II. Stimulus Questions: Rheumatoid Arthritis
a. Define the pathological process and disease progression as well as clinical signs and symptoms associated with rheumatoid arthritis vs. osteoarthritis
RHEUMATOID ARTHRITIS
OSTEOARTHRITIS
Inflammatory autoimmune disease that effects the body systemically (O'Sullivan, Schmidt 2014).
Localized degenerative disease involving a joint (O'Sullivan, Schmidt 2014).
Populations commonly effected
Can occur at any age, but is more common as age increases and more likely to develop in women than men. (O'Sullivan, Schmidt 2014)
Prevalence increases after 40 years of age. Affects more men than women under 50 years, but more women than men after age 50. (O'Sullivan, Schmidt 2014)
Cause
There are some possible theories about what predisposes a person to RA, however the cause is still unknown. (O'Sullivan, Schmidt 2014)
While aging is correlated with osteoarthritis, it does not cause the disease. Similarly to RA, there is no single known factor that causes a person to develop OA. (O'Sullivan, Schmidt 2014)
Disease Progression
In the early stages, there is swelling of the synovial tissue and inflammation in the joint capsule which leads to pain, limited range of motion, and stiffness (Physiopedia, 2017b). The hands are commonly affected in the early stages of RA. (O'Sullivan, Schmidt 2014).
As RA advances, the joint capsule continues to become inflamed and immune cells begin cartilage breakdown (O'Sullivan, Schmidt 2014).
Pannus granulation leads to thickening and scarring of connective tissue as well as adhesions and ankylosis within the joint (O'Sullivan, Schmidt 2014)
Chronic inflammation weakens the joint capsule, leading to joint instability (O'Sullivan, Schmidt 2014). Altered joints can lead to the musculoskeletal deformities seen in later stages of RA (O'Sullivan, Schmidt 2014).
The first osteoarthritic change in articular cartilage is an increase in water content which decreases the stiffness of the matrix and leads to mechanical damage (O'Sullivan, Schmidt 2014).
Proteoglycans are lost in later stages of the disease, decreasing the water content of cartilage and leading to the transfer of compression force to underlying bone (O'Sullivan, Schmidt 2014). The destruction of articular cartilage narrows the joint space (O'Sullivan, Schmidt 2014).
As OA progresses the joints become more stiff, which leads to pain and a decrease in range of motion (O'Sullivan, Schmidt 2014).
Presentation in the Body
Usually present in joints bilaterally and is most common in the cervical spine, feet, and hands (O'Sullivan, Schmidt 2014).
Common symptoms include pain, stiffness, limited range of motion (Physiopedia, 2017b). Additionally joints present with swelling, heat, tenderness, and atrophy of muscles near the affected joints (Physiopedia, 2017b).
Joint stiffness occurs in the morning and commonly lasts at least an hour (O'Sullivan, Schmidt 2014).
Since RA is systemic, it is not limited to the joints. RA can be present in the organs and may cause symptoms such as fatigue, weight loss, or fever (O'Sullivan, Schmidt 2014).
Present in joints unilaterally and most commonly in the hands and wrist, cervical and lumbar spine, hips, knees, and MTP of the great toe (O'Sullivan, Schmidt 2014).
Stiffness occurs due to inactivity
Pain is initially triggered by specific activities, but eventually becomes more constant with severe episodic pain (O'Sullivan, Schmidt, 2014).
Joint stiffness in the morning usually is not generalized and does not last longer than 30 minutes. Joint stiffness occurs due to inactivity (O'Sullivan, Schmidt 2014).
Unlike RA, OA is not systemic so it is not associated with feelings of fatigue, fever, or loss of appetite (O'Sullivan, Schmidt 2014).
b. Advantages and disadvantages of common steroidal and non-steroidal anti-inflammatory as well as traditional disease-modifying and more recent biologic-response, medications used for the management of patients with RA. Mechanisms by which each class of medication may improve the patient’s body structure/function, activity, and participation. Possible side effects and toxicity manifestations.
Steroidal Anti-Inflammatory, ex. Prednisone
The following information reguarding steroidal anti-inflammatories was retrieved from (Majithia & Geraci, 2007) and (Susan O’Sullivan, 2014a).
