Inflammatory joint diseases: Physical Therapy Patient Management Using Current

Evidence

Authors

Ashraf N. Moharram, M.B.B.Ch., M.Sc., F.R.C.S., F.R.C.S.Ed., MD

Professor of Orthopedic Surgery, Cairo University, Egypt
President of Egyptian Society for Surgery of the Hand and Microsurgery (ESSHM)

Mohamed Abdelmegeed, PT, DPT, MSc, DSc, OCS

Orthopedic Physical Therapy Department, Cairo University, Egypt
Dynamic Medical Care, New York, USA

Classification of joint diseases (figure 1):

Degenerative: Inflammatory: Infectious:

• Osteoarthrits • Rheumatoid • Osteomyelitis
(OA) arthritis (RA) • Septic arthritis
• Post-traumatic • Systemic lupus • Tuberculous
arthritis erythromatosis arthritis
• Osteochondoritis (SLE)
dissicans • Ankylosing
Spondylitis (AS)
• Gout
• Psoriatic arthritis

Figure 1. classification of joint diseases

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 Rheumatoid arthritis
Rheumatoid arthritis (RA) is a systemic autoimmune inflammatory disease and results in
persistent inflammation of synovial tissue (figure 2) especially of the wrists, hands and feet.
Individuals with RA are eight times more likely to have functional disability compared with
adults in the general population from the same community. The structures around the joint can
also be affected, like the tendon sheath, the bursa and tendons. This pathology causes pain,
stiffness in the morning and after periods of inactivity, joint swelling, weakness, fatigue and
restricted joint mobility leading to reduced function. Without treatment RA can lead to
irreversible damage, namely deformity and finally provoke considerable physical functional loss
or even permanent disability. Thus, RA causes dramatic interference with quality of life if early
diagnosis and appropriate treatment are not obtained. [1][2]

Figure 2. schematic presentation of a healthy joint and a joint with RA

Incidence:

• The commonest cause of chronic inflammatory joint disease (1-3%).

• A peak incidence around 30- 50 years of age.
• Women are affected 3 or 4 times as commonly as men
• More common (and generally more severe) in the urban communities of Europe and North
America than in the rural populations of Africa.

Patient presentation and physical examination

• Onset is usually insidious, with symptoms emerging over a period of months. Occasionally
the disease starts quite suddenly.
• There may be a previous history of 'muscle pain', tiredness, loss of weight and a general
lack of well-being.

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• In the early stages, the picture is mainly that of a polysynovitis, with soft-tissue swelling
and stiffness. Typically, a woman of 30-40 years complains of pain, swelling and loss of
mobility in the proximal joints of the fingers. As time passes the symptoms 'spread' to other
joints - the wrists, feet, knees and shoulders in order of frequency. Another classic feature
is generalized stiffness after periods of inactivity, and especially after rising from bed in
the early morning.
• Physical signs: may be slight, but usually there is symmetrically distributed: swelling and
tenderness of the metacarpophalangeal joints, the proximal interphalangeal joints and the
wrists.
• Tenosynovitis is common in the extensor compartments of the wrist and the flexor sheaths
of the fingers; it is diagnosed by feeling thickening, tenderness and crepitation over the
back of the wrist or the palm while passively moving the fingers.
• larger joints show; local warmth, synovial hypertrophy and intra-articular effusion may
be more obvious. Movements are often limited but the joints are still stable and deformity
is unusual.
• In the later stages joint deformity becomes increasingly apparent and constant ache of
progressive joint destruction.
• The combination of joint instability and tendon rupture produces the typical 'rheumatoid'
deformities: ulnar deviation of the fingers, radial and volar displacement of the wrists,
valgus knees, valgus feet and clawed toes. Joint movements are restricted and often very
painful.
• Extra-articular Features: in patients with severe disease. The most characteristic is the
appearance of nodules.

Clinical Pearl
In RA, the affection is systemic, symmetrical, and bilateral

Blood investigations:

▪ Normocytic, hypochromic anaemia is common.

▪ In active phases the ESR is raised may reach more than 100 and C-reactive protein may be
present.
▪ Serological tests: for Rheumatoid Factor is positive in about 80% of patients and
antinuclear factors are present in 30%. Neither of these tests is specific and neither is
required for a diagnosis of RA.
▪ Anti-cyclic citrullinated peptide (anti-CCP) antibody testing is particularly useful in the
diagnosis of rheumatoid arthritis, with high specificity, presence early in the disease
process.
▪ Synovial biopsy: Synovial tissue may be obtained by needle biopsy, via the arthroscope,
or by open operation.

