Ann Rheum Dis: first published as 10.1136/ard.11.3.196 on 1 September 1952. Downloaded from REHABILITATION AND TREATMENT BY MOVEMENT OF CONTRACTURES IN RHEUMATOID ARTHRITIS BY GUNNAR EDSTROM From the Department and Clinic for Rheumatic Diseases, University Hospital, Lund, Sweden (RECEIVED FOR PUBLICATION APRIL 15, 1952) Rheumatoid arthritis is a mesenchymal process of the connective tissue. Normal movement is a especially affecting the collagenous connective tissue. factor which forms, regulates, and maintains the Most frequently the process is prolonged, structure. Prolonged incomplete function is des- progressive, and undulant, or, as Hench (1934) tructive in that the nutrition and structure of the expresses it, " potentially reversible ". By means bone, cartilage, and connective tissue are affected. of the 1 1-oxysteroids the activity of the process can Therefore, a joint which has been attacked by now be more easily controlled than heretofore, in rheumatoid arthritis should not be fixed, for example, other words, " the fire can be extinguished " but in a circular cast for a long time, though a shorter " the ashes still have to be removed ". Deformities, fixation in a circular cast may be advisable, especially contractures, and incorrect positions of the joints for reducing the activity in acute exudative arthritis, caused by the disease must be taken care of and and is also suitable in flexion contractures as by copyright. a corrected. traction cast. As a rule, however, such a fixation At present most of those who have become should not last more than one week, and after this crippled by rheumatoid arthritis have not received the mobility of the joint must be exercised. sufficient assistance to " remove the ashes ". The In destructive types of rheumatoid arthritis a right way to rehabilitation has been pointed out by certain period of fixation is often necessary, Krusen (1951) in Rochester and by Rusk (1950) in especially when there is considerable pain on New York. The same principles have been pre- movement. A wide range of joint motion is not viously advanced by Fox and van Breemen (1934) in always our chief aim. The process must first be London and Amsterdam, by Ray (1937) in London, arrested or healed, and this is impossible in a by Haglund (1923) in Stockholm, and by Plate destructive process without absolute rest sufficiently http://ard.bmj.com/ (1922) in Hamburg. The importance of rehabili- prolonged. Our rule is: Rather a painless joint with tation therapy has also been stressed in our depart- restricted motion or ankylosis in a goodposition than ment for the last 15 years (Edstrom, 1942; 1947; a more mobile joint with marked pain on movement 1952a, b). resulting in reducedfunction or non-function. Although in rheumatoid arthritis the process is Another significant factor in rheumatoid arthritis widely spread throughout the organism, the most is the mechanical hypersensibility sometimes encoun- advanced changes are generally observed in or tered. Subcutaneous nodules may occur in areas on September 29, 2021 by guest. Protected around the joints. which have been exposed to blows, and a rheumatoid As a general rule a diseased organ should have arthritic process can begin or recur in a joint which rest. From a biological point of view, however, has been subjected to trauma. For example, this resting should not amount to complete non- arthritis can be produced by various traumas in function. In cardiac and renal disorders, for experimental animals (Edstrom, 1951). On these instance, rest can never be total. Non-function, phenomena the physiology of the adrenal cortex has undesirable from a biological standpoint, can be shed a new light. effected only by the postural and motor organs. Manipulations unnecessary for maintaining the Disuse of a joint has a destructive effect on tissues function of diseased joints should therefore be and functional capacity. The experiments of avoided, but some movement treatment is required Holmdahl and Ingelmark (1946, 1947, 1948), in all cases of rheumatoid arthritis. Ekholm (1951), and Saiif (1950) demonstrate that The ideal movement treatment in cases of rheu- function strongly affects the structure of the osseous matoid arthritis is prophylactic, and is instituted and cartilaginous tissues as well as the structure at the very beginning of the disease to prevent 196 Ann Rheum Dis: first published as 10.1136/ard.11.3.196 on 1 September 1952. Downloaded from REHABILITATION AND TREATMENT OF CONTRACTURES IN ARTHRITIS 197 contractures and incorrect positions. In a hospital metacarpophalangeal joints and the hallux valgus- a physiotherapist or nurse may regularly control the position with lateral deviation develops in the meta- patient's joints, and the Arthritis and Rheumatism tarsophalangeal joints. In both these instances the Foundation of New York has recently published a incorrect positions are taken up because the morbid pamphlet entitled " Home Care in Rheumatoid process causes an imperfect balance between the Arthritis ". groups of