− Advantages: effective short term relief due to a quick anti-inflammation reaction, can be administered as an injection allowing local distribution
− Disadvantages: can demineralize bone if not limited due to cortisol-like response, should only be taken for brief periods at lowest dose possible to elicit desired response
− Improvement of IFC: Effective for relieving pain and managing inflammation quickly until more long-term drugs, such as DMARDs, can become effective
− Side Effects/Toxicity Manifestations: can block immune responses, more at risk for infections, higher blood sugar, potential bone thinning/osteoporosis, adrenal suppression, avascular necrosis, Cushing’s Syndrome: weight gain, loss of emotional control, fatigue (Sharma & Nieman, 2011)
− PT Implications: PT may need to include as many weight bearing exercises as possible to increase the load placed upon the patient’s bones to encourage the calcium to remain in the bones and to prevent bone demineralization. In the event of osteoporosis, PT may need to work on balance and access possible fall risk. PT may need to make sure to check the patient’s skin to ensure that there are no cuts and that there are no obvious infections, due to the suppresses immune response.
Non-steroidal anti-inflammatory, ex: Advil
The following information reguarding NSAIDS was retrieved from (Majithia & Geraci, 2007)
− Advantages: readily available and easy access; NSAIDs inhibit COX-1 and COX-2 enzymes, which prevents prostaglandins from forming to minimize pain and inhibiting vasodilation to reduce inflammation (Wallace, 2013)
− Disadvantages: do not alter the disease course and cannot be used alone, do not reduce joint damage, should only use for brief periods of time, should not be taken if you have a history of liver, kidney, heart, or stomach ulcers (Susan O’Sullivan, 2014a)
− Improvement of IFC: reduce joint pain, swelling, and stiffness through reduction of inflammation
− Side Effects/Toxicity Manifestations: severe digestive tract problems, can increase blood pressure
− PT Implications: PT must be conscientious and wary of sudden increases in blood pressure during exercise and activity. PT may need to make sure to guard the patient more vigilantly or allow more time when changing positions. The PT also needs to be aware of signs of GI dysfunction and ask patient about any possible signs they are experiencing.
Disease modifying ex. Gold, Methotrexate
The following information regarding disease modifying medications was retrieved from (Majithia & Geraci, 2007).
− Advantages: can be taken by pill or injection
− Disadvantages: must have blood tests often, medication can take up to 6 months to work
− Improvement of IFC: slows disease progression and improves long term overall prognosis, eases symptoms of joint pain, fatigue, redness, and swelling, very effective at stopping the attack on the joints by modifying the immune system,
− Side Effects/Toxicity Manifestations: GI intolerance, oral ulcers, alopecia, hepatitis, pneumonitis, cytopenia, rash , teratogenic, retinal toxicity, demyelinating disorders, dizziness, skin pigmentation
− PT Implications: Due to the delayed onset of effectiveness in this type of medication, PT may have to be more conservative in the first 6 months of the medication to ensure that it is having the maximal effect.
Biologic response, ex: Humira, Enbrel
The following information regarding biologic response medications was retrieved from (Majithia & Geraci, 2007).
− Advantages: tend to be better tolerated and can works faster than DMARDs
− Disadvantages: increased risk of infection and TB reactivation, expensive, taken by injection, should not be taken by pregnant women
− Improvement of IFC: stops the inflammatory process through changing the inflammatory cytokines that may trigger an immune response (ex. TNF) that causes the joint damage
− Side Effects/Toxicity Manifestations: injection site reaction, infections, hypersensitivity, COPD manifestations, TBr, demyelinating disorders, leukopenia, GI intolerance, new and reactivation viral infections, respiratory difficulty, cytopenia, rash and pain at the injection site
− PT Implications: PT may need to make sure to check the patient’s skin to ensure that there are no cuts and that there are no obvious infections due to the increased risk caused by taking biologic response medications (Le Saux, Canadian Paediatric Society, & Immunization, 2012).
c. Outline the criteria that the American Rheumatism Association uses to diagnose RA.
According to the 1987 Rheumatoid Arthritis Classification criteria, a patient has to meet at least 4 of these 7 criteria to be diagnosed with rheumatoid arthritis. The first 4 of these criteria are only valid if they persist for at least 6 weeks (Susan O’Sullivan, 2014a). These 7 criteria are:
1. Morning stiffness lasting more than 1 hour
2. Arthritis of 3 or more joint areas (R and L proximal interphalangeal joints, metacarpophalangeal joints, wrist, elbow, knee, ankle, and metatarsophalangeal joints)
3. Arthritis of Hand Joints (proximal interphalangeal or metacarpophalangeal joints)
4. Symmetric arthritis by area
5. Subcutaneous rheumatoid nodules
6. Positive rheumatoid factor
7. Radiographic changes (hand and wrist, showing erosion of joints or unequivocal demineralization around joints)
The diagnostic criteria listed above was found through (Susan O’Sullivan, 2014a)
An updated criteria has been created to diagnose patients with Rheumatoid Arthritis, according to the 2010 Rheumatoid Arthritis Classification a patient has definite rheumatoid arthritis if they score a total of 6 or more points on the following categories (Aletaha et al., 2010) :
1. Joint Distribution (0-5 points): Defines how many joints are involved; the more joints involved, the higher risk the individual is for RA.
