Rehabilitation and physical Rehabilitation and physical medicine in the treatment medicine in the treatment

of rheumatic diseasesof rheumatic diseases

As. PhDr. Kamila Řasová, Ph.D.As. PhDr. Kamila Řasová, Ph.D.

DepartmentDepartment of rehabilitation of rehabilitation

Third Third FacultyFaculty of Medicine of Medicine, Charles University in , Charles University in PraguePrague

Rheumatoid arthritis

Ankylosing spondylitis

Reactive arthritis and psoriatic arthritis

Systemic lupus erythematosus

Systemic sclerosis

Idiopathic inflammatory myopathies

Juvenile idiopathic arthritis

Sjögren syndrome

Gout (Gouty arthritis)

Osteoarthritis

Soft tissue rheumatism

Lyme disease (Lyme arthritis)

Septic arthritis

Rheumatic diseases

Rheumatic diseases (rheumatism) are painful conditions usually caused by inflammation, swelling, and pain in the joints or muscles.Some rheumatic diseases like osteoarthritis are the result of "wear and tear" to the joints. Other rheumatic diseases, such as rheumatoid arthritis, happen when the immune system becomes hyperactive; the immune system attacks the linings of joints, causing joint pain, swelling, and destruction.Almost any joint can be affected in rheumatic disease. There are more than 100 rheumatic diseases.

http://www.webmd.com/rheumatoid-arthritis/an-overview-of-rheumatic-diseases

Sign, symptoms and pSign, symptoms and problems roblems accompaining revmatic diseasesaccompaining revmatic diseases• Pain in jointPain in joint, j, joint swellingoint swelling, j, joint may be warm oint may be warm

to touchto touch, j, joint stiffnessoint stiffness, m, muscle weakness and uscle weakness and joint instabilityjoint instability

• Other organ involvement, feverOther organ involvement, fever

• People are People are physical deconditioned, physical deconditioned, fatiguing, fatiguing, depressed, hopeless, anxious, frustrated and depressed, hopeless, anxious, frustrated and fearful of doing even normal activities.fearful of doing even normal activities.

• It is restricted It is restricted a person’s ability to work, a person’s ability to work, participate in daily and recreational activities participate in daily and recreational activities and may affect their relationships with family and may affect their relationships with family or friends. or friends.

System model – a basis for comprehensive rehabilitation

Umphred D.A., El-Din D. Neurological Rehabilitaton, 2001

CClinical practice, including rehabilitation, linical practice, including rehabilitation, should should be be based on the ICFbased on the ICF model model. This model facilitates the . This model facilitates the structuring, organization and documentation of the structuring, organization and documentation of the whole rehabilitation process. It enables all whole rehabilitation process. It enables all professionals involved in patient care to coordinate professionals involved in patient care to coordinate their actions to achieve the maximum participation in their actions to achieve the maximum participation in life even with impairments resulting from the disease.life even with impairments resulting from the disease.

• Increased political attention towards high-quality Increased political attention towards high-quality rehabilitation for rehabilitation for

Neurological Rehabilitaton, 2001

International Classification of Functioning, Disability and Health (ICF) International Classification of Functioning, Disability and Health (ICF)

Comprehensive Comprehensive rehabilitationrehabilitation• The promotion of a person’s functioning The promotion of a person’s functioning

depends upon a full assessment of depends upon a full assessment of person’s medical, psychological and person’s medical, psychological and social issues that cannot be addressed social issues that cannot be addressed by a single practitioner but require a by a single practitioner but require a team of health professionals. Such team of health professionals. Such teamwork should lead to interventions teamwork should lead to interventions that improve maintenance of functioning that improve maintenance of functioning and minimize disability.and minimize disability.

TeamworkTeamwork• Multidisciplinary Multidisciplinary - - efforts of different team members efforts of different team members

are parallel and discipline oriented. The result will are parallel and discipline oriented. The result will be the sum of the efforts of all team members. be the sum of the efforts of all team members.

