Physiotherapy for rheumatoid arthritis - approaches and treatment

Rheumatoid arthritis

is a chronic autoimmune disease that primarily affects the cartilage and bone tissue of the joints, and can also have extra-articular manifestations.
Starting at a young age, the disease can lead to deformation of joints and limbs
, as well as
disability during working age
.

Rheumatoid arthritis is a malfunction in the human immune system that causes defense cells to attack the body's own soft tissues. This process is accompanied by pain and swelling, leads to the accumulation of synovial fluid and impaired nutrition of the joint. The disease usually begins between the ages of 25 and 50, but can also debut in childhood.

It is impossible to prevent rheumatoid arthritis

- just prolong remission when it has already begun. However, a well-designed treatment plan for rheumatoid arthritis and careful adherence to clinical recommendations in the treatment of rheumatoid arthritis will help preserve joints and meet old age on your feet, and not in bed.

Rheumatoid arthritis is a chronic autoimmune disease

Causes and treatment of rheumatoid arthritis

Rheumatoid arthritis (RA) occurs throughout the globe and ranks 2nd in prevalence in Russia

among all types of arthritis. Although the main cause and treatment of rheumatoid arthritis has not been established, researchers have identified the following factors that influence the onset of RA:

heredity
(in families where relatives already suffer from rheumatoid arthritis, the risk of its manifestation in descendants is higher);
previous infections, especially severe ones
(infectious diseases provoke a strong immune response, which increases the risk of failure);
hormonal disorders or changes in the body
(including those associated with stress, lack of sleep, pregnancy, menopause in women and men);
unbalanced diet, deficiency of vitamins and minerals
;
frequent moves to different climates
;
physical and nervous overload
;
bad habits
(alcoholism, smoking, use of psychoactive substances).

The role of rehabilitation and hardware physiotherapy in the treatment strategy for rheumatic diseases

D.E. Karateev, GBUZ MO "Moscow Regional Research Clinical Institute named after. M.F. Vladimirsky" (MONIKI), Moscow, Russia

E.L. Luchikhina, Moscow Regional Research Clinical Institute named after. M.F. Vladimirsky" (MONIKI), Moscow, Russia

I.P. Osnovina, Federal State Budgetary Educational Institution of Higher Education "Ivanovo State Medical Academy" of the Ministry of Health of Russia, Ivanovo, Russia

A.V. Makevnina, GBUZ MO "Moscow Regional Research Clinical Institute named after. M.F. Vladimirsky" (MONIKI), Moscow, Russia

Summary

Rheumatic diseases represent a serious medical and social problem. The variability of the development mechanisms of this group of diseases requires different approaches: drug and non-drug therapy strategies in modern rheumatology are designed to complement each other. The EULAR recommendations pay insufficient attention to the use of non-drug treatments for joint diseases. According to modern research, multidisciplinary rehabilitation strategies have demonstrated the greatest effectiveness, including, in addition to drug therapy, educational programs, physical training of varying intensity, and the use of hardware rehabilitation methods. Hardware physiotherapy seems to be optimal for the treatment of patients with rheumatic diseases due to greater accessibility and lower cost compared to classical balneo- and peloidotherapy. When using magnetic therapy, there is also greater safety and fewer contraindications to the procedures. The most justified method for treating joint diseases is the use of pulsed magnetic fields, since the sensitivity of biological tissues to them is the highest. The clinical effectiveness of pulsed magnetic therapy has been demonstrated in several randomized, placebo-controlled, multicenter studies. During magnetic field therapy, patients showed a statistically significant reduction in pain and stiffness, and improvement in joint function, which indicates the advisability of including the physical factor in the treatment strategy for rheumatic diseases in combination with drug therapy.

Keywords:

rheumatic diseases, pulsed magnetic field, magnetic therapy, rehabilitation of rheumatic diseases, hardware physiotherapy, non-drug therapy.

Information about the authors:

Karateev D.E - https://orcid.org/0000-0002-2352-4080;
e-mail Luchikhina E.L. — https://orcid.org/0000-0002-6519-1106

Osnovina I.P. — https://orcid.org/0000-0002-4828-5645

Makevnina A.V. — email

Rheumatic diseases (RD), such as osteoarthritis (OA), rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA) represent a serious medical and social problem. They are one of the main causes of chronic pain and, accordingly, the widespread use of analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs). These diseases can quickly lead the patient to disability and early death. At the same time, drug therapy for RD requires careful safety monitoring and is very expensive. The variability of the clinical picture, reflecting the individual characteristics of the mechanisms of disease development, requires different approaches. Thus, in the treatment of pain syndromes in rheumatology with the “mechanical” phenotype of musculoskeletal pain, in addition to the use of painkillers (paracetamol, NSAIDs), active correction of biomechanical disorders using orthotics and other rehabilitation methods is indicated [1]. There is no doubt that the influence of drugs and physical factors on the pathogenesis is an example of a complex influence on the pathological process and, with the right approach, can not only expand the arsenal of doctors in the fight against the disease, but also provide additional clinical effect. An example of a successful combination of physical treatment and drug therapy in the field of immunoinflammatory diseases is PUVA therapy for psoriasis, which is included in clinical guidelines, i.e. into the patient management strategy.

Strategy of drug and non-drug therapy in modern rheumatology

The idea of including various rehabilitation technologies in the complex of treatment of RD is absolutely not new and seems completely natural. If we take RA as an example as a classical model disease, then the main directions of treatment for this pathology, from the point of view of a rheumatologist, should be:

monitoring disease activity
symptom control (pain syndrome)
restoration of joint function (including postoperative rehabilitation)
control of comorbid conditions (osteoporosis, sarcopenia, etc.)

