A multidisciplinary approach can provide arthritis patients with the tools necessary to manage pain and limit flare-ups.
Arthritis is the most common cause of disability among adults in the United States, affecting approximately 52.5 million adults.1 There are many types of arthritis: osteoarthritis (OA), also called degenerative joint disease (DJD), is the most common form. Rheumatoid arthritis (RA) is one of the autoimmune diseases such as Lyme disease, lupus, ankylosing spondylitis, and polymyalgia rheumatica. All of these conditions involve pain and musculoskeletal dysfunction, and often have a deleterious effect on daily function and quality of life.
When patients receive a diagnosis of arthritis or autoimmune disease, they may hear alarming terms such as “severe degeneration,” “systemic inflammation,” and “deformity.” The term arthritis often conjures up images of being old and deteriorating. Others may have heard that it is “just something you have to live with.” In reality, none of these myths are true.
Patients with limited knowledge of the mechanism associated with pain typically find the pain threatening. This can result in lower pain thresholds and increased disability.2 Patient education in the context of a coordinated interdisciplinary approach is a powerful tool in helping patients shift their perspective and take control of their lives.
Interdisciplinary Treatment
Arthritis can negatively affect all domains of life. Therefore, an interdisciplinary approach is essential for success. The evidence strongly supports the use of interdisciplinary programs to help enhance function and feelings of self-efficacy, and manage pain. Khan et al demonstrated that early multidisciplinary treatment following joint replacement can significantly improve activity.3
The Pain and Functional Restoration Program (FRP) at Spaulding Rehabilitation Medford Center specializes in the treatment of chronic painful conditions, including arthritis and autoimmune diseases. The team associated with this program works in conjunction with primary care physicians and rheumatologists. A comprehensive evaluation is completed. Together, the patient and staff collaborate to set up an individualized treatment plan and meaningful goals. Treatment generally includes medical management, physical and occupational therapy, behavioral health, and nutrition.
Participants in FRP become armed with knowledge of their condition, the basic neuroscience of pain and the brain, a toolbox of pain management techniques, and strategies to facilitate safe, comfortable participation in daily tasks.
Exercise for managing pain
For patients affected by arthritis pain symptoms, a gentle t’ai chi or yoga program can be a great way to begin the day. The program can be adapted to any position, and movements may be modified based on comfortable range of motion (ROM). These gentle rhythmic movements help to relax muscles, improve balance, promote weight bearing, and enhance active range of motion.4 Therapists assist patients to incorporate movement patterns and principles into activities of daily living. For example, basic weight shifting used in t’ai chi can help distribute weight evenly while vacuuming and reduce strain on joints. Restorative yoga poses can be used to lower physiologic arousal, decrease muscle tension, and enhance energy level prior to activity.
Patients participate in a quota-based exercise program. They gain a feeling of success by beginning slowly to avoid pain flare-ups. The therapists help reduce fear by adapting exercise to enhance safety and comfort. The importance of including flexibility, strengthening, and cardiovascular exercise is emphasized. If land exercises are too challenging or painful, aqua therapy in a heated pool is a great alternative.5 Treatment recommendations favor low impact activities such as swimming or walking, 3 times a week for 30 minutes to 60 minutes.6 Weight-bearing exercises protect bone integrity. Core exercises are essential for posture, balance, and efficient movement patterns. Combining individualized exercise programs with self-management tools promotes adherence.7
Modalities—The Clinic and at Home
First and foremost, patients are taught to use modalities independently. This promotes autonomy and self-management over their pain. Hot/cold packs are more effective when they are used proactively rather than waiting until the pain is elevated. Therefore, patients are encouraged to utilize them two to three times daily. Trialing a combination of thermal modalities helps individuals identify which one is most efficacious. Ice massage has a significantly beneficial effect on ROM, function, and strength, while cold packs decrease edema in OA patients.8 Heat has been found to decrease pain in OA and RA.9,10 Paraffin has been found to be effective in the short-term for arthritic hands.10 Utilizing paraffin at home can increase comfort and fine motor control.
