logging in or signing up Rehabilitation of Rheumatic Patients drhanyzahran Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: Embed: Flash iPad Dynamic Copy Does not support media & animations Automatically changes to Flash or non-Flash embed WordPress Embed Customize Embed URL: Copy Thumbnail: Copy The presentation is successfully added In Your Favorites. Views: 1174 Category: Education License: All Rights Reserved Like it (1) Dislike it (0) Added: June 15, 2010 This Presentation is Public Favorites: 3 Presentation Description No description available. Comments Posting comment... By: zosnet (5 month(s) ago) very nice and useful presentation can you send me tnx Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript Slide 1: بسم الله الرØمن الرØيم Slide 2: Rehabilitation of Patients with Rheumatic Diseases Dr. Hany Zahran MBBCh; M.Sc; M.D. Consultant Rheumatology & Rehabilitation Pasha Medical Center Slide 4: The aim of rehabilitation is to maximize function and minimize the disability and handicap resulting from the underlying impairment or disease. Rehabilitation of inflammatory rheumatic diseases should begin early and continue throughout the disease course. The impairment and resulting disability caused by rheumatic diseases can be ameliorated by a rehabilitation program even when the disease remains active Slide 5: Even short-term, 6-week programs, consisting of exercise, education, and pain-relief modalities, have been shown to benefit rheumatoid arthritis patients. A home physical therapy program including education, exercise, and removal of environmental hazards can reduce disability, even in the elderly. Slide 6: Typical impairments in rheumatology patients include loss of joint range of motion and muscular weakness. Such impairments may lead to activity limitations or participation restrictions or both (disability). Slide 7: Disability is characterized as the outcome of a complex relationship between an individual's health condition and personal factors with which the individual lives. Society may hinder an individual's performance because it either creates barriers (e.g., inaccessible buildings) or it does not provide facilitators (e.g., lack of available assistive devices). Slide 8: Arthritis and other rheumatic conditions are said to be the leading cause of disability. 3% of all adults have disability due to arthritis and other rheumatic conditions. The prevalence of self-reported arthritis increases with age. By age 65, there is 45-% prevalence of self-reported arthritis, and about 22 % of these have activity limitations Slide 9: Work disability occurs commonly during the course of rheumatic diseases. About 40 % of RA and SLE patients stopped working or decrease working hours within 5 years after the onset of their disease Slide 10: EVALUATION & CLASSIFICATION ASSESSMENT OF FUNCTION Slide 11: Each patient's level of function should be determined so that a suitable rehabilitation program can be planned and the outcome can be easily measured. The level of function is determined by the ability to perform ADL, home activities, and activities outside the home. Slide 12: Activities of daily living are self-care activities and consist of grooming, dressing, feeding, bathing, toileting, ambulating, transfers, continence, and communication. Slide 13: Instrumental activities of daily living require a combination of mental and physical ability and consist of: Functions in the home: Cleaning Cooking Doing laundry Using the telephone Climbing stairs Managing medication Functions external to the home: Working Using public transportation Shopping Money management Social interaction Slide 14: Although most rheumatology & rehabilitation doctors managing patients with rheumatic disorders are appropriately concerned about the degree of inflammation, they may not ascertain which functional activities the patient is capable of performing or not performing. It is important to know how the patient spends a typical day and what his or her difficulties may be in carrying out tasks and recreational activities Slide 15: The original ARA classification of functional impairment was a general four-point scale and was not very specific or useful for measuring improvement in functional activities. Subsequently, other scales have been developed. Some scales are limited to functional assessment for a specific disease, such as RA, multiple sclerosis, or juvenile rheumatoid arthritis, or even to a specific joint, such as the shoulder. Slide 16: Among The most widely used scales for rheumatic diseases are the health assessment questionnaire (HAQ), Dougados functional index (DFI) both are self-administered questionnaire and includes activities of daily living inside and outside the home. Modified HAQ : Are you able to dress yourself, including tying shoelaces and doing up buttons? Are you able to get in and out of bed? Are you able to lift a full cup or glass to your mouth? Are you able to walk outdoors on flat ground? Are you able to wash and dry your entire body? Are you able to bend down to pick up clothing from the floor? Are you able to turn taps on and off? Are you able to get in and out of a car? Score Without any difficulty (0) With some difficulty (1) With much difficulty (2) Unable to do so (3) Modified HAQ DFI composes of 20 questions about ADL:Can you: : DFI composes of 20 questions about ADL:Can you: Put on your shoes? Pull on trousers? Pull on pullover? Get in bath tub? Remain standing for 10 minutes? Climb 1 flight of stairs? Run? Sit down? Get up from a chair? Get into a car? Bend over to pick up an object? squat? Lie down? Turn in bed? Get out of bed? Sleep on your back? Sleep on your stomach? Do your job or house work? Cough or sneeze? Breathe deeply? Without any difficulty (0) Yes with difficulty (1) No (2) Score Slide 19: ASSESSMENT OF FUNCTION INDEPENDENT MEDICAL EVALUATIONS Slide 20: The determination of physical disability is difficult because non medical factors have a significant influence, such as level of education, occupation, income, job satisfaction, motivation, and the presence or absence of psychiatric illness. The associated level of function in rheumatic diseases may fluctuate during the day and from day to day so that one assessment may not be representative of a patient's true abilities. Slide 21: Reported symptoms or disability in osteoarthritis (OA) of the hip and knee may not correlate with radiographic changes. Objective test results may not correlate with perceived disability, as in cases of fibromyalgia. Slide 22: The typical patients of FM are skinny females, with a lot of work responsibility , usually unmarried , little bit kyphotic, having more than 12 trigger points, not