Rehabilitation of RA and AS

1. Current concepts in
Rehabilitation of Rheumatoid
Arthritis & Ankylosing
Spondylitis
Dr Harleen Uppal
Pain & Palliative Care Specialist
Delhi State Cancer Institute, New Delhi

2. Rheumatoid Arthritis
• Chronic, systemic, autoimmune, inflammatory
systemic disease - aggressive inflammatory
changes in synovium- joint pain, stiffness &
swelling ultimately leading to joint damage &
functional debility.
• Hallmark: symmetric peripheral polyarthritis.

3. Rheumatoid Arthritis:
• Worldwide prevalence - 0.5-1% among adults.
• Prevalence of RA in India: 0.28-0.7%.
• Women two to three times more commonly affected
than men.

6. 2010 ACR/ EULAR

7. X ray:
Periarticular erosions

8. Key components of rehabilitation evaluation in
Rheumatic diseases:

9. Factors to be aware of in
Rehabilitative Mx of RA
• Impairments.
• Functional problems.
• Disabilities.
• Stage of disease & joints. (acute, subacute, chronic)
• Functional class by ACR.
• Stage of biomechanical joint integrity. (tendon,
ligament, bone, cartilage)

10. `• Presence of joint effusion & degree. (mild, moderate, severe)
• Other RA extra articular organ system involvement.
• Other musculoskeletal problems present. (bursitis, tendinitis,
neck/ back pain syndromes)
• Comorbid medical conditions (cardiac).
• Current medications.
• Patient’s adjustment to illness, coping skills, compliance level.
• Presence of joint replacements and their age and stability.

11. Variables influencing Impairment,
Function and disability in RA

12. Functional Assessment:
• Assess pain, mobility, ADLs and social skills.
• The “Get Up and Go Test” and the 6- minute walk
tests are useful.
• Health Assessment Questionnaire (HAQ) assesses
mobility, self-care and pain and predicts later
function and morbidity.
• The Arthritis Impact Measurement Scales (AIMS)
assesses communication also.

13. Treatment Goals
• Relieve pain, swelling, fatigue.
• Improve joint function/ prevent loss of function.
• Prevent/ control joint damage.
• Prevent disability & disease related morbidity.
• Maintenance of normal ADL
• Maximization of QOL
• Minimize/ Avoid adverse events.
• Monitor for toxicity.

14. Multidisciplinary Approach
• Appropriate medical management.
• Bed rest during acute flare ups.
• Splinting of actively inflamed joints.
• Pain control.
• Bone sparing agents (for osteoporosis)

15. The Multidisciplinary Team
• Physiatrist in close collaboration with Rheumatologist
• Physiotherapist
• Occupational therapist
• Orthotist
• Psychologist
• Social Worker

16. Rehabilitation Interventions:
• Relative Rest
• Exercise
• Modalities
• Orthoses
• Adaptive Equipment

17. Overview of Rehab:
• Exercises:
• LE strengthening
• Walking
• Whole body physical activity
• Jogging in water
• Combined LE strengthening, flexibility and mobility
• Aerobic exercises
• LE ROM, mobility or flexibility
• Manual therapy with exercises
• Equipments:
• Adaptive for ADL.
• Assistive for ambulation.
• Appropriate footwear or insoles.
• Education:
• Self management
• Weight loss (if obese)
• Activity management or joint protection
• Social support
• Stress management/ relaxation.

18. Relative Rest
• Rest for acutely inflamed joints
• Energy Conservation
• A balance should be maintained between rest and activity.
• side effects of inactivity include decrease ROM, loss of strength, altered joint-
loading response, and decrease aerobic capacity.
• In studies by Mueller (ref 10) patients on strict bed rest lost 1.0% to 1.5% of their
initial strength per day over a two-week period.
• Gerber et al (ref 6) studied the importance of energy conservation and
interruption of daily activities lasting greater than 30 minutes.
• Patients appeared to benefit from the modification of activity and were taught to
recognize those activities that caused pain and fatigue.

