RECOVERY KINETIC OF PATIENTS WITH RHEUMATOID ARTHRITIS. (RA)

Abstract

Clinical picture of the hand is complex rheumatoid impaired at multiple osteo-articular, muscle, tendons, ligaments. Lesions at the punch: tenosinovita extensorilor, sinovita radio-carpal, sidrom head cubits, sidrom carpal canal, redoarea punches, especially in the flex, mainly under the action of flexorilor initially subluxatie web subsequently associated with radial deviation of pumnului.Leziuni at the fingers: a finger deviatta cubits, fingers "thrown in the pen, fingers in buttonhole, policele" in Z "tenosinovitele hand, clinico assessment - functional recovery oriented program, outlines the methodology appropriate to each case, the clinical obiectiveaza obtained by certain procedures, focused on prognosticului.(1)Treatamentof the hand reumatoide. Objectives: preserving functional capacity of the rheumatoid hand, primarily from an articular musculoskeletal, functional capacity preserving outstanding (for each stage of the disease), adjusting activities according to current restantul functional real functional autonomy by maintaining maximum operating capacity remaining real(1). Kinetoterapie - Objectives: prevent deformation and vicious attitudes, maintain or increase joint mobility, increase strength and muscle rezistetei, kinetic treatment should be early, continuous, permanent, adapted evolutionary stage of each patient, the type of deformation adapted existing adapted restantului actual running phase, adapted functional objectives of the needs subiectului.Ergoterapie.(2) [PUBLICATION ABSTRACT]

Viorica LEFTER1

Paul ICHIM1

Andreea Oana CIBU2

1 University "Dunarea de Jos" of Galati, FEFS

2 University "Dunarea de Jos" of Galati, Faculty Medicine

Key words: anchilozing, polyarthritis, kinesitherapy, deviation, splints (orteze)

Abstract

Clinical picture of the hand is complex rheumatoid impaired at multiple osteo-articular, muscle, tendons, ligaments. Lesions at the punch: tenosinovita extensorilor, sinovita radio-carpal, sidrom head cubits, sidrom carpal canal, redoarea punches, especially in the flex, mainly under the action of flexorilor initially subluxatie web subsequently associated with radial deviation of pumnului.Leziuni at the fingers: a finger deviatta cubits, fingers "thrown in the pen, fingers in buttonhole, policele" in Z "tenosinovitele hand, clinico assessment - functional recovery oriented program, outlines the methodology appropriate to each case, the clinical obiectiveaza obtained by certain procedures, focused on prognosticului.(1)Treatamentof the hand reumatoide. Objectives: preserving functional capacity of the rheumatoid hand, primarily from an articular musculoskeletal, functional capacity preserving outstanding (for each stage of the disease), adjusting activities according to current restantul functional real functional autonomy by maintaining maximum operating capacity remaining real(1). Kinetoterapie - Objectives: prevent deformation and vicious attitudes, maintain or increase joint mobility, increase strength and muscle rezistetei, kinetic treatment should be early, continuous, permanent, adapted evolutionary stage of each patient, the type of deformation adapted existing adapted restantului actual running phase, adapted functional objectives of the needs subiectului.Ergoterapie.(2)

Introduction

RA causes a chronic, symmetric, erosive synovitis of joints with synovial. All the joints can be involved. The hallmark of the disorder is chronic, symmetric polyarthritis (synovitis) that affects mostly the hands and feet,signs and symptoms: during the physical examination it is very important to look for the following:stiffhess (more than 30 minutes), tenderness, pain on motion, swelling limitation of motion, deformities, loss of muscles strength,muscles hypotrophy-atrophy.(2) The most important and frequent deformities of the hand are:l. Metacarpophalangeal joints - ulnar deviation:2. Fingers-"swan-neck" deformity results from contracture of the interosseous and flexor muscles and rupture of tendons of the fingers, resulting in a flexion of the MCP joint,hyperextension of PIP joint, and flexion of the DIP joint (see Fig.l) 1. "boutonnière" deformity consists of hyperflexion of the PIP and hyperextension of the DIP joints (see Fig. 1(2).2. "mallet" deformity is the hyperflexion at the PIP,3."Z" deformity of the thumbs (see Fig. l,2bis)(ll)Extra-articular manifestations of RA: Systemic severe morning stiffness, fatigue, malaise, fever, tiredness,weight loss. l.Skin - rheumatoid nodules, vasculitic lesions.2.Respiratory - interstitial lung disease.3. Hematologic - hypochromic-microcytic anemia, Felty's syndrome.4.Neurologic - entrapment neuropathies, myelopathies related to cervical spine instability, depression. 5. Cardiac - inflammatory pericarditis, valvular dysfunction. ó.Metabolic bone disease - osteoporosis. (2)