These tasks largely coincide with the tasks of drug therapy, so drug and non-drug treatment methods, in fact, can be used together, potentiating each other’s effects. Unfortunately, at the turn of the second millennium AD in rheumatology, one can observe a disappointing picture of an ever-increasing gap between drug therapy and non-drug treatment methods. In most cases, both in scientific publications and in practice, pharmacotherapy and physiotherapy/rehabilitation methods are used for the same conditions not only by different specialists, but also completely independently of each other, with minimal consideration of interactions. The gap between rheumatology as a science that studies methods of influencing the immunopathological processes of inflammation, and rehabilitation/physiotherapy is currently very wide. This process seems completely illogical, since, on the one hand, in our country rheumatology began to develop rapidly thanks to the activities of the outstanding doctor, scientist and statesman A.I. Nestrov and actually left physiotherapy and balneology [2], and on the other hand, physical methods of treatment are widely used and preferred by many patients, despite all the efforts of adherents of evidence-based medicine.

In recent years, a fairly definite tradition has been established in global rheumatology: when discussing treatment strategies, focus almost exclusively on drug therapy, especially when it comes to systemic immunoinflammatory diseases. A good example in this case are the recommendations for the management of the most significant RDs developed by the European League Against Rheumatism (EULAR) - one of the most authoritative international organizations of rheumatologists. In the 2021 EULAR recommendations for the management of patients with RA, physical therapy methods are mentioned once in the general sense of the possibility of their use [3], and in the updated version of 2021, the terms “physical therapy” and “rehabilitation” are not used at all meet [4]. In the EULAR recommendations for the management of patients with PsA, non-pharmacological methods are also mentioned once: “...optimal management of patients with PsA also requires the use of non-pharmacological methods, such as patient education and regular exercise” [5]. Even the 2021 recommendations for the treatment of hand OA, although they talk about the participation of a physiotherapist in a multidisciplinary team of specialists, only physical exercises appear among specific techniques [6]. Non-pharmacological therapy is presented somewhat more fully in the EULAR guidelines for the management of patients with early arthritis, which indicate the parallel use of patient education programs, dynamic exercises and occupational therapy at the initial stage of drug therapy [7].

Research in the field of integrated management of patients with rheumatic diseases. Motor rehabilitation programs

Recommendations have been published for the use of a number of non-drug treatment methods in patients with RD, which should be used in combination with pharmacotherapy. Thus, clinical guidelines for healthcare workers on the management of patients with chronic rheumatic pain [8] consider several techniques.

According to the “strength” of recommendations, the main methods are divided as follows:

A (the “strongest” recommendations) - training, physical exercise, orthotics, social rehabilitation, weight control
B - sleep correction
D (the “weakest”) - special assessment of pain and function, development of a personalized pain correction plan, creation of a multidisciplinary team

The 2021 EULAR recommendations for physical activity in patients with arthritis [9] state that exercise should be part of standard treatment, prescribed by medical staff in accordance with the plan, taking into account contraindications and characteristics of the patient, should be personalized and adapted to the specific case, without discussing specific techniques.

A significant amount of work is limited to exercise therapy (PT) programs, which is probably due to good tolerance, the absence of contraindications in most patients and the low cost of such treatment. A group of Canadian experts analyzed the effect of physical exercise on pain and function in gonarthrosis [10]. The authors' selection of 26 high-quality studies showed that various strengthening exercise programs with or without other forms of therapeutic exercise generally increased the effectiveness of treatment of knee OA over a 6-month period. Resistance exercise programs have demonstrated significant improvements in pain relief, physical function, and quality of life. The authors concluded that it is necessary to develop combined behavioral and muscle strengthening strategies to maintain the long-term effects of regular exercise programs. According to M. Williams et al. [11], the use of the SARAH specialized exercise program in 490 patients with RA in combination with standard pharmacotherapy for 12 months led to a decrease in the overall pain score, improved performance on quality of life questionnaires, and better dynamics of hand strength in the main group compared to the control.

An impressive result was demonstrated in a study by J. Veldhuijzen van Zanten et al. [12]. These authors compared 2 small groups of RA patients: group 1 (20 patients) received standard therapy + exercises; Group 2 (23 patients) - standard therapy + biological therapy with tumor necrosis factor inhibitors (TNF-i). Patients in group 2, as would be expected, had a significantly better outcome in terms of pain and disease activity. At the same time, equal results were observed in both groups in terms of function and fatigue, while in group 1, in contrast to group 2, positive dynamics of cardiovascular risk and vascular dysfunction were noted. On the other hand, a Cochrane review of exercise programs for AS found only a small reduction in pain and a slight improvement in functional outcomes, with predominantly low-quality evidence from the studies [13].

A similar review of exercise in hand RA [14], which included seven studies involving 841 patients (aged 20 to 94 years), was unable to determine whether exercise improved hand function and pain in the short term. perspective. Exercise appears to have a positive effect on hand function, but at a very small level, and has little or no effect on pain in the medium to long term. It is unclear whether hand clenching exercise improves function at short-term follow-up, although it is also likely to produce modest improvements in the medium to long term.

The work of Danish scientists was recently published [15], who, against the background of modern antirheumatic therapy, used an additional comprehensive program for hand restoration in RA, which included the following components:

1) defensive strategy; 2) auxiliary devices; 3) special methods of using objects in everyday life; 4) strength exercises.

After an 8-week course, patients with RA showed no differences from the control group in assessing pain during movement and at rest, hand strength, or the need to take analgesics. The use of a specialized HEPA program [16], which included strength exercises, aerobic exercises and group exercises, during two years of observation led to a decrease in the overall subjective assessment of pain in patients with RA, but pain sensitivity to palpation and neuropathic pain manifestations in patients remained at the same level.

