I. Arthritis pathology
It is important to first understand the pathological mechanisms and different types of arthritis to better understand the different clinical symptoms it presents.
Inflammation of the joints causes fluid accumulation and swelling, resulting in an increase in intra-articular pressure. Both the increased intra-articular pressure and the chemical mediators in the joint fluid will stimulate the pain receptors in the synovial membrane, causing the patient to feel joint pain; the increased intra-articular pressure will also compress the blood vessels in the synovial membrane and even cause obstruction of the blood vessels. When the cartilage and bone are eroded, the increased joint fluid will go to the bone and form bone cysts. In addition, the joint fluid can also open up the fragile synovial membrane and joint capsule, resulting in synovial cysts and even joint rupture in severe cases.
Types of arthritis
1.Rheumatoid arthritis
It is a chronic systemic autoimmune disease characterized by synovitis of the joints. The persistent and recurrent attacks of synovitis can lead to destruction of cartilage and bone in the joints, joint dysfunction, and even disability. The incidence of rheumatoid arthritis is higher in women than in men, about two to three times that of men.
2.Osteoarthritis
It refers to the degeneration of cartilage in the joint, involving the subchondral bone, resulting in bone proliferation, deformation, joint dysfunction, and joint pain. The incidence of osteoarthritis is closely related to age, the incidence of age below 45 years old is 2% to 3%; 45 to 64 years old is 24.5% to 30%, more than 65 years old can be as high as 58% to 68%, osteoarthritis occurs in joints with a lot of weight and activity. Such as hip and knee joints.
3.Other arthritis
Seronegative arthritis, ankylosing spondylitis, etc.
Three, arthritis x-ray performance
1, rheumatoid arthritis: soft tissue swelling, joint space narrowing, peri-articular bone sparing.
2, osteoarthritis: joint space narrowing, subchondral bone sclerosis, bone redundancy, cystic changes.
Four, common musculoskeletal disorders
Common musculoskeletal disorders in arthritis include pain, muscle weakness, joint instability and contracture.
(1) Pain
Pain is often the main reason for patients to seek medical consultation. The source of pain may be the synovial membrane, joint capsule, bones, ligaments, synovial bursa, muscles or tendons. Pain usually occurs when the joint moves or bears weight. In addition, prolonged immobility of the joint can cause a feeling of stiffness. Pain is sometimes caused by problems with the nerves.
(2) Muscle weakness
Poor muscle strength is also common in arthritis. Pain can inhibit muscle contraction. In addition, most people with arthritis often experience reduced activity or even prolonged bed rest due to pain, resulting in disuse atrophy.
(3) Joint instability
Arthritis often destroys the structure of cartilage and bone, making the joint cavity smaller; once the joint cavity becomes smaller, the ligaments that hold the joint in place become relatively loose, reducing its function of stabilizing the joint. In addition, muscle weakness affects the stability of the joint. When the joint is unstable, it will not only produce various deformations, but also accelerate the destruction of the joint.
(4) Contracture
The causes of contracture may be caused by joints, such as: destruction of articular cartilage, synovial hyperplasia, abnormal joint structure, fibrosis of the joint capsule; muscle, such as: muscle trauma, ischemia, muscle weakness, fibrosis; soft tissue lesions other than muscle, such as: tendonitis, ligament rupture, trauma, paracartilage cysts (e.g. Baker’s cyst), and Skin and subcutaneous tissue problems (trauma, infection, generalized scleroderma). For arthritis, the most common cause is that when a joint is acutely inflamed, the patient becomes accustomed to fixing the joint in a specific position for a long time, resulting in shortening and fibrosis of the joint capsule, muscles, tendons and ligaments.
V. Why rehabilitation is needed
The treatment of arthritis has changed rapidly in the last decade or two, especially with the development of new anti-rheumatic drugs and advances in surgery, which have helped patients tremendously. However, although the new generation of selective COX-2 non-steroidal anti-inflammatory pain relievers can reduce gastrointestinal side effects, there are still many reports of fatalities due to gastrointestinal bleeding, cardiovascular disease or kidney problems; the development of second-line anti-rheumatic drugs and various immune agents can certainly improve the disease process, but the side effects caused by the drugs cannot be ignored. Newer artificial joint replacements can reduce pain and improve joint function, but only for specific joints, and not for everyone. Early rehabilitation of patients with arthritis can improve the effectiveness of medication or surgery, reduce pain, avoid joint contractures, improve quality of life, and maintain their independence in life and occupation.
Functional assessment
The American Rheumatism Association classifies the function of rheumatoid arthritis into four levels: Level 1 is no restriction in daily life; Level 2 is a patient who can perform various daily activities but has some pain, discomfort or restriction in some joint activities; Level 3 is a patient who has serious problems in daily life and is mostly dependent on others; Level 4 is a patient who is completely dependent on others and usually confined to bed or wheelchair activities.
VII. Rehabilitation treatment
Because of the limitations of other treatments such as medication, rehabilitation is essential; its methods include rest, exercise and physical therapy.
(1) Rest
Systemic rest: resting the joints and muscles of the whole body in bed. Partial rest: Resting part of the joint by means of splint or cast. Resting for too long can produce sequelae such as muscle weakness, joint contracture, bed sores, osteoporosis, and reduced cardiopulmonary endurance.
(2) Exercise
The purpose of treatment: to improve or maintain joint mobility, enhance muscle strength, improve muscle endurance, improve cardiopulmonary endurance, improve bone density, and improve the patient’s overall body function and mental function. Exercise should be done in a gradual manner, starting with appropriate methods to reduce joint pain, then slowly improving joint mobility, followed by muscle strength training, and finally strengthening endurance training and recommending appropriate leisure exercise.