• IInterdisciplinary nterdisciplinary - - working together for the same working together for the same goal. Team members are required to have the skills goal. Team members are required to have the skills of their discipline as well as the ability to contribute of their discipline as well as the ability to contribute to a group effort on behalf of the patient. The to a group effort on behalf of the patient. The treatment programme is synergistic, producing treatment programme is synergistic, producing more than each discipline could achieve more than each discipline could achieve individually. This synergistic approach is obtained individually. This synergistic approach is obtained formally by a team conference. formally by a team conference.

psychotherapsychotherapypy

art therapyart therapy

physiotheraphysiotherapypy

uro - uro - rehabilitationrehabilitation

dance therapydance therapy

canisterapiecanisterapie

speech speech therapytherapy

occupatiooccupational nal therapytherapy

cognitive cognitive rehabilitationrehabilitation

hippotheraphippotherapyy

muzikoterapmuzikoterapieieSocial service

sports therapysports therapy

patientpatient

Patient´s Patient´s family and family and friendsfriends

Process of rehabilitation

Boissonnault W.G., Umphred D.A. Neurological Rehabilitaton, 2001

A visual analogue scale (VAS) a psychometric response scale for subjective characteristics or attitudes that cannot be directly measured.

Wong Baker Faces Pain Scale- a Pain Assessment Tool Used by People in Pain- combines pictures and numbers to allow pain to be rated by the user.The faces range from a smiling face to a sad, crying face. A numerical rating is assigned to each face, of which there are 6 total.

Excerise tolerance 

Never heard of it

I know it but not use in my

patiens

Used in my patients

Heart rate        

Rate of perceived exertion(RPE)*

       

Oxygen consumption, intake, uptake per kgNYHA** Functional Classification

       

Spiroergometry

Gait pattern functions

 

Never heard of it

Have heard of it or seen it

Know how to do it

Spatio-temporal parameters, e.g. stride length, cadence and walk ratio

     

Timed tandem gait      

Muscle power function 

Never heard of it

Have heard of it or seen it

Know how to do it

Medical research council scale (MRC)

     

Repetitive muscle activity testing

     

Motoricity index      

Motor club assessment

     

Testing of Muscle Function

     

Dynamometry

 Mental and psychological

functions

Never heard of it

Have heard of it or seen it

Know how to do it

Mini-Mental State Examination

     

Paced Auditory Serial Additions Test (PASAT)

     

Symbol digit modality test

     

Beck Depression Inventory

     

Hospital Anxiety and Depression Scale

     

Mental Health Inventory (MHI)

Fatigue  Never heard of it

Have heard of it or seen it

Know how to do it

(Modified) Fatigue Impact Scale

     

Fatigue Severity Scale      

Rating scales, e.g. Visual analogue scale, Verbal rating scale

     

Fatigue Scale for motor and cognitive function FSMC

Walking, mobility 

Never heard of it

Have heard of it or seen it

Know how to do it

10 m gait maximal speed

     

10 m gait normal speed

     

Timed 25-Foot Walk      

6 minute walk test      

2 minute walk test      

Ambulatory Index      

Timed up and go test (TUG)Rivermead motor assessment

     

Rivermead Mobility Index Hauser Ambulation Index

     

FSQ* mobility questions

     

Functional Ambulation Categories

     

 Changing and

maintaining body position

Never heard of it

Have heard of it or seen it

Know how to do it

Berg balance scale (BBS)

     

ABC Self Confidence Scale

     

Dynamic gait index (DGI)

     

Dizziness handicap inventory

     

Number of falls      

Tinetti Balance Assessment tool

     

Trunk impairment scale

     

Postural stabilometric platform

     

Using arms and

hands 

Never heard of it

Have heard of it or seen it

Know how to do it

Nine hole peg test      

Box and Blocks test      

Purdue Pegboard      

Action Research Arm Test

     

TEMPA*      

Disabilities of the arm, shoulder and hand (DASH)

     

Wolf Motor Function Test

     

Brunnstrom-Fugl-Meyer testInternational Cooperative Ataxia Rating Scale (ICARS)

Scale for the assessment and rating of ataxia (SARA)

 Work and leisure

Functional Status Questionnaire      Frenchay Activities Index      Modified Social Support Survey (MSSS)Environment Status Scale      

Health –related

quality of life

instruments 

Never heard of

it

Have heard of it or seen it

Know how to do it

Sickness Impact Profile      Short-Form(SF-12, SF-36)      

 Self care Never heard of it

Have heard of it or seen it

Know how to do it

Barthel Index      Incapacity Status Scale

     

Functional Independence Measure (FIM)

     

Multiple Sclerosis – self efficacy scale (MS - SES)

     

FSQ self care questionnaire

     

PPsychosocial state of a person with sychosocial state of a person with chronic painchronic pain - - three classes of chronic three classes of chronic pain patientpain patient

– ddysfunctionalysfunctional:: people who perceived the severity of people who perceived the severity of their pain to be high, reported that pain interfered with their pain to be high, reported that pain interfered with much of their lives, reported a higher degree of much of their lives, reported a higher degree of psychological distress caused by pain, and reported low psychological distress caused by pain, and reported low levels of activitylevels of activity

– interpersonally distressedinterpersonally distressed:: people with a common people with a common perception that significant others were not very perception that significant others were not very supportive of their pain problemssupportive of their pain problems

– adaptive coadaptive coooperspers:: patients who reported high levels of patients who reported high levels of social support, relatively low levels of pain and perceived social support, relatively low levels of pain and perceived interference, and relatively high levels of activity.interference, and relatively high levels of activity.

