, leading to the loss of wages and socioeconomic burdens.

Since two thousand, a burst of biological agents and synthetic antirheumatic drugs has changed the treatment and clinical outcomes of rheumatic diseases; however, pain and physical disability persist in patients with rheumatic diseases. Although physiatrists are not

· Pharmacological treatment of rheumatoid arthritis comprises nonsteroidal antiinflammatory drugs, low-dose oral corticosteroid, and disease-modifying antirheumatic drugs, including conventional synthetic, targeted synthetic, and biological agents.

Rehabilitative management of rheumatic diseases should be

· started with detailed evaluation and include patient education, exercise (strengthening, stretch, aerobic, and recreational), orthoses, and physical modalities (heat, cold, low-power laser, and electric therapy).

much concerned regarding immunology and new biological and synthetic drugs, they pay considerable attention to the biomechanical problems of rheumatic diseases and act as leaders in the rehabilitation team for most musculoskeletal disorders. Because soft tissue lesions are discussed in detail in other chapters, this chapter focuses mainly on arthritis and related disorders.

A diarthrodial or synovial joint is composed of the ends of bones, synovium, cartilage, and a joint capsule, which encloses the joint. The joint capsule is surrounded by ligaments and other periarticular structures such as bursae, tendons, and muscles. The joint capsule contains a joint cavity, which is filled with a lubricating synovial fluid. Diarthrodial joints allow a large range of movement and are the most common joints in the extremities, such as the shoulders, elbows, wrists, hips, knees, and ankles. Arthritis is the inflammation of a joint or joints and is clinically characterized by pain, tenderness, swelling, warmth, and redness. In the chronic stage, joint damage may occur, and deformity, crepitus, reduction in the range of motion of the joint, or abnormal movement pattern may develop. Reduction in the joint range of motion may be caused by joint inflammation (synovial hypertrophy and possible effusion), contracture of soft tissues, or irreversible damage to the articular cartilage or subchondral bone.

Clinical examination of patients with rheumatic diseases should involve observation of the entire person, including movement and posture, and then examination of each region. The procedure of local regional examination includes look, feel, move, and strength. For "look," pay attention to swelling, deformity, skin change, and muscle atrophy. For "feel," one first evaluates warmth by using the backs of the fingers, palpates tenderness, and determines the precise location of swelling. For detection of joint effusion, techniques such as the bulge sign and patellar ballottement may be used. For "move," both active and passive movements are assessed. Active movement is observed mainly to screen for possible lesion location. Pain or limited range of motion are criteria for abnormality.

During passive movement, pain, reduced range of motion, and abnormal "end feel" (sensation of the examiner's hand at end range of motion) should be recorded. "Strength" is usually examined for the contractile tissues (i.e., muscle and tendon). It is usually tested with maximal isometric contraction at the neutral position. If pain and/or weakness during or after the test is reported, a lesion of contractile tissues, including the muscle, tendon, tendon sheath, musculotendinous junction, and tenoperiosteal junction (enthesis), is likely. The exact location of contractile tissue lesions may be determined through palpation or accessory tests (see later). An accessory test is sometimes required for lesion localization (e.g., passive shoulder horizontal adduction to detect an acromioclavicular lesion and passive forearm pronation to provoke pain and thus to detect biceps brachii tendinopathy at the distal insertion). To provoke ligament pain, stretching can be used; to provoke bursa pain, compression or pinching may be used. In addition, joint stability should be evaluated by stressing a joint.

If indicated, imaging studies and laboratory tests should be conducted. In the recent decade, musculoskeletal ultrasound has become popular. The benefits of ultrasound examination are that it is radiation free and is useful for the detection and grading of synovitis, joint effusion, and bony erosion. Laboratory tests include screening for erythrocyte sedimentation rate, C-reactive protein, complete blood count, uric acid, rheumatoid factor, anticitrullinated protein antibody, or anticyclic citrullinated peptide, antinuclear antibody, human leukocyte antigen-B27, and synovial fluid analysis. A combination of history taking, physical examination, imaging studies, and laboratory tests is usually used to arrive at the correct diagnosis or disease classification. For rehabilitation evaluation of rheumatic diseases, the International Classification of Functioning, Disability and Health model is suggested.