rehabilitation of the rheumatoid patientthekahancenter.com/_files/cpmprandrheumatoid.pdf ·...
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Rehabilitation of the Rheumatoid Patient
Center for Pain Medicine and Physiatric Rehabilitation
2002 Medical Parkway Suite 150
Annapolis Maryland 21401
1630 Main Street Suite 215
Chester Maryland
410-571-9000
www.4-no-pain.com
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Role of Rehabilitation
obtain maximum usefulness in function
relief of symptoms
restoration of mobility and strength
prevent deformity
patient education
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Modalities
Compression gloves
Topical ointments
TENS
Acupuncture
Spa therapy
Heat and cold
Hydrotherapy
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Compression Gloves
no effect on hand volume, grip strength, pinch strength, or dexterity
need to be able to provide at least a pressure of 12 mmHg
decrease finger circumference
provide a sense of improved well being
Culic, et al, 1979
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Topical Treatments Ben-Gay (White and Sage, 1971)
decreased motor unit activity
provide a felling of warmth
improved dexterity
subjectively decreased pain
Capsaicin (McCarthy and Mcarty, 1992)
no effect on RA patients
Copper Bracelets (Walker, Beveridge, & Whitehouse)
better than aluminum
controversial
might not hurt to try
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TENS
short-term benefits only
frequency is set at a minimum of 70 Hz
difficult for patient to apply
improvement of pain after TENS treatments range from 40 to 54%
Mannheimer 1978,1979; Kumar, 1982; Langley, 1983
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Acupuncture
Difficult to assess efficacy due to limited literature in English-speaking countries
doesn’t effect swelling, erythema, or ROM
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Spa Therapy
Short term benefits
not cost effective
not covered by insurance
doesn’t hurt to try if patient has access
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Therapeutic Heat
Superficial
has been shown to decrease intra-articular temperature initially
prolonged application (i.e.. Paraffin baths) has been shown to slightly increase intra-articular temperature
no significant change in swelling, ROM, or strength
improves morning stiffness
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Deep Heat Ultrasound (0.1 W/cm2 - 2.5 W/cm2)
no study has proven its effectiveness
Jan & Lai (1991) demonstrated that in combination with exercise the functional incapacity was decreased
Microwave (915 Hz)
need to maintain joint temperature at 42.50
C for 60 minutes to have an effect
has been shown to decrease leukocyte exudate, infiltration, and number of lymphocytes (Weinberger 1989)
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Cold Therapy
subjectively decreases pain on visual analog scale
no significant change in ROM or strength
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Therapeutic Exercise
programs should take into account:
level of local joint and systemic involvement
degree of muscle atrophy
type of pain
patient age
compliance
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Goals of Exercise
Strengthen major muscle groups surrounding joints
improve flexibility
improve endurance
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Rehabilitation of Selective Joints
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The Rheumatoid Hand
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Types of Deformities intercalated segmental collapse
DISI
VISI- most common
Intrinsic plus hand
Swan-Neck
Boutonniere’s
Nalebuff Thumb
Type I- hyperextension of IP
flexion of MCP
Type II- subluxation of trapezio MCP joint
hyperextension of IP
Type III- subluxation of trapezio MCP joint
hyperextension of MCP
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Treatment
avoid weightbearing on radial side of hand
use strongest joint for the job
proper use of hand
avoid Ulnar forces
avoid twisting motion
avoid tight grasping
Splints
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The Rheumatic Foot
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Types of Deformities
Metatarsal head subluxation
Tendocalcaneal synovitis
Pronated
Hallux valgus
Hammertoe
Hallux rigidus
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Treatment
wide toe box
metatarsal bars
medial lifts
NWB orthotics
AFO’s
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The Rheumatic Shoulder
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Types of Deformities
Impingement syndrome
Rotator cuff disease
Adhesive capsulitis
Bicepital tendonitis
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Treatment
Rest, medication, decrease acute inflammation
increase strength of major muscle groups of the shoulder
Neer protocol
avoid PROM
injection
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The Rheumatic Knee
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Treatment
strengthen major muscles groups of the shoulder
avoid closed chain exercises
joint conservation
injection
TKR
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The Rheumatic Elbow
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Treatment
maintain ROM
serial casting
avoid surgery
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Diagnosis require 4 out of 7
morning stiffness
arthritis of 3 joints
symmetrical involvement
positive RF
radiologic changes showing erosion
arthritis of hands involving PIP joints
rheumatic nodules
poor prognostic factor
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Characteristics Involvement of the PIP and MCP > DIP
soft tissue swelling
morning stiffness of approx.. 1 to 2 hours
increase in time of morning stiffness can indicate progression or flare
loss of ROM
dominant hand involvement
Swan-neck deformities
ulnar deviation
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Systemic Complications
Felty’s syndrome
Pericarditis
Pleural effusion
Sjorgen’s
Pulmonary fibrosis
Vasculitis
Crico-arytenoid arthritis
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DDx:
SLE
Reiter’s
Erosive OA
Psoriatic arthritis
Polyarticular gout
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Pharmacological Rx First line
NSAID’s
Second line
hydroxychlorquine (200 mg BID)
sulfsalazide (500mg -2 gm divided)
gold
Third line
methotrexate (7.5 mg -10mg qD)_
AZT
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Pearls about RX
Fenoprofen & Indocin have greatest renal toxicity
Sulindac is least renal toxic
Motrin is least hepatotoxic but can cause meningitis in SLE
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Pearls about Steroid Injections
Depo-medrol
doesn’t dissipate well
Kenalog
dissipates better
has longer action
Ratios of steroid to lidocaine
1:4 for the wrist
1:2 for the shoulder
1:1.5 for the hip