Thus, complex rehabilitation programs based on exercise therapy in different patient populations gave different results, which indicates the need for a multidisciplinary strategy, including the use of additional technologies, such as balneotherapy and instrumental physiotherapy.

In a large-scale domestic work, E.V. Orlova et al. [17, 18] in 135 patients with early RA against the background of modern drug treatment regimens using synthetic basic drugs and glucocorticoids, 4 rehabilitation schemes were used, based on an educational program and exercise therapy, including high-intensity dynamic training using simulators. Two of them also included local air cryotherapy, one included orthotics. Patients in the control group received only drug treatment. As a result of a 6-month observation, it was demonstrated that a comprehensive program using physiotherapy and orthotics was the best in terms of developing positive dynamics of pain syndrome, increasing functional status, quality of life and locomotor function of the musculoskeletal system, as well as the only rehabilitation technique studied that increased the effectiveness of drug therapy in controlling disease activity according to the standard index. A significant improvement in the medium-term outcomes of early RA under the influence of a comprehensive rehabilitation program, including all the main elements of multidisciplinary medical care, showed the feasibility of introducing rehabilitation technologies into the “Treat to Target” strategy for RA from the moment of diagnosis together with drug therapy [19] .

The place of hardware physiotherapy in the treatment strategy for patients with rheumatic diseases

Hardware physiotherapy seems to be optimal for the treatment of patients with RD due to greater accessibility and lower cost compared to balneotherapy.
At the same time, if we talk about such a common method of hardware physiotherapy as magnetic therapy, then it is also necessary to note greater safety and fewer contraindications for such procedures, which is important, given the scale of the problem of RD in our country. From the standpoint of clinical effectiveness, the most justified is the use of pulsed magnetic fields (PMF), since the sensitivity of biological tissues to them is the highest [20]. Equipment for the treatment of UTIs is widely available in Russia. Portable devices Almag+ and Almag-01 are used for a wide range of pathologies (RH, cardiovascular pathology, neurological conditions, trophic disorders of various origins and severity, etc.). The biophysical effect of magnetic fields is based on the ability to induce electric currents in the affected area, the density of which depends on the rate of change and magnitude of the magnetic field, as well as on the electrical conductivity of biological tissues exposed to the influence of the magnetic field. UTIs cause reversible structural changes in cell membranes and their permeability. There is evidence of the direct effect of IMPs on electrolytes, in particular on Ca2+ ions, which affects cell metabolism, free radical reactions, as well as the ability to have a magnetodynamic effect [20]. The clinical effect of UTI has been repeatedly demonstrated in many studies. Thus, in 50 patients with nonspecific low back pain [21], UTI was used in comparison with the use of a placebo procedure. At the same time, the addition of IMP to the usual physiotherapy protocol in the main group gave a significant effect of reducing the severity of pain and restoring functional ability, more significant than in the control group. A randomized study of the effectiveness of magnetic therapy for gonarthrosis [22] involved 66 patients. After one month of use, PMI induced a significant reduction in visual analogue scale (VAS) pain as well as WOMAC scores compared with placebo; 26% of patients in the UTI group stopped taking NSAIDs/analgesics. No side effects were found. A recent meta-analysis of UTI in knee OA and hand OA [23] found that the UTI group had greater pain relief than placebo in knee OA (standardized mean difference (SMD) -0.54, 95% CI –1.04 to –0.04, p=0.03) and hand OA (SMD= –2.85, 95% CI –3.65 to –2.04, p<0.00001).

Similarly, compared with the placebo procedure, a significant improvement in function was observed in the UTI group in patients with knee and hand OA (SMD = -0.34, 95% CI -0.53 to -0.14, p=0. 0006 and SMD= –1.49, 95% CI –2.12 to –0.86, p<0.00001, respectively).

Sensitivity analysis showed that exposure durations of up to 30 min per procedure had better effects compared to exposure durations of more than 30 min. Three meta-analysis studies reported adverse events, however, the pooled results revealed that there were no significant differences in safety between the UTI and placebo treatment groups. The latest large study of UTI in OA [24] was published in 2020. The study group consisted of 231 patients with knee OA (77.9% women, mean age 61.9±12.2 years, body mass index 30.6 ±5.8 kg/m2, median disease duration - 5.0 [2.0; 10.0] years). The patients were randomized into two groups.

Patients of the 1st group underwent IMP using the ALMAG+ device for 14 days, patients of the 2nd group received a false IMP (a device that completely imitates the ALMAG+ device, but does not create a magnetic field). The dynamics of the WOMAC index, the severity of pain at rest and during movement on a 100-mm VAS, the need for NSAIDs and the severity of improvement from the patients’ point of view (on a 5-point scale) were assessed. During the therapy, a statistically significant decrease in pain and stiffness and improvement in function were noted. Thus, the median WOMAC pain index in group 1 decreased from 231 [180; 290] to 110 [60; 166.3] (p<0.001); in group 2 - from 212.4 [145; 260] to 143 [76.5; 200] (p<0.001), the severity of pain at rest (according to VAS) decreased in group 1 from 47 [27.8; 60] to 20 [10; 30] mm (p<0.001); in group 2 - from 40 [20;57.5] to 20 [7.5; 40] mm (p<0.001).