relieved by injection except temporarily , those benefit a lot from massage and hot and cold bathes in addition to tricyclic antidepressant drugs Program OF Rheumatic Disease Rehabilitation : Program OF Rheumatic Disease Rehabilitation REST EXERCISE PHYSICAL MODALITIES ORTHOTICS ASSISTIVE DEVICES Slide 24: Active inflammatory joint disease may benefit much from prolonged systemic rest (bed rest), or from joints given local rest (with splints and braces). However, complete bed rest has no place in the long-term management of rheumatic diseases because of the deleterious effects on the musculoskeletal, cardiovascular, pulmonary, nervous, and urinary systems. REST Slide 25: On the other hand cast immobilization causes a significant loss of muscle mass (disuse atrophy) within 4-6 weeks If a few days of bed rest are required to treat an acute flare of RA, passive and active exercises in bed should be advised to prevent loss disuse atrophy. REST Slide 26: A program of rest for a limited period each day, or rest of particular joints, is preferable to complete bed rest. For ambulatory patients, 1 hour of bed rest during the day may help decrease the fatigue caused by systemic inflammation. REST Slide 27: Rest of specific joints can be provided by orthoses, most commonly by resting and working wrist splints. REST Slide 28: The importance of therapeutic exercise in the management of rheumatic diseases is often inadequately appreciated. Exercise is safe and helpful for SLE and polymyositis. The immediate reaction to a painful stimulus, such as in a joint, is to stop using that joint. For example, knee and hip pain are strongly associated with quadriceps weakness. EXERCISE Slide 29: Exercise therapy can increase aerobic capacity, joint range of motion, endurance, muscle strength, and coordination and can improve joint stability and physical function. Exercises may be prescribed for specific joints or muscles or for part of a program to maintain or improve overall cardiovascular fitness and endurance. EXERCISE Slide 30: In OA of the knee, aerobic and resistive exercise can decrease disability by improving function and decreasing pain. Even the elderly, following falls or hip surgery, can benefit from progressive resistance exercise programs. EXERCISE Therapeutic exercise may be broadly classified into three groups: : Therapeutic exercise may be broadly classified into three groups: Range of motion or stretching Strengthening (resistive) Aerobic (endurance) EXERCISE Slide 32: Exercises are divided into those that are active and those that are passive. The types of strengthening exercises are isometric, isotonic, and isokinetic. A usual program consists of 10 to 20 repetitions with about one half of the maximal power performed two to three times daily. EXERCISE Quadriceps strengthening : Can be obtained by straight leg raising performed from the sitting or recumbent position. The patient should sit in a chair and extend the leg, placing the heel on a second chair or stool of nearly the same height. The leg is held straight, raised about 8 inches, and then returned to the chair. 20 repetitions should be performed at least three times per day. EXERCISE Quadriceps strengthening Slide 35: The gluteal muscles are also important for gait and mobility and work in tandem with the quadriceps muscles. Tightening the buttocks and holding the contraction for several seconds 10 to 20 times twice per day is advisable. EXERCISE Shoulder ROM : Shoulder ROM EXERCISE Shoulder strengthening : Shoulder strengthening To avoid shoulder weakness, the patient can strengthen rotator cuff muscles by using a 1- to 3-pound weight while performing 10 to 20 repetitions of internal and external rotations; the elbow is flexed at 90°, and the arm is held adjacent to the thorax. Elastic band devices, such as the Theraband or sando, may be used to strengthen various muscles, including the shoulder. EXERCISE Slide 38: Because patients with ankylosing spondylitis find it difficult to maintain cardiorespiratory fitness and spinal mobility, active extension exercises, such as swimming and cycling, are appropriate. The goals of an exercise program in ankylosing spondylitis are to relieve pain and stiffness and maintain posture and should include specific joint and back passive stretching and active exercises. EXERCISE Slide 39: Consistent home exercise programs help increase and maintain spinal mobility and reduce pain and stiffness. Group exercises may also encourage patient compliance, support patients psychologically, and are cost effective. Patients with ankylosing spondylitis who exercise two to four hours per week may have less disability and less disease activity than those who exercise less or not at all. EXERCISE Slide 40: Pool therapy provides buoyancy and support through reduction of the effects of gravity by the water. Pool therapy may permit exercising and independent walking even when walking aids or assistance are required on dry land. The water temperature should be 33°C to 34°C for pool exercises. EXERCISE Slide 41: Swimming, bicycling, and other non-weight-bearing conditioning exercises are especially suitable for patients with arthritis. Exercises such as tennis and racquetball are best avoided because of the sudden stresses and strains placed on ligaments and joints from rapid acceleration and deceleration movements that occur during these activities. EXERCISE PHYSICAL MODALITIES : PHYSICAL MODALITIES Physical modalities, such as hot packs, paraffin wax baths, ultrasound, and ice packs, are commonly used to treat the inflammation and pain of rheumatic diseases. Which may allow the patient to have a better range and diminution of pain and swelling. PHYSICAL MODALITIES : PHYSICAL MODALITIES Their usage is variable among rheumatologists. And usually theses Modalities are probably more effective when used along with exercise in a physical therapy program, occupational therapy program, or both. These modalities should be considered as a preparatory to massage and exercise therapy. COLD : COLD Superficial ice has been shown to reduce intra-articular temperature by about six or seven degrees C, and superficial heating may increase intra-articular temperature by about 2 degrees. COLD : COLD Cold applications raise the pain threshold, producing local analgesia. Cold may also temporarily decrease spasticity and muscle spasms by direct action on the muscle spindle. Topical ice therapy has been found to reduce pain in gouty arthritis. Gel filled Joint wraps that can be heated or cooled COLD : COLD Cooling of tissues can be obtained with ice packs or frozen packages. The patient's skin should be protected from ice with a towel or other barrier to prevent