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Physiotherapy methods of relieving pain
8 Physiotherapy methods of relieving pain CAROLEE MONCUR M A R L I N N. S H I E L D S
'Pain is that sensory experience evoked by stimuli that injure or threaten to destroy tissue, defined collectively by every man as that which hurts.' Mountcastle (1974)
The use of physical measures to treat 'that which hurts' in the patient with rheumatic disease has been described by historical notables such as Hippocrates, Aurelianus, and Pliny (Banwell, 1986). Their recommendations took the form of various methods of heat and cold modalities. Similar methods continue to be used by physiotherapists (physical therapists in the USA) for pain treatment in arthritis along with rest, exercise and massage. Currently, in the USA, physiotherapists have a fairly large armamentarium at their disposal for treatment of the patient with arthritis. This chapter describes what the physiotherapist might contribute to pain management in rheumatic disease. P H I L O S O P H Y OF CARE
It is our belief that the best approach to pain treatment is to foster interdisciplinary methods of care with the patient assuming the management of his disease. The patient, therapist and physician should communicate regularly regarding the patient's progress, goals and concerns. The interaction between the therapist and the patient is most successful when the relationship is one of shared, mutual respect, where neither party becomes dependent to the detriment of the other. An atmosphere where the patient may freely ask questions and be involved in the decisions regarding his care should be established early. The therapist must be truthful, without taking away the patient's hope, when explaining what the patient can expect from physiotherapy treatment. In general, it is expected that physiotherapy is most helpful in preventing or correcting deformity, increasing or maintaining mobility, relieving pain, encouraging relaxation techniques, and giving patient education to promote general improvement in patients' management of their disease (Freyburg, 1974; Swezey, 1978; Shields and Moncur, 1983; Erlich, 1986). In order to execute an appropriate and effective plan of care using physical treatment measures, the physician and physiotherapist should have onBaillidre's ClinicalRheumatology--Vol. 1, No. 1, April 1987
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going communication about the patient's status, performance of activities and progress toward goals. If a physician is not knowledgeable about what physiotherapy may offer the patient, most physiotherapists are willing to confer to develop a more complete plan of care. USE OF PHYSICAL MODALITIES A wide variety of physical modalities have been advocated for use in rheumatic diseases to decrease pain, relax musculature, and increase mobility in joints. Swezey (1978) noted that any discussion of the use of therapeutic modalities for arthritis management must not discount the potential impact of the placebo phenomenon. Much is not known about the action of these modalities; hence, the potential for quackery in arthritis. Any discussion regarding the efficacy of therapeutic modalities on pain relief of improvement of a functional task must be taken with full awareness of the placebo effect.
Therapeutic heat Various authors have recommended the use of heat in the treatment of arthritis. Heat may be applied in various forms including: hydrotherapy, moist hot packs, hot baths or showers, paraffin baths, infrared lamps, ultrasound and fluidotherapy (Hardin, 1971; Howell et al, 1971; Swezey, 1978; Moskowitz, 1979; Hunder and Bunch, 1982; Lehman, 1982; Downey, 1986). Lehman (1982) stated that heat is a valuable adjunct which is helpful in managing specific symptoms. In general, heat appears to produce the following desirable therapeutic effects: (1) it increases the extensibility of collagen tissue, (2) it decreases joint stiffness, (3) it produces pain relief, (4) it relieves muscle spasms, (5) it assists in resolution of infammatory infiltrates, oedema and exudates, and (6) it increases blood flow to the area heated. The use of superficial heat is indicated to achieve pain relief, relaxation and as a warming activity prior to exercise of muscles. Most superficial heat modalities require equipment that is readily available to the patient for home use; however, certain precautions must be given. The patient should be instructed that heat be closely monitored or avoided completely when one's sensation is decreased, there is inadequate blood supply to the area, the skin is fragile and when the general circulation is impaired. The above are particularly true if the use of paraffin baths is considered. Paraffin baths have been a traditional choice for superficial heating of hands. More recent data indicate that the use of paraffin is no more effective than any other forms of superficial heat. Furthermore, other forms of superficial heat are less dangerous for the patient to use at home. While there is a widespread use of superficial heat as a form of pain relief, there have been very few controlled studies that have described the actual changes in tissue temperature and the comfort achieved. The question of intra-articular temperature in the management of rheumatic disease is an important one to evaluate. According to Harris and McCroskery (1974),
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excessive heat therapy harms joints by increasing the rate of collagen breakdown by specific collagenases. Feibel and Fast (1976) subsequently postulated that thermal therapy that increases the intra-articular temperature of inflamed joints might enhance joint destruction. Responding to the question of whether heat therapy can accelerate the destructive process of rheumatoid arthritis by increasing intra-articular temperature, Mainardi et al (1979) conducted a prospective study on 17 patients with active symmetrical rheumatoid arthritis over a two-year period. One hand served as control receiving no treatment, while the experimental hand received heat therapy for 30 min twice daily for two years by use of an electrical mitten with a maximum temperature of 40~ The results reported by these investigators were: (1) the intra-articular and skin temperatures increased coincident with each other with the intra-articular temperature being lower than the skin temperature; (2) after the hand was removed from the mitten there was an initial phase of rapid decline in temperature followed by a steady, slow decline returning to baseline in approximately 40min; (3) there were no statistically significant differences between measurements on the first and last visits of joint tenderness, joint swelling and grip strength scores; and (4) there were no statistically significant differences between the control and experimental hand related to progression of proliferative lesions as determined on x-ray. Subjectively, the patients reported a positive experience with this form of therapy; however, most patients did not experience a decrease in morning stiffness or longterm benefit from the heat. Given these findings, one should not diminish the anecdotal reporting of patients who have received even short-term relief from using superficial heat to reduce the pain of their arthritis. Since the practice of administering superficial heat is most cost effective when done by the patient at home, the physician and therapist better serve the patient if an effective home plan of care is instituted. The use of deep-heating devices such as microwave, diathermy, or ultrasound are generally contraindicated for use directly on inflamed painful joints. It has been suggested that these devices tend to cause greater pain, probably because they raise deep tissue temperature (Hollander and Horvath, 1949), increase blood flow (Bonney et al, 1951; Harris and Millard, 1956), and increase intra-articular temperatures producing collagen fibrolysis by rheumatoid synovial collagenase (Harris and McCroskery, 1974). Diathermy may be used for muscle spasms in arthritis, but should be limited to areas where there are no inflamed joints. These types of device require the expertise of a physiotherapist and therefore cannot be used at home by the patient.