2. Serology (0-3 points): A low or high Rheumatoid Factor (RF) and Anti-citrullinated protein antibodies (ACPA) increases risk of being diagnosed with RA.
3. Symptom Duration (0-1 points): If the symptoms last for at least 6 weeks then the patient is at risk for being diagnosed.
4. Acute Phase Reactants (0-1 points): An abnormal C- Reactive Protein (CRP) or Erythrocyte Sedimentation Rate (ESR) increases the risk of Rheumatoid Arthritis.
The diagnostic criteria listed above was found through (Aletaha et al., 2010
d. Describe and explain the usefulness of the WOMAC for the management of a patient with RA.
The American College of Rheumatology described WOMAC as a questionnaire that assesses pain, stiffness, and physical function in patients with osteoarthritis, but is useful for patients with rheumatoid arthritis as well. The WOMAC has been extensively used to examine changes following treatments that include physical therapy (Rheumatology, 2015) .
The following criteria listed by the American College of Rheumatology for the WOMAC consists of 24 items divided into 3 subscales:
− Pain (5 items): during walking, using stairs, in bed, sitting or lying, and standing
− Stiffness (2 items): after first waking and later in the day
− Physical Function (17 items): stair use, rising from sitting, standing, bending, walking, getting in / out of a car, shopping, putting on / taking off socks, rising from bed, lying in bed, getting in / out of bath, sitting, getting on / off toilet, heavy household duties, light household duties
(Rheumatology, 2015)
A scale of 0-4 is used to score the questionnaire: The scale corresponds with the following ratings; None (0), Mild (1), Moderate (2), Severe (3), and Extreme (4). The total is calculated by the sum of each subscale and fall within the following ranges of 0-20 for Pain, 0-8 for Stiffness, and 0-68 for Physical Function. The total for all three subscales gives a total WOMAC score. Higher scores on the WOMAC is correlated with worse pain, stiffness, and functional limitations (WOMAC Osteoarthritis Index, 2017) .
The WOMAC is useful for the management of a patient with RA because it assesses areas such as ADL’s, functional mobility, gait, general health, and quality of life. These assessment areas could be a major part of a PT intervention to improve upon for patients with RA. A physical therapist could treat for pain, stiffness, and physical limitations in order to enhance a patient with rheumatoid arthritis’ quality of life and general health. The WOMAC also allows for a gauge of improvement after treatment. If pain, stiffness, and physical function improve after treatments such as physical therapy, there is objective reasoning that physical therapy produces a positive effect for the patient's QoL (Bellamy, 2016) .
With Rose Wright scoring a 55% on the WOMAC, she has pain, stiffness, and functional limitations, but she is not completely debilitated and shows good signs for improvement.
III. Stimulus Questions: Fibromyalgia
a. Identify clinical signs and symptoms associated with Fibromyalgia vs. Myofascial Pain Syndrome
FIBROMYALGIA
MYOFASCIAL PAIN SYNDROME
Similar Signs and Symptoms
Both fibromyalgia and myofascial pain syndrome are more commonly seen in women than in men (O’Sullivan, Schmidt 2014).
Individuals with fibromyalgia or with myofascial pain syndrome may suffer from sleep disturbances, stress, or anxiety (O’Sullivan, Schmidt 2014).
Unique Signs and Symptoms
− Pain, specific tender points- no referral pattern (Carolyn Kisner, 2012
− Diffuse and widespread pain: Bilaterally (Carolyn Kisner, 2012)
− Numbness, or tingling in the hands, arms, feet and legs (Carolyn Kisner, 2012)
− Pain in trigger points these will have a predictable referral of pain (Carolyn Kisner, 2012)
− Localized pain: This pain is more unilateral (Carolyn Kisner, 2012)
− Deep, aching pain in the muscle(Carolyn Kisner, 2012)
References: The following signs and symptoms from above have all been gathered from (Carolyn Kisner, 2012) and (O'Sullivan, Schmidt 2014).
b. List other members of the healthcare team that play an important role in the management of patients with FM.
Other than physical therapists, one other healthcare member that can play an important role in Fibromyalgia patients is a family-care physician, which according to one study was the type of physician that was consulted the most. Other healthcare teams that could play a major role in the management of fibromyalgia include psychiatrists, which could help FM patients cope with mood disorders like depression, anxiety, fear and anger; occupational therapists, pharmacists, acupuncturists, chiropractors, and rheumatologists were also healthcare professionals that were frequently visited by FM patients.