Criteria for RA (1987, American College of Reumathology Revised)Morning stiffness - lasting at least 1 hour before maximal improvement. 1. Arthritis of 3 or more - At least 3 joint areas simultaneously have had soft-tissue swelling; joint area fluid observed by a physician.2Arthritis of hand joints - At least 1 area swollen (as defined above) in a wrist, MCP, or PIP joint.3. Symmetric arthritis - Simultaneous involvement of the same joint areas (as defined in criterion 2) on both sides of the body (bilateral involvement of PIPs,MCPs, or MTPs is acceptable without absolute symmetry) 4Rheumatoid nodules - Observed by a physician.SSerum rheumatoid factor - Abnormal amounts of serum RF demonstrated by any method. (Studies have shown that around 5% of control subjects present with a positive test result.)6JRadiographic changes - Must include erosions or unequivocal bony calcification localized in, or most marked adjacent to the involved joints.7A patient is considered to have RA if he or she satisfies at least 4 of these 7 criteria. Criteria 1-4 must have been persisted for at least 6 weeks(l.)Causes:The cause of RA is still unclear; there are several incriminating factors as: infectious, hereditary, endocrinic, metabolic, occupational, and psychosocial factors Diagnosis differentials:Osteoarthritis, Systemic lupus erythematosus ,-Gouty arthritis ,Infectious arthritis,Reactive arthritis paraneoplastic syndromes ^Ankylosing spondylitis »Psoriatic arthritis.Laboratories studiesiRheumatoid factor (RF) is present in 75% of the cases, and is an immunoglobulin M (IgM) autoantibody directed against the Fe fragment of immunoglobulin G (IgG). Erythrocyte sedimentation rate is elevated, and it is a good marker of diseases activity. Gamma globulins are usually elevated, leukopenia may occur in the presence of splenomegaly (Felty syndrome) or as a side effect of drug therapy. The platelet counts, C-reactive protein are often elevated Antinuclear antibodies are present in 20% of patients, although in lower titers than in lupus. Joint fluid examination reveals specific changes for inflammatory arthritis end antibodies CCP, specific changes for inflammatory arthritis. (2).

Imaging Studies :Plain radiographs are most valuable and specific. The earliest changes occur in the wrists and fingers or feet, and consist of soft tissue swelling and juxta-articular osteoporosis, space narrowing. Later changes are erosions, diffuse osteoporosis, luxations, and deformities.

Rehabilitation Program:The most important goals include:pain relief,increasing ROM (range of motion),increasing strength and endurance,prevention and correction of deformities, counseling and education for the management of the restrictions made by the disease.Treatment modalities are the following: medication,exercise program occupational therapy .massage therapy, electrotherapy, splint, braces, orthotic devices, walking aids,heat and cold therapy,spa-therapy,surgical car,psychotherapy .Various physical modalities are widely used, but only a few studies , evidence based. This demonstrates the complexity of the disorder and the impossibility to find a proper and univocal treatment (3 Medications ? The goals of pharmacotherapy are to reduce morbidity and prevent complications. The major categories areinon steroidal anti-inflammatory drugs - NSAID (e.g., celecoxib, etoricoxib,nimesulid, meloxicam, diic\oîer\&Q), steroidal anti-inflammatory drugs - SAID (corticosteriods - e.g.,predinisone, betamethasone), disease modifying antirheumatic drugs - DMARDs (e.g., methotrexate, gold compounds, sulfasalazine, antimalarials, Dpenicillamine, leflunomide), or others with more immunosuppressant effects (e.g., cyclophosphamide, azathioprine, cyclosporin),Z?z'o/ogz'c treatment (e.g., infliximab, etanercept, adalimumab, anakinra.