19. Acute flare ups:
• Resting
• Spinling
• Positioning
• Bed Rest

20. Splinting
• Relieves pain
• Relieves muscle spasm
• Prevents deformity

22. UE Orthotics

23. Lower Limb Involvement

24. Lower limb orthosis and
mobility aids:

25. Exercises
• Acute stage: Maintaining ROM, isometric
strengthening
• Subacute, Chronic: Endurance & Strengthening Ex,
ROM Ex, Stretching Ex

26. Exercises:
• Structured Exercise Program.
• Stretching:
• For non-inflamed joints, active or active-assisted stretching of all major joints is
essential to prevent contracture formation, maintain the ROM to perform most ADL.
• Contractures can be prevented by once daily ROM exercise.
• For bedridden patients, proper positioning is necessary to prevent joint contracture
• Treatment of contractures must be done in a safe manner such that overly
aggressive stretching does not occur.
• Additionally, the presence of a bony block must be excluded as a causative factor in
prevention full joint motion.

27. Exercises:
• Strengthening:
• According to Hettinger, daily isometric contractions of
10%-20% of maximum tension held for 10 seconds can
maintain isometric strength.
• In RA patients, it has been shown that isometric
strengthening can lead to ADL performance with reduced
effort and an increase in V02max, which is a measure of
ones work capacity using oxygen consumption.
• Exercise programs should progress slowly, while
monitoring the patients for signs of inflammation

28. Compliance with Exercise:

29. Modalities:
• Superficial heat has its greatest effect on the skin
and subcutaneous tissues (Feibel 1976).
• It is especially useful in circumstances where the
goal is to heat joints that are covered by little soft
tissue such as those in the hands and feet.

30. - Conductive methods
• Hot, moist packs (hydrocollator packs)
• Paraffin wax baths: distal joints of upper and lower
extremities.

31. Convection:
• Hydrotherapy:
• Whirlpool baths (partial body emersion),
• Hubbard tanks (whole body emersion),
• Contrast baths which are specifically used for RA,
neurogenic pain, sprains and strains, and mild
peripheral vascular disease.

32. Heated Pools
• Danneskiold-Samsoe et al (ref 2) studied a small
group of patients to assess the effect of exercise in
a heated pool.
• They suggested that in-water exercise would
decrease the forces against joints, and the warmth
could help decrease joint pain and decrease
muscle spasm.

33. Deep Heat
• Deep heating increases the tissue temperature at a
deeper level without overheating skin and
subcutaneous fat.
• Ultrasound: joint contracture, scar tissue, periarticular
inflammation, bursitis, muscle spasm and pain, and
osteoarthritis.
• Phonophoresis, is proposed to aid in the transdermal
movement of topical medications. The most commonly
used are corticosteroids and local anesthetics.

34. • Diathermy, both short wave and microwave
involve similar principles. Short wave uses lower
frequencies than microwave, and both use
electromagnetic radiation to heat tissue. They are
used to heat relatively superficial muscles and
joints.

35. Cryotherapy
• Cold therapy has several physiologic effects that enhance or suppress
normal responses to certain stressors.
• Reflexive vasoconstriction followed by delayed vasodilation.
• Neuromuscular effects include slowing of nerve conduction velocity, and
decreased firing of the muscle spindles, which have been shown by some
to reduce spasticity.
• Effects in joints are thought to take place by decreasing synovial
collagenase activity, making it effective in inflammatory arthropathies(ref
13).
• General uses of cold include relief of muscle spasm, reduction of
spasticity, and control of inflammation in the acute inflammation
stage.

36. Cryotherapy
• Superficial: Most forms of cryotherapy are
considered superficial include
• Cold packs (conduction), and ice massage
(conduction).

37. Electrical Stimulation
• a. Electrical Nerve Stimulation: The primary delivery mechanism
is via transcutaneous electrical nerve stimulation (TENS). Its use
has been reportedly positive in RA and OA among other
conditions. Common uses include musculoskeletal pain,
peripheral nerve injury, peripheral neuropathy, postsurgical pain,
and complex regional pain syndrome.
• b. Interferential current (IFC): IFC uses alternating current
signals of different frequency in order to penetrate tissue without
discomfort. Proposed uses include musculoskeletal or
neurologic conditions, although, like most other modalities
mentioned, literature fails to demonstrate definite benefits over
placebo.

38. Orthoses
• Joint preservation techniques: patient
independence.
• Orthotic devices can make activities of daily living
much easier, leading to a greater degree of
independence.
• Patient can also be taught which movements to
avoid (i.e., those which create greater tension of
the digits) and appropriate range-of-motion
exercises.

