Rehabilitation strategies to improve physical functioning in patients with musculoskeletal diseases Giesen, F.J. van der

Rehabilitation strategies to improve physical functioning in patients with musculoskeletal diseases

Giesen, F.J. van der

Citation

Giesen, F. J. van der. (2010, June 1). Rehabilitation strategies to improve physical functioning in patients with musculoskeletal diseases. Retrieved from https://hdl.handle.net/1887/15578

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General Introduction

Epidemiology of musculoskeletal conditions

Musculoskeletal conditions comprise over 150 diseases and syndromes, which are usually progressive and associated with pain. At any one time, 30% of the American adults are affected by joint pain, swelling, or limitation of movement. Musculoskeletal conditions are therefore a major burden on individuals, health systems, and social care systems

.

Rheumatoid arthritis (RA) and osteoarthritis (OA) are two common musculoskeletal conditions in rheumatologic and orthopedic practice. In European populations the prevalence of RA ranges from 0.2-1.9%

. In the Netherlands, estimations based on general practitioners’

registries show a prevalence of RA of 7.1 per 1.000 men and 11.0 per 1.000 women

. For OA, the prevalence of primary hip OA in subjects over 55 years is estimated to be 7.5%

whereas for primary knee OA in subjects over 45 years, the prevalence ranges from 14%

to 30%

. Based on Dutch general practitioners’ registries the prevalence of osteoarthritis of the knee, hip or other joints in the extremities was 25.9 per 1.000 men and 52.9 per 1.000 women

. From a national health survey executed in the Netherlands in 2006 it was concluded, based on a random sample of 6931 subjects over 18 years of age, that 2.5% of the Dutch population above 20 years of age suffers from RA and 9.6% from OA

.

Functioning and disability in musculoskeletal conditions

In general, the impact of inflammatory and degenerative joint conditions on many areas of individuals’ lives is substantial, despite the growing number of effective drugs for specific inflammatory rheumatic conditions

and joint replacement surgery. The World Health Organization International Classification of Functioning, Disability and Health (ICF) provides a framework for classifying the consequences of a disease (Figure 1). Within this model, the individual experience of functioning is not considered as the consequence of the disease, but as the result of the interaction between a health condition and both personal attributes and environmental influences (contextual factors)

. According to the ICF, the consequences of a disease may concern ‘Body (anatomical) structures and (physiological) functions’ and ‘Activities’ and ‘Participation’. The different components of this frame work recognize human functioning as a complex interaction of the different areas

.

Figure 1. The model of the International Classification of Functioning, Disability and Health (ICF). This model shows the relationship between the different ICF components. Each component consists of chapters and each chapter consists of categories. The patient perceived problems can be located within the component ‘Body functions and Body structures’ and ‘Activities’ and ‘Participation’.

Health condition (disorder or disease)

Environmental Factors

Personal Factors

Participation Body functions

and Structures

Activities

An ‘Impairment’ is a problem with body structures or functions, including the signs and symptoms of a disease, such as pain, stiffness or fatigue. An ‘Activity limitation’

describes the difficulties that a person may have in executing everyday tasks such as self care. ‘Restriction in participation’ relates to problems experienced by a person regarding societal participation and life situations such as employment or social activities. Disease consequences are modified by ‘Contextual factors’, including both environmental and personal factors. ‘Environmental factors’ make up the physical, social and attitudinal environment in which people live and conduct their lives. ‘Personal factors’, such as gender, self-efficacy, coping style, social and educational background may affect the person’s experience of living with their condition.

For 5 musculoskeletal diseases, RA

, OA

osteoporosis

, low back pain

and chronic wide spread pain

the most important and relevant disease-specific consequences have been listed and labeled according to the ICF classification, resulting in so called ICF Core Sets. ICF Core Sets are fractions of the ICF relevant for specific health conditions.

Brief versions of these core sets serve as minimal standards for reporting on functioning and health in clinical studies and clinical encounters. The comprehensive versions serve as standards for multiprofessional, comprehensive assessments

. ICF Core Sets can be used in daily practice to set and evaluate treatment goals

and they can be used for research purposes, as they provide a framework for the classification of measurement instruments

.

Hand function and disability in RA and OA

In RA, it is estimated that in 80-90% of the patients the hands and wrists are affected

. The inflammation of synovial tissues of joints and tendon sheaths can cause irreversible damage to cartilage, bone, ligaments, capsules and tendons. This process may result in joint instability, limitation in joint mobility and tendon ruptures. In addition, muscular imbalance between agonist and antagonist muscles, which can occur for various reasons, for example tendon rupture or tenosynovitis stenosans, can cause specific deformities like ulnar deviation of the fingers, swan neck and boutonnière deformities. In RA the involvement of the wrists, metacarpalphalangeal (MCP) and proximal interphalangeal (PIP) joints is more common than involvement of the thumb base or distal interphalangeal (DIP) joints

.