Exercise program(ll) KinetotherapyPhysicsd exercise is the most important part of the rehabilitation management of RA. Group exercise should be done whenever possible.beneficial effects of exercise programs for patients with rheumatic diseases:Increases and maintains joint motion<Re-educates and strengthens muscles: Increases static muscle endurance. Increases aerobic capacity.Decreases the number of swollen joints.Enables better biomechanical joint function g. .Increases bone density.Increases overall patient function and well-being (fitness and wellness)Facfors to be considered when designing an exercise program for patients with inflammatory arthritis: Stage of joint involvement. Stadium of systemic involvement.Age of patient. Comorbid medical conditions. Compliance.Preparation for exercise and exercise sequence.Un fortunately in most patients exercise increases pain, and they also feel constantly tired as a result of reduction of aerobic capacity and muscular strength; these are the main reasons for lack of compliance. The first choice of technique, and veiy useful is rest, not only for RA but all inflammatory rheumatic diseases, mostly in acute phases, but prolonged rest can be harmful (see table I). (3). The best method to rest the joint is splinting. Techniques used in RA: active and passive motion, isometric exercise, isotonic and stretching exercises are welcome if they are well done (should be avoided in acute phases), and aquatic therapy.One of the most important advises is to "respect pain": none of the exercises should be forced, because it can increase inflammation, fluid accumulation, and tendon ruptures.

Kinetotherapy. Objectives: Prevent-deformation-and-vicious-attitudesDeviation of cubits forearm and fingers of the radial faces;Mobilization punch in flex-extension will be associating a degree of inclination cubitus .Refreshing cubital posterior (strained if not before) - enable mobilize resistance against the opposite kinetotherapists:Request exaggerated finger in a direction cubital is offset by: -integrity-of-thecollateral-ligaments-(rest-articular-local-,orteza);-for-index-enough-muscle-strength-of-the-flrst-dorsalinterosos-(refreshmg-throughcontractions-resistive);-for-auricular-enough-to-power-opozant-isbone(refreshing)(

Manua-lcontrarezistence-progressive-oneach-finger.

Prevent-deformation .Finger in the neck of the swan .Kinetic program . Refreshing-extensionspunch, (fig. 9) .Meal at the edge of hand, the girl web down, fingers flectate »perform active and active resistance, associated with extension fist inclination cubits resistance-is-applied-metacarpianul-V.(l)

Prevent-deformation.Deformation-in-buttonhole.Refresing-of-the-common-flexor-deeplyfingers.Flex-extension-at-MCF

Mobilization are not flexible in IFP (avoid slipping bandeletes side of the stretcher). Movements are active in only one joint articulations with the restraint should not participate in-the-movement

Active mobilization of MCF articulatiior. (fig. 10,1 1)

Extension-to-enable-contrarezistenta-articulations IFP in keeping with flexible articulations MCF .(fig.11,12)

Prevent-deformation. F olice-in-"Z"

In the early stages - in policelui mobilization and opposition abductie + IF restraint and MCFrectitudine-in-order-to-prevent-hiperextensia-F2 In the late phase -maintenance-pense police mobilization through digital articulatiei trapezo-and-metacarpal-index.(fig.l2,13,14,)

Refresing along the abductor of police. Hands on the table face down web, policele the edge table, abduced the police, il plan goes before the other fingers, the first resistance metacarpian(fig.l2-13)Girl with hands up web, flex proximal phalanx on the first metacarpian, the trumb. Is-led-in-resistanc-against-the-webof-phalanx-I(fig.l4) .

Dorsal face with the hand on the table is rounding strong and opposing policele of finger IV (fig.l5.)Signs of excessive exercise in patients with RA (affirmable for all rheumatic diseases): postexercise pain of more than 2 hours,undue fatigue,unexplained weakness,increased joint swelling.Aquatic therapy should be considered when patients are not in acute phase; the warmth and buoyancy of the water help the muscles relax and make some exercises easier to perform. Re-education of walking can be started in the pool.

Occupational therapy). Plays an important role in the rehabilitation of patients with RA for the following reasons:gives motivated action for the patients,teaches the physiological gestures and prevents joint deformations,deviations (joint protection),offers independency, learn ADLs which are modified by the disabilities. () Massage therapy. Massage should be used because of the following effects:pain relieve,muscle relaxant,increase flexibility,hyperemia,facilitate exercise program,other effects of massage (cardiovascular, respiratory, metabolic). In acute phase massage will avoid inflammated joints and it will treat other segments (e.g., back or arms). QElectrotherapy. It is a very useful treatment modality because of the following effects:ameliorating pain, stimulating circulation decreasing contractures,wemay choosedow frequency current (TENS, diadynamic) medium (interferential),ultrasound,low LASER-therapy. Splint, braces, orthotic devices, walking aMs.Splints are devices supporting or increasing the function of part of the body. There are three main roles of splints: Support-offers a correct Alignment-Protection (S-A-P), other functions are Correction and Immobilization.Functional classification of the orthosis used in RA:

Static or passive splints, which usually have no moving parts and immobilize or rest a joint or limb.Dynamic or lively splints, often have movable parts and allow controlled movement.Orthotic devices have the major role to prevent and correct deviations, and also reduce the signs of inflammation in patients with RA. (see Figure 16,17,18,19)

Once a deformity has been detected the whole team should focus on eliminating it, or at least preventing it from getting worse.Walking aids should be considered if there are severe deformities which make walking difficult, (see )Hand and wrist static splint

Specific attention need in bracing the cervical spine in subluxation/luxation. Sometimes neurosurgical inervention is needed.

