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Basic Treatment in Rheumatoid Arthritis
Basic Treatment in Rheumatoid Arthritis DONALD F. HILL, M.D., F.A.C.P.*
BASIC treatment in rheumatoid arthritis is the best comprehensive or general treatment with established value agreed upon today by the majority of those specializing in arthritis. Faced as we are with an unknown etiology and no specific cure, it became apparent that a sensible . practical program had to evolve out of the best we know today, to prevent disability, give the best chance for an early remission, and at the same time keep patients from grabbing at straws, wasting themselves and their money on one treatment or another of an unproved nature. During the past 25 years such a basic program has been developed independent of the many remedies and so-called cures.! The place of basic treatment is well summarized statistically in a recent bulletin on the conservative treatment of rheumatic disease, written by Duthie of Edinburgh. 2 In this report of long-term studies, conservative treatment resulted in definite improvement in all grades or classes of rheumatoid arthritis-better results in fact than can be claimed by any single mode of therapy. In addition to the basic program of approved and tested methods, we must, of course, be alert and willing to add to this any treatment that may hold promise without harm to the patient. It is time to stop saying, "Nothing can be done for arthritis," and, "You will have to learn to live with it." Basic treatment of rheumatoid arthritis is practical and easily applied without expensive equipment, but time and thoroughness in the details of the full program, with an interest in the patient, are absolutely necessary. Because rheumatoid arthritis is by far the most serious form of arthritis, progressive in crippling, striking all age groups, and producing great economic problems for the individual and family, it becomes the greatest challenge, taxing the skill and ingenuity of the physician. Because of its serious implications, with treatment often running into years, extreme caution must be taken in making the diagnosis and much care
* Member, Governing Staffs, St. Mary's Hospital and Tucson Medical Center. Tucson, Arizona. 393
Donald F. Hill
394
and thought must go into the planning of the program of treatment. Treatment in rheumatoid arthritis is not specific and cannot be casual. To be successful the approach must be from many angles with a comprehensive attack, and not by the use of first one remedy and then another. Correction of all possible faulty factors revealed in the history and on examination, combined with the other proved treatments to follow, is essential to achieve the highest rate of success. A detailed history that elicits all physical, physiological and psychological exciting or aggravating factors is essential. Among these factors stress, both physical and mental, leads the list. Common physical factors are: exposure, loss of weight, disturbed gastrointestinal and glandular function, poor nutrition, fatigue, and acute and chronic infection. Psychological factors often include domestic and family problems and business or financial worries. Physical examination must be thorough, recording all of the defects, degree of deformity, and so on. Laboratory study and x-ray examination, the nature of which is determined by the history and physical examination, should be sufficient to obtain a complete picture of the patient. Basic treatment of rheumatoid arthritis will be discussed under these separate headings: (1) patient orientation and understanding of the problem, (2) diet, (3) bowel management, (4) rest, (5) exercises, (6) occupational therapy, (7) medication, (8) removal of foci of infection, and (9) climate therapy. Consideration will be given in the sections on rest and exercises to the prevention and correction of early deformities. The severe deformities of longer duration require a more specialized type of treatment, hence will not be discussed in the "basic" program. Gold therapy is not indicated in all cases and therefore may not be considered basic treatment, but because of its established value and general use for over 25 years it has been included. THE PROGRAM
1. Patient Orientation and Understanding of the Problem The first and most important step in treatment is to obtain the cooperation of the patient after the examination by a detailed explanation of the problem, the nature of rheumatoid arthritis, course of the disease, and necessity for broad and complete attack over a period of time with an understanding that there are no miracles. The patient should be toldtiiat in spite of the fact there is no cure there is hope and much can be done to prevent crippling and to arrest the disealile. To accomplish th4;a; p:r;-ogram is outlined in detail and preferably in written form for the patient.. 2. Diet
Diet is mentioned early because it is usually the first problem. No single known diet causes or cures arthritis, but the diet must be a part of
Basic Treatment in Rheumatoid Arthritis
395
the prescription. The usual patient with rheumatoid arthritis is underweight and is advised to eat all that he can to gain weight, taking three to six feedings daily. High protein diets are thought to be advantageous and supplements are added as necessary. For the occasional obese patient, a protein reduction diet is in order. Additions of vitamins, hematinics, tonics, digestants, antispasmodics and the like should be considered. 3. Bowel Management
Constipation is often a problem, and for the sake of good nutrition every effort should be made to regulate the bowel with methods avoiding cathartics.
4. Rest
I
Rest, divided into general rest and local rest of involved parts, is more effective when taken for short periods at frequent intervals. Remaining too long in one position, day or night, leads to more stiffness and soreness. The patient must, of course, learn to recognize the optimal amount of rest, which depends upon his general condition as well as the activity of the disease. Bed rest is necessary for the acute phases and especially wit,!t inyolvement of the weight-bearing joints. With improvement, m6re exercise is prescribed as tolerance increases. Any fear of bed rest causing increased disability or stiffness can be easily dispelled by explaining that a course of exercises will be prescribed to keep good muscle tone, joint motion and function while in bed. The bed should be firm and of a non-sag type. Boards under a tight inner-spring mattress usually will serve best. Chairs should have sponge-rubber seats, be of proper height, and have arms and a good back. The proper height is easily obtained with wood blocks or platform. If it is correct the patient will not have to strain getting up and down from the chair. Arms facilitate getting up and down, and a good back gives support to the spine for proper posture. Elevation of the bed and toilet seat also helps relieve strain to knees. Local rest of involved joints is accomplished by a number of simple devices such as cock-up splints for wrists and hands and plaster shells to support legs, ankles and feet. Sandbags are used to keep the legs from rolling, and help to prevent torsion strain at the knee. Footboards are useful to prevent- footdrop. Generally speaking, rest should be taken in maximum comfortable extension and correct posture. Occasionally it is necessary to place a folded towel under the ankle to gain maximum extension of the knee, but at all times the leg should be fully supported from the hip down. By proper methods all of the knee contractions and footdrops are preventable. Figure 82 illustrates the wrong and correct rest positions. The same effect can be secured with any ordinary bed by using blocks under the bed and boards under the mattress.