Contrast baths involve immersing the hand or foot in hot and cold water alternatively. This increases peripheral blood flow and provides an anti-inflammatory effect. It has been suggested that a longer duration in the second bath is necessary to produce sufficient fluctuation in blood flow. Example: hot 3-min, cold 1-min, hot 5-min, repeat three times.11
In addition to independent use, PTs and OTs utilize a variety of modalities. Evidence regarding their effectiveness is mixed.
The following conclusions are drawn from systematic reviews:
Ultrasound
• Ultrasound and laser therapy is beneficial for pain and function in osteoarthritis of the knee, with no adverse effects.12
• Pulsed ultrasound, low level laser therapy, and e-stim were found to be effective in reducing morning stiffness, decreasing the number of swollen/painful joints, and increasing hand strength in patients with RA.13,14
Electrical stimulation
• Interferential treatment shows significant improvements in pain and function with OA.15
• TENS helps decrease pain in RA16; however, the data for OA is inconclusive.10 TENS has the added benefit of being portable, allowing patients to utilize it during home and community tasks.
During FRP, patients participate in community outings and use modalities away from home. During our last outing, a patient with severe degeneration in her neck and OA was thrilled to find that using safe body mechanics, pacing, heat, and ice, she was able to bowl without aggravating her symptoms.
Topical gels and creams also have been used over the years for arthritis pain, and are easily available. Based on a 2013 Cochrane review, the quality and quantity of reviews are insufficient to determine effectiveness. Many patients do report benefit from them, however. In addition to over-the-counter options, physicians may recommend various compound creams that can be effective. It is important to emphasize with patients that they always consult with their physicians, prior to usage, to discuss medication interactions, possible adverse effects, and the most up-to-date information regarding dosage.17
Joint Protection: Splinting, Orthotics, and Adaptive Equipment, Oh My
Treatment of arthritis aims to lower disease activity, improve function, and slow or stop structural damage. Prefabricated or custom splints can help by providing support, improving collapsed joint biomechanics, and maintaining joint integrity. Splinting for RA is effective in correcting deformity and reducing inflammation and pain. Rannou et al has reported that long-term night splinting for thumb OA significantly reduces pain and improves function.18 Thumb splinting also may reduce the need for surgery.19 When considering splinting, it is necessary to be cognizant of the trade-off between the benefits of rest and the risks of immobility. For people with RA, fitting splints and orthoses can be challenging due to deformities. A systematic review focusing on RA showed that splints can decrease pain and increase grip strength. Unfortunately, they also can decrease hand movement.20 For the back and lower extremity, custom-made orthotics in extra depth shoes can increase comfort and tolerance for weight-bearing activities.21
In addition to splinting, patient education in joint protection principles is necessary. For example, patients can practice lifting bags and pots without straining lax PIP joints. The use of joint protection techniques has been found to decrease pain, morning stiffness, and doctor visits in patients with arthritis, as well as improving grip strength, self-efficacy, and function.22 Combining these principles with other cognitive behavioral strategies can help reduce fatigue and enhance participation in fulfilling activities.
Therapists work collaboratively with patients to help them find alternative ways to perform their meaningful tasks without increased pain or strain. Reachers and other adaptive equipment are commonly recommended to help achieve this. It is critical, however, to make sure the client is truly receptive to utilizing the tool. Enlarged writing grips, dycem, angled knives, and adaptive gardening tools have been found to be the most frequently used adaptive aids for those with arthritis.23 RM
Eve Kennedy-Spaien, OTR/L, is an occupational therapist and Certified Pain Management Specialist. She is the Clinical Supervisor of the Pain and Functional Restoration Program at Spaulding Rehabilitation Outpatient Center in Medford, Mass. Kennedy-Spaien has 25 years of experience working in inpatient and outpatient pain management programs. She has published articles, and presented at many venues including NIH and AOTA.
Dianne Kohlhofer, PT, is a physical therapist and advanced clinical specialist in the areas of chronic pain management and industrial rehabilitation. She has more than 30 years of physical therapy experience. Since coming to Spaulding Rehabilitation Hospital in Boston in 1990, Kohlhofer has helped develop and enhance first the inpatient program and now the outpatient pain management programs at Spaulding Outpatient Center in Medford. For more information, contact [email protected].