Rehabilitation goals in RDRehabilitation goals in RD

• reducing reducing and and controlling controlling painpain

• improving moodimproving mood

• enhancing physical enhancing physical functionfunction

• Improve quality of Improve quality of lifelife

Rehabilitation treatmentRehabilitation treatment

• Education and self-managementEducation and self-management

• Exercise, rest, and energy Exercise, rest, and energy conservationconservation

• Manual and mechanical Manual and mechanical therapiestherapies

• Physical modalitiesPhysical modalities

Education and self-Education and self-managementmanagement

• Information on the nature and Information on the nature and prognosis of arthritis; efficacy and prognosis of arthritis; efficacy and side effects of arthritis medications; side effects of arthritis medications; and exercise, pacing, and other and exercise, pacing, and other rehabilitation interventions.rehabilitation interventions.

General General recommendation: Move recommendation: Move to Help Prevent Joint to Help Prevent Joint PainPain• Keep joints healthy by keeping them Keep joints healthy by keeping them

moving. The more you move, the moving. The more you move, the less stiffness you'll have. Whether less stiffness you'll have. Whether you're reading, working, or watching you're reading, working, or watching TV, change positions often. Take TV, change positions often. Take breaks from your desk or your chair breaks from your desk or your chair and move around.and move around.

General General recommendationrecommendation:: Protect Your Body and Protect Your Body and Your JointsYour Joints• Injury can damage joints. So Injury can damage joints. So

protecting your joints your whole life protecting your joints your whole life is important. Wear protective gear is important. Wear protective gear like elbow and knee pads when like elbow and knee pads when taking part in high-risk activities like taking part in high-risk activities like skating. If your joints are already skating. If your joints are already aching, consider wearing braces aching, consider wearing braces when playing tennis or golf.when playing tennis or golf.

General General recommendationrecommendation: : Healthy Weight for Healthy Weight for Healthy JointsHealthy Joints• Even a little weight loss can help. Every Even a little weight loss can help. Every

pound you lose takes four pounds of pound you lose takes four pounds of pressure off your kneespressure off your knees and decreses and decreses the risk of cartilage breakdown.the risk of cartilage breakdown.

• Consider your joints when lifting and Consider your joints when lifting and carrying. Carry bags on your arms carrying. Carry bags on your arms instead of with your hands to let your instead of with your hands to let your bigger muscles and joints support the bigger muscles and joints support the weight.weight.

General General recommendationrecommendation: : Low-Low-Impact Exercise for Impact Exercise for JointsJoints• To protect your joints, your best choices To protect your joints, your best choices

are low-impact options like walking, are low-impact options like walking, bicycling and swimming. That's because bicycling and swimming. That's because high-impact, pounding, and jarring high-impact, pounding, and jarring exercise can increase your risk of joint exercise can increase your risk of joint injuries and may slowly cause cartilage injuries and may slowly cause cartilage damage. Light weight-lifting exercises damage. Light weight-lifting exercises should also be included, but you have to should also be included, but you have to consultconsult it with expert. it with expert.

General General recommendationrecommendation:: Strengthen Muscles Strengthen Muscles Around JointsAround Joints• Stronger muscles around joints mean Stronger muscles around joints mean

less stress on those joints. Research less stress on those joints. Research shows that having weak thigh muscles shows that having weak thigh muscles increases your risk of knee increases your risk of knee osteoarthritis, for example. Even small osteoarthritis, for example. Even small increases in muscle strength can reduce increases in muscle strength can reduce that risk. that risk.

• Avoid rapid and repetitive motions of Avoid rapid and repetitive motions of affected joints.affected joints.

General General recommendationrecommendation:: Full Full Range of Motion is KeyRange of Motion is Key

• Move joints through their full range Move joints through their full range of motion to reduce stiffness and of motion to reduce stiffness and keep them flexible. Range of motion keep them flexible. Range of motion refers to the normal extent joints can refers to the normal extent joints can be moved in certain directions. be moved in certain directions.