396
Donald F. Hill
Knees. A contracted or flexed knee that cannot rest comfortably in extension on the bed must have additional support. This is best accomplished by the use of a plaster shell, open on top and made to fit the leg held in maximum comfortable extension. To make the shell, an assistant holds the leg in maximum extension and the foot up in proper position and the leg is wrapped with two or three layers of cotton batting and plaster is applied. The batting and plaster are started at the hips and carried down over the foot and up to a point 1 or 2 inches beyond the toes. A cast that is long enough keeps the bedclothes off the feet or
Fig. 82. A, Wrong rest position. E, Correct rest position.
toes. After the solid cast is made and while it is still soft, a strip 1 to 2 inches wide is easily cut out of the top and the cast is spread, thus giving high side-walls to prevent the leg from falling out. When dry it is lined with stockinet and adjusted so the patient can get in and out easily. The casts are pinned together or held upright in place by sandbags placed laterally on the bed, making it unnecessary to tie them to the legs. The patient is instructed to rest in them day and night for as many hours as he "can do so comfortably. Sometimes, it takes a while to become accustomed to resting on the back, with legs in casts. When fatigue or aching develops the legs should be removed and rested in flexion for a short period before they are returned to the casts. It should be mentioned also, that after resting the legs in the casts the first flexion on coming out is painful but of no significance. As flexors relax, small felt pads (approximately 1 to 2 inches wide, 6 inches long, and Y2 inch thick) are placed under the ankle above the heel to take up the slack. If there
Basic Treatment in Rheumatoid Arthritis
397
is a contraction of more than 20 to 30 degrees, it may be necessary to make a second cast after the patient has straightened his knees beyond the usefulness of the first cast (Fig. 83). In knee contractions of only a few months' duration (sometimes longer), complete extension to 180 degrees usually can be accomplished in a short time with these rest measures and corrective exercises to be described later. Where knee contractions have existed for many months or years, it is less likely that one will get full extension through this method alone, and to complete the straightening a manipulation or posterior capsulotomy will be necessary. However, before any manipulation or surgical pro-
Fig. 83. Plaster shells.
cedure on the knees, the patient should have the opportunity to gain all he can with the use of the rest casts and corrective exercises; he is measured monthly and only when he fails to show increase in extension and strength at the monthly check-up is he ready for manipulation or surgical operation. Most failures after manipulation or operation can be attributed to muscles too weak to carry on after the straightening is accomplished, the result of inadequate preparation with muscle training. Final correction of knee contractions by manipulation or capsulotomy is not, of course, part of the basic program, but is mentioned because the attending physician should recognize when this is necessary, plan for it, and select the consultant with experience in this type of corrective work in rheumatoid arthritis. The wrists and fingers are the next most common joints requiring protection. This is best accomplished by using a light weight cock-up splint extending from the forearm just below the elbow to a point just proximal
398
Donald F. Hill
to the interphalangeal joints and far enough to support the proximal phalanges (Fig. 84) . In molding the splint, the distal end should be pushed up under the proximal phalanges to prevent phalangeal subluxation. The lateral side should be made high enough to prevent or correct ulnar deviation of the fingers. A cock-up splint holding the wrist in extension permits a good grip, even if the wrist becomes ankylosed. The material most readily at hand and satisfactory is four or five layers of plaster lined with one or two thin layers of cotton batting. The cast when hard can be covered with stockinet which is readily removed and can be washed periodically. Synthetics, if available, make excellent lightweight, durable cock-up splints. They can often be easily snapped on
Fig. 84. Note correction of ulnar deviation, also cock-up and length of cast to permit good grip and use of fingers.
