Physical For Rheumatic Disease C. M. GODFREY, MD

Exercise This illustrates the general principle that in ordering SUMMARY exercises for patients with joint disease, it is vital that the exercise be given in such a manner that the tendons pass remains an important tool in over the center of the joint and do not cause deformation. rheumatic disease treatment even though great This may be accomplished by applying external forces (the strides have been made with chemotherapy. free fingers of the patient, therapist or a small block of Much physical therapy is misused, however, and wood) so that the tendon is properly aligned. physicians should ensure that the exercises Muscles may be strengthened in patients with rheumatic ordered for a patient do not contribute to joint diseases either for general or for particular purposes. In deformity. Underwater exercise, heat therapy, patients with chronic disease there is a frequent lossof traction, massage and splinting as well as a muscle tone through the whole body due to the lack of an warm and sympathetic staff are all good aids in exercise regimen or normal daily activity. The prescription rehabilitating the rheumatic patient, but careful of bed exercises, including deep breathing, increases the supervision is neededfor maximum benefit. general muscle tone and feeling of wellbeing. Particular areas may require special exercise programs. Stiffness and weakness of the hand may have resulted from the disease processes. This stiffness may frequently be W HILE great strides have been made by chemotherapy avoided by the use of passive movements (performed by the it 7in treating rheumatism and , physical therapy patient, family member or therapist) in which the joint. is remains an important 'therapeutic tool. However, in con- put through a full range of painless movement. This is trast to the specificity of indications and dosage of particularly useful in preventing deformity at the gleno- medicine, physical therapy is frequently carried out in a humeral joint and femoro acetabular joint. Instruction non-specific and unsupervised manner. This lack of direc- must be given that the movement is to be carried through tion may lead to increased morbidity, increased cost and the painless range and then just one degree further in order decreased availability of the service to patients who do have to avoid flaring up the disease process. specific indications. Muscle may be built by two methods - isometric or Physical therapy includes exercise, heat and cold applica- isotonic exercises. With isotonic procedures the muscle tions, massage, traction and splinting. In addition, the contracts as powerfully as possible pulling the joint physical therapist may help assess muscle strength and through its range of movement. Exercise programs, such as functional ability. The wise physician, who has set a de Lormes, see the muscle being loaded with increasing treatment goal for his patient, learns that the above weight and the patient striving to move the joint through a modalities, used specifically, can increase his patient's range of movement against the weight applied. This does wellbeing, prevent deformity and prepare that patient for result in increase of muscle strength, but traumatizes the return to work. joint because of the bio-mechanical forces involved in Exercises are the most misused type of therapy. While it lifting the weight. Isotonic exercises are not advisable for is difficult to cause actual damage with applications of heat patients with degenerative or acute joint disease. For these or other agencies of physical therapy, improper exercises patients isometric exercises should be used. In these the can cause more pain or, in particular, add to the forces joint is positioned and weight applied in such a manner that causing deformity. For example, take the- hand with the joint does not move. In isotonic exercises the tension . With the involvement of the MCP and within the muscle remains constant and the joint moves but subsequent stretching of the lateral collateral ligaament, in the isometric exercises the position of the joint is there is a tendency of the proximal phalanx to sublux constant yet the tension wifhin the muscle increases with anteriorly and swing ulnar-ward during grasping activities. Yet how many rheumatoid patients are implored by Dr. Godfrey is associate professor in the Department of treatment staff to "make a fist"? When they do grip, the Rehabilitation Medicine, University ofToronto, andHead of flexor and extensor tendons of the phalanges, which should the Department of Rehabilitation Medicine at Toronto's pass over the center of the MCP joint, swing toward the Sunnybrook and Wellesley hospitals. ulnar side causing deforming forces on the joint.