During the therapy, the need for taking NSAIDs also decreased: in group 1, the drug was discontinued or its dosage was reduced in 33.1% of patients, in group 2 - in 16.8% (p = 0.006). For all indicators, the dynamics in patients of group 1 were statistically more significant than in group 2. The treatment result was rated as “good” or “excellent” by 58.5% of patients in group 1 and 39.8% in group 2 (p<0.001). No serious adverse reactions were observed during true or sham UTI therapy. In two patients receiving sham UTI therapy, treatment was interrupted due to increased joint pain. Currently, a long-term, double-blind, placebo-controlled trial “Evaluation of the effectiveness and safety of the magnetic therapy device “ALMAG+” in the treatment of osteoarthritis of the knee joints” of the portable therapeutic device “ALMAG+” is being conducted (Certificate EN ISO 13485: 2012 + AC: 2012, registration No. 44221 117836, Reg. No. 3007075140).

Patients with primary and secondary (as a manifestation of inflammatory rheumatic disease) OA of the knee joint of Kellgren-Lawrence stage I-III were included in the study against the background of stable drug therapy. Three UTI courses of 20 procedures were planned over the course of a year in the active treatment group and the placebo group (sham therapy - inactive device), 35 patients each. In addition to clinical methods for assessing effectiveness, instrumental monitoring is carried out using ultrasound and MRI of the knee joint. The study protocol was approved by the local ethics committee.

Preliminary results of this ongoing study were reported at the EULAR 2021 Congress [25]. To date, 23 patients (7 men, 16 women, mean age 54.6±11.2 years) have completed the 1st course of UTI. The table presents the differences (Δ) between the initial indicators and the indicators in patients with knee OA after the 1st course of UTI for the main clinical parameters in the active treatment and placebo (sham procedures) groups.

There was a significantly more pronounced change in pain at rest, as well as a trend towards more pronounced changes in pain on movement and in the WOMAC index and Lequesne index in the group receiving active procedures. No treatment-related adverse events were observed.

Dynamics of decrease (Δ) in the main clinical parameters in patients with knee OA after the 1st course of UTI [25]

Parameter	Active device (n=11)	Placebo - inactive device (n=12)	p
Δ VAS pain with movement Δ VAS pain at rest Δ WOMAC index Δ Lequesne index [26]	15 [0; 38,5] 10 [0; 34] 3 [2; 10] 3 [0; 4]	5 [1,25; 10,5] 1 [0; 2,75] 2 [0; 4,5] 1 [0,25; 2,5]	0,053 0,043 0,174 0,258

Note. p — significance of differences between groups; VAS - visual analogue scale; WOMAC—Western Ontario and McMaster Universities Osteoarthritis Index [27].

Conclusion

Thus, the use of hardware treatment methods in the complex treatment strategy for RD is pathogenetically justified and clinically effective. Physiotherapeutic treatment of UTIs using the ALMAG+ device has a fairly pronounced analgesic and mobilizing effect, which, if widely used, can lead to the following positive trends:

better pain control;
reducing the need for analgesics and NSAIDs;
increasing mobility;
improving quality of life.

Treatment of UTI is relatively safe compared to other types of physiotherapy and balneotherapy, and is also more accessible. All of the above indicates the advisability of including hardware treatment methods, including UTI, in the treatment strategy for OA and RA, as well as, possibly, other RDs in in combination with drug therapy.

Literature:

Karateev A.E. Musculoskeletal pain: identification of clinical phenotypes and a rational approach to treatment. Almanac of Clinical Medicine. 2019;47(5):445-453.
Shostak N.A. School of Academician A.I. Nesterova. Medical Affairs. 2006;3:86-90.
Smolen JS, Landewé R, Bijlsma J, Burmester G, Chatzidionysiou K, Dougados M, Nam J, Ramiro S, Voshaar M, van Vollenhoven R, Aletaha D, Aringer M, Boers M, Buckley CD, Buttgereit F, Bykerk V, Cardiel M, Combe B, Cutolo M, van Eijk-Hustings Y, Emery P, Finckh A, Gabay C, Gomez-Reino J, Gossec L, Gottenberg JE, Hazes JMW, Huizinga T, Jani M, Karateev D, Kouloumas M, Kvien T, Li Z, Mariette X, McInnes I, Mysler E, Nash P, Pavelka K, Poór G, Richez C, van Riel P, Rubbert-Roth A, Saag K, da Silva J, Stamm T, Takeuchi T, Westhovens R , de Wit M, van der Heijde D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. Ann Rheum Dis. 2017;76:960977. https://doi.org/:10.1136/annrheumdis-2016-210715
Smolen JS, Landewé RBM, Bijlsma JWJ, Burmester GR, Dougados M, Kerschbaumer A, McInnes IB, Sepriano A, van Vollenhoven RF, de Wit M, Aletaha D, Aringer M, Askling J, Balsa A, Boers M, den Broeder AA , Buch MH, Buttgereit F, Caporali R, Cardiel MH, Cock DD, Codreanu C, Cutolo M, Edwards CJ, van Eijk-Hustings Y, Emery P, Finckh A, Gossec L, Gottenberg JE, Hetland ML, Huizinga TWJ, Koloumas M, Li Z, Mariette X, Müller-Ladner U, Mysler EF, da Silva JAP, Poor G, Pope JE, Rubbert-Roth A, Ruyssen-Witrand A, Saag KG, Strangfeld A, Takeuchi T, Voshaar M, Westhovens R , van der Heijde D. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2021 update. Ann Rheum Dis. 2020;79:685-699. https://doi.org/10.1136/annrheumdis-2019-216655
Gossec L, Baraliakos X, Kerschbaumeret A, de Wit M, McInnes I, Dougados M, Primdahl J, McGonagle DG, Aletaha D, Balanescu A, Balint PV, Bertheussen H, Boehncke WH, Burmester GR, Canete JD, Damjanov NS, Kragstrup TW, Kvien TK, Landewé RBM, Lories RJU, Marzo-Ortega H, Poddubnyy D, Manica SAR, Schett G, Veale DJ, den Bosch FEV, van der Heijde D, Smolen JS. EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2021 update. Ann Rheum Dis. 2020;79:700-712. https://doi.org/10.1136/annrheumdis-2020-217159
Kloppenburg M, Kroon FPB, Blanco FJ, Doherty M, Dziedzic KS, Greibrokk E, Haugen IK, Herrero-Beaumont G, Jonsson H, Kjeken I, Maheu E, Ramonda R, Ritt MJPF, Smeets W, Smolen JS, Stamm TA, Szekanecz Z, Wittoek R, Carmona L. 2021 update of the EULAR recommendations for the management of hand osteoarthritis. Ann Rheum Dis. 2019;78:16-24. https://doi.org/10.1136/annrheumdis-2018-213826
Combe B, Landewe R, Daien CI, Hua C, Aletaha D, Álvaro-Gracia JM, Bakkers M, Brodin N, Burmester GR, Codreanu C, Conway R, Dougados M, Emery P, Ferraccioli G, Fonseca J, Raza K, Silva-Fernández L, Smolen JS, Skingle D, Szekanecz Z, Kvien TK, van der Helm-van Mil A, van Vollenhoven R. 2021 update of the EULAR recommendations for the management of early arthritis. Ann Rheum Dis. 2017;76(6):948-959. https://doi.org/10.1136/annrheumdis-2016-210602
Geenen R, Overman CL, Christensen R, Åsenlöf P, Capela S, Huisinga KL, Husebø MEP, Köke AJA, Paskins Z, Pitsillidou IA, Savel C, Austin J, Hassett AL, Severijns G, Stoffer-Marx M, Vlaeyen JWS, Fernández-de-Las-Peñas C, Ryan SJ, Bergman S. EULAR recommendations for the health professional's approach to pain management in inflammatory arthritis and osteoarthritis. Ann Rheum Dis. 2018;77(6):797-807. https://doi.org/10.1136/annrheumdis-2017-212662
Rausch Osthoff AK, Niedermann K, Braun J, Adams J, Brodin N, Dagfinrud H, Duruoz T, Esbensen BA, Günther KP, Hurkmans E, Juhl CB, Kennedy N, Kiltz U, Knittle K, Nurmohamed M, Pais S, Severijns G, Swinnen TW, Pitsillidou IA, Warburton L, Yankov Z, Vlieland TPMV. 2021 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis. Ann Rheum Dis. 2018;77(9):1251-1260. https://doi.org/10.1136/annrheumdis-2018-213585
Brosseau L, Taki J, Desjardins B, Thevenot O, Fransen M, Wells GA, Imoto AM, Toupin-April K, Westby M, Gallardo ICA, Gifford W, Laferrière L, Rahman P, Loew L, Angelis GD, Cavallo S, Shallwani SM, Aburub A, Bennell KL, der Esch MV, Simic M, McConnell S, Harmer A, Kenny GP, Paterson G, Regnaux JP, Lefevre-Colau MM, McLean L. The Ottawa panel clinical practice guidelines for the management of knee osteoarthritis. Part two: strengthening exercise programs. Clin Rehabil. 2017;31(5):596-611. https://doi.org/10.1177/0269215517691084
Williams MA, Williamson EM, Heine PJ, Nichols V, Glover MJ, Dritsaki M, Adams J, Dosanjh S, Underwood M, Rahman A, McConkey C, Lord J, Lamb SE. Strengthening And stretching for Rheumatoid Arthritis of the Hand (SARAH). A randomized controlled trial and economic evaluation. Health Technol Assess. 2015;19(19):1-222. https://doi.org/10.3310/hta19190
Veldhuijzen van Zanten JJCS, Sandoo A, Metsios GS, Stavropoulos-Kalinoglou A, Ntoumanis N, Kitas GD. Comparison of the effects of exercise and anti-TNF treatment on cardiovascular health in rheumatoid arthritis: results from two controlled trials. Rheumatol Int. 2019;39(2):219-225. https://doi.org/10.1007/s00296-018-4183-1
Regnaux JP, Davergne T, Palazzo C, Roren A, Rannou F, Boutron I, Lefevre-Colau MM. Exercise programs for ankylosing spondylitis. Cochrane Database Syst Rev. 2019;10(10):CD011321. . https://doi.org/10.1002/14651858.CD011321.pub2
Williams MA, Srikesavan C, Heine PJ, Bruce J, Brosseau L, Hoxey-Thomas N, Lamb SE. Exercise for rheumatoid arthritis of the hand. Cochrane Database Syst Rev. 2018;7(7):CD003832. https://doi.org/10.1002/14651858.CD003832.pub3
Ellegaard K, von Bülow C, Røpke A, Bartholdy C, Hansen IS, Rifbjerg-Madsen S, Henriksen M, Wæhrens EE. Hand exercise for women with rheumatoid arthritis and decreased hand function: an exploratory randomized controlled trial. Arthritis Res Ther. 2019;21(1):158. https://doi.org/10.1186/s13075-019-1924-9
Löfgren M, Opava CH, Demmelmaier I, Fridén C, Lundberg IE, Nordgren B, Kosek E. Long-term, health-enhancing physical activity is associated with reduction of pain but not pain sensitivity or improved exercise-induced hypoalgesia in persons with rheumatoid arthritis. Arthritis Res Ther. 2018;20(1):262. https://doi.org/10.1186/s13075-018-1758-x
Orlova E.V., Karateev D.E., Amirdzhanova V.N. The effectiveness of an individual rehabilitation program for patients with rheumatoid arthritis. Scientific and practical rheumatol. 2012;50(1):45-53.
Orlova E.V., Karateev D.E., Kochetkov A.V. Comprehensive rehabilitation of patients with early rheumatoid arthritis: results of a 6-month program. Scientific and practical rheumatol. 2013;51(4):398-406.
Orlova E.V., Karateev D.E., Kochetkov A.V., Surnov A.V. Comparative effectiveness of four rehabilitation programs in patients with early rheumatoid arthritis. Bulletin of the Ivanovo Medical Academy. 2014;19(2):37-42.
Agafonov B.V., Sekirin A.B., Smirnova S.N., Topchiy N.V., Gorenkov R.V., Larinsky N.E., Sushinsky V.E., Ivanitsky L.V. The use of magnetic therapy and some other therapeutic physical factors in general medical practice (family medicine). A manual for doctors. M: MONIKI; 2021.
Elshiwi AM, Hamada HA, Mosaad D, Ragab IMA, Koura GM, Alrawaili SM. Effect of pulsed electromagnetic field on nonspecific low backpain patients: a randomized controlled trial. Braz J Phys Ther. 2019;23(3):244-249. https://doi.org/10.1016/j.bjpt.2018.08.004
Bagnato G, Miceli G, Marino N, Sciortino D, Bagnato GF. Pulsed electromagnetic fields in knee osteoarthritis: a double blind, placebo-controlled, randomized clinical trial. Rheumatology. 2016;55(4):755-762, https://doi.org/10.1093/rheumatology/kev426
Wu Z, Ding X, Lei G, Zeng C, Wei J, Li J, Li H, Yang T, Cui Y, Xiong Y, Wang Y, Xie D. Efficacy and safety of the pulsed electromagnetic field in osteoarthritis: a meta- analysis. BMJ Open. 2018;8(12):e022879. https://doi.org/10.1136/bmjopen-2018-022879
Karateev A.E., Pogozheva E.Yu., Sukhareva M.L., Lila A.M., Ivanov A.V., Osnovina I.P., Shchashkova O.V., Borisova S.V., Larinsky N. S., Israelyan Yu.A., Afoshin S.A., Bondarenko T.P., Repchanskaya E.A., Chernyavskaya L.A., Pupina S.P., Darmova T.V. Evaluation of the effectiveness and safety of magnetic therapy for osteoarthritis. Results of the multicenter, blind, placebo-controlled study COSMO (Clinical Evaluation of Modern Magnetic Therapy for Osteoarthritis). Scientific and practical rheumatology. 2020;58(1):55-61.
Karateev D, Makevnina A, Tangieva A, Luchikhina E, Hamhoeva H. Double-blind placebo-controlled trial of pulsed electromagnetic field therapy in knee osteoarthritis (preliminary results). Ann Rheum Dis. 2020;79(suppl1):1918, https://doi.org/10.1136/annrheumdis-2020-eular.6396
Lequesne MG. The algofunctional indicators for hip and knee osteoarthritis. J Rheumatol. 1997;24:779-781.
Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt L. Validation study of WOMAC: a health status instrument for measuring clinically-important patient-relevant outcomes following total hip or knee arthroplasty in osteoarthritis. Journal of Orthopedic Rheumatology. 1988;1:95-108.