and off, whereas a 2 inch ace bandage or small straps are necessary to hold the plaster shells in place. These supports, if light weight and properly made, can be worn most of the time without too much trouble. The fingers are left sufficiently free to reach the thumb, allowing the patient many activities with his hands while wearing the casts. The cock-up splint is removed for bathing, exercises and the like. Shoulder and elbow contractions are best prevented by teaching methods of resting these parts in extension and abduction, along with corrective exercises. Hip contraction with limited motion presents one of the most difficult problems because once rheumatoid arthritis starts in a hip it usually progresses with more and more disability, often to ankylosis regardless of all efforts with conservative measures. Sometimes the progress . of
Basic Treatment in Rheumatoid Arthritis
399
disability in the hip can be slowed up and occasionally arrested by the of crutches, rest off of the feet, proper bed exercises and, if possible, popl exercises. Hip arthroplasties in the past have been mostly failures. With improved technique during the past few years, much better and worthwhile results are being obtained. Early cases of active arthritis in the hip with intractable pain can now be relieved and motion maintained on a useful weight-bearing joint. Here again adequate training in the basic routine of exercises leads to better results. Feet, when very sore with active arthritis, must have rest and be relieved of weight-bearing. The amount of rest off the feet or amount of weight-bearing allowed also varies considerably with the state of the disease. Proper shoes of adequate size, straight last and low broad heels are best. Because of the frequency of metatarsal involvement with tendency to hammer toe contraction, metatarsal pads or bars on the shoes are usually indicated. Longitudinal arch supports may also be necessary. In advanced metatarsal involvement with hammer toe contraction, metatarsal head resection properly done gives good results-a painless useful foot in a high percentage of cases. \l~e
5. Exercise Exercise, both general and specific corrective, of the right kind and amount, is the most important single item in maintaining function and preventing deformity. A full range of motion of the joint each day is the best guarantee of maintaining motion. Exercises build muscle support for joints, which helps to prevent strain of joints when they. are used. Exercise improves circulation more effectively than all the masSage that one can buy. These facts should be explained to the patient and to obtain the utmost in results he should understand his capacity for exercise or tolerance. All exercises, general and corrective, must be regular in amount daily, starting below the patient's capacity and systematically adding to the number and resistance every three or four days to tolerance. A safe increase is 10 per cent. By this method damage or lasting soreness from overexercise does not ensue. Rule of Tolerance. It is explained to the patient that pain duringexercise is of no consequence, provided it subsides shortly after the exercise period and there is no increased pain or soreness the following day when the same exercise is repeated. A careful list of instructions "from head to toe" along with actual demonstration or teaching will help guarantee continued use of exercises with the maximum benefit. The physician or physical therapist must master a system of exercises with the variations through passive, active, assistive and resistive, to instruct and guide the patient adequately. The type of exercise, amount, and frequency.:o0f check-ups will depend upon the stage of the diseaseJlllas well as the patient's intelligence and faithfulness in following instructions. ..
!-,
400
Donald F. Hill
A suggested basic list of exercises for a starting point follows. These may be modified to the patient's particular needs. Some muscle groups, of course, take more exercise while others take less depending on the patient's tolerance or local joint involvement. CORRECTIVE EXERCISES
1. Lying on back, legs straight: Take a deep breath, expanding the chest. Hold
the chest expanded until the count of 5; then relax. 2. Lying on back, legs straight: Contract the abdominal muscles, flattening the abdomen. Hold the abdomen flat while breathing naturally in the chest. 3. Hands: s. Make a fist. b. Stretch the fingers straight. c. Spread the fingers apart. d. Pull the thumb over to the tip of each finger making as round a circle as possible. 4. Hand resting on the bed, palm down, or on body if elbow will not straighten: Raise the hand for wrist motion. 5. Elbow bent at a right angle; upper arm resting on the bed: a. Bring the fingers to the tip of the shoulder. b. Keeping the palm turned up, push the hand down toward the bed, straightening the elbow. 6. Arms resting at sides; palms toward body: a. Raise the arm sideways away from the body, and back. b. Raise the arm, thumb leading, forward, upward, and as far back as it will go, and down the same way. c. Raise the arm forward, upward, the same way, and as far back as it will go; then swing the arm out to the side and around back to the side. 7. Lying on back, legs straight: Curl the toes over; keep the toes curled and tUrn the foot in and pull the foot up, stretching the heel-cord; hold the three motions until the count of 5. Then relax the whole foot. 8. Lying on back, legs straight: Contract the muscles on top of the thigh, pulling on the patella (kneecap) and flattening the knee. This exercise is increased up to 10 times a day, 10 times each if knees are particularly involved. 9. Lying on back, legs straight: Holding the leg straight, take the leg 15 inches to the side and back. Do not go far enough to tilt the pelvis. 10. Lying on back, knees bent, feet on the bed: Raise the knee toward the chest; straighten the knee by lifting the foot in the air, stretching up with the heel; let the knee bend and the foot return to the starting position. Alternate knees. 11. Lying on back, knees bent, feet on the bed: Pull in the abdomen; then squeeze the buttocks muscles as if to roll the seat up off the bed, tilting the pelvis and flattening the lower back hard on the bed. 12. Lying on back,legs straight: Flatten the neck by making a double chin, and at the same time stretch up through the top of the head as if to pull the ears away from the shoulders. 13. Lying on back, legs straight: Turn the cheek as far as possible toward the bed; stretch, keeping shoulders flat on the bed; come back to straight position and rest. 14. Lying on back, legs straight: Pinch the shoulder blades together.