CANADIAN FAMILY PHYSICIAN * JANUARY, 1971 51 loading. Isometric exercises can be applied to specified waves to cause deeper heating. The sound waves are muscle groups and result in effective build-up of muscle produced from a four centimeter diameter head which is strength with minimal further trauma to the involved joint. capable of producing heat over a similar area, deep in the In rheumatoid patients there are areas where deformity tissues. Thus the application of sound is reserved for small occurs more often - the ulnar deformity of the MCP joints areas where specific heating is required - individual joints for instance, or valgus deformity of the knees and ankles. rather than areas. It is particularly effective in treating the Proper application of isometric exercises, particularly in the femoro-acetabular joint, lateral joints of the spine and MCP lower extremities, can delay or avert these deformities. It joints. Its effectiveness depends on proper link-up with the must be realized that the anti-valgus muscles at the knee are patient and it may be necessary to check that the therapist not the quadriceps but rather the medial compartment has applied the proper technique to insure that heat is muscles - gracilis, sartorius, semimembranosis, semiten- produced in the appropriate place. dinosis. Therefore, the commonly applied quadricep Prolonged administration of short-wave or regimen does not prevent rheumatoid deformity but may ultra-sound - more than two to three weeks - without make it more possible. At the ankle, the posterior tibial is appropriate relief of distress, strongly suggests that it has the key muscle and it must be exercised specifically. Unless been improperly ordered or improperly applied. muscles are exercised specifically to prevent deformity, the The application of cold can decrease pain in muscle deforming forces may become stronger as the anti-deform- spasm and tightness. Chipped ice or stroking with a ing forces are built up with the result that the patient "popsicle" (a cube of ice frozen to the end of a tongue receives no benefit. depressor) may reduce muscle tightness effectively. It too is an effective way of treating the patient in the home. Underwater Exercise An effective way of exercising the acutely involved Use of Traction and Massage patient is by using a pool for underwater exercises. This The application of mechanical forces such as traction relieves joints of gravitational forces and permits specific may frequently reduce pain and increase range of move- application of the exercise program. Similarly, overhead ment. Cervical traction, applied in a clinic or at home, may springs or a therapist's supporting hand may enable specific change dynamic forces about the neck with relief of pain exercise programs to be carried out. Patients should be due to cervical spondylosis and radiculitis. Work out a encouraged to take an active part in measuring their muscle treatment regimen of how much weight should be applied. ability and should be given realistic goals. For example, If the patient is treated in the upright position then no quadricep holds in the adult should be about 40 pounds for distracting force can be applied before the weight of the normal. Similarly, the anti-valgus muscles should hold 40 head is overcome - approximately 12 pounds. A thera- pounds. Hand grip strength in the adult should be about peutic weight of 15 pounds is usually necessary to achieve 250 mm. of mercury (using a sphygmomanometer bulb). some relief of pain. Therefore, the prescription for traction in the upright position should start at about 30 pounds. Uses of Heat However, if the patient is treated supine, 15 pounds can be An effective way of reducing pain and spasm of the removed from this prescription. As can be seen the state of arthritic joint is by the application of heat. This may be the patient's dentition, temporo-mandibular joints and done by the application of surface heating agencies such as other factors may determine treatment. Similarly, as a infra-red, hot water or wax: or "deep" heating agencies result of your examination of the patient, traction may be such as short-wave diathermia or ultra-sound. It is not applied in extension, neutral or forward flexed, or lateral known why heat relieves pain or muscle tightness. The flexed positions. Tractions should be applied for 20 surface heating agents may act as counter irritants, in the minutes. Intermittent traction is rarely more effective than same manner that irritating lotions act. continuous traction and indeed in some cases causes Most patients will have tried home heating applications increased pain due to improper positioning of the patient. and may have become addicted to their use. Generally, the Lumbar traction is frequently ineffective because of the heat is applied for too long a period. It seems that more difficulty in positioning a pelvic belt so that it does apply effective relief of pain can be given when the heat is applied distracting forces to the lumbar spine. In ordering lumbar for up to 30 minutes and then discontinued. (This has traction the physician must determine that adequate something to do with opening the vascular bed in tfie area apparatus is available to gain his goal of treatment. being treated.) Diathermia is a deeper heating agent and may be used Massage effectively to heat areas such as the shoulder joint, axial Massage is a useful means of reducing pain, stretching spine, femoro-acetabular joints and knee joints. The most tissues and regaining range of movements in joints. It has common problem associated with its application is