Therapeutic cold The value of ice in the treatment of the arthritides, low back pain, and bursitis has been discussed extensively by Lehman (1982). This author suggested that the application of ice is best used to relieve pain and decrease inflammation. Evaluation of the effectiveness of its use in rheumatoid
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arthritis is fraught with difficulties and few controlled studies have been completed. Current thinking regarding the use of cryotherapy is based on early reports in the literature and anecdotal histories. Table 1 summarizes the use of cold applications. Table 1.
Summary of the use of cold applications.
Indications for use
Reduce pain and the symptoms of inflammation Reduce muscle spasm and clonus Reduce swelling and bleeding from mechanical trauma Postsurgicallyfor knee, hip, or foot surgery, wrist fusions,shoulder surgery, tendon surgery, manipulations, bone grafts, etc. Acute or subacutely involved rheumatoid joints Low back pain Acute subacromial or subdeltoid bursitis Myofascialpain and myofibrositis Techniques for application
Immersion in ice water Cold compresses containing melting ice shavings Ice massage with a block of ice Evaporative eooling with ethyl chloride spray Frozen gel packs Cold slush packs made from denatured alcohol and water Bags of frozen vegetables such as peas Contrast baths (used alternatively with heat)
Moskowitz (1979) noted that patients with osteoarthritis who experience increased pain with the use of heat might benefit from the use of cold applications. Swezey (1978) summarized the issues surrounding the use of heat or cold in the treatment of rheumatic disease. H e suggested that decisions regarding their use are made on empirical observations that the relief of pain for acute inflammatory and traumatic conditions is best achieved by cold compresses. Conversely, subacute to chronic inflammation is best relieved by heat. The initial response to cold application may be a sensation of mild pain followed by numbness. Certainly the patient's response to the application is going to determine its continued use. If one is attempting to cool a joint, the cold packs should be placed directly over it; however, efforts should be made to avoid contact with major nerves iocated close to the pack as this may be excessively painful to the patient. The pack may be kept in place until numbness occurs but should be removed if the patient has increased pain. The amount of time required for cooling the part will vary according to the amount of subcutaneous fat present on the individual. In an obese person cooling may take 30 min while in a more lean person only 10 min will be required. Careful observation of the patient will reveal whether the patient is hypersensitive to cold. Severe adverse reaction to cold is rare; however, hypersensitivity may occur. The typical symptoms appearing as a result of the release of histamine are cold urticaria, erythema, itching, or sweating.
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Facial flushing, puffiness of the eyelids, laryngeal oedema and respiratory embarrassment may occur. In severe reactions, cold anaphylaxis and gastrointestinal symptoms may result. Patients may have the general symptoms of malaise, chills and fever. In those patients that produce cryoglobulins, chills, fever, and blindness may be observed. Tissue damage from frostbite is possible (Lehman, 1982). The above syndromes should be watched for in patients that have systemic lupus erythematosus, atypical pneumonia, leukocytoclastic vasculitis, rheumatoid disease, progressive systemic sclerosis, or multiple myeloma (Lehman, 1982). Treatment with cold is contraindicated in patients with Raynaud's phenomenon or other vascular pathology (Banwell, 1986). Most patients with arthritis can be instructed regarding the proper use of cold application at home. Such things as paper cups filled with water and frozen for use as an ice massage, bags of frozen vegetables for ice packs, or ice bags may be used.
Hydrotherapy The use of water as a therapeutic agent to soothe the body or its parts has been in use since ancient Egypt and Rome. While modern physiotherapy departments make use of whirlpools, Hubbard tanks, and therapeutic pools, it is important that those who suffer pain from rheumatic disease learn that appropriate use of their bathtub or shower can be a useful form of hydrotherapy. The ease with which the patient can use the buoyancy of the water to ~help move their joints is generally believed to be a positive outcome of hydrotherapy. Table 2 lists the guidelines for use of various hydrotherapy equipment. Certain precautions need to be observed when recommending that a patient immerse themselves in water with a temperature over 38~ Total immersion of the body in water over this temperature will raise the body core Table 2.
Guidelines for use of hydrotherapy.
Types of equipment Whirlpool baths Hubbard tanks LoBoy whirlpool baths Therapeutic pools
Types of exercises Passive motion that occurs as a result of buoyancy Assisted motion occurring through gentle contraction of the muscles and upward thrust of the water Controlled resistance exercise can occur by increasing the speed with which the patient moves the part or body while in the water
Guidelines for pool therapy Temperature should range from 35.5~ to 38~ Two to three times weekly in the pool is sufficient Acclimatize the patient to the pool slowly One hour is the maximum length a patient should stay in the pool once acclimatized
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temperature. Some patients will complain of nausea or dizziness. Other patients will report increased joint pain and stiffness the day after being in the pool. Patients with a compromised vascular system should not be immersed in a pool with a high water temperature as this increases cardiac work (Wickersham, 1984). There are a variety of benefits that may be achieved from activity in the therapeutic pool. These include relaxation, gentle exercises, temporary relief from pain and stiffness, and socialization with other patients. Joint traction
Joint traction for pain relief and increasing mobility in the knees and hips has been well established (Rodnan and Schumacher, 1983; Swezey, 1978). Whether cervical and lumbar spine traction used in the presence of disc disease is beneficial on a long-term basis remains to be established. Traction can be applied either mechanically or manually; however, caution should be used when the joint to receive traction has excessive laxity or deterioration. Cervical traction and/or mobilization as accomplished by a physiotherapist is contraindicated in a patient with cervical subluxation due to rheumatoid arthritis, in ankylosed cervical joints, or cervical instability. Mobilization or manipulation of other joints than the cervical spine has been used; however, documentation of the efficacy of these techniques remains anecdotal. Di Fabio (1986) reported that the high incidence of spontaneous recovery from low back syndromes clouded the results of mobilization research, particularly if proper controls were not used. Acupuncture and transcutaneous electrical nerve stimulation
The ancient Chinese practice of acupuncture has been investigated as a possible method of relief of pain in arthritis. Its efficacy for use in arthritis has been approached with scepticism by some and support for its use as a shortterm control of pain by others. Controlled studies have not demonstrated that acupuncture is more effective for pain relief than placebo (Man and Barager, 1974; Matsumoto et al, 1974; Gaw et al, 1975; Lee et al, 1975; Moore and Berk, 1976; Lewith and Machin, 1983; Melzack and Katz, 1984). Transcutaneous electrical nerve stimulation (TENS) has become a popular modality for relief of pain. This form of treatment has evolved from the gate theory of Melzack and Wall. It was thought by Bishop (1980) that TENS, acupuncture and stimulus-produced analgesia may share common effector mechanisms involving enkephalinergic neurons. TENS is known to block C-fibre mediated pain. The periosteum, synovium and joint capsule are supplied by these sensory fibres and have a low conduction velocity. Theoretically, TENS should be useful in the treatment of joint pain. Mannheimer and Carlsson (1979) determined that high-intensity TENS reduced joint pain in 18 of 19 patients with rheumatoid arthritis. TENS has been demonstrated to be effective in reducing pain in patients with chronic low back pain (Melzack et al, 1983), knee pain from osteoarthritis (Taylor et al, 1981), Sudeck's atrophy and reflex sympathetic dystrophy (Bodenheim and Bennett, 1983).