6. Occupational Therapy Occupational therapy has been sadly neglected in the past and only recently is it receiving some of the attention that it deserves. Basically,
Basic Treatment in Rheumatoid Arthn:tis
401
people want to be independent and not a burden to someone else. That they may become burdens is a great fear that poisons many arthritics. Every effort should be made to encourage the patient to do for himself all he possibly can without harming the joints or making himself worse. The overambitious type must be protected and guarded from doing too much. Sometimes a change of occupation will keep the patient selfsupporting without distracting from his basic treatment or harming him. In the more severely disabled, special devices become more important to facilitate their handling special jobs. Workshops for the crippled or disabled have resulted in more employers finding these people valuable and useful in special jobs. 7. Medication
Hundreds of drugs are advertised but aspirin is still the drug of choice for controlling pain and soreness. Aspirin may be used freely to promote rest but not to kill pain and thus permit the patient to do more than is good for his joints. Narcotics are rarely needed and then for short periods only. Cortisone and ACTH have dramatic immediate effect but will rarely effect a permanent remission in long-term cases. Troublesome and at times serious side effects are further drawbacks. There is a place for this form of therapy but only with a full understanding of the problem and then only as part of a complete program. Transfusions, 300 to 500 cc. given at weekly intervals, have a dramatic effect on some patients in the acute or subacute stages, with fever and anemia, and in some although they are not anemic. Gold, after more than 25 years of use, remains an effective agent in arresting active rheumatoid arthritis. In the past not much was known about gold, and serious reactions, even deaths, occasionally resulted from too large a dosage and inadequate checking for toxic reactions. The availability of ACTH reduces further the risk of serious reaction. The fact that gold therapy does not appear advantageous in the statistical articles on conservative treatment does not mean that the drug is of no value. In many patients the improvement on a basic program will be sufficient and further measures, such as gold, are unnecessary. There are cases, however, in which active arthritis will continue and progressive crippling take place in spite of the best basic program. It is in this group, where basic treatment has failed to arrest the disease and permanent disability becomes imminent, that gold has its place. Holbrook, in a survey in 1948 covering 24 sources and 2143 patients, found that 60 per cent showed marked improvement or remission. a Gold is a toxic drug, but by giving doses not to exceed 25 to 50 mg. and always omitting the drug when there is any sign of toxicity, the serious reaction can be largely avoided. METHOD. Of the gold preparations, Solganol Band Myochrisine have
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Donald F. Hill
been the most widely used. The initial injection should be 5 mg. intramuscularly. The patient is warned about possible skin, mucous membrane or kidney reactions, and told to report any of these or anything unusual. The urine is checked each week for albumin, casts and red blood cells; the circulating blood cell and platelet count every third or fourth injection. The gold is given at weekly intervals in doses of 10 to 15 mg. up to 25 mg., occasionally 50 mg. With this dosage schedule and a careful check for reactions, we have not experienced a serious reaction in the past twenty years. Many patients will periodically show mild dermatitis or albuminuria, which disappears in a short time when the gold is omitted. The gold is omitted at any sign of beginning reaction and resumed cautiously when it subsides. Gold is excreted very slowly; consequently, the omission of the drug for a few weeks does not materially alter the ultimate effect. Not infrequently, when there is a genuine gold reaction, one also notices the first real evidence of remission, though the majority of patients who experience remission may never show a toxic reaction. The total dosage required varies a great deal, some patients experiencing remission after 200 to 300 mg. total dosage, whereas others may require over 1000 mg. As long as there is no toxic reaction the injections probably should be continued for three to six months before they are decided to be of no value. Once remission is begun or established, it is now standard practice to continue with gold at increased intervals of two, three or four weeks, to maintain the gold level in the individual. In so doing it is easier and quicker to stop an exacerbation by resuming the weekly injection than it would be by another "course" after the patient has been off gold for many months. Many patients are being controlled by injections at two to four week intervals without serious trouble and with fewer exacerbations than those receiving gold in courses. New drugs and treatments will be advocated from time to time and these must be tested, but let us be wary, for hundreds have come and gone when put to the test of long-term results in controlled series. While we are searching and testing new substances, let us make certain that the patient is on a good basic program to prevent disability. 8. Removal of Foci of Infection
Removal of foci of infection once had first priority in the management of rheumatoid arthritis. Actually, in only an occasional patient will the course of the disease be directly altered by this maneuver. In spite of this, it is recommended that foci of infection be removed as a measure to improve general health. Selection of the right time is important inasmuch as an acute flare-up or spread frequently occurs when the focus is removed while the patient is physically under par or without adequate protection as when a tooth or tonsil is removed. In general, it is best to wait until the patient is "built up" generally. If it is thought best to
Basic Treatment in Rheumatoid Arthritis
403
remove a focus of infection early, or for that matter at any time, it is good practice to protect the individual with antibiotics and possibly a transfusion or two. 9. CliInate
Climate is a very real factor to most patients with arthritis. On inquiry they will claim sensitivity to dampness, cold, or most particularly to weather change. They are weather sensitive and worse at certain times of year or under certain conditions. Unfortunately, we still have no yardstick or test to measure the degree of effect of climate or determine which patients will be affected. Humidity and cold are important to some, while the majority are probably more sensitive to barpmetric pressure changes. This probably explains why many will feel better in an area where there are minor barometric pressure changes. Only a few experience dramatic benefit by climate therapy though many will apparently receive some relief. SUMMARY
Basic treatment, including a description of the established and accepted measures in management of rheumatoid arthritis, has been pre!lented. A personal experience of over 25 years, as well as reported series of patients treated by general measures alone, indicates that basic treatment is essential in rheumatoid arthritis today. Every patient with rheumatoid arthritis should have the benefit of a sound basic program before using any of the more dramatic measures. REFERENCES 1. Holbrook, W. P. and Hill, D. F.: Manual of Rheumatic Diseases. Chicago, The
Year Book Publishers, 1952. 2. Duthie, J. J. R.: The Value of Long-Term Conservative Treatment in Rheumatoid Arthritis. Bulletin on Rheumatic Diseases, Arthritis and Rheumatism Foundation, New York, May, 1954. 3. Holbrook, W. P.: Recent Advances in the Management of Patients with Rheumatoid Arthritis. New York Med. 4: 7 (April 5) 1948. 2430 E. Sixth Street Tucson, Arizona