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 In 80-90% of the patients with rheumatoid arthritis the
cervical spine is involved, which can lead to instability,
caused by the ligamentous laxity. Usually the
instability occurs between the first and second cervical
vertebrae. This instability can lead to pain and
neurological symptoms, like headache and tingling in
the fingers. [1] X-ray with open mouth view (figure 3)
should be ordered if ligamentous instability is
suspected in cervical spine.
Figure 3. Open mouth view
The Sharp-Purser test (figure 4) is used to assess the integrity of the
transverse or cruciform ligament of C1-2. The test intends to identify
excessive movement between, or a subluxation of, the atlas on the
axis. As originally described by Sharp and Purser,63 the patient is
seated. The physical therapist will stabilize the spinous process of C2
(axis) with one hand while the other hand will be placed on the
patient’s forehead. The physical therapist will passively flex the
patient’s head and neck to between 20o and 30o. With C2 stabilized,
the physical therapist will create a posteriorly directed force on the
patient’s forehead. The examiner must make sure that the force is a
translation force and not one that creates capital extension.

A positive test would be if there is cranial movement with the

posteriorly directed force on the forehead without the axis moving.
This would indicate that C1 has subluxed anteriorly on C2 and the
force created by the physical therapist has reduced the subluxation. Figure 4. Sharp-Purser test
A negative test is indicated if the physical therapist feels C2
immediately move posteriorly as the translation force is applied to the patient’s forehead. Other
indications of a positive test would be reproduction of myelopathic symptoms during flexion,64
or a decrease in symptoms during the posteriorly directed movement of the atlas on the
axis.65,66 This test was found to have a specificity of 0.96 and a sensitivity of 0.69. The
reliability of this test has not been examined.

Clinical Pearl
Cervical spine manipulation is contraindicated in
patients with RA.

Figure 5. difference in pathology between an RA

joint (left), and an OA joint (right)
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Management

• There is no cure for RA. It is not necessarily a crippling disease, that much can be done
to improve symptoms and delay progression and live an active life despite some functional
limitations.
• A multidisciplinary approach is needed from the beginning: ideally the therapeutic team
should include a rheumatologist, orthopedic surgeon, physical therapist, occupational
therapist, orthotist and social worker.
• Priorities of management are: (1) stop the synovitis; (2) keep the joints moving; (3) prevent
deformity; (4) reconstruct; (5) rehabilitate.
• DMARDs (disease modifying anti-rheumatic agents) e.g. methotrexate, can slow the
progression of joint destruction and deformity
• Surgical treatment, operative treatment is aimed for the inflammatory focus elimination,
reduction of the pain syndrome severity, the function loss, and the joint deformity
correction. The mostly used operative interventions are tenoectomy, synovectomy,
arthrodesis, total endoprosthesis.[9]

Physical therapy:
At the present, there is no therapy that can completely heal RA. But there are treatments that
achieve pain relief and the slowdown of the activity of RA to prevent disability and increase
functional capacity. RA patients are unfortunately committed to a treatment for life. [11] The
benefits of physical therapy interventions have been well documented.

The most common components of PT/OT for RA hands

are exercise therapy, joint protection advice and
provision of functional splinting and assistive devices,
massage therapy, exercise and patient
education. Dynamic exercise (aerobic capacity and/or
muscle strength training) was effective in improving
muscular endurance and strength, without detrimental
effects on disease activity or pain. Swimming and an
unloading treadmill (figure 6) are excellent options prior
to dry-land activities.

The therapy goals in most cases are:

• Improvement in disease management knowledge
• Pain control
• Improvement in activities of daily living
• Improvement in Joint stiffness (Range of
motion)
• Prevent or control joint damage Figure 6. Alter-G anti-gravity treadmill
• Improve strength
• Improve fatigue levels
• Improve quality of life
• Improve aerobic condition
• Improve stability and coordination

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Splinting:
Orthosis and splinting prevent the development of deformities and support joints

Therapeutic Exercise:
There is evidence suggesting that exercise improves general muscular endurance and strength
without detrimental effects on disease activity or pain in rheumatoid arthritis. However, few
studies have investigated the effect of exercises for the rheumatoid hand. Some improvement in
strength, mobility and/or function with no negative effects have been reported, although the long
term effectiveness has not been established due to various weaknesses in trial design.[19] (level
1B)

