Physiotherapy modalities are commonly used in the treatment of

Arthritis.

1) cold/hotapplications,
2) electrical stimulation
3) hydrotherapy.
Controlled studies performed with adequate numbers of cases and using validated
objective measures to evaluate various physiotherapy and rehabilitation methods in
arthritis are quite rare. This is because the disease process may be affected by various
factors, and the actual effectiveness of the investigated agents is difficult to determine.
However, various physiotherapy agents are commonly used in daily practice; most often,
their use is based on personal experiences.
Cold/Hot Applications

Cold/hot modalities are the most commonly used physical agents in arthritis treatment.
It is well known that cold application is mostly used in acute stages whereas hot is used in
chronic stages of Arthritis.
By using heat, analgesia is accomplished, muscle spasm relieved, and elasticity of
periarticular structures obtained. Heat can be used before exercise for maximum benefit.
Thermotherapy may be applied as a superficial hot-pack, infrared radiation, paraffin,
fluidotherapy, or hydrotherapy. Applications are recommended for 10–20 minutes once or
twice a day. Caution is necessary in patients with sensorial deficits and impaired vascular
circulation in hands and feet because of burn risk. Cold application is preferred in active
joints where intra-articular heat increase is undesired. Cold-pack, ice, nitrogen spray, and
cryotherapy are different methods of applying cold-therapy.
Cartilage-destroying enzymes are produced within the inflamed joints of patients.
Levels of destructive enzymes such as collagenase, elastase, hyaluronidase, and protease
are affected by the temperature of local joints. With temperatures of 30° Celsius or lower,
effects of these enzymes are negligibly small. Normal intra-articular temperature is 33°
Celsius, whereas it may rise up to 36° Celsius in patient. Increasing intra-articular
temperature is also related to an increase in collagenase activity and cartilage damage.
Despite the inhibition of cell proliferation and metabolic activation within the synovial fluid
at 41–42° Celsius, it cannot be used as a therapeutic method because of irreversible joint
damage. Various studies have investigated the changes within joints upon application of
heat. Intra-articular temperature increased by superficial heat application. In the first 5
minutes, the joint temperature decreased but subsequently, as expected, it began to rise. It
has been suggested that within the first few minutes, superficial vessels become dilated and
circulation moves away from the inflamed synovial tissue. The opposite of this occurs during
the cold application. Effects of heat application change between normal healthy subjects
and patients with inflamed joints. Accordingly, skin temperature rises with paraffin at the
most and intra-articular joint temperature with diathermy application. Temperature
increase with short-wave diathermy application continues for 40 minutes. However, it has
been observed that increased intra-articular temperature has no beneficial effect on clinical
prognosis or radiologic progression. Skin temperature decreases the most by cold air
application, whereas intra-articular temperature decreases the most by ice application.
Increased intra-articular temperature by cold-pack application may be explained by
reactional temperature rise with short-term application, which was previously mentioned.

Electrical Stimulation

Electrostimulation is used in patients with Arthritis to relieve pain. Transcutaneous

electrical nerve stimulation (TENS) therapy is the most commonly used method.
Mannheimer and Carlsson applied TENS at various frequencies and reported that the
highest frequency TENS was the most beneficial, with an analgesia that persisted up to 18
hours. Various studies have reported an increase in hand grip strength after daily
application of 15 minutes of TENS and a decrease in pain after using TENS once a week for 3
weeks. Levy and colleagues observed reduction of synovial fluid and inflammatory exudate
following TENS application in acute arthritis and suggested that pain relief may be partially
explained by this effect. Postoperative pain control by TENS therapy following knee joint
arthroplasty reduces need for analgesic drugs and hospital stays. Due to the variations
between the materials and methods of the studies, it is difficult to interpret TENS
applications. Nevertheless, TENS is generally a short-acting therapy (6–24 hours), and the
most beneficial frequency is 70 Hz. It also has a high placebo effect. It cannot be used in
every painful joint simultaneously, which is a disadvantage in patients with polyarticular
involvement.
Interferential current can also be used for analgesia. Studies have shown its efficacy on pain
relief, swelling, and improvement in ROM, Also, no difference was found between
interferential current and TENS in the magnitude of analgesia.