BASIC treatment in rheumatoid arthritis is the best comprehensive or general treatment with established value agreed upon today by the majority of those specializing in arthritis. Faced as we are with an unknown etiology and no specific cure, it became apparent that a sensible . practical program had to evolve out of the best we know today, to prevent disability, give the best chance for an early remission, and at the same time keep patients from grabbing at straws, wasting themselves and their money on one treatment or another of an unproved nature. During the past 25 years such a basic program has been developed independent of the many remedies and so-called cures.! The place of basic treatment is well summarized statistically in a recent bulletin on the conservative treatment of rheumatic disease, written by Duthie of Edinburgh. 2 In this report of long-term studies, conservative treatment resulted in definite improvement in all grades or classes of rheumatoid arthritis-better results in fact than can be claimed by any single mode of therapy. In addition to the basic program of approved and tested methods, we must, of course, be alert and willing to add to this any treatment that may hold promise without harm to the patient. It is time to stop saying, "Nothing can be done for arthritis," and, "You will have to learn to live with it." Basic treatment of rheumatoid arthritis is practical and easily applied without expensive equipment, but time and thoroughness in the details of the full program, with an interest in the patient, are absolutely necessary. Because rheumatoid arthritis is by far the most serious form of arthritis, progressive in crippling, striking all age groups, and producing great economic problems for the individual and family, it becomes the greatest challenge, taxing the skill and ingenuity of the physician. Because of its serious implications, with treatment often running into years, extreme caution must be taken in making the diagnosis and much care
* Member, Governing Staffs, St. Mary's Hospital and Tucson Medical Center. Tucson, Arizona. 393
Donald F. Hill
394
and thought must go into the planning of the program of treatment. Treatment in rheumatoid arthritis is not specific and cannot be casual. To be successful the approach must be from many angles with a comprehensive attack, and not by the use of first one remedy and then another. Correction of all possible faulty factors revealed in the history and on examination, combined with the other proved treatments to follow, is essential to achieve the highest rate of success. A detailed history that elicits all physical, physiological and psychological exciting or aggravating factors is essential. Among these factors stress, both physical and mental, leads the list. Common physical factors are: exposure, loss of weight, disturbed gastrointestinal and glandular function, poor nutrition, fatigue, and acute and chronic infection. Psychological factors often include domestic and family problems and business or financial worries. Physical examination must be thorough, recording all of the defects, degree of deformity, and so on. Laboratory study and x-ray examination, the nature of which is determined by the history and physical examination, should be sufficient to obtain a complete picture of the patient. Basic treatment of rheumatoid arthritis will be discussed under these separate headings: (1) patient orientation and understanding of the problem, (2) diet, (3) bowel management, (4) rest, (5) exercises, (6) occupational therapy, (7) medication, (8) removal of foci of infection, and (9) climate therapy. Consideration will be given in the sections on rest and exercises to the prevention and correction of early deformities. The severe deformities of longer duration require a more specialized type of treatment, hence will not be discussed in the "basic" program. Gold therapy is not indicated in all cases and therefore may not be considered basic treatment, but because of its established value and general use for over 25 years it has been included. THE PROGRAM
1. Patient Orientation and Understanding of the Problem The first and most important step in treatment is to obtain the cooperation of the patient after the examination by a detailed explanation of the problem, the nature of rheumatoid arthritis, course of the disease, and necessity for broad and complete attack over a period of time with an understanding that there are no miracles. The patient should be toldtiiat in spite of the fact there is no cure there is hope and much can be done to prevent crippling and to arrest the disealile. To accomplish th4;a; p:r;-ogram is outlined in detail and preferably in written form for the patient.. 2. Diet
Diet is mentioned early because it is usually the first problem. No single known diet causes or cures arthritis, but the diet must be a part of
Basic Treatment in Rheumatoid Arthritis
395
the prescription. The usual patient with rheumatoid arthritis is underweight and is advised to eat all that he can to gain weight, taking three to six feedings daily. High protein diets are thought to be advantageous and supplements are added as necessary. For the occasional obese patient, a protein reduction diet is in order. Additions of vitamins, hematinics, tonics, digestants, antispasmodics and the like should be considered. 3. Bowel Management
Constipation is often a problem, and for the sake of good nutrition every effort should be made to regulate the bowel with methods avoiding cathartics.
4. Rest
I
Rest, divided into general rest and local rest of involved parts, is more effective when taken for short periods at frequent intervals. Remaining too long in one position, day or night, leads to more stiffness and soreness. The patient must, of course, learn to recognize the optimal amount of rest, which depends upon his general condition as well as the activity of the disease. Bed rest is necessary for the acute phases and especially wit,!t inyolvement of the weight-bearing joints. With improvement, m6re exercise is prescribed as tolerance increases. Any fear of bed rest causing increased disability or stiffness can be easily dispelled by explaining that a course of exercises will be prescribed to keep good muscle tone, joint motion and function while in bed. The bed should be firm and of a non-sag type. Boards under a tight inner-spring mattress usually will serve best. Chairs should have sponge-rubber seats, be of proper height, and have arms and a good back. The proper height is easily obtained with wood blocks or platform. If it is correct the patient will not have to strain getting up and down from the chair. Arms facilitate getting up and down, and a good back gives support to the spine for proper posture. Elevation of the bed and toilet seat also helps relieve strain to knees. Local rest of involved joints is accomplished by a number of simple devices such as cock-up splints for wrists and hands and plaster shells to support legs, ankles and feet. Sandbags are used to keep the legs from rolling, and help to prevent torsion strain at the knee. Footboards are useful to prevent- footdrop. Generally speaking, rest should be taken in maximum comfortable extension and correct posture. Occasionally it is necessary to place a folded towel under the ankle to gain maximum extension of the knee, but at all times the leg should be fully supported from the hip down. By proper methods all of the knee contractions and footdrops are preventable. Figure 82 illustrates the wrong and correct rest positions. The same effect can be secured with any ordinary bed by using blocks under the bed and boards under the mattress.