tissue damage. COLD : COLD Only superficial tissues can be cooled, because no deep cooling devices are available. Cooling causes vasoconstriction, with a reduction of blood flow and a decrease in metabolic activity in the region treated and is followed by histamine release and hyperaemia. HEAT : HEAT For centuries, heat has been used to alleviate the pain of joint and other diseases. Heat therapy probably began with mud baths, mineral waters, hot springs, and spas. It is possible that heating affects sensory and muscle nerve endings. However, placebo effects may play an important role in the effectiveness in any pain treatment. HEAT : HEAT Common methods of superficial heating include: hot packs, heating pads, Hydrocollator packs, paraffin wax, hot water bottles, heated pools and whirlpools, and infrared lamps. HEAT : HEAT Heating pads should be set with a timer to avoid burns, which can occur if the patient falls asleep. Slide 51: A Hydrocollator pack contains silica gel covered by cloth; it is warmed in a hot water bath. The silica allows prolonged retention of heat. Because the temperature of these packs can be high, they are usually wrapped in a towel before application to prevent burns. HEAT HEAT : Paraffin wax treatment, a principal method to heat the hands, can be set up at home. A wax mixture is first heated to a liquid form. The patient then dips a hand in and out of the wax until several layers have adhered. The hand can be wrapped with a towel to maintain the heat. HEAT Slide 53: The partially solidified glove of wax retains warmth for about 20 minutes. Although a somewhat messy application, wax is particularly useful for patients with hand arthritis and deformities because the wax can mold to any surface. Combined paraffin wax with an exercise program leads to decreased stiffness and increased ROM of the hand. HEAT HEAT : Deep heat modalities including short waves, microwaves, and ultrasound. Proved advantage over superficial heat in management of rheumatic diseases. ultrasound treatment was shown to improve grip strength in rheumatoid arthritis. HEAT Heat and cold modalities should be avoided in: : Patients who cannot communicate feelings of discomfort, such as very young, comatose, or demented patients. Patients with malignancy; fresh hematomas; open wounds; ischemic areas; areas with metal implants, pacemakers, or other electric-mechanical devices, eyes and uteruses of pregnant women. Heat and cold modalities should be avoided in: HEAT OR COLD? : HEAT OR COLD? The decision whether to use superficial heat or cold is subjective. Because neither modality appears to affect inflammation adversely, the primary considerations for use are cost, availability, experience of the physician, and patient preference. HEAT OR COLD? : HEAT OR COLD? Based on the observation that heat increases intra-articular temperature, it is suggested that cooling be used for joints that are acutely inflamed. Cooling is also used in the first 24 hours after acute musculoskeletal trauma because of bleeding and swelling of the tissues. The pain of subacute and chronic inflammation is more responsive to superficial moist heat and is often preferred by patients. HYDROTHREAPY : HYDROTHREAPY Hydrotherapy in a Hubbard tank can provide superficial heat to multiple joints and may help reduce morning stiffness. HYDROTHREAPY : HYDROTHREAPY Spa therapy, which includes bathing in thermal or mineral waters (balneotherapy), has been shown to be helpful for patients with ankylosing spondylitis and possibly other rheumatic diseases. ELECTROTHERAPY : ELECTROTHERAPY Transcutaneous electrical nerve stimulation (TENS) is another physical modality commonly used for the treatment of pain. An intermittent low-voltage current is applied to the skin. TENS is noninvasive and has few side effects but should probably not be used in patients with pacemakers. ELECTROTHERAPY : ELECTROTHERAPY The most popular concept regarding the mechanism is the gate theory of pain of Melzack and Wall. Presumably, the current produced by the device closes the gate & prevents transmission of pain impulses. ELECTROTHERAPY : ELECTROTHERAPY Electrotherapy can also be used to stimulate muscles by causing muscle contractions in the hope of improving muscle strength in a patient unable to exercise on his or her own because of pain or active inflammatory disease. Includes: electric currents, didynamic current, interfrential currents. ELECTROTHERAPY : ELECTROTHERAPY Last but not least is LASER therapy which can be used either to relief pain or to help healing of open wounds. Slide 64: Orthotic devices include braces, splints, corsets, collars, and shoe modifications. A properly prescribed orthosis restores lost function or helps to maintain optimal function by altering biomechanics and reducing pain. Orthoses decrease forces passing through painful weight-bearing joints, stabilize subluxating joints, improve motion patterns, and maximize functional positioning. ORTHOTICS Slide 65: Unless the underlying inflammation is treated, orthotic devices cannot prevent deformity. An orthosis may also allow a highly inflamed joint to fuse in the best functional position. Lighter orthoses require less energy and oxygen consumption in their use. ORTHOTICS Slide 66: Thermoplastic is a plastic that can be reheated multiple times to change its shape. This is advantageous because, as joint swelling decreases, the old splint can simply be reheated and remolded, saving the expense of a new one. Thermoplastic is lightweight and ideally suited for non-weight-bearing splints. After heating, thermoplastic can be applied to the patient directly over a cloth and then molded as it cools. Thermoset plastic, in contrast, cannot be reheated or remolded, but is stronger and more durable. ORTHOTICS Slide 67: Thermoset is suited for use in such applications as an ankle-foot orthosis. Because of the higher temperatures required for molding, the plastic cannot be applied to the patient directly. A plastic cast must first be molded on the patient, increasing the time and expense required for construction. ORTHOTICS Slide 68: Splints may be static or dynamic and resting or working. Static rest splints are worn during periods when joint movement is not needed, usually at night, and provide pain relief. Static work splints are worn during the day and must accommodate some movement (e.g., a wrist splint that allows a child with JRA to write at school). SPLINTS Slide 69: Dynamic splints have movable parts that may include metal, gas, electrical, and elastic components. Such devices may replace lost muscle power or may be used to strengthen weak muscles or reduce or prevent contractures. For example, loss of finger