(3) The types of exercise are classified according to the purpose of exercise.
1.Movement of joints or improvement of joint mobility (ROM): Passive exercise, active-assisted exercise, active exercise.
2, muscle strength strengthening: isometric exercise, isotonic exercise (centripetal contraction centrifugal contraction), isometric exercise (centripetal contraction centrifugal contraction)
3.Improve cardiorespiratory endurance.
(4) The choice of exercise and the advantages and disadvantages
1.Passive exercise: not applicable to acute arthritis, in the chronic phase of arthritis, if the joint or soft tissue stiffness or contracture, then passive exercise combined with various tension techniques or relaxation (mobilization) to improve the mobility of the joint or soft tissue.
2.Active auxiliary exercises: When the patient’s joints are inflamed and swollen, active auxiliary exercises can be used to avoid joint contracture. Since the patient can control his or her joints when exercising, it is less likely to cause muscle spasm.
3.Active movement: When the acute inflammation subsides and the joint is no longer painful, the patient can move the joint completely by his own strength, which is suitable for the chronic or subacute stage of arthritis.
4.Isometric exercise: Because the muscle contraction does not increase the intra-articular pressure, the injury to the joint is also very small, so this contraction is suitable for most patients with chronic arthritis.
5, isotonic exercise: high intensity (high impedance) low frequency and low intensity (low impedance) high frequency, the former is less time consuming, but easy to hurt the joints, especially inflamed joints; the latter is safer, but more time consuming, if sustained for a considerable period of time, can also improve muscle endurance. In order to improve the safety of isotonic exercise, can be used in a small range of ways or in the water for a variety of sports.
6, isometric exercise: medium speed (120 to 180 degrees / sec) isometric contraction is suitable for mild arthritis patients, while low speed (30 to 90 degrees / sec) is too large impedance, and is not suitable for most arthritis patients. As for the high speed (>180 degrees/sec), although the impedance is not too high, it is difficult for most patients to reach that fast speed.
(5) Precautions for exercise
The purpose of rehabilitation is to help patients reduce pain and disability in their limbs in order to achieve independence in life and occupation. Appropriate rehabilitation measures can enhance the function of the joints and improve the quality of life.
Centrifugal muscle contractions are more likely to cause minor damage to muscle fibers, resulting in so-called delayed muscle soreness, and should therefore be used with caution. The American College of Sports Medicine recommends that plyometric strengthening exercises be performed at least twice a week, with 8-12 repetitions per session, and at least 48 hours between sessions. It is not advisable to hold one’s breath during plyometric training to avoid cardiovascular complications.
(6) Physical therapy
Including cold therapy, hot compress, wax therapy, ultrasound, short wave, electrical stimulation, etc. Therapeutic effects: reduce the pain of the patient’s limbs, reduce muscle spasm, improve the ductility of soft tissues, and enhance joint mobility. After treatment, the need for anti-inflammatory and pain relieving agents is reduced, so it can reduce various side effects caused by drugs, such as gastrointestinal bleeding and kidney dysfunction. However, the natural course of the disease cannot be changed.
1, cold therapy: cold therapy can reduce muscle spasm, reduce joint inflammation and pain, and can inhibit the activity of collagen on the synovial membrane because of the reduction of temperature in the joint. For patients with joint or soft tissue contractures, cold therapy is often used to ensure the effectiveness of treatment after doing tension exercises. Cold therapy can stop bleeding and reduce swelling, so it is suitable for the treatment of acute arthritis or muscle and bone joint trauma. Pain and swelling after exercise therapy can also be eliminated with cold therapy. There are many types of cold therapy, including immersion, cold (ice) compress, ice massage and spray method. Cold therapy single treatment time varies from 5 to 20 minutes.
2, heat therapy: shallow heat therapy, heat transmission depth of 1 cm or less under the skin, including heat packs, heat pads, wax therapy, hot water bags, infrared, heated hydrotherapy tank, pools and spas, etc.. The other is deep heat therapy, the depth of heat transmission is more than 1 cm, including: short wave, ultrasound and microwave, etc. The therapeutic effects are pain relief, muscle relaxation, improvement of collagen ductility, and joint mobility. Deep treatment with stretching exercises to improve the mobility of joints or soft tissues.
3, hydrotherapy: the purpose of hydrotherapy is to relax the muscles, and its thermal effect can also increase the extensibility of collagen tissue, so it can be used as a preparatory action before sports treatment. In addition, the water has buoyancy and viscosity (viscosity), so it can provide patients with a variety of exercises without hurting the joints. The motor can mix air and water into the hydrotherapy tank, causing a vortex, which has the effect of massage. Because the water has buoyancy, so the depth of the water can be used to provide different degrees of limb assistance; in addition, the viscosity of the water can also be used as a resistance to muscle training.
4, electrical stimulation: therapeutic effects: pain relief, enhance muscle strength, delay muscle atrophy and reduce muscle spasm. Low frequency wave, frequency in 100 pps (pulse per second) below, transcutaneous electrical nerve stimulation (transcutaneous electric nerve stimulation, TENS); medium frequency wave, frequency usually between 1000 to 10000 pps. Electrical stimulation is commonly used to treat lower back pain, osteoarthritis, rheumatoid arthritis, rigid spondylitis, and other soft tissue lesions.
(7) Orthopedic devices
Including splint (splint), brace (brace), spinal brace (spinal orthosis), soft back brace (corset), cervical collar and various foot and ankle braces, etc. Therapeutic effects: to reduce the load and pain of joints or soft tissues; to improve the stability of joints, so that the joints can be maintained in the best biomechanical position to maximize their functions; to improve joint mobility.