Post Isometric Relaxation Post Isometric Relaxation (PIR)(PIR)• The post-isometric relaxation technique The post-isometric relaxation technique

begins by placing the muscle in a begins by placing the muscle in a stretched position. Then an isometric stretched position. Then an isometric contraction is exerted against minimal contraction is exerted against minimal resistance. Relaxation and then gentle resistance. Relaxation and then gentle stretch follow as the muscle releases. stretch follow as the muscle releases. This technique was applied to tight, This technique was applied to tight, tender muscles that are commonly tender muscles that are commonly associated with musculoskeletal painassociated with musculoskeletal pain

Manual and mechanical Manual and mechanical therapiestherapies

• manual therapy is defined as a manual therapy is defined as a clinical approach utilizing skilled, clinical approach utilizing skilled, specific hands-on techniques, specific hands-on techniques, including but not limited to including but not limited to manipulation/mobilization, used by manipulation/mobilization, used by the physical therapistthe physical therapist

General General recommendationrecommendation:: Know Know Your Joints' LimitsYour Joints' Limits

• It's normal to have some aching It's normal to have some aching muscles after exercising. muscles after exercising.

• But if your pain lasts longer than 48 But if your pain lasts longer than 48 hours, you may have overstressed hours, you may have overstressed your joints. Don't exercise so hard your joints. Don't exercise so hard next time. Working through the pain next time. Working through the pain may lead to injury or damage.may lead to injury or damage.

General General recommendationrecommendation: : Protect Joints With Good Protect Joints With Good PosturePosture

• Stand and sit up Stand and sit up straight. Good posture straight. Good posture protects your joints all protects your joints all the way from your the way from your neck down to your neck down to your knees. knees.

Pain treatmentPain treatment

• "Pain can be treated not only by "Pain can be treated not only by trying to cut down the sensory input, trying to cut down the sensory input, but also by influencing the but also by influencing the motivational-affective and cognitive motivational-affective and cognitive factors as well."factors as well."

Pain receptorsPain receptors• These are bare sensory nerve endings that network These are bare sensory nerve endings that network

throughout all organs and tissues of the body (except throughout all organs and tissues of the body (except the brain)the brain)

• They respond to many types of stimuli eg extremes of They respond to many types of stimuli eg extremes of temperature, lacerations, or anything that is potentially temperature, lacerations, or anything that is potentially damaging to the tissue.damaging to the tissue.

• When actual injury occurs, Bradykinin (the most potent When actual injury occurs, Bradykinin (the most potent pain producing chemical/enzyme known) is released pain producing chemical/enzyme known) is released from the damaged cells. from the damaged cells.

• This bradykinin attaches to the pain receptors (free This bradykinin attaches to the pain receptors (free nerve endings) causing them to transmit pain impulses.nerve endings) causing them to transmit pain impulses.

Neural Pathways in PainNeural Pathways in Pain

• These painful impulses travel to the central These painful impulses travel to the central nervous system through two different fibresnervous system through two different fibres

• 1. The fibres that transmit impulses quickly are 1. The fibres that transmit impulses quickly are called A-delta fibres. The types of sensations called A-delta fibres. The types of sensations they carry are localised, sharp, pricking, brief they carry are localised, sharp, pricking, brief sensations.sensations.

• 2. The fibres that transmit impulses more 2. The fibres that transmit impulses more slowly are called C fibres. The types of slowly are called C fibres. The types of sensations they carry are dull, burning, aching, sensations they carry are dull, burning, aching, longer lasting sensations.longer lasting sensations.

• Both these fibres send impulses by releasing a transmission Both these fibres send impulses by releasing a transmission agent called Substance P. Both fibres (A-delta and C) follow a agent called Substance P. Both fibres (A-delta and C) follow a similar pathway up the spinal cord until they reach the Brainsimilar pathway up the spinal cord until they reach the Brain..

• C fibres end in the lower regions of the forebrain whereas C fibres end in the lower regions of the forebrain whereas AA--delta fibres go straight onto the motor and sensory areas of the delta fibres go straight onto the motor and sensory areas of the cortex.cortex.

• The lower regions of the forebrain do not assess the pain signals The lower regions of the forebrain do not assess the pain signals as dramatically as the motor and sensory areas of the cortex. as dramatically as the motor and sensory areas of the cortex.