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Paxton (1980) reported that patients were satisfied with the effectiveness of TENS in reducing their pain and increasing their ability to engage in activity. However, Griffin and McClure (1981) reported that adverse reactions may occur in patients with rheumatoid arthritis who are receiving TENS. Those noted followed treatment of a patient to relieve pain in her wrists and hands. The patient developed numbness, distension of superficial veins in her arms, and severe pain subsequent to stimulation. Others have reported skin irritations around the electrodes, unpleasant sensations, cardiac arrhythmia and interference with cardiac pacemakers. Inadequate evaluation of treatment outcome is probably the greatest weakness of the reported clinical studies on TENS for chronic pain control. Most investigators use the patient's report of subjective improvement as the sole measure of treatment outcome. Subjective judgement of pain severity and location, as well as treatments and medications, are quite variable. This coupled with the psychological aspects of chronic pain make objective evaluation of the person with chronic pain difficult. The use of parameters such as range of joint motion, strength, muscle girth, and ability to complete functional activities would increase the objectivity of the assessment of TENS (Gersh and Wolf, 1985). The advantage of this modality is that it can be used by the patient at home after appropriate instruction has been given by the physiotherapist. It is most useful in localized areas of pain such as the neck, shoulders, knee or low back. PRINCIPLES OF REST AND JOINT PROTECTION There appears to be general agreement that rest is a significant component in the conservative management of rheumatic disease, particularly rheumatoid and juvenile rheumatoid arthritis (Gault and Spyker, 1969; Mills, 1971; Smith and Polley, 1978; Hunder and Bunch, 1982; Melvin, 1982; Rothschild, 1982; Downey, 1986). Partridge and Duthie (1963) and Gault and Spyker (1969) were early advocates of incorporating principles of rest in the treatment of rheumatoid arthritis and related arthritides. Both groups used splinting to immobilize acutely painful joints for short periods of time. While excessive rest is not advocated, there needs to be a judicious balance between rest and activity in rheumatoid arthritis. Eight to 10 h of sleep at night coupled with one to two 90min rest periods during the day are commonly recommended. These rest periods are advocated even in the absence of active synovitis. Some suggest short periods of bedrest during the day will improve endurance and work tolerance while decreasing pain. Patients also need to be encouraged to pace their activities, limiting their exertion when they find themselves increasingly fatigued. A satisfactory programme for treatment of osteoarthritis of weightbearing joints is weight loss, if applicable, and moderate exercises for short periods throughout the day. Excessive activity of painful joints should be discouraged and individuals whose occupations require prolonged overactivity of the joint (such as standing, sitting or lifting) should modify their schedules.
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Joint protection and energy conservation should be emphasized to the patient with painful inflamed joints. Joints which are painful or weak because of arthritis or overly fatigued are more prone to injury from ordinary stress. A patient should be taught about alternative means of performing their work to minimize joint stress. Large joints with large muscles should be used for protection in preference to small joints. The use of assistive devices, splints, braces, orthoses, casts, and ambulatory aids will help to reduce the stresses placed on painful joints. The above devices may be supplied by an orthotist, physiotherapist, or occupational therapist. Considerable attention has been given recently to the use of various forms of relaxation techniques to assist the patient with arthritis in the management of stress, tension and pain. While it is not a panacea, teaching the patient some methods of relaxation may be a useful tool that is palliative in nature. Two of the more common methods used are Jacobson's Progressive Relaxation and the Relaxation Response. These can be doneat any time of the day at the patient's convenience (Lorig and Fries, 1983). The patient should be told that no scientific claim is made for these techniques and they should not be substituted for a sound medical programme. AND WHAT ABOUT EXERCISE FOR PAIN?
The question is often asked by patients when they are taught an exercise programme to maintain range of motion or strengthen their muscles: 'If I do these exercises, will the pain go away?' The patient and the therapist are faced with a double-edged sword. When the arthritis pain has reduced a patient's activity level, decreased strength of muscles occurs from disuse. The effort to return to the former functional level may itself be painful. Pain can immobilize the patient quickly leading to additional loss of function, loss of alertness, and depression. Often, after careful evaluation of the patient's status, giving the person a well-thought-out exercise programme with joint protection in mind, can givethe patient something to do besides concentrate on their pain. In addition, systematic exercise can give the patient hope and goals for which to strive. We try to help the patient understand that exercise judiciously accomplished may not relieve their pain but will help to keep them mobile and functional. It has been our experience that some patients become rather astute in being able to differentiate between the deep bone pain experienced in the joint, and pain from other sources such as exerciseinduced pain stiffness. Patients should be instructed that when they begin exercising they may experience sore muscles. When joints are inflamed in septic or rheumatoid arthritis, the patient should be encouraged to perform range of motion exercise only once or twice and then let the joint rest. The patient may use the 'after-pain' rule to determine when they have done too much. Pain that stays for longer than 2 h after exercise indicates overuse of the joint. No exercise should cause acute pain. This does not mean that the patient should stop exercising, but rather adjust to a comfort zone. Management of pain in the lower back continues to be an enigmatic