extension from rupture of the extensor tendons in RA may be replaced by elastic bands on a splint, which hold the fingers in extension. SPLINTS Slide 70: Braces are used on the lower limbs to decrease weight-bearing or to provide stability. Today, braces can be fabricated from lightweight metal, such as aluminium, with plastic components, increasing their usefulness and compliance by the patient. Compliance is a major problem with splints and braces. BRACES Specific Types of Orthoses Wrist splints : Specific Types of Orthoses Wrist splints The most commonly prescribed splints in RA, JRA , CTS. Resting or night wrist splints have 10 to 40°of extension at the wrist, 20 to 70° flexion of the MCP joints, and 10 to 20° of flexion at the PIP joints and DIP joints. Specific Types of Orthoses Wrist splints : Specific Types of Orthoses Wrist splints Working splints that allow greater joint movement and function are used during the day. The thumb is separated with a C-bar to prevent adduction deformity. Specific Types of Orthoses Corsets : Specific Types of Orthoses Corsets Corsets and abdominal binders may assist weak abdominal muscles and provide support to the lumbar spine. Specific Types of Orthoses Cervical Collars : Specific Types of Orthoses Cervical Collars Subluxation of the atlantoaxial joint can occur in RA, and when surgery is not indicated, cervical collars may be prescribed. Cervical collars include soft collars, the Philadelphia collar, and the sterno-occipital-mandibular immobilizer. Specific Types of OrthosesShort Leg Brace : Specific Types of OrthosesShort Leg Brace In OA and RA, long and short leg braces are sometimes used to try to reduce instability and control knee movements. A brace to support the knee usually consists of thigh and calf enclosures, two uprights, and a hinge at the level of the knee that permits flexion and extension. Specific Types of Orthoses Ankle-foot Orthosis : Specific Types of Orthoses Ankle-foot Orthosis An ankle-foot orthosis provides medial and lateral stability in place of lax ligaments and controls ankle plantar and dorsiflexion in a patient with foot drop. Inversion and eversion straps can be added to further control ankle stability. Specific Types of Orthoses Ankle-foot Orthosis : Specific Types of Orthoses Ankle-foot Orthosis In patients with anesthetic feet, an external ankle-foot orthosis composed of double metal uprights, a fixed or movable ankle, and metal stirrups directly fixed to the shoe is preferred. Specific Types of Orthoses : Specific Types of Orthoses Joint subluxation also results in loss of foot arches, uneven weight distribution, and pain. Arch supports placed in shoes can help reform these arches. Specific Types of Orthoses : Specific Types of Orthoses Asymmetric joint involvement in adult RA or OA may also lead to differences in leg lengths if bone or articular cartilage is destroyed on one side. A lift may be added to the shoe of the short leg. The amount of the shoe rise should be one half to three quarters of the leg length discrepancy. If the leg length discrepancy is not a recent event and is asymptomatic, it is probably better not to treat it. ASSISTIVE DEVICES : ASSISTIVE DEVICES When needed, a wide variety of assistive devices are available to reduce disability. An experienced occupational therapist can recommend which devices are appropriate for each patient, including those that aid the patient in dressing, such as button hooks, long-handled reachers, and sock aids. ASSISTIVE DEVICES : ASSISTIVE DEVICES A rocker knife allows the patient to cut food with one hand. High toilet seats, bathroom-wall grab bars, and bath seats aid in hygiene. It is important to determine patient compliance with and the usefulness of the aids provided and whether modifications are needed. ASSISTIVE DEVICES : ASSISTIVE DEVICES Mobility devices, such as walkers, crutches, canes, and wheelchairs, are easily accessible and provide immediate assistance. These devices are used when lower extremity joint instability, pain, weakness, fatigue, paralysis, or balance problems limit independent ambulation. Weight-bearing is reduced through the diseased limb or limbs. ASSISTIVE DEVICES : ASSISTIVE DEVICES Balance is improved by widening the base of support so that the patient's center of gravity can be shifted, safely enhancing proprioceptive input. However, any type of assisted mobility requires more physical effort than normal walking. The choice of an assistive device is based on the impairment and the resulting disability. Such devices add to safety in ambulation and can prevent falls in the elderly, which can result in devastating hip fractures. Canes : Canes A properly used cane can reduce more than 25 % of the body weight supported by the contralateral limb during gait. To determine cane length, a measurement should be taken from the level of the greater trochanter or distal wrist crease to the heel of the shoe. Canes : Canes With cane use, the shoulders should be level and the elbow flexed at about 30 degrees. Canes can be constructed of metal or wood. Metal is more durable and can be adjusted, whereas wood is cheaper Single-Point, Tripod, and Quadripod Bases : Single-Point, Tripod, and Quadripod Bases Although a single-point cane (i.e., straight cane) is most common, tripod and quadripod bases are also available. These canes provide a broader base of support with three or four points of floor contact. Single-Point, Tripod, and Quadripod Bases : Single-Point, Tripod, and Quadripod Bases The cane legs that are closest to the lower limb of the patient are usually shorter to allow clearance of the foot. Tripod and quadripod canes, however, are not practical on stairs and usually result in a slower gait pattern, because all three or four legs must contact the floor to maintain patient stability. Crutches : Crutches Crutches are prescribed when more stability is required than is provided by a cane or when one leg must be kept off the ground. Types of crutches include axillary, forearm, and platform (i.e., trough) crutches. Walkers : Walkers Walkers are prescribed for patients who require considerable external support. Good bilateral grasp and upper extremity strength are required for their use. Walkers are cumbersome and can be difficult to maneuver, especially on deep carpeting. They cannot be used on stairs. Wheelchairs : Wheelchairs Wheelchairs are underused, possibly because of their cost and the failure to recognize their benefit for the disabled. For patients unable to propel a wheelchair manually, an electric wheelchair, although expensive, is a consideration because it can improve the quality of life by maintaining independent mobility. You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.