396
Donald F. Hill
Knees. A contracted or flexed knee that cannot rest comfortably in extension on the bed must have additional support. This is best accomplished by the use of a plaster shell, open on top and made to fit the leg held in maximum comfortable extension. To make the shell, an assistant holds the leg in maximum extension and the foot up in proper position and the leg is wrapped with two or three layers of cotton batting and plaster is applied. The batting and plaster are started at the hips and carried down over the foot and up to a point 1 or 2 inches beyond the toes. A cast that is long enough keeps the bedclothes off the feet or
Fig. 82. A, Wrong rest position. E, Correct rest position.
toes. After the solid cast is made and while it is still soft, a strip 1 to 2 inches wide is easily cut out of the top and the cast is spread, thus giving high side-walls to prevent the leg from falling out. When dry it is lined with stockinet and adjusted so the patient can get in and out easily. The casts are pinned together or held upright in place by sandbags placed laterally on the bed, making it unnecessary to tie them to the legs. The patient is instructed to rest in them day and night for as many hours as he "can do so comfortably. Sometimes, it takes a while to become accustomed to resting on the back, with legs in casts. When fatigue or aching develops the legs should be removed and rested in flexion for a short period before they are returned to the casts. It should be mentioned also, that after resting the legs in the casts the first flexion on coming out is painful but of no significance. As flexors relax, small felt pads (approximately 1 to 2 inches wide, 6 inches long, and Y2 inch thick) are placed under the ankle above the heel to take up the slack. If there
Basic Treatment in Rheumatoid Arthritis
397
is a contraction of more than 20 to 30 degrees, it may be necessary to make a second cast after the patient has straightened his knees beyond the usefulness of the first cast (Fig. 83). In knee contractions of only a few months' duration (sometimes longer), complete extension to 180 degrees usually can be accomplished in a short time with these rest measures and corrective exercises to be described later. Where knee contractions have existed for many months or years, it is less likely that one will get full extension through this method alone, and to complete the straightening a manipulation or posterior capsulotomy will be necessary. However, before any manipulation or surgical pro-
Fig. 83. Plaster shells.
cedure on the knees, the patient should have the opportunity to gain all he can with the use of the rest casts and corrective exercises; he is measured monthly and only when he fails to show increase in extension and strength at the monthly check-up is he ready for manipulation or surgical operation. Most failures after manipulation or operation can be attributed to muscles too weak to carry on after the straightening is accomplished, the result of inadequate preparation with muscle training. Final correction of knee contractions by manipulation or capsulotomy is not, of course, part of the basic program, but is mentioned because the attending physician should recognize when this is necessary, plan for it, and select the consultant with experience in this type of corrective work in rheumatoid arthritis. The wrists and fingers are the next most common joints requiring protection. This is best accomplished by using a light weight cock-up splint extending from the forearm just below the elbow to a point just proximal
398
Donald F. Hill
to the interphalangeal joints and far enough to support the proximal phalanges (Fig. 84) . In molding the splint, the distal end should be pushed up under the proximal phalanges to prevent phalangeal subluxation. The lateral side should be made high enough to prevent or correct ulnar deviation of the fingers. A cock-up splint holding the wrist in extension permits a good grip, even if the wrist becomes ankylosed. The material most readily at hand and satisfactory is four or five layers of plaster lined with one or two thin layers of cotton batting. The cast when hard can be covered with stockinet which is readily removed and can be washed periodically. Synthetics, if available, make excellent lightweight, durable cock-up splints. They can often be easily snapped on
Fig. 84. Note correction of ulnar deviation, also cock-up and length of cast to permit good grip and use of fingers.