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problem. Prospective investigations on firefighters demonstrated that those who were more physically fit experienced fewer episodes with back injuries than those who were less fit (Cady et al, 1979). The physiotherapy programme for back pain may include the use of ice packs and a modality such as TENS to treat the acute pain and muscle spasm. Individually designed exercise programmes require combinations of endurance, strength, flexibility, and coordination activities to increase physical fitness. Back School can give the patient proper education and understanding of their disease. Ergonomics, in other words the proper and efficient use of the spine in work and recreation, should be stressed. The goal is to return the patient to work and a normal life as quickly as possible without creating excessive dependency on the medical care system. Endurance exercises may be brisk walking, cycling, jogging or swimming. It has been our experience that patients with other forms of arthritis, without significant lower extremity involvement, may also benefit from an aerobic exercise programme. For patients with more limiting disease in weight-bearing joints, exercise may be done in a warm pool. The buoyancy of the water may reduce the stresses of weight bearing while allowing aerobic activity. One important benefit of an aerobic exercise programme is the increased endurance the patient achieves if he is systematic with his programme. Fordyce (1978) suggested that when pain is 'puzzling in its distribution, onset, or time pattern, it is possible that the real trouble is depression'. He recommends that the patient be placed on a balanced programme of medication, exercises and increased activity according to the patient's tolerance. The physician and physiotherapist can help to reinforce the patient's cooperation by inquiring about the progress the patient is making with both the medication and exercise programme. SUMMARY
Management of pain in the person with arthritis requires interdisciplinary team work with the patient being the final manager. It is important that any health care provider perceive the patient as a person who happens to have arthritis--not as 'an "arthritic".' Defining a person by one's disease process is dehumanizing. The patient has the same aspirations as anyone who is ablebodied--to be free from disease. While the patient may know that a cure is not imminent, there is still the hope for one. Therefore, as the patient comes for physiotherapy, there may be a hidden wish that the moist packs, TENS, or therapeutic pool will be curative. It is important that the patient understand that no equipment in the physiotherapy department has curative powers. This will help avoid unnecessary dependency behaviours on the part of the patient. Careful instruction and supervision of the patient by the physiotherapist, in concert with reinforcement from the physician, can prepare the patient to apply heat, cold, or a variety of treatments at home. Although the patient is given the responsibility for this part of his care, periodic follow-up and reassessment should be completed to determine
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c h a n g e s in his p h y s i o l o g i c a l , p s y c h o l o g i c a l , a n d f u n c t i o n a l status. P h y s i o therapists who have a clear understanding of the physical treatment of pain a s s o c i a t e d w i t h t h e r h e u m a t i c d i s e a s e s c a n b e a v a l u a b l e asset t o m e d i c a l care. REFERENCES
Banwell BF (1986) Physical therapy in arthritis management. In Erlich GE (ed.) Rehabilitation Management of Rheumatic Conditions, pp 264-284. Baltimore: Williams & Wilkins. Bishop B (1980) Pain: its philosophy and rationale for management: Part III. Physical Therapy 60: 24-37. Bodenheim R & Bennett JH (1983) Reversal of a Sudeck's atrophy by the adjunctive use of transcutaneous electrical nerve stimulation: a case report. Physical Therapy 63: 1287-1288. Bonney GLW, Hughes RA & Janus O (1951) Blood flow through the normal human knee segment. Clinical Science 11: 167. Cady LD, Bischoff DP, O'Connell ER et al (1979) Strength and fitness and subsequent back injuries in firefighters. Journal of Occupational Medicine 21: 269-272. Di Fabio RP (1986) Clinical assessment of manipulation and mobilization of the lumbar spine: a critical review of the literature. Physical Therapy 66: 51-53. Downey JA (1986) The physiatrist in rheumatoid arthritis management. In Erlich GE (ed.) Rehabilitation Management of Rheumatic Conditions, pp 24-30. Baltimore: Williams & Wilkins. Edich GE (1986) Preface. In Erlich GE (ed.) Rehabilitation Management of Rheumatic Conditions, pp ix-xiv. Baltimore: Williams & Wilkins. Feibel A & Fast A (1976) Deep heating of joints: a consideration. Archives of Physical Medicine and Rehabilitation 57: 513. Fordyce WE (1978) Evaluating and managing chronic pain. Geriatrics 33: 59-62. Freyburg R H (1974) The roles of patient and physician in the management of arthritis. In Hollander JL (ed.) The Arthritis Handbook, pp 65-81. Pennsylvania: Merck, Sharp & Dohme. Gault S & Spyker JM (1969) Beneficial effect of immobilization of joints in rheumatoid and related arthritides: a splint study using sequential analysis. Arthritis and Rheumatism 12: 34-44. Gaw AC, Chang LW & Shaw LC (1975) Efficacy of acupuncture on osteoarthritic pain: a controlled double blind study. New England Journal of Medicine 293: 375-378. Gersh MR & Wolf SL (1985) Applications of transcutaneous electric nerve stimulation in the management of patients with pain. Physical Therapy 65: 314-336. Griffin JW & McClure M (1981) Adverse reactions to transcutaneous electrical nerve stimulation in a patient with rheumatoid arthritis. Physical Therapy 61: 354-355. Hardin JG (1971) Approaches to the patient with degenerative joint disease. Modern Treatment g: 840-850. Harris ED & McCroskery PA (1974) The influence of temperature and fibril stability on degradation of cartilage collagen by rheumatoid synovial collagenase. New England Journal of Medicine 260: 1-6. Harris ED & Millard JG (1956) Clearance of radioactive sodium from the knee. ClinicalScience 15: 9.
Hollander JL & Horvath SM (1949) The influence of physical therapy procedures on the intraarticular temperature of normal and arthritis subjects. American Journal of Medical Science 218: 543-548. Howell DS, Altman RD, Brown HE et al (1971) A comprehensive regimen for osteoarthrit~s. Medical Clinics of North America 55: 457-469. Hunder GC & Bunch TW (1982) Treatment of rheumatoid arthritis. Bulletin on the Rheumatic Diseases 32: 1-6. Lee PK, Andersen TW, Modell JH et al (1975) Treatment of chronic pain with acupuncture. Journal of the American Medical Association 232:1133-1135. Lehman JF (1982) Therapeutic Hot and Cold. Baltimore: Williams & Wilkins. 641 pp.