39. ADL:
• Self care focuses on dressing, feeding, hygiene, and grooming.
• Adaptations for utensils include built-up handles and plate guards.
• Dressing aids include zipper pulls, velcro straps, and button aids.
• Grooming and hygiene are limited by the inability to grasp and hold
objects.
• A utensil cuff is a strap that can accommodate small items, such as a
toothbrush. With the proper training, these can be important adjuncts for
independent living.
• raised toilet seats
• special chairs and bed

40. Activities of daily living

41. Ankylosing Spondylitis

42. Classification of AS:
• ESSG criteria(1991)
• Inflammatory back pain(IBP) or
• Asymmetrical, lower limb predominant synovitis
• and any one of following
1. Positive family history
2. Psoriasis
3. IBD
4. Alternating gluteal pain
5. Enthesopathy
6. Sacroiliitis
• (Sensitivity 86%, Specificity 87%)

43. Diagnosis of AS:
• Previous criteria
• Rome(1961)
• New York(1966)
• Lacked sensitivity and specificity
• Modified New York criteria(1984) presently used
• Clinical
• Low back pain of at least 3 months duration improved by exercise and not relieved by rest
• Limitation of lumbar spine mobility in frontal and sagittal plane
• Chest expansion decreased relative to normal value for age and sex
• Radiological
• B/L sacroiliitis grade 2 to 4
• Unilateral sacroiliitis grade 3 to 4
• Definite AS – Unilateral grade 3 to 4 or bilateral grade 2 to 4 in the presence of any one clinical criteria

46. Changes on plain X ray
Symmetrical Sacroilitis

47. • Flattening of normal anterior concavity of the vertebral
body(‘squaring’) - Earliest vertebral change
• ‘Syndesmophytes’
• ‘Bamboo Spine’ – bridging at several levels
• Osteoporosis
• Hyperkyphosis of the thoracic spine
• Erosive arthritis of peripheral joints
• ‘Spurs’ at sites of Enthesopathy

49. Rehabilitation
• In a RCT, a program of supervised physiotherapy
( hydrotherapy, exercises and sporting activities
twice weekly for 3 hours per session) resulted in
improved overall health and less stiffness, as
reported by the patient.

50. • Lying prone for 15-30 mins once or several times a
day is useful to reverse the tendency toward
kyphosis, which is aggravated by pain and fatigue
and flexion contractures of the hip joints.
• Patients should sleep fully supine on a firm
mattress with only a small neck support pillow

51. Rehab Interventions
• Patient education
• Application of heat or cold
• Transcutaneous nerve stimulation
• Hydrotherapy : increases muscle strength without joint overuse
• Shoe inserts for Achilles tendinitis and Plantar fasciitis
• Splints :
✓ provide joint rest
✓ reduce inflammation
✓ allow functional use of joints that would otherwise be limited by pain

52. • Aids and adaptive devices :
✓ raised toilet seats
✓ special chairs and bed
✓ special grips that can assist in self care
• Extra depth shoe in case of dactylitis
• For patients with axial involvement, maintain a normal upright
posture through stretching of paravertebral musculature and
correction of tendency toward kyphotic posture
• Splinting combined with goal oriented exercises for prevention/
improvement of non fixed contractures

53. The Bath Indices
• Created in BATH in England
• 4 BATH indices developed
• BASMI- the BATH AS metrology index
• BASDAI- the BATH AS disease activity index
• BASFI- the BATH AS metrology index
• BAS-G- the BATH AS patient global score
• All consist of a set of questionnaires
• Answered on VAS 0-10
• Total score range 0-10

54. BASMI
• Objectively assesses axial status
regarded as cervical, dorsal,
lumbar, hip and pelvic soft tissue
• 5 clinical measurements used
• Cervical rotation
• Tragus to wall distance
• Lumbar side flexion
• Modified Schober’s test
• Intermalleolar distance

55. BASMI
Measurement Score
0 1 2
Tragus-to-wall < 15 cm 15 to 30 cm >30 cm
Lumbar flexion (modified Schober) > 4 cm 2 to 4 cm < 4 cm
Cervical rotation > 70º 20 to 70º < 20º
Lumbar side flexion > 10 cm 5 to 10 cm < 5 cm
Intermalleolar distance > 100 cm 70 to 100 cm < 70 cm
Jenkinson, T R., et al; Journal of Rheumatology 1994