In OA, the hand is the most frequent site of involvement

, with a reported peak prevalence of radiographic DIP joint OA of up to 64% in men and 76% in women over 70 years of age in the general population

. The prevalence of symptomatic hand OA in people over 70 years of age is reported to be 13.4% for men and 26.2% for women

.

In hand OA, hand function disability is caused by degeneration of the joints involving cartilage, subchondral bone, capsules and ligaments. The degenerative process results in pain, limitations in joint mobility and joint deformity. Clinical hallmarks of hand OA are Heberden and Bouchard nodes with or without deformity affecting the characteristic target joints. Specific deformities in hand OA are: lateral deviation of PIP or DIP joints, and subluxation and adduction of the thumb base. Radiological features of this process include joint space narrowing, sclerosis and marginal osteophytes

.

The problems in hand function that patients with RA and OA may experience include

pain, impaired grip strength and limited dexterity, which have important consequences for

many activities in daily life. Although the ‘fine hand use’ activities domain is included in the

ICF Core Sets for both RA and OA

, knowledge regarding specific problems in activities

is lacking.

Evaluation of hand function in RA and OA

Hand function assessment in patients with RA or OA usually comprises history taking, clinical examination and radiographic assessment. Clinical examination may for example include an assessment of joint range of motion (goniometry)

and/or muscle strength (dynamometry)

.

Conventional radiographs are a widely used imaging technique to demonstrate morphologic changes of the hands in RA

and OA

. In addition, recent studies in inflammatory arthritis have demonstrated ultrasound to be more sensitive to synovitis than clinical examination, more sensitive than conventional radiographs to the presence of cortical defects, and have reasonable sensitivity compared with magnetic resonance imaging for the presence of synovitis and cortical defects

. Ultrasound also appears to be useful to assess OA both in the clinic and in clinical trials as it has a higher resolution than conventional radiographs, does not involve ionizing radiation, and allows multi-planar, dynamic imaging of joints

. In RA, magnetic resonance imaging (MRI) and especially dynamic MRI becomes a more commonly used imaging technique as it yields additional information about joint inflammation and complements clinical and biological examination

. MRI is not widely used for clinical purposes in OA, but is recognized to have great potential in research as whole joint assessment helps to discriminate between different patterns of intra articular involvement in OA

.

Hand function on the level of activities can be measured by means of performance tests.

If a standardized assessment is needed, for clinical or research purposes, there are various hand function-specific performance tests or questionnaires available, some of which have been specifically validated in RA or OA

. Because daily activities concerning the hands and involvement of other joints of the upper extremity may vary largely among individuals, and are influenced by environmental and personal factors, the problems in hand function that individual patients experience may be very specific. It is therefore questionable to what extent the activities included in standardized performance tests or questionnaires are relevant to individual patients with a specific hand condition. Therefore, there is a need for more insights in the problems individual patients with specific musculoskeletal conditions involving the hands experience. This knowledge can be used in the development of (sets of) measurement instruments for the assessment of patients with musculoskeletal diseases and hand function problems, and in the development of patient selection criteria for specific interventions.

Apart from diagnostic tests aimed at the hand, it is important to evaluate the total functioning of the whole upper extremity, as both in RA and OA, multiple joints including the elbow or shoulder may be involved.

Treatment modalities for hand function disability in RA and OA

Interventions aiming to improve hand function have to be specifically tailored to the individual patient’s needs and expectations. As mentioned above, the etiology of hand function problems in musculoskeletal conditions is complex, and patients’ definitions of hand function disability and optimal hand function may vary largely.

Interventions aiming specifically at hand function can be divided into conservative and

surgical treatment.

Conservative treatment

Exercises. In RA, a systematic review showed that daily exercise for at least 4 months including range of motion and isometric strengthening exercises may increase grip strength, but results on range of motion were inconsistent across studies, subjects, and joints

. In another study, that was published after the inclusion period of the review, it was found that compared with a traditional program aiming at improving range of motion and maintaining hand strength, an intensive hand exercise programme aiming at improving hand strength is well tolerated and more effective in improving hand function in patients with RA

. A systematic review on exercise therapy after MCP arthroplasty in RA patients concluded, based on the results of only one study, that continuous passive motion alone may not be recommended for increasing motion or strength after MCP arthroplasty

.

In OA, results of a study into the effectiveness of strength training showed a positive effect on grip strength and pain

.

Joint protection programs. Studies on the effectiveness of educational joint protection programs aimed at the hand in RA showed, in both early and established disease, improvements in pain, functional ability and symptoms up to a followup of 4 years

. In hand OA, a combined intervention of joint protection, assistive devices, and hand exercises improved grip and hand function after 3 months of followup

. The evidence for joint protection alone in hand OA is lacking.

Splints. In RA, wrist working splints are effective in reducing pain, but can have a detrimental effect on dexterity

. With respect to resting splints, the currently available data suggest, that these splints might not be an effective routine treatment for patients with rheumatoid arthritis

. Regarding finger splints, there is evidence that they can enhance dexterity in RA patients with deformities in general and more specifically in patients with swan neck deformities

. Because different types of finger splints are available, it is not clear if the different splints are comparable in their effectiveness and in patient satisfaction.