Source:

Issues of balneology, physiotherapy and therapeutic physical culture, 2021, T. 97, No. 5, p. 87-93 doi.org/10.17116/kurort20209705187

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Symptoms and treatment of rheumatoid arthritis

A characteristic feature of rheumatoid arthritis is the symmetry of the lesions

- the disease affects the same joints on the left and right sides of the body. Often the small joints of the foot and hand, wrist and ankle joints are the first to suffer; with early onset and other factors of the unfavorable course of the disease, large (elbow, shoulder, knee and other) joints of the body can be affected.

The symptoms and treatment of rheumatoid arthritis are not constant. Pain and other signs of the disease may recede (sometimes for a very long time), and then return again under the influence of physical shock or psycho-emotional stress. Although the symptoms and treatment of rheumatoid arthritis can vary significantly from case to case, doctors focus on the following signs:

swelling of the soft tissues in the area of the affected joints (especially noticeable on the fingers);
soreness of the joints (decreased when they are bent), redness and increased sensitivity of the skin over them, muscle pain;
stiffness of movements in the joints, especially in the morning or after a long rest (lasts from half an hour to an hour, gradually goes away after warming up);
a general increase in body temperature (from a feeling of mild fever to 38°C - often RA is “masked” as ARVI);
chronic fatigue and loss of strength;
loss of appetite and weight loss;
changes in the condition of the skin and nails;
anemia (noticeable by the pallor of the mucous membranes).

Extra-articular symptoms can manifest themselves in the area of the heart and blood vessels, persistent dryness of the mucous membranes, and the appearance of rheumatoid nodules under the skin around the joints. In the absence of drug treatment for rheumatoid arthritis, in approximately 15% of patients, serious joint deformities develop within the first 6-8 years after the first exacerbation

.
Because of this, the muscles, ligaments and tendons surrounding the joints, as well as the heads of the bones, suffer. The rate of progression of the disease varies from case to case, but on average, irreversible changes in the osteoarticular system (including contractures - persistent restrictions on mobility) are observed in the first 10 years of the disease
.

The symptoms and treatment of rheumatoid arthritis in women differ slightly from the course of the disease in men:

the disease occurs on average 3 times more often than in men, since women naturally have a stronger immune response;
during pregnancy, when a woman’s immunity decreases so that the body does not reject the child, the condition of RA may improve (however, soon after childbirth it worsens again);
symptoms and treatment of rheumatoid arthritis in women are on average more severe than in men;
In women, finger joints, jaw and knee joints are more often affected, and changes in the central nervous system caused by RA are more likely to appear.