fallen into general disfavor in North America, possibly improper positioning of the patient with subsequent because of the time and skill it requires for proper increase of pain. For example, patients with hyperextension application. Friction massage, where heavy force is used to problems in the lumbar spine may be treated in the prone mobilize tissues, is indicated in conditions where there is position with a pillow underneath the chest, causing further loss of mobility. The binding down of tissues which is seen hyperextension and increase of pain. It may be necessary to in post-fractures, chronic lymphoedemetous extremities and specify the position in which the patient should be treated. after burns, may be alleviated with the use of friction Short-wave diathermy uses the energy of electrical massage. currents via electro-magnetic waves to cause heat in the Effleurage as a stroking action may reduce the pain deeper portions of the body. Ultra-sonic heat uses sound which results from muscles which are tight and in spasm as 52 CANADIAN FAMILY PHYSICIAN * JANUARY, 1971 the result of trauma or anxiety. Massage procedures may be metal, previously considered to be a contra-indication to combined with manual mobilization of joints. They are shortwave diathermia, can be ignored if it is stainless steel particularly effective in the reduction of pain which may or a non-magnetizeable metal. result from loss of mobility in shoulder and foot problems. Possibly one of the greatest problems involved in the use The prescription for physical therapy may involve of physical therapy is the addictive factor. Patients get used several of the above agencies as for example, ultra sound, to being treated. This is not surprising as most forms of friction massage and. isometric exercises. physical therapy are pleasant, do not lower the white blood count and do not cause constipation. However, take care to Judicious Splinting use this expensive therapeutic agent sparingly. Specific Patients with rheumatoid disease who have an acute direction to the therapy staff will insure that the indicated flare-up of a peripheral joint may be given considerable treatment your patient requires is carried out. This helps relief with judicious splinting. It is necessary to determine avoid some of the contemporary rituals which engulf the the optimum position in which the joint should be therapeutic field. For example, currently, peripheral neuro- immobilized and for how long the immobilization is to be muscular facilitation exercises are being ascribed a curative maintained. The MCP joints are usually most comfortable in or restorative power which has not yet been verified by 100 of flexion. The knee, unless for very short periods, is objective viewers. While the use of this exercise regimen splinted in 00 flexion. The resting splint must be fabricated may give considerable satisfaction to the therapist, it is in such a manner that the joint is completely protected. For doubtful whether it results in more gain to the patient - example, when splinting the radiocarpal area, the resting and it takes longer to apply and must be done on an splint should extend from the proximal third of the individual basis. Similarly, there are "magic" powers forearm to just distal to the PIP joints. Frequently in ascribed to some types of electro-magnetic heating. Ultra- rheumatoid disease the PIPs are involved and the splint sonic radiation is felt by some non-critical observers to have should extend distal to the DIPs. In general the fingertips a special effect on wound healing. No reasonable investiga- should be left clear of the cast if the splints are being tion has ever shown this to be the case and indeed most applied bilaterally. Otherwise, the patient will not be able results have indicated that the sole results of sonation is to apply the splints himself. The patient may be instructed heating of tissues. to wear the resting splints on alternate nights on a particular joint. Resting splints may be supplemented with work Warm and Sympathetic Staff splints where a joint is maintained at relative rest while the The treatment situation in a therapy department can be joints surrounding it are doing normal activity. turned to great advantage by a warm and sympathetic staff Splinting material may be plaster of paris or some of the who have sufficient acumen to motivate a patient to the plastic preparations (Sansplint or Plastazote) which are goal sought by the physician. There are many well-recorded thermal setting and may be contoured closely to the cases where the patient's recovery has been the result of affected area. Specific assessment leads to specific treat- who the therapist is rather than what she does. On the ment which leads to better results. The patient who is to other hand, there are cases where the therapist manages to wear a splint must be given clear instructions as to how long instill in the patient a dependence on flashing lights and it is to be worn and how it is to be applied. buzzing machinery, an inability to accept and an There are few contra-indications to the application of urge to seek forever the definitive cure in the electro- physical therapy. Generally, if the treatment causes pain it magnetic spectrum. should be discontinued. The presence of pace-makers or The physician is responsible for the prescription of other indwelling electronic apparatus excludes the use of physical therapy. He is also responsible for the quality electro-magnetic or sound type generators. Indwelling control of how that therapy is carried out. 4

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