ROM exercises:
In acute phase: isometric/static exercises to be held for 6 seconds and repeated 5–10 times each
day; load = 40% 1RM. in chronic phase: functional exercises like swimming, walking, cycling
for a minimum of 4 repetitions for each joint in 2 to 3 days. These exercises increase the mobility
of the joint, but the concerned joint should not be loaded during these exercises.[24]

Strengthening:
Moderate-intensity exercise therapy. Each exercise must be repeated 8-10 times and a minimal
start intensity of 30-50 percent of 1 repetition maximum (RM).
Aerobic condition exercises:
There are two types of exercises to improve the aerobic condition: Intensive exercises and
moderate-intensive exercises. The intensive exercise therapy has a minimum duration of 20
minutes per session and this 3 times a week with an intensity of 65 to 90 percent of the maximal
heart rate. The moderate-intensive exercise therapy has a minimum duration of 30 minutes per
session and this 5 times a week with an intensity of 55 to 64 percent of the maximal heart rate.
The aim of these exercises is to improve the muscle endurance and aerobic capacity.
Monitoring the exercise should be performed regularly to avoid over stressing the joints or
exceed the patient tolerance. This can be achieved through different exercise tolerance tests:
• Age-adjusted maximum heart rate (AAMHR)= 220-age
• Target HR (karvonen’s formula): 60%-80% (HR max.- resting HR) + Resting HR.
• VO2max: HR max. 60%-80%= 50%-85% VO2 max. =50%-85% HR reserve
(karvonens’).
• Rate of perceived exertion (RPE): the Borg RPE scale presented in figure 7 can be used
to monitor the exercise tolerance. When the patient is on anti-hypertensive drugs,
therapists should not depend on HR as the primary indicator to monitor exercise as these
drugs affect the ability of HR to rise in response to exercise intensity. The RPE can be
used instead. RPE value of 12-13 (somewhat hard) = 60% of HR range. RPE value of 16
(hard)= 85% of HR range. Disadvantage of using this scale is that it cannot be used in
patients with depression, in addition, some patient may find unfamiliarity with its use.

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 Figure 7. the original Borg scale for rating of perceived exertion

Ankylosing Spondylitis
Ankylosing Spondylitis (AS) is a common chronic inflammatory rheumatic disease with
unknown etiology. AS is associated with the HLA-B27 antigen and also with other chronic
inflammatory diseases. AS affects the axial skeleton and sacroiliac joints (figure 8), causing
characteristic inflammatory back pain, which can lead to structural and functional impairments
and a decrease in quality of life.[1][2][3][4][5] Affected joints progressively become stiff and
sensitive due to a bone formation at the level of the joint capsule and cartilage. It causes a
decreased range of motion and gives the spine an appearance similar to bamboo, hence the
alternative name "bamboo spine" (figure 9, 10).
Although not often recognized, ankylosing spondylitis can also cause peripheral joint pain,
particularly in the hips, knees, ankles, shoulders and neck.[6] It involves synovial and
cartilaginous joints, as well as sites of tendon and ligamentous attachment.[3][5]Early diagnosis
and treatment helps to control the pain and stiffness and may reduce or prevent significant
deformity. Pain in AS can be caused by sacroiliitis, enthesitis and spondylitis.[2] Initially the
sacroiliac joints, are inflamed progressed to damage and fusion (figure 11). Subsequently the
inflammation moves to entheses, where ligaments and tendons integrate into bone.[6]

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 Figure 8. the SIJ, a common site for
Figure 9. schematic presentation of
affection with AS
a normal spine and a bamboo spine

Incidence:

❖ Males are affected more frequently than females in a 3:1 ratio

❖ The usual age at onset is between 15 and 40 years.
❖ There is a strong tendency to familial aggregation and association with the genetic marker
HLA-B27 (90-95% of patients with ankylosing spondylitis, compared to a 6 to 9%
incidence in the normal population).
❖ Its prevalence is highest among white people (0.1-0.2%), less common in African
American and rare among Japanese.