Rehabilitation of Rheumatic Patients drhanyzahran Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: Embed: Flash iPad Dynamic Copy Does not support media & animations Automatically changes to Flash or non-Flash embed WordPress Embed Customize Embed URL: Copy Thumbnail: Copy The presentation is successfully added In Your Favorites. Views: 1174 Category: Education License: All Rights Reserved Like it (1) Dislike it (0) Added: June 15, 2010 This Presentation is Public Favorites: 3 Presentation Description No description available. Comments Posting comment... By: zosnet (5 month(s) ago) very nice and useful presentation can you send me tnx Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript Slide 1: بسم الله الرØمن الرØيم Slide 2: Rehabilitation of Patients with Rheumatic Diseases Dr. Hany Zahran MBBCh; M.Sc; M.D. Consultant Rheumatology & Rehabilitation Pasha Medical Center Slide 4: The aim of rehabilitation is to maximize function and minimize the disability and handicap resulting from the underlying impairment or disease. Rehabilitation of inflammatory rheumatic diseases should begin early and continue throughout the disease course. The impairment and resulting disability caused by rheumatic diseases can be ameliorated by a rehabilitation program even when the disease remains active Slide 5: Even short-term, 6-week programs, consisting of exercise, education, and pain-relief modalities, have been shown to benefit rheumatoid arthritis patients. A home physical therapy program including education, exercise, and removal of environmental hazards can reduce disability, even in the elderly. Slide 6: Typical impairments in rheumatology patients include loss of joint range of motion and muscular weakness. Such impairments may lead to activity limitations or participation restrictions or both (disability). Slide 7: Disability is characterized as the outcome of a complex relationship between an individual's health condition and personal factors with which the individual lives. Society may hinder an individual's performance because it either creates barriers (e.g., inaccessible buildings) or it does not provide facilitators (e.g., lack of available assistive devices). Slide 8: Arthritis and other rheumatic conditions are said to be the leading cause of disability. 3% of all adults have disability due to arthritis and other rheumatic conditions. The prevalence of self-reported arthritis increases with age. By age 65, there is 45-% prevalence of self-reported arthritis, and about 22 % of these have activity limitations Slide 9: Work disability occurs commonly during the course of rheumatic diseases. About 40 % of RA and SLE patients stopped working or decrease working hours within 5 years after the onset of their disease Slide 10: EVALUATION & CLASSIFICATION ASSESSMENT OF FUNCTION Slide 11: Each patient's level of function should be determined so that a suitable rehabilitation program can be planned and the outcome can be easily measured. The level of function is determined by the ability to perform ADL, home activities, and activities outside the home. Slide 12: Activities of daily living are self-care activities and consist of grooming, dressing, feeding, bathing, toileting, ambulating, transfers, continence, and communication. Slide 13: Instrumental activities of daily living require a combination of mental and physical ability and consist of: Functions in the home: Cleaning Cooking Doing laundry Using the telephone Climbing stairs Managing medication Functions external to the home: Working Using public transportation Shopping Money management Social interaction Slide 14: Although most rheumatology & rehabilitation doctors managing patients with rheumatic disorders are appropriately concerned about the degree of inflammation, they may not ascertain which functional activities the patient is capable of performing or not performing. It is important to know how the patient spends a typical day and what his or her difficulties may be in carrying out tasks and recreational activities Slide 15: The original ARA classification of functional impairment was a general four-point scale and was not very specific or useful for measuring improvement in functional activities. Subsequently, other scales have been developed. Some scales are limited to functional assessment for a specific disease, such as RA, multiple sclerosis, or juvenile rheumatoid arthritis, or even to a specific joint, such as the shoulder. Slide 16: Among The most widely used scales for rheumatic diseases are the health assessment questionnaire (HAQ), Dougados functional index (DFI) both are self-administered questionnaire and includes activities of daily living inside and outside the home. Modified HAQ : Are you able to dress yourself, including tying shoelaces and doing up buttons? Are you able to get in and out of bed? Are you able to lift a full cup or glass to your mouth? Are you able to walk outdoors on flat ground? Are you able to wash and dry your entire body? Are you able to bend down to pick up clothing from the floor? Are you able to turn taps on and off? Are you able to get in and out of a car? Score Without any difficulty (0) With some difficulty (1) With much difficulty (2) Unable to do so (3) Modified HAQ DFI composes of 20 questions about ADL:Can you: : DFI composes of 20 questions about ADL:Can you: Put on your shoes? Pull on trousers? Pull on pullover? Get in bath tub? Remain standing for 10 minutes? Climb 1 flight of stairs? Run? Sit down? Get up from a chair? Get into a car? Bend over to pick up an object? squat? Lie down? Turn in bed? Get out of bed? Sleep on your back? Sleep on your stomach? Do your job or house work? Cough or sneeze? Breathe deeply? Without any difficulty (0) Yes with difficulty (1) No (2) Score Slide 19: ASSESSMENT OF FUNCTION INDEPENDENT MEDICAL EVALUATIONS Slide 20: The determination of physical disability is difficult because non medical factors have a significant influence, such as level of education, occupation, income, job satisfaction, motivation, and the presence or absence of psychiatric illness. The associated level of function in rheumatic diseases may fluctuate during the day and from day to day so that one assessment may not be representative of a patient's true abilities. Slide 21: Reported symptoms or disability in osteoarthritis (OA) of the hip and knee may not correlate with radiographic changes. Objective test results may not correlate with perceived disability, as in cases of fibromyalgia. Slide 22: The typical patients of FM are skinny females, with a lot of work responsibility , usually unmarried , little bit kyphotic, having more than 12 trigger