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Medical Rehabilitation: the Effects of Aquatic Physiotherapy in Patients with Rheumatoid Arthritis

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Medical Rehabilitation: the Effects of Aquatic Physiotherapy in Patients with Rheumatoid Arthritis MEDICAL REHABILITATION: THE EFFECTS OF AQUATIC PHYSIOTHERAPY IN PATIENTS WITH RHEUMATOID ARTHRITIS KHAMIS YASS CHIAD AL-QUBAEISSY A thesis submitted in partial fulfilment of the requirements of the Manchester Metropolitan University, for the degree of Doctor of Philosophy (Ph.D.) September 2013 Manchester Metropolitan University in collaboration with NHS Executives/Central Manchester Foundation Trust (CMFT) & Salford Royal Foundation Trust (SRFT) 2013 1 ABSTRACT Background: Hydrotherapy is frequently indicated in the management of rheumatoid arthritis (RA) patients. Few randomised controlled trials (RCTs) have investigated the effects of hydrotherapy in RA and their findings are inconclusive. Aims: The aim of this thesis was to evaluate the difference in outcomes (including physical function, quality of life, disease activity, psychological wellbeing and cost) between a 6-week course of hydrotherapy compared to land-based therapy for patients with RA. Methods: Forty-three patients (mean age = 60 years; SD = 15.3) diagnosed with RA were randomly assigned into either a hydrotherapy plus home exercise (n = 21) or land based therapy plus home exercise group (n = 22). Hydrotherapy included a weekly 45 minutes session for six weeks in addition to a home-exercise programme. Land-therapy included weekly 45 minutes sessions over six weeks plus home-exercise therapy. Patients were assessed at baseline (Test 1); six weeks (Test 2), three months (Test 3), and six months (Test 4) post-treatment. The Primary outcome measured was functional ability using the Health Assessment Questionnaire-Disability Index (HAQ-DI). Secondary outcomes, including HAQ VAS (pain scale), HAQ-GWB (general wellbeing), HRQoL using the EQ-5D VAS, EQ-5D tariff, EQ-5D profile and Quality Adjusted Life Years (QALYs) were calculated. Disease Activity was measured using RA Disease Activity Index (RADAI) and Disease Activity Score 28 (DAS28). Hospital Anxiety and Depression Scale (HADs) was used to measure psychological wellbeing. Costs to the provider (NHS), society and patient were also collected. Results: Change scores were calculated for all outcome measures between Test 1 and 2; Test 1 and 3; Test 2 and 3 and were used for data analysis. Patients treated with hydrotherapy experienced improvement in functional ability (HAQ-DI; p < 0.001), pain (HAQ VAS; p < 0.001), general wellbeing (HAQ-GWB; p < 0.001), HRQoL (EQ-5D VAS; p = 0.021), psychological wellbeing (HADs; p = 0.023). Moderate correlation was found in all RA patients between the RADAI and DAS28 (r = 0.328, p = 0.032). Moderate correlation was found between depression score (HAD-D) and RADAI (r = 0.578, p < 0.001); there was also moderate significant correlation between anxiety score (HAD-A) and RADAI (r = 0.425, p = 0.005). Predictors of functional disability in patients with RA were RADAI, EQ-5D tariff, GWB, depression score and anxiety score. The characteristics of patients recruited to this study reflected the RA population in Greater Manchester in terms of age, disease duration (DD), gender, body mass index (BMI) and DAS28. Finally, there were no difference between hydrotherapy and land-based treatment in terms of costs to the patient or society, however, when four patients were treated in the pool compared to one patient on land, hydrotherapy was less costly and more effective in improving functional disability. Conclusions: RA patients in the hydrotherapy group showed significant improvement in physical function, psychological well-being, quality of life and reduced health care utilisation compared to those in the land-therapy group. Group hydrotherapy is also less costly compared to one–to-one treatment on land. Keywords: Rheumatoid Arthritis, exercise therapy, hydrotherapy, land therapy, aquatic exercise, functional ability, functional disability, physical function, disease activity, psychological well-being, health related quality of life and quality of life. 2 DEDICATION This thesis is dedicated to: My brothers (Jumaa, Mohammad, Satar and Rahman) My wife Amnna and My children Without whom, there would be no point. 