Regarding splinting interventions, in hand OA, there is some evidence that splinting may help relieve pain in persons with carpometacarpal osteoarthritis

.

Surgical treatment

Surgical interventions for hand involvement in RA and OA can be divided into preventive procedures, such as synovectomy of joints or tendons, and reconstructive interventions including for example tendon reconstruction, resection arthroplasties, partial or total arthrodesis, and joint replacements.

Surgical interventions for hand function problems in patients with RA may vary largely with the underlying pathophysiology, stage and extent of the disease, and individual needs and expectations. Because of the variety in clinical presentations of RA patients with problems in hand function and the methodological difficulties in studies investigating surgical interventions aiming at these problems, a clear definition of surgical indications or criteria for choosing a specific procedure is lacking

. However, stepwise surgical approaches to the RA patient with hand function problems have been described

. In addition, although studies regarding the evaluation of MCP joint replacement surgery usually involved observational methodology

, more recent studies show prospective methodology

.

In hand OA, a systematic review regarding surgery for thumb base arthritis identified

7 studies on the effectiveness of five surgical procedures: trapeziectomy, trapeziectomy

with interposition arthroplasty, trapeziectomy with ligament reconstruction, trapeziectomy

with ligament reconstruction and tendon interposition (LRTI), and joint replacement. It was

concluded that no procedure produced greater grip strength than any other. However, all

procedures were found to improve grip strength as compared to the pre-operative state. For

pain and physical function, there was insufficient evidence to be conclusive. Trapeziectomy appeared safer and was associated with fewer complications than the other procedures studied in this review. Trapeziectomy with LRTI appeared to have more complications than without LRTI

. Interpretation of the available studies is hampered by differences between the characteristics of the populations or individuals studied, in particular with respect to the presence or absence of instability of the first carpometacarpal joint and/or MCP 1 and/or 2 joints, which can make ligament reconstruction necessary after trapeziectomy.

An essential part of the surgical intervention is the evaluation of outcomes

. However, measurement instruments may not cover all domains in which patients may experience problems

, which warrants additional research into measurement instruments with a comprehensive focus for hand function in musculoskeletal diseases.

A multidisciplinary approach towards hand function disability

The complexity of hand function problems in RA or OA may warrant the involvement of professionals from various disciplines including, apart from the rheumatologist and/or orthopedic surgeon, the rehabilitation specialist, the general practitioner, the physical therapist, or occupational therapist.

Multidisciplinary care with a general focus has been studied extensively, in particular in RA

. However, knowledge regarding multidisciplinary care with a specific focus on the hand in RA or OA is lacking. Presently, a comprehensive approach to hand function problems is often provided in specialized rheumatology, orthopedic or rehabilitation centers, general hospitals, or private clinics. With respect to inflammatory and degenerative conditions involving the hands, little is known about the characteristics of patients seen by a multidisciplinary team, the interventions that are proposed and executed, as well as their outcomes.

Implementation of evidence based interventions in rehabilitation in RA and OA Exercise is a common non-pharmacological and non-surgical treatment strategy in RA and OA. Dynamic exercise therapy in RA has been studied extensively, and proved to be effective in enhancing cardio-vascular fitness, muscle strength, physical and mental functioning and quality of life

, without detrimental effects on disease activity or radiological joint damage

. As a result, exercise therapy is recommended in many clinical guidelines and recommendations for the management of RA

. In OA, exercise therapy was found to improve pain and physical function in knee OA

, and pain in hip OA

and is included in clinical practice guidelines and recommendations

.

However, despite the available evidence, implementation in daily practice appears to be limited. So far, only a limited number of papers

have described barriers and facilitators for the implementation of specific exercise programs for people with musculoskeletal conditions

. Therefore there is a need for more comprehensive evaluations regarding the implementation of evidence based exercise interventions in this patient group.

The aim of this thesis is to study rehabilitation strategies to improve physical functioning in patients with musculoskeletal conditions, in particular RA, and is divided into two parts:

Part 1 (Chapters 2, 3, 4 and 5) describes interventions aiming at reducing disability in

patients with musculoskeletal conditions and hand function problems, as well as their

evaluation.

Part 2 (Chapters 6 and 7) describes the implementation of evidence based interventions aiming at reducing disability in patients with RA in daily practice.

In Chapter 2 the results of a pilot study into the effects of a multidisciplinary approach towards hand function problems in patients with musculoskeletal conditions are presented.

Chapter 3 presents the results of a randomized controlled trial on the effectiveness of two finger splints for patients with RA and swan neck deformities, and in Chapter 4 the patients’ perspectives on hand function problems and finger splints were investigated in the same population. Chapter 5 describes the responsiveness of various outcome measures to assess the effect of multidisciplinary team care for hand function disability in RA.

Chapter 6 describes the implementation of an intensive exercise therapy program for patients with RA, and Chapter 7 describes the barriers and facilitators regarding the implementation of an internet based exercise intervention in patients with RA.

A summary of the results and a general discussion are presented in Chapter 8.

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