(Lacasse, Bourgault, & Choiniere, 2016)
c. Describe indications and contraindications, and “red flags†for the use of the following commonly-utilized classes of drugs for the management of FM.
Pain
Tramadol (narcotic pain reliever)
− Indications: moderate to severe pain
− Contraindications:
o Medical conditions/predispositions: severe breathing problems, addictive behaviors (drugs, alcoholism, etc.), blockage in stomach or intestines, sedatives, pregnancy
o Medications: Narcotics, tranquilizers, monoamine oxidase inhibitors (MAOI)
− Red Flag: Major adverse reactions include blurred vision, hyperalgesia, dizziness, change in walking or balance, fainting, numbness and tingling in hands or feet.
o The patient is taking Cymbalta and Tramadol; this combination can cause serotonin syndrome. This can include symptoms such as confusion, hallucination, seizure, extreme changes in blood pressure, increased heart rate, muscle spasms or stiffness, and tremors.
("Medications for Fibromyalgia," 2017)
Non-Steroidal Anti-Inflammatory
Ibuprofen
− Indications: pain reliever, fever reducer, headaches, muscle aches, arthritis, backache, toothaches
− Contraindications: heart disease, just before or after a heart bypass surgery, pregnancy, connective tissue diseases, hypertension, liver or kidney disease, asthma , smoking, diabetes
− Red Flag: Major adverse reactions damage or bleeding of the intestines or stomach and nausea
o Cymbalta and ibuprofen taken together can increase the risk of bleeding. This is more prevalent in the elderly or in those with liver and kidney disease. Although the patient is not taking ibuprofen at this time, if they were to add it to their regimen of medication, this would be an important interaction to consider.
("Ibuprofen" 2017)
Antidepressants: Tricyclic or Serotonin Norepinephrine Reuptake Inhibitors (SNRI)
Cymbalta (Duloxetine)
− Indications: major depressive disorder, general anxiety disorder, sleep problems, neuropathic pain, restlessness, chronic pain disorders, chronic muscle or joint pain
− Contraindications: liver or kidney disease, seizures or epilepsy, bleeding or blood clotting disorder, high blood pressure, narrow angle glaucoma, bipolar disorder, drug addiction or suicidal thoughts, taken MAOI in the past 14 days
− Red Flag: Major adverse reactions include blurred vision, confusion, dizziness, fainting, fast or irregular heartbeat, constipation, hypertension or orthostatic hypertension, general tiredness and weakness, and tightness in chest.
o The patient is taking Cymbalta and Flexeril which can increase the risk of a rare but serious condition called the serotonin syndrome. This can cause symptoms such as confusion, hallucination, blurred vision, muscle spasms or stiffness.
o The patient is taking Cymbalta and Ambien; taking the two together can increase side effects such as dizziness, drowsiness, confusion, and cause difficulty with concentrating.
("Medications for Fibromyalgia," 2017)
(O'Sullivan, Schmidt 2014)
Muscle Relaxers
Flexeril (cyclobenzaprine)
− Indications: muscle spasms and musculoskeletal pain
− Contraindications: thyroid disorder, heart block, recently had a heart attack, congestive heart failure, heart rhythm disorder, taken an MAO in the past 14 days, liver disease, glaucoma, enlarged prostate, problems with urination
− Red Flag: Major adverse reactions include clumsiness, unsteadiness, confusion, fainting, and ringing or buzzing ears.
o The patient is taking Flexeril and Tramadol; these can have major interactions with narcotic pain medications which and can lead to side effects including respiratory distress, coma, and even death. While the patient is not taking any additional narcotic pain medications at this time, it is important to consider the interaction if another narcotic was indicated for use.
("Medications for Fibromyalgia," 2017)
Central Nervous System-Acting
Lyrica
− Indications: pain, seizures, anxiety, sleep disorders, diabetes
− Contraindications: mood disorder, depression, suicidal thoughts, heart problems, bleeding disorder, low levels of platelets in your blood, kidney disease, diabetes, drug or alcohol addiction, pregnancy
− Red Flag: Major adverse reactions include difficult or labored breathing, shortness of breath, tightness in chest, dizziness, and unusual tiredness or weakness.
o Lyrica can cause a severe allergic reaction to occur. Some symptoms of a severe allergic reaction are swelling of the face or mouth, difficulty breathing, or a skin rash, blisters, or hives. Because the patient is currently taking Lyrica, therefore the patient should be conscious of any of these signs or symptoms.
("Medications for Fibromyalgia," 2017)
d. Outline the criteria that the American College of Rheumatology uses to diagnose FM.
1990 Diagnostic Materials: The following material was taken from "The pathophysiology, diagnosis and treatment of fibromyalgia."