56. BASDAI
• Consists of 10 cm visual analog scales
• 6 questions pertainining to 5 major symptoms of AS
• Fatigue
• Spinal pain
• Joint pain/swelling
• Areas of localized tenderness
• Morning stiffness
• To give each symptom equal weighing, the mean of two scores relating to
morning stiffness is taken

57. • How would you describe the overall level of fatigue you have experienced
• NONE VERY SEVERE
• 2. How would you describe the overall level of AS neck, back or hip pain you have had
• NONE VERY SEVERE
• 3. How would you describe the overall level of pain/swelling in joints other than neck, back or hip
• NONE VERY SEVERE
• 4.How would you describe the overall level of discomfort you have had from areas tender to touch/
pressure
• NONE VERY SEVERE
• 5.How would you describe the overall level of discomfort you have had from the time you woke up
• NONE VERY SEVERE
• 6. How long does your morning stiffness last from the time you woke up
• NONE VERY SEVERE

59. Ex for AS: Consensus
statement
• Recommendation 1: Assessment:
• Individual exercise prescription; thorough and
reproducible assessment, which includes
musculoskeletal and psychosocial factors, and AS-
specific measures, including objective axial
mobility and chest expansion (CBR).

60. • The Bath Ankylosing Spondylitis Metrology Index
(BASMI) : most widely reported, validated objective
axial mobility measure.
• Strength, balance or cardiorespiratory function
should be assessed.

61. • Recommendation 2: Monitoring:
• Feedback, particularly mobility measures, can be important
for exercise adherence.
• BASMI raw scores are more sensitive to change than index
scores
• In BASMI, lumbar side flexion is the most sensitive to
change
• The Edmonton AS Metrology Index (EDASMI) [98] may be
useful for patient self-monitoring

62. • Recommendation 3: Safety
• Throughout all aspects of exercise prescription,
especially for those with more severe or later
disease, the physical changes of AS must be
considered.
• These include the amount of bony change/
ankylosis, balance and mobility changes,
osteoporosis and cardiorespiratory consequences
of the disease (CBR).

63. • High impact exercise/physical activity (e.g.,
contact sports, martial arts, four wheel driving,
boating in rough seas, fairground rides)
• High velocity or strongly resisted exercise,
especially trunk flexion/rotation
• Excessive end range mobility gain following total
hip replacement

64. • Recommendation 4: Disease management
• Stabilisation with anti-TNF therapy can be a
“window of opportunity, to optimise mobility and
physical fitness

65. • Recommendation 5: AS-specific exercise—
Mobility
• Individual exercise prescription with an emphasis
on spinal mobility is paramount for best
management of AS. Maintaining mobility of
peripheral joints is also essential.

66. • Recommendation 6: AS-specific exercise—
others
• Stretching, strengthening, cardiopulmonary and
functional fitness are important components to
include in a balanced exercise programme

67. • Recommendation 7: Physical activity
• Regular physical activity should be encouraged to
promote general health, well-being and functional
outcomes (EBR, grade B)

68. • Recommendation 8: Adherence
• It is important to assess adherence with regular
exercise, encourage motivation and promote
ongoing self-management
• (EBR, grade B)

69. • Recommendation 9: Exercise setting
• Priority should be given to patient preference in
exercise choice, to enhance adherence and
optimise positive outcomes.
• AS-specific group therapy and warm water
exercise may be beneficial adjuncts to an
individual’s regular home exercise program.

70. Effects Of Home Based Exercise Therapy On Spinal
Mobility, Fatigue, Quality Of Life, Disease Activity
And Functional Capacity In Patients With
Ankylosing Spondylitis
Dr Prajna M Ranjani, Dr Sanjay Wadhwa, Dr Uma Kumar, Dr U Singh,
Dr SL Yadav, All India Institute of Medical Sciences, New Delhi

71. • Spinal mobility- BASMI score
• Functional capacity- BASFI score
• Disease activity –BASDAI score
• Overall well being- BAS-G score
• Quality of life – ASQoL score
• Fatigue -MAF score

72. Conclusion
• Home based exercise program for a period of 3
months improved the sense of well being, quality of
life, fatigue levels, and improvement in activities of
daily living and reduce disease activity in patients
with Ankylosing Spondylitis.
• Not much change in spinal mobility
• Home based exercise program simple and cost
effective

73. Take Home Message!
• Increased disease activity = reversible
• Joint damage sets in = disease progression/
irreversible changes.
• Hence Early Intervention by the Rehabilitation team
is the need of the hour.