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Lewith GT & Machin D (1983) On the evaluation of the clinical effects of acupuncture. Pain 16: 111-127. Lorig K & Fries JF (1983) The Arthritis Helpbook. Menlo Park: Addison-Wesley. 190 pp. Mainardi CL, Walter JM, Speigal PK et al (1979) Rheumatoid arthritis: failure of daily heat therapy to affect its progression. Archives of Physical Medicine and Rehabilitation 60: 390-393. Man SL & Barager FD (1974) Preliminary clinical study of acupuncture in rheumatoid arthritis. Journal of Rheumatology 1: 126-129. Mannheimer C & Carlsson CA (1979) The analgesic effect of transcutaneous nerve stimulation (TENS) in patients with rheumatoid arthritis: a comparative study of different pulse patterns. Pain 6: 329-334. Matsumoto T, Levy B & Ambruso V (1974) Clinical evaluation of acupuncture. American Surgeon 40: 400-405. Melvin JL (1982) Joint protection and energy conservation. In Melvin JL (ed.) Rheumatic Disease: Occupational Therapy and Rehabilitation, pp 351-371. Philadelphia: FA Davis. Melzack R & Katz J (1984) Articulotherapy fails to relieve chronic pain: a controlled crossover study. Journal of the American Medical Association 251: 1041-1043. Melzack R, Vetere P & Finch L (1983) Transcutaneous electrical nerve stimulation for low back pain: a comparison of TENS and massage for pain and range of motion. Physical Therapy 63: 489--493. Mills JA (1971) The conservative management of rheumatoid arthritis. Modern Treatment 8: 753-760. Moore ME & Berk SN (1976) Acupuncture for chronic shoulder pain: An experimental study with attention to the role of placebo and hypnotic susceptibility. Annals of Internal Medicine 84" 381. Moskowitz RW (1979) Management of osteoarthritis. Hospital Practice14: 75-87. Mountcastle VB (1974) Pain and temperature sensibilities. In Mountcastle VB (ed.) Medical Physiology, pp 348-381. St Louis: CV Mosby. Partridge MJ & Duthie J JR (1963) Controlled trials of the effect of complete immobilization of the joints in rheumatoid arthritis. Annals of the Rheumatic Diseases 22: 91. Paxton SL (1980) Clinical uses of TENS. Physical Therapy 60: 38--44. Rodnan GP & Schumacher HR (1983) Rehabilitative and restorative therapy of patients with rheumatic disease. Primer On Rheumatic Disease, pp 202-204. Atlanta: National Arthritis Foundation. Rothschild BM (1983) Rheumatology: A Primary Care Approach. New York: Yorke Medical Books. Shields MN & Moncur C (1983) Arthritis: independence vs dependence. ClinicalManagement in Physical Therapy 3: 34-36. Smith RD & Polley HF (1978) Rest therapy for rheumatoid arthritis. Mayo Clinic Proceedings 53: 141-145. Swezey RL (1978) Therapeutic modalities for pain relief. In Swezey RL (ed.) Arthritis: Rational Therapy and Rehabilitation, pp 133-148. Philadelphia: WB Saunders. Taylor P, Hallett M & Flaherty L (1981) Treatment of osteoarthritis of the knee with transcutaneous electrical nerve stimulation in a patient with rheumatoid arthritis. Pain 11: 233-240. Wickersham BA (1984) Hydrotherapy. In Riggs GK & Gall EP (eds) Rheumatic Diseases: Rehabilitation and Management, pp 131-149. Boston: Butterworths.
'Pain is that sensory experience evoked by stimuli that injure or threaten to destroy tissue, defined collectively by every man as that which hurts.' Mountcastle (1974)
The use of physical measures to treat 'that which hurts' in the patient with rheumatic disease has been described by historical notables such as Hippocrates, Aurelianus, and Pliny (Banwell, 1986). Their recommendations took the form of various methods of heat and cold modalities. Similar methods continue to be used by physiotherapists (physical therapists in the USA) for pain treatment in arthritis along with rest, exercise and massage. Currently, in the USA, physiotherapists have a fairly large armamentarium at their disposal for treatment of the patient with arthritis. This chapter describes what the physiotherapist might contribute to pain management in rheumatic disease. P H I L O S O P H Y OF CARE
It is our belief that the best approach to pain treatment is to foster interdisciplinary methods of care with the patient assuming the management of his disease. The patient, therapist and physician should communicate regularly regarding the patient's progress, goals and concerns. The interaction between the therapist and the patient is most successful when the relationship is one of shared, mutual respect, where neither party becomes dependent to the detriment of the other. An atmosphere where the patient may freely ask questions and be involved in the decisions regarding his care should be established early. The therapist must be truthful, without taking away the patient's hope, when explaining what the patient can expect from physiotherapy treatment. In general, it is expected that physiotherapy is most helpful in preventing or correcting deformity, increasing or maintaining mobility, relieving pain, encouraging relaxation techniques, and giving patient education to promote general improvement in patients' management of their disease (Freyburg, 1974; Swezey, 1978; Shields and Moncur, 1983; Erlich, 1986). In order to execute an appropriate and effective plan of care using physical treatment measures, the physician and physiotherapist should have onBaillidre's ClinicalRheumatology--Vol. 1, No. 1, April 1987
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going communication about the patient's status, performance of activities and progress toward goals. If a physician is not knowledgeable about what physiotherapy may offer the patient, most physiotherapists are willing to confer to develop a more complete plan of care. USE OF PHYSICAL MODALITIES A wide variety of physical modalities have been advocated for use in rheumatic diseases to decrease pain, relax musculature, and increase mobility in joints. Swezey (1978) noted that any discussion of the use of therapeutic modalities for arthritis management must not discount the potential impact of the placebo phenomenon. Much is not known about the action of these modalities; hence, the potential for quackery in arthritis. Any discussion regarding the efficacy of therapeutic modalities on pain relief of improvement of a functional task must be taken with full awareness of the placebo effect.
Therapeutic heat Various authors have recommended the use of heat in the treatment of arthritis. Heat may be applied in various forms including: hydrotherapy, moist hot packs, hot baths or showers, paraffin baths, infrared lamps, ultrasound and fluidotherapy (Hardin, 1971; Howell et al, 1971; Swezey, 1978; Moskowitz, 1979; Hunder and Bunch, 1982; Lehman, 1982; Downey, 1986). Lehman (1982) stated that heat is a valuable adjunct which is helpful in managing specific symptoms. In general, heat appears to produce the following desirable therapeutic effects: (1) it increases the extensibility of collagen tissue, (2) it decreases joint stiffness, (3) it produces pain relief, (4) it relieves muscle spasms, (5) it assists in resolution of infammatory infiltrates, oedema and exudates, and (6) it increases blood flow to the area heated. The use of superficial heat is indicated to achieve pain relief, relaxation and as a warming activity prior to exercise of muscles. Most superficial heat modalities require equipment that is readily available to the patient for home use; however, certain precautions must be given. The patient should be instructed that heat be closely monitored or avoided completely when one's sensation is decreased, there is inadequate blood supply to the area, the skin is fragile and when the general circulation is impaired. The above are particularly true if the use of paraffin baths is considered. Paraffin baths have been a traditional choice for superficial heating of hands. More recent data indicate that the use of paraffin is no more effective than any other forms of superficial heat. Furthermore, other forms of superficial heat are less dangerous for the patient to use at home. While there is a widespread use of superficial heat as a form of pain relief, there have been very few controlled studies that have described the actual changes in tissue temperature and the comfort achieved. The question of intra-articular temperature in the management of rheumatic disease is an important one to evaluate. According to Harris and McCroskery (1974),
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excessive heat therapy harms joints by increasing the rate of collagen breakdown by specific collagenases. Feibel and Fast (1976) subsequently postulated that thermal therapy that increases the intra-articular temperature of inflamed joints might enhance joint destruction. Responding to the question of whether heat therapy can accelerate the destructive process of rheumatoid arthritis by increasing intra-articular temperature, Mainardi et al (1979) conducted a prospective study on 17 patients with active symmetrical rheumatoid arthritis over a two-year period. One hand served as control receiving no treatment, while the experimental hand received heat therapy for 30 min twice daily for two years by use of an electrical mitten with a maximum temperature of 40~ The results reported by these investigators were: (1) the intra-articular and skin temperatures increased coincident with each other with the intra-articular temperature being lower than the skin temperature; (2) after the hand was removed from the mitten there was an initial phase of rapid decline in temperature followed by a steady, slow decline returning to baseline in approximately 40min; (3) there were no statistically significant differences between measurements on the first and last visits of joint tenderness, joint swelling and grip strength scores; and (4) there were no statistically significant differences between the control and experimental hand related to progression of proliferative lesions as determined on x-ray. Subjectively, the patients reported a positive experience with this form of therapy; however, most patients did not experience a decrease in morning stiffness or longterm benefit from the heat. Given these findings, one should not diminish the anecdotal reporting of patients who have received even short-term relief from using superficial heat to reduce the pain of their arthritis. Since the practice of administering superficial heat is most cost effective when done by the patient at home, the physician and therapist better serve the patient if an effective home plan of care is instituted. The use of deep-heating devices such as microwave, diathermy, or ultrasound are generally contraindicated for use directly on inflamed painful joints. It has been suggested that these devices tend to cause greater pain, probably because they raise deep tissue temperature (Hollander and Horvath, 1949), increase blood flow (Bonney et al, 1951; Harris and Millard, 1956), and increase intra-articular temperatures producing collagen fibrolysis by rheumatoid synovial collagenase (Harris and McCroskery, 1974). Diathermy may be used for muscle spasms in arthritis, but should be limited to areas where there are no inflamed joints. These types of device require the expertise of a physiotherapist and therefore cannot be used at home by the patient.