Heat and cold therapy Patient's preference should direct the prescription of heat or cold. Cold is preferable for treatment of an acutely inflamed joint. Application of cold results in decreased pain and decreased muscle spasm. Cold may be delivered by ice packs, topical sprays, or ice water.In other cases warmth is well tolerated and useful as a pain reliever and for reducing stiffness. Warm therapy is frequently performed by wax bathing the hands, feet and/or knees. After the wax is peeled off the patient is asked to work through a few exercises (mobilization).Heat treatment should be followed by exercise.

Spa-therapy. Spa-therapy is used in a stabile stage of RA. There is evidence based for the use of thermal, sulfurous, salted and carbonated mineral water and for mud therapy as well.

Surgical care. The purpose of surgical intervention in patients with RA includes correction of deformities and functional improvement. A number of surgical procedures are available to obtain these goals (excision of synovial membrane, reconstructions, and joint replacements). (11)

RECUPERAREA KINETICÄ A PACIENTUOR CU POLIARTRITÄ REUMATOIDÄ (PR)

Viorica LEFTER1

Paul ICHIM1

Andreea Oana CIBU2

1 Universitatea "Dunärea de Jos" Galati, FES

2 Universitatea "Dunärea de Jos" Galati, Facultatea de Medicina

Cuvinte cheie: poliartritá, kinetoterapie, anchilozä, deviatie, orteze.

Rezumat

Tabloul clinic al mâinii reumatoide este complex cu afectan multiple la nivel osteo-articular, muscular, tendoane, ligamente . Leziuni la nivelul pumnului:tenosinovita extensorilor ,sinovita radiocarpiana ,sidrom de cap cubital ,sidrom de canal carpían ,redoarea pumnului, mai ales ín flexie, sub actiunea preponderenta a flexorilor, initial subluxatie palmara, ulterior asociata cu deviatia radiala a pumnului. Leziuni la nivelul degetelor: deviatta cubitalä a degetelor,.degete "în gît de lebädä,degete "in butonierä, policele "in ?", tenosinovitele mâinii .Evaluarea clinico - functionalä orienteazä programul recuperator,contureazä metodologia adecvatä fiecarui caz, obiectiveaza efectele clinice obtinute prin anumite proceduri,orienteazä asupra prognosticului.Tratamentul mâinii reumatoide. Obiective xonservarea capacitatii functionale a mâinii reumatoide, în primul rând sub aspect musculo-articular,prezervarea capacitatii functionale restante (pentru flecare etapa în parte a bolii),adaptarea la activitatile cúrente în functie de restantul functional real,mentinerea autonomiei functionale prin exploatare maximala a capacitatilor reale restante. Kinetoterapia - Obiective: prevenirea deformarilor Si a atitudinilor vicioase,mentinerea sau creSterea mobilitatii articulare,creSterea fortei Si rezistetei musculare,tratamentul kinetic trebuie sä fie,precoce , continuu, permanent ,adaptat fazei evolutive a fiecarui pacient, adaptât tipului de deformare existent, adaptât restantului functional real de etapa, adaptât necesitätilor functionale obiective aie subi ec tului . Ergoterapi e . (2)

Introdúcele

Poliartritá reumatoidä (PR) este recunoscutâ în prezent ca o boalà severa, autoîntretinuta si progresiva, care induce leziuni osteoarticulare importante, cu deficit functional si pierderea capacitatii de munca, asociindu-se cu o mortalitate prematura considerabilä, ce reduce semnificativ speranta de viata a bolnavilor eu PR.(1) Poliartritá reumatoidä (PR) numitä si artritä reumatoidä (AR) este o artropatie cronica, cu carácter progresiv, distructiv si déformant, însotitade multiple manifestali sistemice.(l)

Tabloul clinic al mâinii reumatoide.Complex.Afectari multiple la nivel osteo-articular, muscular, tendoane, ligamente

Leziuni la nivelul pumnuluiTenosmovita extensorilor - o tumefactie trapezoidala care coboara pana la baza metacafienelor.Sinovita radio-carpiana - o masa inflamatorie fixa.

Sdr. de cap cubital - o proeminenta a stiloidei cubitale palpabila datorata subluxatiei posterioare a capului ulnei prin artrita radio-ulnara si ruperea ligamentului colateral al ulnei.