points, not relieved by injection except temporarily , those benefit a lot from massage and hot and cold bathes in addition to tricyclic antidepressant drugs Program OF Rheumatic Disease Rehabilitation : Program OF Rheumatic Disease Rehabilitation REST EXERCISE PHYSICAL MODALITIES ORTHOTICS ASSISTIVE DEVICES Slide 24: Active inflammatory joint disease may benefit much from prolonged systemic rest (bed rest), or from joints given local rest (with splints and braces). However, complete bed rest has no place in the long-term management of rheumatic diseases because of the deleterious effects on the musculoskeletal, cardiovascular, pulmonary, nervous, and urinary systems. REST Slide 25: On the other hand cast immobilization causes a significant loss of muscle mass (disuse atrophy) within 4-6 weeks If a few days of bed rest are required to treat an acute flare of RA, passive and active exercises in bed should be advised to prevent loss disuse atrophy. REST Slide 26: A program of rest for a limited period each day, or rest of particular joints, is preferable to complete bed rest. For ambulatory patients, 1 hour of bed rest during the day may help decrease the fatigue caused by systemic inflammation. REST Slide 27: Rest of specific joints can be provided by orthoses, most commonly by resting and working wrist splints. REST Slide 28: The importance of therapeutic exercise in the management of rheumatic diseases is often inadequately appreciated. Exercise is safe and helpful for SLE and polymyositis. The immediate reaction to a painful stimulus, such as in a joint, is to stop using that joint. For example, knee and hip pain are strongly associated with quadriceps weakness. EXERCISE Slide 29: Exercise therapy can increase aerobic capacity, joint range of motion, endurance, muscle strength, and coordination and can improve joint stability and physical function. Exercises may be prescribed for specific joints or muscles or for part of a program to maintain or improve overall cardiovascular fitness and endurance. EXERCISE Slide 30: In OA of the knee, aerobic and resistive exercise can decrease disability by improving function and decreasing pain. Even the elderly, following falls or hip surgery, can benefit from progressive resistance exercise programs. EXERCISE Therapeutic exercise may be broadly classified into three groups: : Therapeutic exercise may be broadly classified into three groups: Range of motion or stretching Strengthening (resistive) Aerobic (endurance) EXERCISE Slide 32: Exercises are divided into those that are active and those that are passive. The types of strengthening exercises are isometric, isotonic, and isokinetic. A usual program consists of 10 to 20 repetitions with about one half of the maximal power performed two to three times daily. EXERCISE Quadriceps strengthening : Can be obtained by straight leg raising performed from the sitting or recumbent position. The patient should sit in a chair and extend the leg, placing the heel on a second chair or stool of nearly the same height. The leg is held straight, raised about 8 inches, and then returned to the chair. 20 repetitions should be performed at least three times per day. EXERCISE Quadriceps strengthening Slide 35: The gluteal muscles are also important for gait and mobility and work in tandem with the quadriceps muscles. Tightening the buttocks and holding the contraction for several seconds 10 to 20 times twice per day is advisable. EXERCISE Shoulder ROM : Shoulder ROM EXERCISE Shoulder strengthening : Shoulder strengthening To avoid shoulder weakness, the patient can strengthen rotator cuff muscles by using a 1- to 3-pound weight while performing 10 to 20 repetitions of internal and external rotations; the elbow is flexed at 90°, and the arm is held adjacent to the thorax. Elastic band devices, such as the Theraband or sando, may be used to strengthen various muscles, including the shoulder. EXERCISE Slide 38: Because patients with ankylosing spondylitis find it difficult to maintain cardiorespiratory fitness and spinal mobility, active extension exercises, such as swimming and cycling, are appropriate. The goals of an exercise program in ankylosing spondylitis are to relieve pain and stiffness and maintain posture and should include specific joint and back passive stretching and active exercises. EXERCISE Slide 39: Consistent home exercise programs help increase and maintain spinal mobility and reduce pain and stiffness. Group exercises may also encourage patient compliance, support patients psychologically, and are cost effective. Patients with ankylosing spondylitis who exercise two to four hours per week may have less disability and less disease activity than those who exercise less or not at all. EXERCISE Slide 40: Pool therapy provides buoyancy and support through reduction of the effects of gravity by the water. Pool therapy may permit exercising and independent walking even when walking aids or assistance are required on dry land. The water temperature should be 33°C to 34°C for pool exercises. EXERCISE Slide 41: Swimming, bicycling, and other non-weight-bearing conditioning exercises are especially suitable for patients with arthritis. Exercises such as tennis and racquetball are best avoided because of the sudden stresses and strains placed on ligaments and joints from rapid acceleration and deceleration movements that occur during these activities. EXERCISE PHYSICAL MODALITIES : PHYSICAL MODALITIES Physical modalities, such as hot packs, paraffin wax baths, ultrasound, and ice packs, are commonly used to treat the inflammation and pain of rheumatic diseases. Which may allow the patient to have a better range and diminution of pain and swelling. PHYSICAL MODALITIES : PHYSICAL MODALITIES Their usage is variable among rheumatologists. And usually theses Modalities are probably more effective when used along with exercise in a physical therapy program, occupational therapy program, or both. These modalities should be considered as a preparatory to massage and exercise therapy. COLD : COLD Superficial ice has been shown to reduce intra-articular temperature by about six or seven degrees C, and superficial heating may increase intra-articular temperature by about 2 degrees. COLD : COLD Cold applications raise the pain threshold, producing local analgesia. Cold may also temporarily decrease spasticity and muscle spasms by direct action on the muscle spindle. Topical ice therapy has been found to reduce pain in gouty arthritis. Gel filled Joint wraps that can be heated or cooled COLD : COLD Cooling of tissues can be obtained with ice packs or frozen packages. The patient's skin should be protected from ice with a towel or other