Therapeutic cold The value of ice in the treatment of the arthritides, low back pain, and bursitis has been discussed extensively by Lehman (1982). This author suggested that the application of ice is best used to relieve pain and decrease inflammation. Evaluation of the effectiveness of its use in rheumatoid
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arthritis is fraught with difficulties and few controlled studies have been completed. Current thinking regarding the use of cryotherapy is based on early reports in the literature and anecdotal histories. Table 1 summarizes the use of cold applications. Table 1.
Summary of the use of cold applications.
Indications for use
Reduce pain and the symptoms of inflammation Reduce muscle spasm and clonus Reduce swelling and bleeding from mechanical trauma Postsurgicallyfor knee, hip, or foot surgery, wrist fusions,shoulder surgery, tendon surgery, manipulations, bone grafts, etc. Acute or subacutely involved rheumatoid joints Low back pain Acute subacromial or subdeltoid bursitis Myofascialpain and myofibrositis Techniques for application
Immersion in ice water Cold compresses containing melting ice shavings Ice massage with a block of ice Evaporative eooling with ethyl chloride spray Frozen gel packs Cold slush packs made from denatured alcohol and water Bags of frozen vegetables such as peas Contrast baths (used alternatively with heat)
Moskowitz (1979) noted that patients with osteoarthritis who experience increased pain with the use of heat might benefit from the use of cold applications. Swezey (1978) summarized the issues surrounding the use of heat or cold in the treatment of rheumatic disease. H e suggested that decisions regarding their use are made on empirical observations that the relief of pain for acute inflammatory and traumatic conditions is best achieved by cold compresses. Conversely, subacute to chronic inflammation is best relieved by heat. The initial response to cold application may be a sensation of mild pain followed by numbness. Certainly the patient's response to the application is going to determine its continued use. If one is attempting to cool a joint, the cold packs should be placed directly over it; however, efforts should be made to avoid contact with major nerves iocated close to the pack as this may be excessively painful to the patient. The pack may be kept in place until numbness occurs but should be removed if the patient has increased pain. The amount of time required for cooling the part will vary according to the amount of subcutaneous fat present on the individual. In an obese person cooling may take 30 min while in a more lean person only 10 min will be required. Careful observation of the patient will reveal whether the patient is hypersensitive to cold. Severe adverse reaction to cold is rare; however, hypersensitivity may occur. The typical symptoms appearing as a result of the release of histamine are cold urticaria, erythema, itching, or sweating.
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Facial flushing, puffiness of the eyelids, laryngeal oedema and respiratory embarrassment may occur. In severe reactions, cold anaphylaxis and gastrointestinal symptoms may result. Patients may have the general symptoms of malaise, chills and fever. In those patients that produce cryoglobulins, chills, fever, and blindness may be observed. Tissue damage from frostbite is possible (Lehman, 1982). The above syndromes should be watched for in patients that have systemic lupus erythematosus, atypical pneumonia, leukocytoclastic vasculitis, rheumatoid disease, progressive systemic sclerosis, or multiple myeloma (Lehman, 1982). Treatment with cold is contraindicated in patients with Raynaud's phenomenon or other vascular pathology (Banwell, 1986). Most patients with arthritis can be instructed regarding the proper use of cold application at home. Such things as paper cups filled with water and frozen for use as an ice massage, bags of frozen vegetables for ice packs, or ice bags may be used.
Hydrotherapy The use of water as a therapeutic agent to soothe the body or its parts has been in use since ancient Egypt and Rome. While modern physiotherapy departments make use of whirlpools, Hubbard tanks, and therapeutic pools, it is important that those who suffer pain from rheumatic disease learn that appropriate use of their bathtub or shower can be a useful form of hydrotherapy. The ease with which the patient can use the buoyancy of the water to ~help move their joints is generally believed to be a positive outcome of hydrotherapy. Table 2 lists the guidelines for use of various hydrotherapy equipment. Certain precautions need to be observed when recommending that a patient immerse themselves in water with a temperature over 38~ Total immersion of the body in water over this temperature will raise the body core Table 2.
Guidelines for use of hydrotherapy.