Hydrotherapy

There has been widespread use of balneotherapy by patients with rheumatic diseases
since the old times in search of a cure for their ailment. Therefore, there are some
suggestions that the science of rheumatology has been developed in balneotherapy.
Initially, the term “balneotherapy” was used to discriminate thermal and mineral water
therapy from hydrotherapy, but today these terms are often used interchangeably. In
recent years, balneotherapy has served as one of the therapeutic alternatives in other
rheumatoid diseases, particularly in chronic degenerative diseases. Objectives of
balneotherapy are to increase ROM, to strengthen muscles, to relieve painful muscle
spasms, and to improve the patient's well-being.
Balneotherapy in arthritis treatment is a disputed issue. O'Hare and colleagues have
reported an increase in diuresis, hemodilution, and a reduction in rheumatoid factor levels.
In contrast, Becker has attributed the main effect to a decrease in joint loading, relaxation,
and an increase in general physical conditioning. There have been studies showing beneficial
effects of balneotherapies on several factors such as reduction in pain and grip strength.
Effectiveness of balneotherapy is not only associated with hot water but also with the
minerals contained in the water. It has been claimed that mineral waters have some positive
effects in balneotherapy. Water has mechanical, chemical, and physical action mechanisms.
Its mechanical action occurs during the bath when the body weight decreases by 50% to
90% depending on the type of bath. In cases of muscle weakness or widespread painful joint
inflammation, this action allows the patients to perform their exercise programs. In
addition, various studies have shown that balneotherapy leads to muscle, tendon, and
ligament relaxation and a feeling of well-being. Here the action mechanism provides
exponential benefits. Decreasing perception of pain by increasing the pain thresholds at free
nerve endings, relieving muscle spasm by effecting gamma muscle fibers, peripheral
vasodilatation, and removal of painful mediators are among these mechanisms. In addition,
balneotherapy has a sedating effect by increasing acetylcholine release from the central
nervous system through activation of parasympathetic nervous system. Endorphin release
throughout the therapy also contributes to improved action mechanisms.
Effects of balneotherapy on the immune system have recently become a subject of interest.
There are some speculations about its immunostimulatory and inhibitory effects. In
particular, alterations in release of interleukin-1 and interleukin-6, tumor necrosis factor-
alpha, and gamma-interferon, which have a role in etiopathogenesis of inflammatory
arthritis, have been reported.
Environmental changes while at balneotherapy should also be considered. Physical and
mental comfort, cessation of home duties, and vacation atmosphere are among positive
factors that may also contribute to the healing process.
In conclusion, although the effects of balneotherapy are currently not clarified, it is a
palliative treatment in rheumatoid diseases through various mechanisms. There is need for
further appropriately designed studies encompassing assessment of quality of life as an
outcome measure.

Physiotherapy treatment is important in helping patients with Arthritis manage their

disease. In conjunction with occupational therapists, physiotherapists educate patients in
joint protection strategies, use of assistive devices, and performance of therapeutic
exercises.

Joint Protection Strategies

Joint protection strategies, such as rest and splinting, using compressive gloves, assistive
devices, and adaptive equipment, have beneficial effects in managing Arthritis symptoms
and deformities.
 Rest and Splinting
The joints should be put into rest during the acute stage of the disease. Bed rest relieves
the pain in cases of extensive joint involvement. It is critical, at this stage, to put the joints
into rest at a functional position. Rest position should be as follows: shoulder joint in 45°
abduction, both wrist joints in 20° to 30° dorsal flexion, fingers slightly in flexion, hips at 45°
abduction without any flexion, knees totally extended, and feet in a neutral position. Splints
may be used to give desired position at rest and functional positioning to the involved active
joints. Increased compliance can be gained by offering the patient splints made of soft
materials.Orthosis and splinting are used for the following objectives: to diminish pain and
inflammation, to prevent development of deformities, to prevent joint stress, to support
joints, and to decrease joint stiffness.
Various reports have shown benefits of wrist splints in controlling pain and inflammation
and preventing the development of deformities Flexible wrist orthosis increases hand grip
strength by 20% to 25%. Various ring orthoses have been developed to prevent finger
deformities. Major factors determining patient compliance to the orthosis are size of the
orthosis, the heat generated at the skin by the orthosis, hardness of the parts in contact
with the skin, and whether it interferes with functions of the hand. Joint stress in the feet
may be alleviated by medial arc supporting pad at the sole of the foot and by metatarsal
pad. Viscoelastic soles may decrease shock loading occurring at proximal tibia during the
gait, by up to 40%. Philadelphia corset may be recommended if atlantoaxial involvement is
present. Orthosis provides better immobilization and may be used in the presence of
cervical instability.

Compression Gloves

Patients using compression gloves have reported reduced joint swelling and increased
well-being. However, there is no positive evidence regarding improved grip strength or hand
functions from using gloves. Improvement may be provided by using compression gloves for
hour intervals or only at night in patients with inflammation in their hands or fingers. Gentle
compression is beneficial because of the containment of joint swelling and subsequent
decrease of pain.

Assistive Devices and Adaptive Equipment

Occupational therapy improves functional ability in patients with Arthritis.