muscles working on the joints in question. Corrective therapy is called for when contractures In rheumatoid arthritis a more or less pronounced or incorrect positions have already developed. atrophy of the musculature occurs, but all muscles Hospital care is necessary in severe cases, but do not atrophy to the same degree. The atrophy contractures can occasionally be treated at home. may also occur on account of nutritional distur- bances originating in the morbid process and not Development of Contractures and Incorrect Positions solely due to inactivity (Landoff, 1942). Large muscles are less sensitive to these disturbances than Arthritic processes start as synovitis, spread the small ones (Alwall, 1939), and the latter are gradually into the surrounding connective tissue, therefore most markedly weakened. In addition causing perioedema and exudation, and finally to their flexion and traction function, these small attack cartilage and bone tissue. In the later stages, muscles in the hands and feet possess a radially exudative proliferative conditions occasionally pre- (medially) active component; the larger muscles of dominate; exudative arthritis occurs often in the forearm and the leg have an ulnarly (laterally) combination with increased exudation in the joint. effective component. Thus, as a result of the In other instances the exudation recedes, the irregular muscular atrophy, an increased pressure synovial fluid and the perioedema are reduced, and occurs on the ulnar (lateral) portion of the meta- degeneration and destruction ensue; the cartilage carpophalatngeal (metatarsophalangeal) joints. is destroyed, and the bone tissue becomes more and more ulcerated, especially in the smaller joints of the Therapy carpus and tarsus where all the small bones are by copyright. sometimes fused together. Rest in Bed.-As in other chronic infections, prolonged rest in bed is often an important factor in Contractures.-The acute stage of an arthritic the treatment ofan early stage ofrheumatoid arthritis. process is often characterized by considerable It must, however, be prescribed and supervised, and swelling and pain, particularly on movement, and should be combined with exercise of the affected the patient holds the joint in the position which limbs. causes the least tension. This optimal position is As long as there is no contracture in any joint of usually a moderate flexion and if the joint is allowed the lower extremities the patient should get up every to remain in such a relaxed position, contractile day for short periods to take care of his personal elements are affected and the range of movement is hygiene, leave the sick-room for a while, eat without http://ard.bmj.com/ reduced, so that the patient cannot extend the joint assistance, and walk to his bath and treatments. fully nor flex it completely, and a flexion contracture Such mild daily exercise should also be combined has developed. with mild movement therapy. Febrile patients A flexion contracture of this type is very rarely must remain in bed but the supervision of their entirely or partly caused by changes in the bone; joints should be even more careful. this occurs only in late stages of the arthritic process An extended position often provides the most where reactive bone changes have developed in effective rest for the joint. The arthritic should connection with ulceration and destruction. Tension avoid lying with crooked and flexed joints. Under on September 29, 2021 by guest. Protected therapy is then fairly hopeless. As a rule, the con- no circumstances should knee-pads be employed. tracture is brought about by changes in the soft To avoid the development of talipes equinus through tissue, sometimes in the musculature and the the weight of the cover, a foot-arch, foot-board, or insertions of the tendons. The possibility of foot-pads should be employed, and splints are often restoring by means of movement therapy a normal useful to keep the limbs extended. or functionally satisfactory range of joint motion Exercise Therapy while in Bed.-If the patient does not will then depend upon the age of the patient and the possess the strength to b- up and about, one must start degree of change in the soft parts. Prolonged, with exercises in bed. Arms and legs should be softened careful traction is usually more effective than up by means of light active or assisting movements under violent manipulation. the instruction of a physiotherapist or nurse. Appliances should be employed as soon as possible; they often Incorrect Positions.-These usually develop in have a stimulating effect on the patient, as he can then a similar manner. Ulnar deviation develops in the better observe his progress. Ann Rheum Dis: first published as 10.1136/ard.11.3.196 on 1 September 1952. Downloaded from 198 ANNALS OF THE RHEUMATIC DISEASES An exercise apparatus for the musculature of the lower extremities is shown in Fig. 1. Electrical muscular exercise may also be given by means of a tonizator or some similar apparatus, using alternating current.