Types of equipment Whirlpool baths Hubbard tanks LoBoy whirlpool baths Therapeutic pools
Types of exercises Passive motion that occurs as a result of buoyancy Assisted motion occurring through gentle contraction of the muscles and upward thrust of the water Controlled resistance exercise can occur by increasing the speed with which the patient moves the part or body while in the water
Guidelines for pool therapy Temperature should range from 35.5~ to 38~ Two to three times weekly in the pool is sufficient Acclimatize the patient to the pool slowly One hour is the maximum length a patient should stay in the pool once acclimatized
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temperature. Some patients will complain of nausea or dizziness. Other patients will report increased joint pain and stiffness the day after being in the pool. Patients with a compromised vascular system should not be immersed in a pool with a high water temperature as this increases cardiac work (Wickersham, 1984). There are a variety of benefits that may be achieved from activity in the therapeutic pool. These include relaxation, gentle exercises, temporary relief from pain and stiffness, and socialization with other patients. Joint traction
Joint traction for pain relief and increasing mobility in the knees and hips has been well established (Rodnan and Schumacher, 1983; Swezey, 1978). Whether cervical and lumbar spine traction used in the presence of disc disease is beneficial on a long-term basis remains to be established. Traction can be applied either mechanically or manually; however, caution should be used when the joint to receive traction has excessive laxity or deterioration. Cervical traction and/or mobilization as accomplished by a physiotherapist is contraindicated in a patient with cervical subluxation due to rheumatoid arthritis, in ankylosed cervical joints, or cervical instability. Mobilization or manipulation of other joints than the cervical spine has been used; however, documentation of the efficacy of these techniques remains anecdotal. Di Fabio (1986) reported that the high incidence of spontaneous recovery from low back syndromes clouded the results of mobilization research, particularly if proper controls were not used. Acupuncture and transcutaneous electrical nerve stimulation
The ancient Chinese practice of acupuncture has been investigated as a possible method of relief of pain in arthritis. Its efficacy for use in arthritis has been approached with scepticism by some and support for its use as a shortterm control of pain by others. Controlled studies have not demonstrated that acupuncture is more effective for pain relief than placebo (Man and Barager, 1974; Matsumoto et al, 1974; Gaw et al, 1975; Lee et al, 1975; Moore and Berk, 1976; Lewith and Machin, 1983; Melzack and Katz, 1984). Transcutaneous electrical nerve stimulation (TENS) has become a popular modality for relief of pain. This form of treatment has evolved from the gate theory of Melzack and Wall. It was thought by Bishop (1980) that TENS, acupuncture and stimulus-produced analgesia may share common effector mechanisms involving enkephalinergic neurons. TENS is known to block C-fibre mediated pain. The periosteum, synovium and joint capsule are supplied by these sensory fibres and have a low conduction velocity. Theoretically, TENS should be useful in the treatment of joint pain. Mannheimer and Carlsson (1979) determined that high-intensity TENS reduced joint pain in 18 of 19 patients with rheumatoid arthritis. TENS has been demonstrated to be effective in reducing pain in patients with chronic low back pain (Melzack et al, 1983), knee pain from osteoarthritis (Taylor et al, 1981), Sudeck's atrophy and reflex sympathetic dystrophy (Bodenheim and Bennett, 1983).
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Paxton (1980) reported that patients were satisfied with the effectiveness of TENS in reducing their pain and increasing their ability to engage in activity. However, Griffin and McClure (1981) reported that adverse reactions may occur in patients with rheumatoid arthritis who are receiving TENS. Those noted followed treatment of a patient to relieve pain in her wrists and hands. The patient developed numbness, distension of superficial veins in her arms, and severe pain subsequent to stimulation. Others have reported skin irritations around the electrodes, unpleasant sensations, cardiac arrhythmia and interference with cardiac pacemakers. Inadequate evaluation of treatment outcome is probably the greatest weakness of the reported clinical studies on TENS for chronic pain control. Most investigators use the patient's report of subjective improvement as the sole measure of treatment outcome. Subjective judgement of pain severity and location, as well as treatments and medications, are quite variable. This coupled with the psychological aspects of chronic pain make objective evaluation of the person with chronic pain difficult. The use of parameters such as range of joint motion, strength, muscle girth, and ability to complete functional activities would increase the objectivity of the assessment of TENS (Gersh and Wolf, 1985). The advantage of this modality is that it can be used by the patient at home after appropriate instruction has been given by the physiotherapist. It is most useful in localized areas of pain such as the neck, shoulders, knee or low back. PRINCIPLES OF REST AND JOINT PROTECTION There appears to be general agreement that rest is a significant component in the conservative management of rheumatic disease, particularly rheumatoid and juvenile rheumatoid arthritis (Gault and Spyker, 1969; Mills, 1971; Smith and Polley, 1978; Hunder and Bunch, 1982; Melvin, 1982; Rothschild, 1982; Downey, 1986). Partridge and Duthie (1963) and Gault and Spyker (1969) were early advocates of incorporating principles of rest in the treatment of rheumatoid arthritis and related arthritides. Both groups used splinting to immobilize acutely painful joints for short periods of time. While excessive rest is not advocated, there needs to be a judicious balance between rest and activity in rheumatoid arthritis. Eight to 10 h of sleep at night coupled with one to two 90min rest periods during the day are commonly recommended. These rest periods are advocated even in the absence of active synovitis. Some suggest short periods of bedrest during the day will improve endurance and work tolerance while decreasing pain. Patients also need to be encouraged to pace their activities, limiting their exertion when they find themselves increasingly fatigued. A satisfactory programme for treatment of osteoarthritis of weightbearing joints is weight loss, if applicable, and moderate exercises for short periods throughout the day. Excessive activity of painful joints should be discouraged and individuals whose occupations require prolonged overactivity of the joint (such as standing, sitting or lifting) should modify their schedules.
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Joint protection and energy conservation should be emphasized to the patient with painful inflamed joints. Joints which are painful or weak because of arthritis or overly fatigued are more prone to injury from ordinary stress. A patient should be taught about alternative means of performing their work to minimize joint stress. Large joints with large muscles should be used for protection in preference to small joints. The use of assistive devices, splints, braces, orthoses, casts, and ambulatory aids will help to reduce the stresses placed on painful joints. The above devices may be supplied by an orthotist, physiotherapist, or occupational therapist. Considerable attention has been given recently to the use of various forms of relaxation techniques to assist the patient with arthritis in the management of stress, tension and pain. While it is not a panacea, teaching the patient some methods of relaxation may be a useful tool that is palliative in nature. Two of the more common methods used are Jacobson's Progressive Relaxation and the Relaxation Response. These can be doneat any time of the day at the patient's convenience (Lorig and Fries, 1983). The patient should be told that no scientific claim is made for these techniques and they should not be substituted for a sound medical programme. AND WHAT ABOUT EXERCISE FOR PAIN?