and off, whereas a 2 inch ace bandage or small straps are necessary to hold the plaster shells in place. These supports, if light weight and properly made, can be worn most of the time without too much trouble. The fingers are left sufficiently free to reach the thumb, allowing the patient many activities with his hands while wearing the casts. The cock-up splint is removed for bathing, exercises and the like. Shoulder and elbow contractions are best prevented by teaching methods of resting these parts in extension and abduction, along with corrective exercises. Hip contraction with limited motion presents one of the most difficult problems because once rheumatoid arthritis starts in a hip it usually progresses with more and more disability, often to ankylosis regardless of all efforts with conservative measures. Sometimes the progress . of
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disability in the hip can be slowed up and occasionally arrested by the of crutches, rest off of the feet, proper bed exercises and, if possible, popl exercises. Hip arthroplasties in the past have been mostly failures. With improved technique during the past few years, much better and worthwhile results are being obtained. Early cases of active arthritis in the hip with intractable pain can now be relieved and motion maintained on a useful weight-bearing joint. Here again adequate training in the basic routine of exercises leads to better results. Feet, when very sore with active arthritis, must have rest and be relieved of weight-bearing. The amount of rest off the feet or amount of weight-bearing allowed also varies considerably with the state of the disease. Proper shoes of adequate size, straight last and low broad heels are best. Because of the frequency of metatarsal involvement with tendency to hammer toe contraction, metatarsal pads or bars on the shoes are usually indicated. Longitudinal arch supports may also be necessary. In advanced metatarsal involvement with hammer toe contraction, metatarsal head resection properly done gives good results-a painless useful foot in a high percentage of cases. \l~e
5. Exercise Exercise, both general and specific corrective, of the right kind and amount, is the most important single item in maintaining function and preventing deformity. A full range of motion of the joint each day is the best guarantee of maintaining motion. Exercises build muscle support for joints, which helps to prevent strain of joints when they. are used. Exercise improves circulation more effectively than all the masSage that one can buy. These facts should be explained to the patient and to obtain the utmost in results he should understand his capacity for exercise or tolerance. All exercises, general and corrective, must be regular in amount daily, starting below the patient's capacity and systematically adding to the number and resistance every three or four days to tolerance. A safe increase is 10 per cent. By this method damage or lasting soreness from overexercise does not ensue. Rule of Tolerance. It is explained to the patient that pain duringexercise is of no consequence, provided it subsides shortly after the exercise period and there is no increased pain or soreness the following day when the same exercise is repeated. A careful list of instructions "from head to toe" along with actual demonstration or teaching will help guarantee continued use of exercises with the maximum benefit. The physician or physical therapist must master a system of exercises with the variations through passive, active, assistive and resistive, to instruct and guide the patient adequately. The type of exercise, amount, and frequency.:o0f check-ups will depend upon the stage of the diseaseJlllas well as the patient's intelligence and faithfulness in following instructions. ..
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A suggested basic list of exercises for a starting point follows. These may be modified to the patient's particular needs. Some muscle groups, of course, take more exercise while others take less depending on the patient's tolerance or local joint involvement. CORRECTIVE EXERCISES
1. Lying on back, legs straight: Take a deep breath, expanding the chest. Hold
the chest expanded until the count of 5; then relax. 2. Lying on back, legs straight: Contract the abdominal muscles, flattening the abdomen. Hold the abdomen flat while breathing naturally in the chest. 3. Hands: s. Make a fist. b. Stretch the fingers straight. c. Spread the fingers apart. d. Pull the thumb over to the tip of each finger making as round a circle as possible. 4. Hand resting on the bed, palm down, or on body if elbow will not straighten: Raise the hand for wrist motion. 5. Elbow bent at a right angle; upper arm resting on the bed: a. Bring the fingers to the tip of the shoulder. b. Keeping the palm turned up, push the hand down toward the bed, straightening the elbow. 6. Arms resting at sides; palms toward body: a. Raise the arm sideways away from the body, and back. b. Raise the arm, thumb leading, forward, upward, and as far back as it will go, and down the same way. c. Raise the arm forward, upward, the same way, and as far back as it will go; then swing the arm out to the side and around back to the side. 7. Lying on back, legs straight: Curl the toes over; keep the toes curled and tUrn the foot in and pull the foot up, stretching the heel-cord; hold the three motions until the count of 5. Then relax the whole foot. 8. Lying on back, legs straight: Contract the muscles on top of the thigh, pulling on the patella (kneecap) and flattening the knee. This exercise is increased up to 10 times a day, 10 times each if knees are particularly involved. 9. Lying on back, legs straight: Holding the leg straight, take the leg 15 inches to the side and back. Do not go far enough to tilt the pelvis. 10. Lying on back, knees bent, feet on the bed: Raise the knee toward the chest; straighten the knee by lifting the foot in the air, stretching up with the heel; let the knee bend and the foot return to the starting position. Alternate knees. 11. Lying on back, knees bent, feet on the bed: Pull in the abdomen; then squeeze the buttocks muscles as if to roll the seat up off the bed, tilting the pelvis and flattening the lower back hard on the bed. 12. Lying on back,legs straight: Flatten the neck by making a double chin, and at the same time stretch up through the top of the head as if to pull the ears away from the shoulders. 13. Lying on back, legs straight: Turn the cheek as far as possible toward the bed; stretch, keeping shoulders flat on the bed; come back to straight position and rest. 14. Lying on back, legs straight: Pinch the shoulder blades together.