Occupational therapy interventions such as assistive devices and adaptive equipments have
beneficial effects on joint protection and energy conservation in arthritic patients.Assistive
devices are used in order to reduce functional deficits, to diminish pain, and to keep
patients' independence and self-efficiency. Loading over the hip joint may be reduced by
50% by holding a cane. In fact, most of these instruments are originally designed for patients
with neurologic deficits; therefore, certain adaptations may be needed for them to be used
in patients with arthritis. Elevated toilet seats, widened gripping handles, arrangements
related with bathrooms, etc. might all facilitate the daily life. The procedures needed to
increase compliance of the patient with the environment and to increase functional
independence are mainly determined by the occupational therapist. Catalogues introducing
various assisting equipment models designed for every kind of requirement should be
presented to patients.

Massage Therapy
Massage is a commonly used treatment tool that improves flexibility, enhances a feeling
of connection with other treatment modalities, improves general well being, and can help to
diminish swelling of inflamed joints. Dhondt and colleagues have reported that pain
thresholds both at the massage site and at the knee and ankle have decreased after
applying oscillatory manual massage to the intervertebral paraspinal region. Massage is
found to be effective on depression, anxiety, mood, and pain. This finding leads to the
question of whether there are some changes in peripheral nociceptive perception and
central information in Arthritis. Also, massage decreases stress hormone levels.

Therapeutic Exercise
Muscle weakness in patients with Arthritis may occur because of immobilization or
reduction in activities of daily living. Maintenance of normal muscle strength is important
not only for physical function but also for stabilization of the joints and prevention of
traumatic injuries. It may be proposed that exercise therapy has beneficial effects on
increasing physical capacity rather than reducing the activity of the disease.
Prior to establishing an exercise program for patients with Arthritis, the following
characteristics should be considered: whether the involvement of the joints is local or
systemic, stage of the disease, age of the patient, and compliance of the patient with the
therapy. Duration and severity of the exercise are adjusted according to the patient. ROM
exercises, stretching, strengthening, aerobic conditioning exercises, and routine daily
activities may be used as components of exercise therapy.
There should be no straining exercises during the acute arthritis. However, every joint
should be moved in the ROM at least once per day in order to prevent contracture. In the
case of acutely inflamed joints, isometric exercises provide adequate muscle tone without
exacerbation of clinical disease activity. Moderate contractures should be held for 6 seconds
and repeated 5–10 times each day. It should be remembered that if isometric exercises are
performed in a magnitude of more than 40% of maximum voluntary contraction, they may
lead to impairment in blood circulation and fatigue after the exercise. If the disease activity
is low, then isotonic exercises should be performed by using very low weights. Low-intensity
isokinetic knee exercises (by 50% of the maximum voluntary contraction) were reported to
be safe and effective in patients with Arthritis. If pain persists more than 2 hours or too
much fatigue, loss of strength, or increase in joint swelling occurs after an exercise program,
then it should be revised. Also, walking does not lead to intra-articular pressure increase in
healthy subjects but does so in a knee with inflammation and effusion. Thus, patients with
active arthritis should particularly avoid activities such as climbing stairs or weight lifting.
Producing excessive stress over the tendons during the stretching exercises should be
avoided. In sudden stretches, tendons or joint capsules may be damaged. Finally, in chronic
stage with inactive arthritis, conditioning exercises such as swimming, walking, and cycling
with adequate resting periods are recommended. They increase muscle endurance and
aerobic capacity and improve functions of the patient in general, and they also make the
patient feel better.

Patient Education

In patients with Arthritis, sociopsychological factors affecting the disease process such as
poor social relations, disturbance of communication with the environment, and
unhappiness and depression at work are commonly encountered. Scholten and colleagues
have organized multidisciplinary education with the participation of rheumatologists,
orthopedicians, physiotherapists, psychologists, and social workers for patients with
arthritis. In this program, there is information about benefits and adverse effects of drug
therapy, importance of physiotherapy, use of orthosis, psychological coping methods, self-
relaxation, and various diets. In addition, patients are taught how to perform the scheduled
exercises and how to protect the joints during routine daily life. Patients who have
participated in this program have revealed improvement in disability associated with the
disease, psychosocial interaction, and clinical prognosis. All clinics that deal with the
treatment of rheumatic diseases should provide education and information to their patients
about their condition and the various physical therapy and rehabilitative options that are
available to improve their quality of life.