• The cortex provides immediate attention for the sharp localised The cortex provides immediate attention for the sharp localised pain signals, whereas the pain signals, whereas the CC fibres carrying dull aching pain fibres carrying dull aching pain signals are assessed more from an emotional/motivational signals are assessed more from an emotional/motivational perspective in the forebrain.perspective in the forebrain.

• TThere are two types of pain, transmitted by two here are two types of pain, transmitted by two separate sets of pain-signaling pathways in the separate sets of pain-signaling pathways in the central nervous system.central nervous system.

• Sudden, short-term pain, such as the pain of cutting a Sudden, short-term pain, such as the pain of cutting a finger, is transmitted by a group of pathways that finger, is transmitted by a group of pathways that Melzack calls the "lateral" system, because they pass Melzack calls the "lateral" system, because they pass through the brain stem on one side of its central core. through the brain stem on one side of its central core.

• Prolonged pain, on the other hand, such as chronic Prolonged pain, on the other hand, such as chronic back pain, is transmitted by the "medial" system, back pain, is transmitted by the "medial" system, whose neurons pass through the central core of the whose neurons pass through the central core of the brain stem.brain stem.

Role of painRole of pain

• Pain is part of the body's defense Pain is part of the body's defense system, producing a reflexive system, producing a reflexive retraction from the painful stimulus, retraction from the painful stimulus, and tendencies to protect the affected and tendencies to protect the affected body part while it heals, and avoid body part while it heals, and avoid that harmful situation in the future.that harmful situation in the future.

• People with congenital insensitivity to People with congenital insensitivity to pain have reduced life expectancy.pain have reduced life expectancy.

Pain behavioursPain behaviours• facial grimacing and guarding facial grimacing and guarding

• increase or decrease in vocalizationsincrease or decrease in vocalizations

• changes in routine behavior patterns and changes in routine behavior patterns and mental status changesmental status changes ( (withdrawn social withdrawn social behavior and possibly experience a behavior and possibly experience a decreased appetite and decreased nutritional decreased appetite and decreased nutritional intakeintake, , moaning with movement or when moaning with movement or when manipulating a body part, and limited range manipulating a body part, and limited range of motion are also potential pain indicators. of motion are also potential pain indicators.

Gate Control Theory, Gate Control Theory, Patrick Patrick Wall and Ronald MelzackWall and Ronald Melzack, , 19651965• This theory states that pain is a function of the This theory states that pain is a function of the

balance between the information traveling into balance between the information traveling into the spinal cord through large nerve fibersthe spinal cord through large nerve fibers ( (carry carry non-nociceptive informationnon-nociceptive information)) and information and information traveling into the spinal cord through small traveling into the spinal cord through small nerve fibersnerve fibers((carry nociceptive informationcarry nociceptive information)). If . If the relative amount of activity is greater in large the relative amount of activity is greater in large nerve fibers, there should be little or no pain. nerve fibers, there should be little or no pain. However, if there is more activity in small nerve However, if there is more activity in small nerve fibers, then there will be pain.fibers, then there will be pain.

1) Without any stimulation, both large and small nerve fibers are quiet and the inhibitory interneuron (I) blocks the signal in the projection neuron (P) that connects to the brain. The "gate is closed" and therefore NO PAIN.2) With non-painful stimulation, large nerve fibers are activated primarily. This activates the projection neuron (P), BUT it ALSO activates the inhibitory interneuron (I) which then BLOCKS the signal in the projection neuron (P) that connects to the brain. The "gate is closed" and therefore NO PAIN.3) With pain stimulation, small nerve fibers become active. They activate the projection neurons (P) and BLOCK the inhibitory interneuron (I). Because activity of the inhibitory interneuron is blocked, it CANNOT block the output of the projection neuron that connects with the brain. The "gate is open", therefore, PAIN!!

• From the spinal cord, the messages go directly to From the spinal cord, the messages go directly to several places in the brain including the thalamus, several places in the brain including the thalamus, midbrain and reticular formation.midbrain and reticular formation.

• Some brain regions that receive nociceptive Some brain regions that receive nociceptive information are involved in perception and emotion. information are involved in perception and emotion. Also, some areas of the brain connect back to the Also, some areas of the brain connect back to the spinal cord - these connections can change or modify spinal cord - these connections can change or modify information that is coming into the brain. In fact, this is information that is coming into the brain. In fact, this is one way that the brain can REDUCE pain. one way that the brain can REDUCE pain.