1. "Widespread (four-quadrant) pain both above and below the waistline present for at least 3 months.
2. Tenderness on pressure (tender points) of at least 11 of 18 specified sites and the presence of widespread pain for diagnosis.
3. Ruling out all other conditions that could cause symptoms"
(Arnold, 2010)
2010 ACR Fibromyalgia Diagnostic Criteria (Modified 2011): The following material was taken from the 2010 ACR Fibromyalgia Diagnostic Criteria from townsendletter.com.
1. "Widespread pain index (WPI) greater than or equal to 7 and symptom severity (SS) scale score of greater than or equal to 5 or WPI 3-6 and SS scale score greater than or equal to 9.
2. Symptoms have been present at a similar level for at least 3 months.
3. The patient does not have a disorder that would otherwise explain the pain."
4. Widespread Pain Index and Symptom Scale:
Citation: http://www.townsendletter.com/Nov2013/FibromyalgiaDiagnosticCriteria.pdf
e. Describe and explain the usefulness of the FIQR for the management of patients with FM.
("2010 ACR Fibromyalgia Diagnostic Criteria", 2011)
The Fibromyalgia Impact Questionnaire (FIQ) is one of the most common tools used to evaluate patients with fibromyalgia. However, since the FIQ was deemed too complicated to use, it never gained any traction for applying it in the clinic, so the FIQR was made (Bennett et al., 2009). The FIQR is a revised version of the questionnaire to make it much more simple and applicable to the clinic. The FIQR is broken down into three parts and they include function, overall impact, and symptoms; it also involves questions regarding memory, tender points, balance, and environmental sensitivity (Bennett et al., 2009). According to Bennett et.al one of the major differences between the two questionnaires are the specific questions asked in each of the three categories. In the functional section, questions are asked in way to eliminate gender and ethnicity bias that were present in the original FIQ (Bennett et al., 2009). The questions in the FIQR have been changed to reflect a better balance between large-muscle activities in the upper and lower extremities (Bennett et al., 2009). The overall impact category, is divided into two separate categories, the overall impact of Fibromyalgia on functional ability and on the perception of reduced function (Bennett et al., 2009). Lastly, the third category, symptoms, has mostly the same questions from the original FIQ with regards to pain, stiffness, depression and lack of sleep, but it also includes a lot of questions as mentioned above on memory, tenderness, and balance (Bennett et al., 2009). According to the study done by Bennett et. al on the FIQR, it was very effective in distinguishing between those patients with fibromyalgia than those with other similar diseases such as rheumatoid arthritis, systemic lupus erythematosus, and major depressive disorder. The study also had good evidence that the FIQR correlates well with the original FIQ, so that previous scores could be compared over to the newer version, and they also reported that taking the survey only takes a short period of time to complete, which is beneficial for the patients in the clinic (Bennett et al., 2009).
IV. Evidence-Based Interventions
a. Identify reasons for using or not using physical agents for the management of patients with RA or FM.
RHEUMATOID ARTHRITIS:
Pain for individuals with Rheumatoid Arthritis (RA) can often times be a constant struggle. This patients are always in need of ways to alleviate pain, both so that they do not have to suffer, but also so they can function effectively throughout their day. This makes the application of physical agents an essential aspect of treatment for patients with RA. The Ottawa panel provides a review of much of the relevant literature for some of the most commonly used physical agents for relieving pain associated with RA. The focus of almost all the data discussed was on the various joints in the hand and reducing pain and symptoms that manifested there. To start off, there were 5 RCTs relevant to the effects of low-level laser therapy (LLLT), most looking at a variety of outcomes including pain, function, grip strength, and ROM. Of these 5, four, Goats et al, Hall et al, Johannsen et al and Walker et al, report a statistically significant drop in pain levels with 2-3 sessions of LLLT per week for 4-10 week however, pooling these studies there was no convincing effect on factors involving function such as grip force and ROM. The 5th study, which was done by Palmgren et al in 1989 actually saw the complete opposite results showing improvements in swelling, ROM, and morning stiffness, but saw no difference in pain reduction with LLLT when compared to a placebo. Despite the popularity of ultrasound in clinics, the data is sparse when it comes to randomized controlled trials looking specifically of the effects of ultrasound on RA. Konrad K. in 1994 conducted a double blinded placebo-controlled, randomized trial with 50 patients that had a diagnosis of RA. The results suggested thermal ultrasound 3 sessions per week for 3 weeks saw significant improvements in pain, number of tender joints, grip force and morning stiffness time. Moving onto TENS, Abelson et al in 1983 measured the effects of acupuncture-like TENS on patients with RA and found a huge, 67% reduction in pain at rest on the VAS when compared to a placebo group. This same magnitude of improvement was not seen in the 1984 Langley et al study that instead