PRM interventions for osteoarthritis and inflammatory arthropathies. Functional assessment, physical modalities, kinesiotherapy, patient education, and prevention of functional decline

01Two kinds of joint disease

The diseases themselves are covered in their own topics: osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis and reactive arthritis. Here we need only what changes the rehabilitation.

Think of cartilage as the tread on a tyre. In osteoarthritis the tread wears faster than the body can mend it, because the joint carries too much load or carries it badly. The bone underneath thickens, grows spurs (osteophytes) and the joint stiffens. Pain comes with use and eases with rest. Stiffness after rest lasts only minutes.

In the inflammatory arthropathies the problem is not wear but an attack. The immune system inflames the joint lining (synovitis) in rheumatoid arthritis, or the places where tendons and ligaments join bone (enthesitis) in the spondyloarthritides: ankylosing spondylitis, psoriatic, reactive and enteropathic arthritis. The disease comes in flares. Morning stiffness lasts more than 30 minutes, pain is often worse at rest, and there is fatigue and sometimes disease outside the joints (skin, eyes, bowel).

02Functional assessment

The aim is to measure what the disease takes from the person, so goals can be set and progress shown. It follows the ICF ladder: the body (pain, range, strength), activities (walking, dressing), and participation (work, family, sport). The general method is in functional assessment.

03Goals of rehabilitation

The goals are the same five words on every slide, but each has a reason:

1. Less pain and inflammation, because pain stops people moving, and not moving makes everything worse.
2. Better range of motion, because a joint that stiffens in a bad position cannot be used even when the pain goes.
3. Stronger muscles around the joint, because muscle is the joint's shock absorber and its brace.
4. Fewer deformities and contractures, mainly in inflammatory disease, where soft tissues are stretched and weakened by inflammation.
5. Independence and quality of life: walking, self-care, work, sport.

Short-term goals are concrete and close (walk 200 metres with a stick in two weeks); long-term goals are about life (return to work, keep living alone).

04Kinesiotherapy

Kinesiotherapy is the backbone of treatment in every guideline. Its logic is simple. Cartilage has no blood vessels and is fed by joint fluid squeezed in and out by movement, so moderate movement feeds it. Strong thigh muscles soften every footstep that would otherwise land on the knee. Fit, active people feel less pain and have better mood and sleep. In trials the average gain in pain and function is real but modest, so exercise is chosen because it is safe, cheap and helps the whole body, and it works only while it is kept up.

In osteoarthritis

• Strengthening: the quadriceps for the knee, the hip abductors and extensors for the hip, the grip for the hand. Start with isometric and short-arc work, then closed-chain exercises (sit-to-stand, mini-squats, step-ups), then resistance bands and weights.
• Range of motion and stretching: keep full knee extension and hip extension, the first movements to go.
• Aerobic exercise at low impact: walking, cycling, swimming and exercise in water, where buoyancy takes off part of the body weight.
• Balance and proprioception training, because a worn joint sends poorer position signals and falls rise.
• Functional training: stairs, rising from a chair, getting in and out of a car.

strengthening sessions

2–3times a weekstrengthening sessions

moderate aerobic activity, built up gradually

150minutes a weekmoderate aerobic activity, built up gradually

pain during exercise that is acceptable if it settles by the next day

5out of 10pain during exercise that is acceptable if it settles by the next day

Pain during exercise is expected at first and is usually not a sign of harm. A common working rule (the pain-monitoring model): mild pain during exercise is fine if it settles within a day and does not build week by week; if it does, reduce the load, not stop. Exercise helps only while it is kept up, so the programme must fit the patient's life.

In inflammatory arthropathies

The rule is to treat the flare and the remission differently.

In a flare, no forceful stretching and no heavy resistance through the inflamed joint: inflamed capsule and ligaments are soft and tear or stretch, which is how deformities begin.

In ankylosing spondylitis

The disease fuses the spine in a stooped, bent-forward position and stiffens the rib joints. Exercise pushes the other way, every day:

• Spinal extension and rotation exercises, and hip extension stretches.
• Deep breathing and chest expansion exercises, to keep the rib joints and vital capacity.
• Lying prone for 15 to 20 minutes a day, and a firm bed with a thin pillow.
• Aerobic exercise; swimming suits the disease well.
• Group or supervised exercise works better than home exercise alone.

05Physical modalities

Physical modalities lower pain and stiffness for a while, so that the patient can move and exercise. That is their job. The choice follows the state of the joint.

1. 1

   Is the joint inflamed?

   Hot, red, swollen, painful at rest: no heat, no deep heating. Choose cold, rest in a splint, perhaps low-frequency analgesic currents.
2. 2

   Is it stiff and cold?

   A quiet, stiff joint: heat before exercise loosens collagen, relaxes muscle and eases pain.
3. 3

   Is there metal?

   A joint replacement or plate rules out shortwave and microwave diathermy over it.
4. 4

   Is it helping?

   If a course does not help, stop it rather than repeat it.

06Patient education and joint protection

Most of the work happens at home, so the patient has to understand the disease and own the plan.

• Weight loss in overweight people with knee or hip osteoarthritis: each kilogram lost takes about four kilograms off the knee at every step. Any loss helps, and 10 per cent of body weight helps more than 5.
• Joint protection: spread a load over many joints (carry a bag on the forearm, not the fingers), use the strongest joint for the job, avoid holding one position for long, avoid tight pinch and twisting the wrist in rheumatoid hands, use thick-handled tools.
• Pacing and energy conservation, for fatigue in inflammatory disease: plan the day, alternate work and rest, sit for tasks that can be done sitting.
• Walking aids: a stick held in the hand opposite the painful hip or knee, its handle at wrist height with the elbow bent about 20 to 30 degrees. A frame when balance is poor.
• Orthoses and splints: resting wrist and hand splints in rheumatoid arthritis, worn at night in a functional position; thumb-base splints in hand osteoarthritis; good shoes with soft soles. Knee braces and wedged insoles are not given routinely in knee osteoarthritis.
• Home and work changes: raised chairs and toilet seats, rails, a shower stool.
• Lifestyle: regular activity, not smoking (smoking worsens rheumatoid arthritis and ankylosing spondylitis), good sleep, treatment of low mood.

07Preventing functional decline

The danger in chronic joint disease is a spiral: pain makes people move less, the muscles waste, the joints stiffen and the heart and lungs decondition, so the next effort hurts more. Rehabilitation breaks the spiral at each turn.

Safety points

• Rheumatoid neck: inflammation can loosen the ligaments between the first and second cervical vertebrae (atlantoaxial instability). Neck pain, tingling in the hands or weakness when the head bends forward needs imaging before neck exercise; no manipulation or traction of a rheumatoid neck.
• Ankylosing spondylitis: a fused, osteoporotic spine breaks after small falls, and a fracture can injure the cord. No spinal manipulation; new back pain after a minor fall needs imaging.
• Glucocorticoid treatment: fragile skin under electrodes and hot packs, and fragile bone.
• Numb skin, poor circulation: test sensation before any heat or cold.
• When to send back: a new hot joint, fever, or a sudden loss of function means infection, a flare or a tendon rupture until proven otherwise.

The multidisciplinary team is the physiatrist, the rheumatologist, the orthopaedic surgeon when the joint fails, the physiotherapist (rehabilitator), the occupational therapist, the nurse, the psychologist, the dietitian and, at the centre, the patient and family. When conservative care no longer gives a tolerable life, the next step is a joint replacement.