Characteristics/Clinical Presentation
• Usually an insidious onset of back pain in the sacroiliac (SI) joints and gluteal regions
and progresses to involve the entire spine. [7]
• Morning stiffness lasting greater than 30 minutes is a common subjective complaint,
• Waking up in the second half of the night.
• Pain and stiffness increase with inactivity and improve with exercise.[5]
• Variable involvement of peripheral joints, eyes, skin, heart and intestinal systems. [7]
• The hips, shoulders and knees are the most commonly and most severely affected of the
extremity joints. [5]
• Intermittent breathing difficulties may also be a common complaint because AS may
cause a decrease in chest expansion.
• X-rays are the most useful imaging modality in AS, although they may be normal in the
early phases. X-ray shows up areas where the bone has been worn away by the condition.
The vertebrae of the spine may start to fuse together because the ligaments between them
become calcified (figure 10).
• MRI scanning may also be useful in identifying early sacroiliitis. MRI of the sacroiliac
joints is more sensitive than either plain X-ray or CT scan in demonstrating sacroiliitis.

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 Figure 10. Appearance of bamboo Figure 11. Bilateral fusion of SI
spine in an PA x-ray film joints

Clinical Pearl
A probable diagnosis of AS is made if three clinical criteria are present

• Low back pain and stiffness for at least 3 months, which improves with exercise,
but is not relieved by rest
• Limited lumbar spinal motion in sagittal (flexion, extension) and frontal (side
flexion) planes
• Chest expansion decreased relative to normal values corrected for age and sex

Examination
The following signs are helpful in diagnosis of AS:
• Clinical signs are sometimes minimal in the early stages of the disease.
• Search for signs of enthesitis (Tenderness at the insertion of the tendo Achillis), 'foot
strain', or intercostal pain and tenderness.
• Slight flattening of the lower back and limitation of extension in the lumbar spine. There
may be diffuse tenderness over the spine and sacroiliac
joints,
• In established cases the posture is typical: loss of the
normal lumbar lordosis, increased thoracic kyphosis and a
forward thrust of the neck; upright posture and balance are
maintained by standing with the hips and knees slightly
flexed, and in late cases these may become fixed (figure 12).
• Spinal movements are diminished in all directions, but
loss of extension is always the earliest and the most severe
disability. It is revealed dramatically by the 'wall test': the
patient is asked to stand with his or her back to the wall;
heels, buttocks, scapulae and occiput should all be able to Figure 12. posture in AS
touch the wall simultaneously. If extension is seriously diminished the patient will find this
impossible.
• In the most advanced stage the spine may be completely ankylosed from occiput to
sacrum. Marked loss of cervical extension may restrict the line of vision to a few paces.

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 • A modified Schober’s test (figure 13) can be used
to test lumbar spine mobility in patients with AS.
if the distance between the proximal and distal
points in the figure on the low back decreased to
less than 5 cm (difference between distance when
the patient is standing and the distance when the
patient bends forward while his knees are
extended), it indicates decreased lumbar mobility.
• Chest expansion often markedly decreased. Chest Figure 13. Modified Schober’s test
expansion test should be performed to detect abnormal
chest expansion. The therapist determines the fourth intercostal space, and with a tape
measure, the therapist measures the difference between full expiration and full inspiration
(figure 14). If the difference is decreased to less than 2.5cm from the normative value for
age and gender, it is considered a positive test.

Figure 14. measurement of chest expansion

Physical therapy:

Treatment is essentially to minimize or prevent deformity. These deformities are excessive dorsal
kyphosis with compensatory cervical lordosis and hip flexion contracture. Non-Surgical treatment
involves:

• Proper sleeping posture on a solid, flat bed without pillow. Frequent sleeping or lying in
prone position.
• Posture exercises with upper back hyperextension (performed with avoidance of lumbar
hyperextension).
• Breathing exercises to increase or maintain rib cage excursion, as well as instruction in
abdominothoracic breathing.
• Range of motion exercises for hips and knees to prevent flexion limitation and
contractures.
• Periodic rest periods with avoidance of fatigue.
• Bracing or corseting (combined with exercises). [1]

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In addition to these exercises, aerobic exercises such as swimming and walking are
recommended. Research has shown a significant increase in chest expansion following
swimming programs and a significant increase in VO2 and Six Minute Walk Test distances in
patients practicing swimming and/or walking aerobic exercises. [8] Aerobic exercises lead to a
bigger chest expansion and therefore a better functional capacity and also decrease the chances
of respiratory failure.

A study by Ince et al. proposed a multimodal exercise program for patients with AS. Their
exercise in table 1 is recommended to be performed 2 times per week minimum, for 6 Months

Table 1. multimodal exercise program for subjects with AS

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