6. Occupational Therapy Occupational therapy has been sadly neglected in the past and only recently is it receiving some of the attention that it deserves. Basically,
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people want to be independent and not a burden to someone else. That they may become burdens is a great fear that poisons many arthritics. Every effort should be made to encourage the patient to do for himself all he possibly can without harming the joints or making himself worse. The overambitious type must be protected and guarded from doing too much. Sometimes a change of occupation will keep the patient selfsupporting without distracting from his basic treatment or harming him. In the more severely disabled, special devices become more important to facilitate their handling special jobs. Workshops for the crippled or disabled have resulted in more employers finding these people valuable and useful in special jobs. 7. Medication
Hundreds of drugs are advertised but aspirin is still the drug of choice for controlling pain and soreness. Aspirin may be used freely to promote rest but not to kill pain and thus permit the patient to do more than is good for his joints. Narcotics are rarely needed and then for short periods only. Cortisone and ACTH have dramatic immediate effect but will rarely effect a permanent remission in long-term cases. Troublesome and at times serious side effects are further drawbacks. There is a place for this form of therapy but only with a full understanding of the problem and then only as part of a complete program. Transfusions, 300 to 500 cc. given at weekly intervals, have a dramatic effect on some patients in the acute or subacute stages, with fever and anemia, and in some although they are not anemic. Gold, after more than 25 years of use, remains an effective agent in arresting active rheumatoid arthritis. In the past not much was known about gold, and serious reactions, even deaths, occasionally resulted from too large a dosage and inadequate checking for toxic reactions. The availability of ACTH reduces further the risk of serious reaction. The fact that gold therapy does not appear advantageous in the statistical articles on conservative treatment does not mean that the drug is of no value. In many patients the improvement on a basic program will be sufficient and further measures, such as gold, are unnecessary. There are cases, however, in which active arthritis will continue and progressive crippling take place in spite of the best basic program. It is in this group, where basic treatment has failed to arrest the disease and permanent disability becomes imminent, that gold has its place. Holbrook, in a survey in 1948 covering 24 sources and 2143 patients, found that 60 per cent showed marked improvement or remission. a Gold is a toxic drug, but by giving doses not to exceed 25 to 50 mg. and always omitting the drug when there is any sign of toxicity, the serious reaction can be largely avoided. METHOD. Of the gold preparations, Solganol Band Myochrisine have
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been the most widely used. The initial injection should be 5 mg. intramuscularly. The patient is warned about possible skin, mucous membrane or kidney reactions, and told to report any of these or anything unusual. The urine is checked each week for albumin, casts and red blood cells; the circulating blood cell and platelet count every third or fourth injection. The gold is given at weekly intervals in doses of 10 to 15 mg. up to 25 mg., occasionally 50 mg. With this dosage schedule and a careful check for reactions, we have not experienced a serious reaction in the past twenty years. Many patients will periodically show mild dermatitis or albuminuria, which disappears in a short time when the gold is omitted. The gold is omitted at any sign of beginning reaction and resumed cautiously when it subsides. Gold is excreted very slowly; consequently, the omission of the drug for a few weeks does not materially alter the ultimate effect. Not infrequently, when there is a genuine gold reaction, one also notices the first real evidence of remission, though the majority of patients who experience remission may never show a toxic reaction. The total dosage required varies a great deal, some patients experiencing remission after 200 to 300 mg. total dosage, whereas others may require over 1000 mg. As long as there is no toxic reaction the injections probably should be continued for three to six months before they are decided to be of no value. Once remission is begun or established, it is now standard practice to continue with gold at increased intervals of two, three or four weeks, to maintain the gold level in the individual. In so doing it is easier and quicker to stop an exacerbation by resuming the weekly injection than it would be by another "course" after the patient has been off gold for many months. Many patients are being controlled by injections at two to four week intervals without serious trouble and with fewer exacerbations than those receiving gold in courses. New drugs and treatments will be advocated from time to time and these must be tested, but let us be wary, for hundreds have come and gone when put to the test of long-term results in controlled series. While we are searching and testing new substances, let us make certain that the patient is on a good basic program to prevent disability. 8. Removal of Foci of Infection
Removal of foci of infection once had first priority in the management of rheumatoid arthritis. Actually, in only an occasional patient will the course of the disease be directly altered by this maneuver. In spite of this, it is recommended that foci of infection be removed as a measure to improve general health. Selection of the right time is important inasmuch as an acute flare-up or spread frequently occurs when the focus is removed while the patient is physically under par or without adequate protection as when a tooth or tonsil is removed. In general, it is best to wait until the patient is "built up" generally. If it is thought best to
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remove a focus of infection early, or for that matter at any time, it is good practice to protect the individual with antibiotics and possibly a transfusion or two. 9. CliInate
Climate is a very real factor to most patients with arthritis. On inquiry they will claim sensitivity to dampness, cold, or most particularly to weather change. They are weather sensitive and worse at certain times of year or under certain conditions. Unfortunately, we still have no yardstick or test to measure the degree of effect of climate or determine which patients will be affected. Humidity and cold are important to some, while the majority are probably more sensitive to barpmetric pressure changes. This probably explains why many will feel better in an area where there are minor barometric pressure changes. Only a few experience dramatic benefit by climate therapy though many will apparently receive some relief. SUMMARY
Basic treatment, including a description of the established and accepted measures in management of rheumatoid arthritis, has been pre!lented. A personal experience of over 25 years, as well as reported series of patients treated by general measures alone, indicates that basic treatment is essential in rheumatoid arthritis today. Every patient with rheumatoid arthritis should have the benefit of a sound basic program before using any of the more dramatic measures. REFERENCES 1. Holbrook, W. P. and Hill, D. F.: Manual of Rheumatic Diseases. Chicago, The
Year Book Publishers, 1952. 2. Duthie, J. J. R.: The Value of Long-Term Conservative Treatment in Rheumatoid Arthritis. Bulletin on Rheumatic Diseases, Arthritis and Rheumatism Foundation, New York, May, 1954. 3. Holbrook, W. P.: Recent Advances in the Management of Patients with Rheumatoid Arthritis. New York Med. 4: 7 (April 5) 1948. 2430 E. Sixth Street Tucson, Arizona