Management of Specific Joints

Ø Hands:

Resting splints are used commonly to treat hand involvement in early and active
Arthritis.
All resting splints should be custom-made in order to ensure correct fit and joint positioning,
and to be acceptable to the patient.
Short-term use may still offer some symptomatic benefit and help to prevent deformity.
Splints may also help to prevent deterioration of deformities such as ulnar deviation, swan-
neck or Boutonniere deformities.
Local corticosteroid injections are often used as a means of reducing active synovitis in one
or more PIP or MCP joint, or to treat flexor tendon nodules or flexor tenosynovitis, in which
there may be limited active flexion of the fingers but nevertheless a good range of passive
movement.
 Ø Wrists:

Proprietary splints can be invaluable in helping to maintain function, reducing pain and
preventing deformity of the wrists.
It is important to appreciate that poor wrist function will undoubtedly contribute
significantly to poor overall hand function. More rigid polythene or prefabricated splints
may sometimes be considered particularly if wrist mobility is already reduced.
Long-term restriction of movement should not occur, although a stiff wrist held in an
optimal
position may still be relatively pain-free and functional.
Carpal tunnel syndrome, due to entrapment of the median nerve, is a common associated
problem in Arthritis and may lead to hand pain and sensory symptoms.
Confirmation of the diagnosis using nerve conduction studies should be obtained if possible.
If symptoms do not improve despite the regular use of splints, control of the activity of the
rheumatoid disease and a local steroid injection, then surgery to decompress the carpal
tunnel may need to be considered.

Ø Elbows:

A programme of active exercises and education to encourage movement and prevent

flexion deformities of the elbows is of paramount importance in Arthritis.
If the elbows are particularly inflamed such that the patient's capacity for conducting the
recommended exercise programme is compromised, and if other causes of inflammation
have been excluded, a corticosteroid injection into the joint or bursa may be given in an
attempt to reduce pain and to enable maintenance of exercises in order to preserve range
of movement in the joint.
Rheumatoid nodules occur in approximately 25-30% of patients with Arthritis. Surgical
removal may be considered, particularly if infection of the nodule occurs.

Ø Shoulders:

Shoulder involvement is common in Arthritis, and should be anticipated and addressed

in the form of a specific programme of exercise and education in order to prevent loss of
movement and function.
Restriction of abduction and external rotation of the shoulder should be sought from an
early stage and monitored closely, and the patient's exercise programme modified
accordingly if the range of movement shows signs of deterioration.
A painful arc of movement of the shoulder joint suggests tendonitis, which may, if
diagnosed in its early stages, respond to a local steroid injection.
 Ø Cervical spine:

The cervical spine is commonly affected in Arthritis and the consequent effects of this on
the spinal cord may lead to serious complications or even death.
Therefore, before embarking upon any course of physiotherapy, X-rays of the cervical spine
should be taken in flexion, extension and with an open-mouth view.
This issue should also be borne in mind when preparing patients for anaesthesia, and during
surgery and postoperative management. Soft and rigid cervical collars may be of
symptomatic value for some Arthritis patients with neck problems, although many patients
find them uncomfortable.

Ø Dorsal spine and lumbar spine:

The lower spine is rarely affected by Arthritis. Any episodes of sudden acute onset of
pain should be investigated for possible vertebral collapse, especially if the patient has been
treated with glucocorticoids.

Ø Hips:

Acute synovitis of the hips in Arthritis is relatively rare unless it forms part of more
widespread exacerbation in inflammation involving other joints. Pain arising from the hip
joint itself is usually felt in the groin, whilst pain over the lateral aspect of the hip may often
arise as
referred pain from the lower lumbar spine or pelvis, or may indicate a subtrochanteric
bursitis. An ultrasound scan or an MRI scan can be useful in confirming the presence of
synovitis in the hip, for example by demonstrating the presence of fluid in the joint.
An active exercise programme, with hydrotherapy, should be used to help reduce
symptoms, maintain hip movement and improve muscle strength.

Ø Knees:

Active synovitis in the knee occurs commonly in both early and chronic Arthritis. Pain
may cause the knee to adopt a flexed position.
Early treatment is essential and may involve resting splints, serial plaster or thermoplastic
splinting and active quadriceps exercises in an effort to maintain range of movement. As
always, a strong emphasis should be placed on the prevention of deformity as well as
symptom management, and the vital importance of this should be explained carefully and
repeatedly to the patient from the outset.

Ø Ankles and feet:

Ankle pain may often arise from the subtalar joint, for which, if other measures have
failed, brief immobilisation in a light weight-bearing plaster of Paris is still sometimes used.
Similarly, use of below-knee callipers and orthoses to immobilise the subtalar joint whilst
allowing flexion at the ankle joint is still sometimes used for intractable ankle pain prior to
surgery.
The metatarsophalangeal joints are frequently the first joints affected in Arthritis, but
despite this the symptoms and signs of MTP involvement are often overlooked. Prevention
of pressure areas is essential as, apart from being focal areas of pain and functional
impairment, they may also serve as a portal of entry for infection.

MIHIR MEHTA 2nd Year M.P.T STUDENT.