3 ACKNOWLEDGEMENTS I would like to extend my sincere thanks to the following: Universities: Manchester Metropolitan University/the-Graduate School. Collaborative Bodies: NHS Executive, Central Manchester University Hospitals, Salford Royal Foundation Trust. Students and Clinicians: I would especially like to thank all the physiotherapists who treated RA patients, with very special thanks to William Gregory, Caroline Owen, & Sarah Houghton. Particular thanks go to all the consultant rheumatologists for allowing us access to their patients. I would also like to thank Julie Morris for her statistical advice and consultation. I would like to thank those friends and family who have believed in me during this long but rewarding journey, especially Adel Al-Mangoush, Maytham Alabbas & Ghalib Ibrahim. I always promised myself I would thank those who started it all; staff in MDT clinic in Rheumatology department at Hope Hospital, mainly William Gregory – so here it is – thank you. Great thanks also go to Dr Cordelia and Nick Jones, who has been a proof-readers of my work. And last, but not least, I am very grateful to all my supervisory team, precisely Dr Peter Goodwin, Dr Abebaw Yohannes, Dr Francis Fatoye, Dr Rachel Gorodkins, Dr Pauline Ho & Professor Robert Cooper – thank you very much indeed for all your kind support and significant contribution to my study. I would especially like to mention Dr Goodwin, thank you for your tireless support, endless optimism, generous time and wealth of advice. Thanks are also extended to Lindsey Barnes (Research Nurse in Kellgren Rheumatology Centre/CMFR) for her kind support. Great thanks for the representation of the Ministry of Higher Education/Iraq (Iraqi Cultural Attaché/London) for their kind financial support. Without their financial support, I could not have finished this work. Finally, I am most grateful to the Ministry of Health/Iraq for their agreement to give me this marvellous opportunity. 4 Table of contents ABSTRACT………………………………………………………………………………2 DEDICATION…………………………………………………………………………….3 ACKNOWLEDGEMENTS……………………………………………………………...4 CHAPTER ONE: INTRODUCTION ........................................................................... 20 1.1 BACKGROUND TO THE STUDY ................................................................................. 20 1.1.1 Hydrotherapy ................................................................................................... 24 1.2 STUDY AIMS ............................................................................................................ 25 1.2.1 Primary aim ..................................................................................................... 25 1.2.2 Secondary aims ................................................................................................ 25 1.3 HYPOTHESIS ............................................................................................................ 26 1.4 OUTLINE OF THESIS ................................................................................................. 27 1.5 SUMMARY ............................................................................................................... 28 CHAPTER TWO: RHEUMATOID ARTHRITIS: BACKGROUND ....................... 29 2.1 INTRODUCTION ........................................................................................................ 29 2.2 DEFINITIONS AND CLINICAL FEATURES ................................................................... 29 2.3 DIAGNOSTIC CRITERIA OF RHEUMATOID ARTHRITIS (RA) ...................................... 32 2.4 EPIDEMIOLOGY OF RHEUMATOID ARTHRITIS (RA) ................................................. 35 2.5 RISK FACTORS FOR RHEUMATOID ARTHRITIS (RA) ................................................ 39 2.5.1 Genetic factors ................................................................................................. 39 2.5.2 Non-genetic risk factors ................................................................................... 39 2.5.3 Environmental factors ...................................................................................... 41 2.6 PATHOPHYSIOLOGY................................................................................................. 42 2.7 ANATOMY OF SYNOVIAL JOINTS ............................................................................. 45 2.8 MUSCULOSKELETAL AND EXTRA-ARTICULAR MANIFESTATIONS ........................... 46 2.9 TREATMENT STRATEGIES ........................................................................................ 48 2.9.1 Pharmacological treatment .............................................................................. 49 2.9.2 Non-pharmacological treatment ...................................................................... 57 2.10 OVERALL SUMMARY ............................................................................................. 64 CHAPTER THREE: HYDROTHERAPY DETAILS ................................................. 66 3.1 INTRODUCTION ........................................................................................................ 66 3.2 HISTORICAL BACKGROUND ..................................................................................... 69 3.3 PRINCIPLES OF HYDROTHERAPY.............................................................................. 70 3.4 MECHANISM OF ACTION .........................................................................................
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