barrier to prevent tissue damage. COLD : COLD Only superficial tissues can be cooled, because no deep cooling devices are available. Cooling causes vasoconstriction, with a reduction of blood flow and a decrease in metabolic activity in the region treated and is followed by histamine release and hyperaemia. HEAT : HEAT For centuries, heat has been used to alleviate the pain of joint and other diseases. Heat therapy probably began with mud baths, mineral waters, hot springs, and spas. It is possible that heating affects sensory and muscle nerve endings. However, placebo effects may play an important role in the effectiveness in any pain treatment. HEAT : HEAT Common methods of superficial heating include: hot packs, heating pads, Hydrocollator packs, paraffin wax, hot water bottles, heated pools and whirlpools, and infrared lamps. HEAT : HEAT Heating pads should be set with a timer to avoid burns, which can occur if the patient falls asleep. Slide 51: A Hydrocollator pack contains silica gel covered by cloth; it is warmed in a hot water bath. The silica allows prolonged retention of heat. Because the temperature of these packs can be high, they are usually wrapped in a towel before application to prevent burns. HEAT HEAT : Paraffin wax treatment, a principal method to heat the hands, can be set up at home. A wax mixture is first heated to a liquid form. The patient then dips a hand in and out of the wax until several layers have adhered. The hand can be wrapped with a towel to maintain the heat. HEAT Slide 53: The partially solidified glove of wax retains warmth for about 20 minutes. Although a somewhat messy application, wax is particularly useful for patients with hand arthritis and deformities because the wax can mold to any surface. Combined paraffin wax with an exercise program leads to decreased stiffness and increased ROM of the hand. HEAT HEAT : Deep heat modalities including short waves, microwaves, and ultrasound. Proved advantage over superficial heat in management of rheumatic diseases. ultrasound treatment was shown to improve grip strength in rheumatoid arthritis. HEAT Heat and cold modalities should be avoided in: : Patients who cannot communicate feelings of discomfort, such as very young, comatose, or demented patients. Patients with malignancy; fresh hematomas; open wounds; ischemic areas; areas with metal implants, pacemakers, or other electric-mechanical devices, eyes and uteruses of pregnant women. Heat and cold modalities should be avoided in: HEAT OR COLD? : HEAT OR COLD? The decision whether to use superficial heat or cold is subjective. Because neither modality appears to affect inflammation adversely, the primary considerations for use are cost, availability, experience of the physician, and patient preference. HEAT OR COLD? : HEAT OR COLD? Based on the observation that heat increases intra-articular temperature, it is suggested that cooling be used for joints that are acutely inflamed. Cooling is also used in the first 24 hours after acute musculoskeletal trauma because of bleeding and swelling of the tissues. The pain of subacute and chronic inflammation is more responsive to superficial moist heat and is often preferred by patients. HYDROTHREAPY : HYDROTHREAPY Hydrotherapy in a Hubbard tank can provide superficial heat to multiple joints and may help reduce morning stiffness. HYDROTHREAPY : HYDROTHREAPY Spa therapy, which includes bathing in thermal or mineral waters (balneotherapy), has been shown to be helpful for patients with ankylosing spondylitis and possibly other rheumatic diseases. ELECTROTHERAPY : ELECTROTHERAPY Transcutaneous electrical nerve stimulation (TENS) is another physical modality commonly used for the treatment of pain. An intermittent low-voltage current is applied to the skin. TENS is noninvasive and has few side effects but should probably not be used in patients with pacemakers. ELECTROTHERAPY : ELECTROTHERAPY The most popular concept regarding the mechanism is the gate theory of pain of Melzack and Wall. Presumably, the current produced by the device closes the gate & prevents transmission of pain impulses. ELECTROTHERAPY : ELECTROTHERAPY Electrotherapy can also be used to stimulate muscles by causing muscle contractions in the hope of improving muscle strength in a patient unable to exercise on his or her own because of pain or active inflammatory disease. Includes: electric currents, didynamic current, interfrential currents. ELECTROTHERAPY : ELECTROTHERAPY Last but not least is LASER therapy which can be used either to relief pain or to help healing of open wounds. Slide 64: Orthotic devices include braces, splints, corsets, collars, and shoe modifications. A properly prescribed orthosis restores lost function or helps to maintain optimal function by altering biomechanics and reducing pain. Orthoses decrease forces passing through painful weight-bearing joints, stabilize subluxating joints, improve motion patterns, and maximize functional positioning. ORTHOTICS Slide 65: Unless the underlying inflammation is treated, orthotic devices cannot prevent deformity. An orthosis may also allow a highly inflamed joint to fuse in the best functional position. Lighter orthoses require less energy and oxygen consumption in their use. ORTHOTICS Slide 66: Thermoplastic is a plastic that can be reheated multiple times to change its shape. This is advantageous because, as joint swelling decreases, the old splint can simply be reheated and remolded, saving the expense of a new one. Thermoplastic is lightweight and ideally suited for non-weight-bearing splints. After heating, thermoplastic can be applied to the patient directly over a cloth and then molded as it cools. Thermoset plastic, in contrast, cannot be reheated or remolded, but is stronger and more durable. ORTHOTICS Slide 67: Thermoset is suited for use in such applications as an ankle-foot orthosis. Because of the higher temperatures required for molding, the plastic cannot be applied to the patient directly. A plastic cast must first be molded on the patient, increasing the time and expense required for construction. ORTHOTICS Slide 68: Splints may be static or dynamic and resting or working. Static rest splints are worn during periods when joint movement is not needed, usually at night, and provide pain relief. Static work splints are worn during the day and must accommodate some movement (e.g., a wrist splint that allows a child with JRA to write at school). SPLINTS Slide 69: Dynamic splints have movable parts that may include metal, gas, electrical, and elastic components. Such devices may replace lost muscle power or may be used to strengthen weak muscles or reduce or prevent contractures. For