used high frequency TENS which saw no improvement from baseline. This would be consistent with the theories of pain modulation that suggest high level TENS would merely gate pain during use, where as low level TENS would cause twitch contractions leading to endorphin release and longer lasting pain reduction. Moving on to one of the most common physical agents seen in clinic, the classic cold pack. Bulstrode et al in 1986 saw improvements in patients thermographic index, though very marginally, but functionally and for pain, there were no improvements. Finally, the Ottawa panel references Dellhag et al 1992, a study that compared a group of RA patients treated with a combination of Parrafin wax and exercise, and an untreated control group and also compared a group only getting the wax treatment with no exercise. In all outcomes for the wax only group, there was no effect of treatment at all, and in fact there was even greater stiffness in the wax group by 31% than the completely untreated group. When wax was combined with exercise there were much greater improvements with increased hand ROM, decreased pain in both active ROM and resisted ROM. The Ottawa panel does fail to mention how any soft tissue work impacts patients with RA. In 2013 Field et al looked at 42 adults with RA. A massage therapist massaged their upper limbs and shoulders once a week for 4 weeks. Additionally, some self-massage methods were shown to the patients. There was a group that had very light pressure for massage (control), and then a group that was given moderate pressure. The group who were given moderate pressure massages actually saw improvements in pain and grip strength, and additionally saw improved feelings of anxiety and depression. Especially in pain, these improvements were seen before and after a session on a given day, and also f
("Ottawa Panel Evidence-Based Clinical Practice Guidelines for Electrotherapy and Thermotherapy Interventions in the Management of Rheumatoid Arthritis in Adults," 2004)
(Field, T., Diego, M., Delgado, J., Garcia, D., & Funk, C. G. (2013). Rheumatoid arthritis in upper limbs benefits from moderate pressure massage therapy. Complement Ther Clin Pract, 19(2), 101-103. doi:10.1016/j.ctcp.2012.12.001)
Massage
− Massage has been indicated to reduce pain and increase mobility, as well as reduce stress and anxiety
− Shown in a study to improve grip strength, increase wrist/elbow flexion ROM and shoulder abduction ROM, and improve feelings of depression and anxiety ("Ottawa Panel Evidence-Based Clinical Practice Guidelines for Electrotherapy and Thermotherapy Interventions in the Management of Rheumatoid Arthritis in Adults," 2004)
FIBROMYALGIA:
Fibromyalgia is associated with widespread, diffuse pain, therfore patients seek various types of modalities to he
Electrotherapy
− Beneficial, motor cortex stimulation with epidural electrodes
− Motor cortex stimulation is based on evidence of thalamic dysfunction in chronic pain and significant changes in thalamic activity with motor cortex stimulation (Citak-Karakaya, Akbayrak, Demirturk, Ekici, & Bakar, 2006; Gur, 2006; Imamura, Cassius, & Fregni, 2009)
Ultrasound
− Improve sustained muscle contractions
− Increase permeability of the cell membrane
− Increased angiogenesis in ischemic tissue repair
− Patients seem to report improvement in pain intensity, a reduction in complaints about lack of sleep and a positive impact on the functional activities of daily living (Citak-Karakaya et al., 2006; Gur, 2006)
Heat Therapy
− The use of Waon therapy (soothing warmth therapy)
− Patients were placed in a far infrared-ray dry sauna maintained at a temperature of 60 degrees C for 15 minutes, and then transferred to a room maintained at a temperature of 26-27 degrees C, where they were covered with a blanket from the neck down for 30 minutes
− Patients reported a decrease in pain according to the visual analog scale (VAS) and the FIQ
Manual Therapy
− May resolve a transient flare, but unlikely to alleviate the pain completely
− Risk of patients becoming dependent on it, therefore use of passive manual therapy modalities should be limited. (Susan O’Sullivan, 2014)
EMG
− Neuromuscular reeducation using EMG can be used to teach patients to relax overactive muscles and contract muscles as needed without widespread over-recruitment (Susan O’Sullivan, 2014)
Massage
− Various forms have shown short-term benefits, but long term benefits only occur when combined with exercise and patient education (Susan O’Sullivan, 2014)
Dry Needling
− Studies have shown that dry needling therapy has reduced myofascial trigger points, especially useful on the thoracic and lumbar muscles
− Myofascial trigger point in the Latissimus Dorsi, Iliocostalis, Multifidus, and Quadratus Lumborum muscles(Castro-Sanchez et al., 2017)
b. Outline indications, contraindications, and precautions to treatment when developing and implementing interventions for patients with RA or FM. Provide references, as available, to support your clinical decision-making. Your product should address the following areas:
i) Range of Motion
ii) Flexibility
iii) Peripheral Joint Mobilization
iv) Resistance exercise
v) Aerobic Exercise (include a brief explanation of a quota-based aerobic program)
RHEUMATOID ARTHRITIS:
The following information regarding fibromyalgia interventions was retrieved from ("Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises in the management of rheumatoid arthritis in adults," 2004) unless cited otherwise.