Diagnosis and treatment of rheumatoid arthritis

In the initial stages, rheumatoid arthritis is difficult to differentiate from other connective tissue diseases, so your doctor may prescribe a comprehensive examination. Diagnosis and treatment of rheumatoid arthritis necessarily include:

oral interview, history taking, incl. information about the disease in relatives;
initial physical examination and joint mobility testing;
X-ray examination;
biochemical analysis of blood and urine (test for ESR and CRP);
immunological blood test for rheumatic factor;
MRI (not always).

Timely diagnosis and treatment of rheumatoid arthritis helps to avoid joint deformation and involvement of internal organs in the inflammatory process

(lungs, heart, eyes)

X-ray examination is one of the ways to diagnose rheumatoid arthritis

Treatment of rheumatoid arthritis

Treatment for a diagnosis of rheumatoid arthritis is aimed at solving several problems at once:

Non-drug treatments for rheumatoid arthritis

Conservative therapy is preferable in the treatment of rheumatoid arthritis

. Treatment is carried out on an outpatient basis; placement of the patient in a hospital and compliance with bed rest is required only in exceptional cases.

In addition to physical therapy, clinical guidelines for the treatment of rheumatoid arthritis include the following:

avoid physical activity and stress;
dress warmly and do not overheat in the sun;
travel to other climate zones as little as possible;
quit smoking and alcohol;
go to bed before midnight;
use special insoles (if there are deformities);
engage in swimming and other supportive sports.

Patients need alternating rest and physical activity and normalization of their diet.

Physiotherapy in the treatment of rheumatoid arthritis

Physiotherapeutic procedures help relieve pain, strengthen the muscles and ligaments that support the joint, and increase the amplitude of voluntary movements. Most techniques are used during remission and are contraindicated in case of exacerbation

. However, magnetic therapy and drug electrophoresis are widely used to relieve inflammation in the acute phase.

electrophoresis with lidocaine;
cryotherapy;
ozone therapy, ozokerite;
amplipulse;
shock wave therapy
;
phonophoresis;
ultrasound therapy;
radon, iodine-bromine, sodium chloride and hydrogen sulfide baths, mud therapy, other balneological techniques;
mechanical and kinesiotherapy;
massage and manual therapy;
paraffin applications.

To treat pain in rheumatoid arthritis of the feet, sports or orthopedic shoes with a pronounced heel and metatarsal pads are also recommended. “Physiotherapy” is also possible at home - to relieve pain, you can apply ice compresses for 5-15 minutes.

Therapeutic exercise for rheumatoid arthritis

Gymnastics for rheumatoid arthritis prevents contracture and helps maintain range of motion in the joint. Its role in relieving inflammation is also important - the stronger the muscles, ligaments and tendons, the less the load on the structural elements of the joint and the easier the disease.

Clinical recommendations for the treatment of rheumatoid arthritis during exacerbation allow only passive flexion-extension movements

(when the patient performs movements in the joint manually, without loading the muscles), in some cases - swimming. Passive movements with severe pain and muscle tone are best performed in a warm bath.

To maintain muscle mass and finger motor skills, the following exercises for the hands are used:

Place your hands on the tabletop, palms down, and then raise your hands so that your palms are facing straight in front of you. Lower your brushes. Repeat 10-15 times.
Place your hands on the tabletop, palms down, and then turn them over, palms up. Perform 10 times.
Connect each finger in turn with the tips of the thumb - from the index to the little finger and back. Repeat 3-4 times.
Stretch your arms in front of you and rotate your hands, first clockwise and then counterclockwise. Repeat 6-8 times. Then clench your fingers into fists and rotate your fists.
Take an apple, a tennis ball or a silicone expander ball and clasp it with the fingers of one hand, squeezing lightly. Then do the exercise for the other hand. Repeat 5-6 times.

At the end of the session, rub your palms together.

It is recommended to perform this complex daily, and also do not forget about 5-minute warm-ups if your professional activity involves stress on your arms. If rheumatoid arthritis has affected other joints, you can perform standard sets of exercises recommended for arthritis of these joints.

Important: physical therapy exercises should not cause pain!

When performing exercises through force, without listening to acute or sharp pain,
you can only harm your joints!
Occupational therapy is also used as exercise for rheumatoid arthritis. In the remission stage, patients with damage to the interphalangeal and wrist joints are shown activities that develop fine motor skills of the fingers and strengthen the muscles of the wrist and hand - for example, modeling from dough, clay or plasticine, exercises with an expander, fingering rosaries. If the pathological process has affected the elbow and knee joints, you should think about purchasing specialized special expanders

Surgical treatment of rheumatoid arthritis

Surgical treatment of rheumatoid arthritis is indicated only when persistent contractures develop that interfere with the patient’s daily life, as well as when neoplasms (for example, Baker’s cyst) appear that require surgical intervention. The basis for surgery is severe deformation of the joints

which interferes with the patient’s daily self-care—in this case,
endoprosthetics
.
In case of severe inflammatory damage to the synovial cartilage, a partial synovectomy
(excision of the affected area) is performed.

There are different types of treatment for arthritis

Is it true that a physiotherapist and a rehabilitation specialist are synonymous?

The term physiotherapy is quite often used as a synonym for rehabilitation. However, this is not entirely correct. Physiotherapy is an important component of medical rehabilitation and a broader discipline. Rehabilitation, in turn, focuses on restoring physical fitness.

Rehabilitation literally means returning people with disabilities to an active life. It includes several sections:

1. Therapeutic (medical) rehabilitation . This includes treatment procedures aimed at returning a person to a full social life or creating conditions for his normal existence.