example, loss of finger extension from rupture of the extensor tendons in RA may be replaced by elastic bands on a splint, which hold the fingers in extension. SPLINTS Slide 70: Braces are used on the lower limbs to decrease weight-bearing or to provide stability. Today, braces can be fabricated from lightweight metal, such as aluminium, with plastic components, increasing their usefulness and compliance by the patient. Compliance is a major problem with splints and braces. BRACES Specific Types of Orthoses Wrist splints : Specific Types of Orthoses Wrist splints The most commonly prescribed splints in RA, JRA , CTS. Resting or night wrist splints have 10 to 40°of extension at the wrist, 20 to 70° flexion of the MCP joints, and 10 to 20° of flexion at the PIP joints and DIP joints. Specific Types of Orthoses Wrist splints : Specific Types of Orthoses Wrist splints Working splints that allow greater joint movement and function are used during the day. The thumb is separated with a C-bar to prevent adduction deformity. Specific Types of Orthoses Corsets : Specific Types of Orthoses Corsets Corsets and abdominal binders may assist weak abdominal muscles and provide support to the lumbar spine. Specific Types of Orthoses Cervical Collars : Specific Types of Orthoses Cervical Collars Subluxation of the atlantoaxial joint can occur in RA, and when surgery is not indicated, cervical collars may be prescribed. Cervical collars include soft collars, the Philadelphia collar, and the sterno-occipital-mandibular immobilizer. Specific Types of OrthosesShort Leg Brace : Specific Types of OrthosesShort Leg Brace In OA and RA, long and short leg braces are sometimes used to try to reduce instability and control knee movements. A brace to support the knee usually consists of thigh and calf enclosures, two uprights, and a hinge at the level of the knee that permits flexion and extension. Specific Types of Orthoses Ankle-foot Orthosis : Specific Types of Orthoses Ankle-foot Orthosis An ankle-foot orthosis provides medial and lateral stability in place of lax ligaments and controls ankle plantar and dorsiflexion in a patient with foot drop. Inversion and eversion straps can be added to further control ankle stability. Specific Types of Orthoses Ankle-foot Orthosis : Specific Types of Orthoses Ankle-foot Orthosis In patients with anesthetic feet, an external ankle-foot orthosis composed of double metal uprights, a fixed or movable ankle, and metal stirrups directly fixed to the shoe is preferred. Specific Types of Orthoses : Specific Types of Orthoses Joint subluxation also results in loss of foot arches, uneven weight distribution, and pain. Arch supports placed in shoes can help reform these arches. Specific Types of Orthoses : Specific Types of Orthoses Asymmetric joint involvement in adult RA or OA may also lead to differences in leg lengths if bone or articular cartilage is destroyed on one side. A lift may be added to the shoe of the short leg. The amount of the shoe rise should be one half to three quarters of the leg length discrepancy. If the leg length discrepancy is not a recent event and is asymptomatic, it is probably better not to treat it. ASSISTIVE DEVICES : ASSISTIVE DEVICES When needed, a wide variety of assistive devices are available to reduce disability. An experienced occupational therapist can recommend which devices are appropriate for each patient, including those that aid the patient in dressing, such as button hooks, long-handled reachers, and sock aids. ASSISTIVE DEVICES : ASSISTIVE DEVICES A rocker knife allows the patient to cut food with one hand. High toilet seats, bathroom-wall grab bars, and bath seats aid in hygiene. It is important to determine patient compliance with and the usefulness of the aids provided and whether modifications are needed. ASSISTIVE DEVICES : ASSISTIVE DEVICES Mobility devices, such as walkers, crutches, canes, and wheelchairs, are easily accessible and provide immediate assistance. These devices are used when lower extremity joint instability, pain, weakness, fatigue, paralysis, or balance problems limit independent ambulation. Weight-bearing is reduced through the diseased limb or limbs. ASSISTIVE DEVICES : ASSISTIVE DEVICES Balance is improved by widening the base of support so that the patient's center of gravity can be shifted, safely enhancing proprioceptive input. However, any type of assisted mobility requires more physical effort than normal walking. The choice of an assistive device is based on the impairment and the resulting disability. Such devices add to safety in ambulation and can prevent falls in the elderly, which can result in devastating hip fractures. Canes : Canes A properly used cane can reduce more than 25 % of the body weight supported by the contralateral limb during gait. To determine cane length, a measurement should be taken from the level of the greater trochanter or distal wrist crease to the heel of the shoe. Canes : Canes With cane use, the shoulders should be level and the elbow flexed at about 30 degrees. Canes can be constructed of metal or wood. Metal is more durable and can be adjusted, whereas wood is cheaper Single-Point, Tripod, and Quadripod Bases : Single-Point, Tripod, and Quadripod Bases Although a single-point cane (i.e., straight cane) is most common, tripod and quadripod bases are also available. These canes provide a broader base of support with three or four points of floor contact. Single-Point, Tripod, and Quadripod Bases : Single-Point, Tripod, and Quadripod Bases The cane legs that are closest to the lower limb of the patient are usually shorter to allow clearance of the foot. Tripod and quadripod canes, however, are not practical on stairs and usually result in a slower gait pattern, because all three or four legs must contact the floor to maintain patient stability. Crutches : Crutches Crutches are prescribed when more stability is required than is provided by a cane or when one leg must be kept off the ground. Types of crutches include axillary, forearm, and platform (i.e., trough) crutches. Walkers : Walkers Walkers are prescribed for patients who require considerable external support. Good bilateral grasp and upper extremity strength are required for their use. Walkers are cumbersome and can be difficult to maneuver, especially on deep carpeting. They cannot be used on stairs. Wheelchairs : Wheelchairs Wheelchairs are underused, possibly because of their cost and the failure to recognize their benefit for the disabled. For patients unable to propel a wheelchair manually, an electric wheelchair, although expensive, is a consideration because it can improve the quality of life by maintaining independent mobility.