Exercise for RA has been studied at length using a wide variety of types, intensities and durations. Presently, the Ottawa Panel stands by the findings that when treating RA, a therapist should include therapeutic exercise, in particular for improving pain, overall function, grip strength and lower limb-strength. Interestingly enough exercise does seem to be not quite as effective for patients with RA as it is in a healthy individual. A 1996 study by Mannerkorpi and Bjelle saw only a slight, statistically insignificant improvement in improving ADL function, relieving pain and ROM, from giving a group of RA patients a home resistance exercise program for the shoulder, 3x per week for 8 weeks when compared to a group doing no exercise at all. Additionally a 1971 study by Mills et al. comparing a physical therapy program with another group on 22hrs of bedrest per day for 4 weeks, followed by 18hrs of bed rest for 6 weeks actually saw statistically insignificant trends in favor of the bed rest group when measuring ROM, joint tenderness, and 50 ft walk time. Moreover van den Ende et al in 1996 found that with high intensity exercise RA patients saw no improvement in pain and joint mobility and actually saw trends favoring a non-exercising control group. There is definitely a good amount of data that suggests at least certain types of exercise done in these studies are not the most effective, however there are still large benefits to be had from exercise even for RA patients when it comes to meaningful functional movements. Mills et al found improvements in grip strength in their patients, additionally Hoenig et al found significant changes in proximal interphalangeal joint ROM in the hand. Furthermore McMeeken et al found quite large improvements in pain on the VAS scale by an average of -1.7cm, which was a 41% change from baseline. Additionally Nordemar et al found that patients who were undergoing strength training were 43% less likely to take sick leave due to their ailment than a control group. Finally, improvements in both muscle strength and aerobic capacity, both huge markers for overall functionality that slow health decline with age were seen in a number of studies, such as Van den Ende et al and Bilberg et al, with the use of a dynamic exercise program which primarily referred to exercise on a bicycle at home.
In the case of Rose Wright, first and foremost we would want to consider the contraindications and precautions at play with RA. If we saw that the patient presented with a hot, very swollen joint, or with a fever, or weight loss, we would consider these red flags suggesting possible infection and would have her see her rheumatologist. According to the American college of sports medicine (Wilkins, Lippincott Williams 2013) considering the patient is very weak and not particularly mobile, it is essential that we begin with low impact exercises like stretching, walking or even swimming, in order to just hope to maintain range of motion and prevent further loss of strength and ROM. During times of a significant flare up of RA, which is indicative by severe inflammation of the joints, strenuous exercise, and high-impact exercise types are contraindicated and should be avoided in order to allow time for reduction in swelling, usually a few days of rest are indicated followed by a progression to low impact exercise. Resistance exercise particularly for the lower extremity to help prevent future falls would be indicated. Additionally, upper extremity, shoulder exercises could be implemented, as there is a slight trend in the data that suggests it could be helpful, despite there not being a statistically significant effect. Also low impact aerobic exercise such as biking for both upper and lower extremity, would be effective for improving Rose’s overall functionality, while not having a jarring, painful, irritating effect on her joints.
("Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises in the management of rheumatoid arthritis in adults," 2004)
Interventions:
− Range of Motion/ Flexibility: Stretching, Tai Chi, Yoga
o 10-15 minutes, 2x a week
− Patient Education- educate patient on the exercise techniques that she can perform at home as well as FITT principles to adhere to for maintenance
o Lifestyle changes increase Physical activity with HEP
("Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises in the management of rheumatoid arthritis in adults," 2004)
FIBROMYALGIA
The following information regarding fibromyalgia interventions was retrieved from (Busch et al, 2011). (Busch et al., 2011)
Interventions for fibromyalgia patients is highly dependent on the individual’s specific pain and limitations. Complementary medicine is also often included along with more traditional treatments to help them find relief. It is highly recommended to promote self-efficacy in patients with fibromyalgia. This helps with the patient’s performance during exercises and also their future adherence to the exercise program. To promote adherence, it is also recommended to start with low-intensity exercise and gradually progress. We looked at one study using a RCT on the application of self-myofascial release to provide benefits such as fatigue, ROM, and perceived pain. The study assessed the impact of self-myofascial release program on cervical spine, shoulder, and hip ROM. Improvements were found in ROM in the intervention group compared to the control group. Also, utilizing traditional yoga poses, meditation, and breathing exercises in conjunction with range of motion and relaxation exercises in water resulted in significant improvement of range of motion, global pain rating, and an overall improvement of fibromyalgia symptoms, and functional deficits. Evidence supporting flexibility exercise in treatment of fibromyalgia is very limited. However, it is indicated to include stretching exercises as part of the cool-down at the end of treatment. There are no valid indications for joint mobilizations with fibromyalgia patients. These could potentially lead to increased pain in patients. Also, in patients that it provides pain relief, they could become reliant on these treatments instead of other options. Progressive resistance exercise was found to be a feasible mode of exercise for women with FM, improving muscle strength, health status, and current pain intensity when assessed immediately after the interventions. This was seen in a RCT that implemented resistance training 2x/week for 15 weeks in fibromyalgia patients. When implementing resistance exercises for fibromyalgia patients, it is recommended to start with lower resistance than what is predicted as normal for same age individuals. Intensity can be increased once current intensity is performed without exacerbating symptoms for 1-2 weeks. It is important to avoid significant post-exertion pain and fatigue with exercises, as this can lead to reduced adherence by the patient.
Other studies have shown that Pilates, which emphasize core strengthening, posture, coordination of breathing with movement, patients who participated in one-hour sessions, four times a week, for four weeks, they experienced a significant reduction in pain according the Visual Analog Scale, and the FIQR. When developing aerobic interventions, prescribing a quota-based aerobic program has been indicated with fibromyalgia patients to increase adherence and performance in aerobic exercise. It has been shown in studies to increase the distance walking by patients as well as decreasing fibromyalgia-associated symptoms. Aerobic and strengthening exercise have produced the most consistent positive results in fibromyalgia patients, however it is strongly recommended to include multiple types of exercises. Exercise also should be tailored to patient preferences and setting. The main goal is to achieve optimal benefits and long-term adherence; therefore, the chosen interventions and intensities must be careful to avoid any exercise-related fatigue, pain, or musculoskeletal injury.
(Busch et al, 2011)
V. Phases of Tissue Healing
a. List clinical indicators to confirm that a patient presents with an acute injury?
Acute: The most common clinical indicators to confirm that a patient presents with an acute injury are the cardinal signs of inflammation (Susan O'Sullivan, 2014b). These cardinal signs include redness, heat, swelling, pain, and loss of function. These indicators may present before ROM limitations and indicate that the body wants to protect itself from further injury. For example, patients with Rheumatoid Arthritis, an autoimmune disease, have their body's immune system attack natural structures of the body such as synovial tissue associated with the joints, tendon sheaths, bursae, and lining of organs (Susan O'Sullivan, 2014a). Although Fibromyalgia patients suffer from acute flare-ups at specific tender points, this is not part of the inflammation phase of tissue healing. Physical Therapists should approach therapy in the inflammation phase by focusing on relieving pain, protecting the joints at risk, and facilitate function via passive range of motion or assistive devices (Susan O'Sullivan, 2014a).
b. List clinical indicators to confirm that a patient is either in the proliferative (sub-acute) or remodeling (chronic) phase of healing?
Proliferative: Patients that present in the proliferative phase of healing have reduced cardinal signs of inflammation such as a reduction in pain, swelling, and redness, which allow for improved ROM and function that was severely limited during the acute phase (Susan O'Sullivan, 2014b). The patient should tolerate increased movement that was too painful during the inflammation phase and be able to perform AROM within pain-free limits. The patient should not engage in any resistance training that could cause inflammation and disrupt the sub-acute phase of healing. For patients in this phase, physical therapists should focus on promoting function and healing. Specifically, patients with rheumatoid arthritis benefit well from graded aerobic exercise to promote healing because it has been shown to improve function without aggravating joint symptoms (Harkcom, Lampman, et al, 2011). In addition, physical therapists should begin rehabilitation focused on restoring joint mobility and improving muscle strength and endurance within pain-free limitations (Susan O'Sullivan, 2014b).
Remodeling: Patients that present in the remodeling phase of healing have minimal pain, absence of inflammation, and continued improvement with ROM and strength which allows for a gradual return to ADL's (Susan O'Sullivan, 2014b). These patients are now in the chronic phase and are not limited by pain, but are limited via resistance in soft tissue structures such as muscle and joint stiffness. With these limitations present, physical therapists should focus on functional strength and endurance activities to enhance quality of life and keep limitations at bay. Also, PT's should work with patients in the chronic phase of healing by incorporating ergonomic training for long-term joint protection that the patient could infuse into normal day life (Susan O'Sullivan, 2014b).