2. Vocational rehabilitation . Aimed at creating conditions for performing professional activities. It includes a number of activities to help people with disabilities get into work. Among them are assessment of psychophysical abilities, career guidance, selection of the optimal place of work and professional retraining.

3. Social rehabilitation . Aimed at the integration of people with disabilities into society. Includes activities aimed at developing skills of correct behavior in various life situations, eliminating social barriers - educational, architectural and economic.

Rehabilitation may also include a psychological aspect. Physiotherapy works exclusively with physiology. Although as a result of physiotherapeutic procedures, an improvement in the patient’s psychological state may be observed.

If rehabilitation is usually associated with the treatment of professional athletes, patients after injuries, paralysis, and congenital defects, then physical therapy is relevant for almost everyone. The techniques help both in the prevention and treatment of a wide range of diseases.

Pharmacotherapy of rheumatoid arthritis

Treatment of rheumatoid arthritis with medications

This is the main type of therapy. Basic therapy for RA is carried out for life and on an ongoing basis (taking immunosuppressants is stopped only during ARVI or other illnesses). However, with the help of it and the treatment of rheumatoid arthritis with new generation drugs, it is possible to achieve long-term remission, in which taking other medications is not required.

Basic antirheumatic therapy

Basic anti-inflammatory drugs

(DMARDs) -
immunomodulators
,
immunosuppressants
,
cytotoxics
- slow down the rate of disease progression. Their main function is to prevent irreversible damage to connective and bone tissue by their own immune cells. DMARDs improve the functional mobility of joints, improve the patient’s quality of life and help fight pain, which is sometimes so severe that it prevents patients from sleeping.

Chondroprotectors

Although chondroprotectors

- or
correctors of bone and cartilage tissue metabolism
- play an auxiliary role in the treatment of rheumatoid arthritis with drugs; they directly affect the structural integrity of the joint.
Chondroprotective drugs serve as sources of natural polymers - chondroitin
and
glucosamine
.
Without these substances it is impossible to imagine the functioning of joints, because they are part of synovial fluid (a natural lubricant and “nutrient solution” for cartilage), cartilage and other types of connective tissue. Chondroitin sulfate helps strengthen bones, stimulates the production of hyaluronic acid, and has an analgesic and anti-inflammatory effect. And most importantly, it suppresses the action of enzymes from dead cells
(they can destroy healthy ones!) and
improves cartilage regeneration
. A lack of glucosamine and chondroitin sulfate causes crunching in the joints, reduces the quality of cartilage tissue cells, makes them unstable and susceptible to destruction, and worsens the shock-absorbing characteristics of cartilage.

Since the natural consumption of these components with food (in the form of tendons and cartilage) has decreased, they can only be “acquired” through the use of special medications, for example, such as: Artracam

Nonsteroidal anti-inflammatory drugs

The treatment plan for rheumatoid arthritis includes the use of NSAIDs. These symptomatic treatments (in the form of tablets, capsules, ointments or creams) help relieve pain and swelling, and calm the inflammatory process in the acute phase of the disease. Since NSAIDs can only be taken in courses (no longer than 10-12 days), they are prescribed only for exacerbations of RA. The main purpose of NSAIDs is to treat pain in rheumatoid arthritis that cannot be treated with conventional analgesics.

. Their use is not recommended for peptic ulcers, gastritis, dyspepsia and other gastrointestinal diseases.

Glucocorticosteroids

Glucocorticoid drugs have a more powerful anti-inflammatory effect than NSAIDs, but are prescribed only if the latter are ineffective. This is due to more serious side effects and the inability to use steroid hormones frequently. They do not protect joints from destruction and are addictive, losing effectiveness over time.

New generation drugs for the treatment of rheumatoid arthritis

Genetically engineered biological drugs are considered the last word in the treatment of rheumatoid arthritis

-
selective immunosuppressants
.
Such drugs selectively suppress the activity of various cells of the immune system (mainly T and B cells). They are especially effective in combination with basic therapy drugs
.

The choice of a specific new generation drug for the treatment of rheumatoid arthritis is strictly dependent on the course of the disease, its stage and specificity, and is impossible without a medical examination and tests.

New generation drugs sharply reduce inflammatory activity, prevent the appearance of erosions on articular surfaces and reduce the area of existing lesions. Injections of new generation biological drugs for the treatment of rheumatoid arthritis are provided in cases where DMARDs are ineffective.

It is necessary to follow a diet during treatment for rheumatoid arthritis

What types of physical therapy are used for treatment

In addition to the ultrasound therapy and electrical myostimulation discussed above, there is a wide range of procedures. Among them:

Electrophoresis . This method is based on the simultaneous use of direct electric current and the introduction of drugs under the skin. With this method of drug delivery, the therapeutic effect is more intense.
Phonophoresis . The method is based on the introduction of drugs under the skin using ultrasound. The procedure is completely painless, while perfectly stimulating metabolic processes and ensuring high-quality transportation of medications.
Intravenous laser treatment (ILBT) . The procedure is a laser blood purification. Under the influence of a laser, hematopoiesis functions improve, metabolism accelerates, and cholesterol levels decrease.
Hirudotherapy . The method is based on the use of medicinal leeches. A course of hirudotherapy has an immunostimulating and rejuvenating effect and serves to prevent the formation of blood clots.
Exercise therapy . Therapeutic exercise has both a general strengthening effect and eliminates violations of certain functions. The exercise program is selected taking into account the patient’s medical history, age and condition.

Among the physiotherapeutic procedures, it is also worth noting magnetic therapy, halotherapy, cryotherapy, therapeutic baths, and mud therapy. Medical massage occupies a special place among physiotherapeutic methods.