References:
1. Prevalence of Doctor-Diagnosed Arthritis and Arthritis-Attributable Activity Limitation, United States 2010-2012. MMWR. 2014:62(44):869-873. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6244a1.htm?s_cid=mm6244a1_w. Accessed March 28, 2014.
2. Jackson T, Pope L, Nagasaka T, Fritch A, Lezzi T, Chen H. The impact of threatening information about pain on coping and pain tolerance. Br J Health Psychol. 2005;10:441-51.
3. Khan F, Ng L, Gonzales S, Hale T, Turner-Stokes L. Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy. Cochrane Database Syst Rev. 2001;7.
4. Ullig T. Tai chi and yoga as complementary therapies in rheumatologic conditions. Best Pract Res Clin Rheumatol. 2012;26(3):387-398.
5. Ettinger WH, Burns R, Messier SP, et al. A randomized control trial comparing aerobic exercise and resistance exercises with a health education program in older adults. JAMA. 1997;277:25-31.
6. Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity and public health in older adults: recommendations from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39:1435-1445.
7. Jordan JL, Holden MA, Mason EE, Foster NE. Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2010;1.
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9. Valdes K, Marik T. A systematic review of conservative interventions for osteoarthritis of the hand. J Hand Ther. 2010;23:334-49.
10. Welch V, Brosseau L, Casimiro L, et al. Thermotherapy for treating rheumatoid arthritis. Cochrane Database Syst Rev. 2002.
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12. Rutjes AWS, Nuesch E, Sterchi R, et al. Transcutaneous electrostimulation for osteoarthritis of the knee. Cochrane Database Syst Rev. 2010;1.
13. Casimiro L, Brosseau L, Welch V, et al. Therapeutic ultrasound for the treatment of rheumatoid arthritis. Cochrane Database Syst Rev. 2002;3.
14. Brosseau L, Welch V, Wells, GA, et al. Low level laser therapy (classes I, II, and III) for treating rheumatoid arthritis. Cochrane Database Syst Rev. 2005;4.
15. Gundog M, Atamaz F, Kanyilmaz S, et al. Interferential current therapy in patients with knee osteoarthritis: comparison of the effectiveness of different amplitude-modulated frequencies. Am J Phys Med Rehabil. 2012;91(2):107-13.
16. Brosseau L, Yonge KA, Wells GA, et al. Transcutaneous electrical nerve stimulation for the treatment of rheumatoid arthritis in the hand (TENS). Cochrane Database Syst Rev. 2003.
17. Cameron M, Chrubasik S. Topical herbal therapies for treating osteoarthritis. Cochrane Database Syst Rev. 2013;6.
18. Rannou F, Dimet J, Boutron I, et al. Splint for base-of-thumb osteoarthritis: a randomized trial. Ann Intern Med. 2009;150:661-9.
19. Berggren M. Reduction in the need for operation after conservative treatment of osteoarthritis of the first carpometacarpal joint: a seven year prospective study. Scand J Plast Reconstr Hand Surg. 2001;35:415-417.
20. Steultjens EEMJ, Dekker JJ, Bouter LM, Schaardenburg DD, Kuyk MAMAH, Van den Ende ECHM. Occupational therapy for rheumatoid arthritis. Cochrane Database Syst Rev. 2009;4.
21. Egan M, Brosseau L, Farmer M, et al. Splints and orthosis for treating rheumatoid arthritis. Cochrane Database Syst Rev. 2010;7.
22. Freeman K, Hammond A, Lincoln NB. Use of cognitive behavioral arthritis education programs in newly diagnosed rheumatoid arthritis. Clin Rehabil. 2002;16:828-36.
23. Stamm TA, Machold KP, Smolen JS, et al. Joint protection and home hand based exercises improve hand function in patients with hand osteoarthritis: a randomized controlled trial. Arthritis Rheum. 2002;47(1):44-49.