The question is often asked by patients when they are taught an exercise programme to maintain range of motion or strengthen their muscles: 'If I do these exercises, will the pain go away?' The patient and the therapist are faced with a double-edged sword. When the arthritis pain has reduced a patient's activity level, decreased strength of muscles occurs from disuse. The effort to return to the former functional level may itself be painful. Pain can immobilize the patient quickly leading to additional loss of function, loss of alertness, and depression. Often, after careful evaluation of the patient's status, giving the person a well-thought-out exercise programme with joint protection in mind, can givethe patient something to do besides concentrate on their pain. In addition, systematic exercise can give the patient hope and goals for which to strive. We try to help the patient understand that exercise judiciously accomplished may not relieve their pain but will help to keep them mobile and functional. It has been our experience that some patients become rather astute in being able to differentiate between the deep bone pain experienced in the joint, and pain from other sources such as exerciseinduced pain stiffness. Patients should be instructed that when they begin exercising they may experience sore muscles. When joints are inflamed in septic or rheumatoid arthritis, the patient should be encouraged to perform range of motion exercise only once or twice and then let the joint rest. The patient may use the 'after-pain' rule to determine when they have done too much. Pain that stays for longer than 2 h after exercise indicates overuse of the joint. No exercise should cause acute pain. This does not mean that the patient should stop exercising, but rather adjust to a comfort zone. Management of pain in the lower back continues to be an enigmatic
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problem. Prospective investigations on firefighters demonstrated that those who were more physically fit experienced fewer episodes with back injuries than those who were less fit (Cady et al, 1979). The physiotherapy programme for back pain may include the use of ice packs and a modality such as TENS to treat the acute pain and muscle spasm. Individually designed exercise programmes require combinations of endurance, strength, flexibility, and coordination activities to increase physical fitness. Back School can give the patient proper education and understanding of their disease. Ergonomics, in other words the proper and efficient use of the spine in work and recreation, should be stressed. The goal is to return the patient to work and a normal life as quickly as possible without creating excessive dependency on the medical care system. Endurance exercises may be brisk walking, cycling, jogging or swimming. It has been our experience that patients with other forms of arthritis, without significant lower extremity involvement, may also benefit from an aerobic exercise programme. For patients with more limiting disease in weight-bearing joints, exercise may be done in a warm pool. The buoyancy of the water may reduce the stresses of weight bearing while allowing aerobic activity. One important benefit of an aerobic exercise programme is the increased endurance the patient achieves if he is systematic with his programme. Fordyce (1978) suggested that when pain is 'puzzling in its distribution, onset, or time pattern, it is possible that the real trouble is depression'. He recommends that the patient be placed on a balanced programme of medication, exercises and increased activity according to the patient's tolerance. The physician and physiotherapist can help to reinforce the patient's cooperation by inquiring about the progress the patient is making with both the medication and exercise programme. SUMMARY
Management of pain in the person with arthritis requires interdisciplinary team work with the patient being the final manager. It is important that any health care provider perceive the patient as a person who happens to have arthritis--not as 'an "arthritic".' Defining a person by one's disease process is dehumanizing. The patient has the same aspirations as anyone who is ablebodied--to be free from disease. While the patient may know that a cure is not imminent, there is still the hope for one. Therefore, as the patient comes for physiotherapy, there may be a hidden wish that the moist packs, TENS, or therapeutic pool will be curative. It is important that the patient understand that no equipment in the physiotherapy department has curative powers. This will help avoid unnecessary dependency behaviours on the part of the patient. Careful instruction and supervision of the patient by the physiotherapist, in concert with reinforcement from the physician, can prepare the patient to apply heat, cold, or a variety of treatments at home. Although the patient is given the responsibility for this part of his care, periodic follow-up and reassessment should be completed to determine
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c h a n g e s in his p h y s i o l o g i c a l , p s y c h o l o g i c a l , a n d f u n c t i o n a l status. P h y s i o therapists who have a clear understanding of the physical treatment of pain a s s o c i a t e d w i t h t h e r h e u m a t i c d i s e a s e s c a n b e a v a l u a b l e asset t o m e d i c a l care. REFERENCES
Banwell BF (1986) Physical therapy in arthritis management. In Erlich GE (ed.) Rehabilitation Management of Rheumatic Conditions, pp 264-284. Baltimore: Williams & Wilkins. Bishop B (1980) Pain: its philosophy and rationale for management: Part III. Physical Therapy 60: 24-37. Bodenheim R & Bennett JH (1983) Reversal of a Sudeck's atrophy by the adjunctive use of transcutaneous electrical nerve stimulation: a case report. Physical Therapy 63: 1287-1288. Bonney GLW, Hughes RA & Janus O (1951) Blood flow through the normal human knee segment. Clinical Science 11: 167. Cady LD, Bischoff DP, O'Connell ER et al (1979) Strength and fitness and subsequent back injuries in firefighters. Journal of Occupational Medicine 21: 269-272. Di Fabio RP (1986) Clinical assessment of manipulation and mobilization of the lumbar spine: a critical review of the literature. Physical Therapy 66: 51-53. Downey JA (1986) The physiatrist in rheumatoid arthritis management. In Erlich GE (ed.) Rehabilitation Management of Rheumatic Conditions, pp 24-30. Baltimore: Williams & Wilkins. Edich GE (1986) Preface. In Erlich GE (ed.) Rehabilitation Management of Rheumatic Conditions, pp ix-xiv. Baltimore: Williams & Wilkins. Feibel A & Fast A (1976) Deep heating of joints: a consideration. Archives of Physical Medicine and Rehabilitation 57: 513. Fordyce WE (1978) Evaluating and managing chronic pain. Geriatrics 33: 59-62. Freyburg R H (1974) The roles of patient and physician in the management of arthritis. In Hollander JL (ed.) The Arthritis Handbook, pp 65-81. Pennsylvania: Merck, Sharp & Dohme. Gault S & Spyker JM (1969) Beneficial effect of immobilization of joints in rheumatoid and related arthritides: a splint study using sequential analysis. Arthritis and Rheumatism 12: 34-44. Gaw AC, Chang LW & Shaw LC (1975) Efficacy of acupuncture on osteoarthritic pain: a controlled double blind study. New England Journal of Medicine 293: 375-378. Gersh MR & Wolf SL (1985) Applications of transcutaneous electric nerve stimulation in the management of patients with pain. Physical Therapy 65: 314-336. Griffin JW & McClure M (1981) Adverse reactions to transcutaneous electrical nerve stimulation in a patient with rheumatoid arthritis. Physical Therapy 61: 354-355. Hardin JG (1971) Approaches to the patient with degenerative joint disease. Modern Treatment g: 840-850. Harris ED & McCroskery PA (1974) The influence of temperature and fibril stability on degradation of cartilage collagen by rheumatoid synovial collagenase. New England Journal of Medicine 260: 1-6. Harris ED & Millard JG (1956) Clearance of radioactive sodium from the knee. ClinicalScience 15: 9.
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