• Two areas of the brain that are involved in reducing Two areas of the brain that are involved in reducing pain are the periaqueductal gray and the nucleus pain are the periaqueductal gray and the nucleus raphe magnus. raphe magnus.

Nociception lead to active change of standard movement pattern with aim tonot irritate damged palce and activate functional restitution.

Pain - nocicepton interpreted at the concious level lead to concious tonic muscle reaciton in sense of spasm often accompained by reflex inhibition of antagonists (e.g. Tightness of m. iliopspas lead to inhibition of m. gluteus maximus)rarely by clonus.

Possibilities how to reduce Possibilities how to reduce painpain

1)1)Spinal level: Close the gateSpinal level: Close the gate

2)2)Subcortical level: activation of limbic Subcortical level: activation of limbic system and system and hypothalamus-pituitary-hypothalamus-pituitary-adrenal axisadrenal axis

3)3)Cortical level: cognitive training, Cortical level: cognitive training, afirmative trainingafirmative training

„„Sedare dolorem divinum est.“ Sedare dolorem divinum est.“ CiceroCicero

Conditions that open or close the gate

 Conditions that open the gate

Conditions that close the gate

Physical conditions

Extent of the injury

Medication

 Inappropriate activity level

Counterstimulation, eg massage

Emotional Conditions

Anxiety or worryPositive emotions – afirmative training

  Tension Relaxation  Depression Rest

Mental conditions

Focusing on the pain

Intense concentration or distraction

  BoredomInvolvement and interest in life activities

Other pain reduce pain –creating of define nociceptive afference inhibit other painfull aference„derivative therapy“

vacutherapyAcupuncture

1.Stimulation of large diameter nerve fibers that inhibit pain ("close the gate").2.Could be placebo effect. Causes release of endorphins ("the body's own morphine-like substances„, Reduces anxiety.3.Some types of acupuncture may stimulate small diameter nerve fibers and inhibit spinal cord pain mechanisms (this would not agree with the gate control theory)

Transcutaneous ElectricalNerve Stimulation (TENS)

1.Stimulation of large diameter nerve fibers which "close the gate" and reduce pain.2.Could be placebo effect.

TENS involves the passage of low-voltage electrical current to electrodes pasted on the skin.

STRES/BOLEST

HIPOKAMPUS

HYPOTHALAMUS

HYPOFÝZA

NADLEDVINAkatecholaminy

RAPHE

astrocyty

NO

ON

LC

Sympatickággl

thymocyty

NACRH

CRH

ACTH

Deliberace HPA

glukokortikoidy

Stress(aerobic training)

1.Activation of endogenous opiate system (endorphins)2.Activation of non-opiate pain inhibitory system

Physiotherapy based on neurophysiological prinicples - an activation of the cerebellum and consequently via hypothalamus – paleocerebellum and the neocerebellum limbic system; part of a limbic system is hypothalamus that owing to the hypothalamus-pituitary-adrenal axiscan

Motorické programy aktivující terapie

Automatické programy aktivující terapie

Physical modalities that Physical modalities that reduce pain and stiffnessreduce pain and stiffness• Thermotherapy – heat therapy, cryotherapyThermotherapy – heat therapy, cryotherapy

– Heat can increase the inflammatory response Heat can increase the inflammatory response and possibly increase joint damage, but this and possibly increase joint damage, but this has not been supported empirically – has not been supported empirically – contraindications in inflamation.contraindications in inflamation.

• Electromagnetic fields Electromagnetic fields

• Low-power laserLow-power laser

• Transcutaneous electrical nerve stimulationTranscutaneous electrical nerve stimulation

• UltrasoundUltrasound

ConclusionConclusion• Rehabilitation improves range of motion, strength, and Rehabilitation improves range of motion, strength, and

functional activities and must be individualized according to the functional activities and must be individualized according to the disease activity, accumulated joint damage, and the patient's disease activity, accumulated joint damage, and the patient's goals and interests. goals and interests.

• High-impact exercises such as jumping, basketball, etc. should High-impact exercises such as jumping, basketball, etc. should be avoided.be avoided.with significant rheumatic disease.with significant rheumatic disease.

• Medium-impact exercises such as walking, jogging, bicycling, Medium-impact exercises such as walking, jogging, bicycling, and swimming are appropriate, unless there is severe joint and swimming are appropriate, unless there is severe joint inflammation.inflammation.Severely inflamed joints should only be subjected to gentle Severely inflamed joints should only be subjected to gentle mobilization and stretching within the available range mobilization and stretching within the available range of movement.of movement.