Sdr de canal carpían - inflamaría carpului + lipsa de elasticitate a ligamentului transvers,asociat cu compresia nv median la trecerea sa prin canalul carpían

Redoarea pumnului, mai ales in flexie, sub actiunea preponderenta a flexorilor, initial subluxatie palmara, ulterior asociata cu deviatia radiala a pumnului.

Leziuni la nivelul degetelor

1. Deviatia cubitala a degetelor leziune característica - subluxatia anterioara MCF apare gradat primul semn - instabilitatea articulatiei - tractiunea tendoanelor lungului flexor care deplaseaza artic. slabita si instatola, in directie palmara - extensorii contracareaza flexia <=> devierea este reductibila =>ulterior extensorii sunt si ei antrenati in deviatia cubitala, parasesc promotoriul MCF, ajung in spatial intermetacarpo - falangian

Alte consecinte: dizlocatia artic RC inferioare, subluxatia dorsala a capului cubital (coafarea apofizei stiloide), deplasarea ant. a tendonului cubitalului posterior

2.Degete "in gat de l ebada "Sinovita proliferativa a MCF si subluxatia FI la nivelul MCF <=> hiperextensia IFP (actiunea a extensorului asupra FII) => alunecare dorsala a tendoanele extensoare laterale spre linia mediana, se relaxeaza si pierd actiunea de extensori asupra FUI care este supusa actiunii actiunii preponderente a flexorului comun profund asupra FUI <=> flexia IFD- afectarea prehensiunea digito-palmara si polici-digitala

3.Degete "in butoniera" - Sinovita proliferativa a IFP care invadeaza si distruge bande leta mediana a aparatului extensor la nivelul fetei dorsale a IFP, cu afectarea insertici extensorilor pe falanga II "=> flexia IFP si pierderea extensiei active. - Bandeletele laterale ale extensorilor ,aluneca in pozitie palmara, pe fata laterala a IFP care proemina intre eie ca intr-o butoniera., nemaifiind frenate prin insertia pe FU si fiind distruse la nivelul fetelor laterale ale IFP>=> hiperextensia FIII.Flexia moderata a IFP este tolerabila, neafectand prea mult prehensiunea. Flexia mare a IFP afecteaza insa prehensiunea digito-palmara si polidigitala.

4.Policele "in Z" - sinovita MCF => flexia FI ca urmare a insuficientei scurtului extensor si actiunii predominante a muschilor tenarieni - ruptura tend, flexorul profund alpolicelui => hiperextensia IF - afectarea articulatiei trapezo-metacarpiene cu atitudine antalgica in flexie si adductie a primului metacarpian - ruptura tendonului lungului extensor *=> subluxatia externa a bazei primului metacarpian .(6)

5. Tenosinovitele mainii .2/3 bolnavi cu PR, frecvent in etapa initiala .Tenosinovitele inflamatorii initiale regresive => leziuni ireversibile. Rupturi posibile - cazuri vechi, varstnici, tendoane fragilizate prin leziuni de vecinatate (sinovite, subluxatii etc)(2)

Acestea sunt: tenosinovita pumnului si a policelui (a primului tunel dorsal - tenosinovita de Quervain) - pentru tend, lungului abductor si scurtului extensor al policelui,tenosinovita canalului digitai (a flexorilor), mai frecvente la index si auricular; Tenosinovita nodulara (degete "in resort"): flexia degetului nórmala dar extensia dupa flexie nu este posibila decat dupa un "declin" dureros, sau cu asocierea unei extensii pasive.Toate tipurile lezionale pot fi asocíate cu : noduli reumatoizi in zonele de presiune, fen. de vasculita, tulburari neurologice

Evaluarea Clinico - Functionala

* orienteaza programul recuperator

* contureaza metodologia adecvata fiecarui caz

* obiectiveaza efectele clinice obtinute prin anumite proceduri

* orienteaza asupra prognosticului

Bilant evolutiv (durata redolii matinale, intensitatea durera - VAS si indice Ritchie, nr de articulara tumefiate, sdr biologie de inflamatie, ex radiologie ).Bilant articular Bilant muscular. Testarea capacitatii aerobe - test de mars.Deformari articulare reduetibile/ ireduetibile si consecintele functionale. Bilant functional (Lee, HAQ) - prehensiunea si locomotia(5)

Diagnosticul imagistic al mainii reumatoide

Afectare precoce: stiloida ulnara - sediul de electie al primelor modif. Rx (osteoporoza, microgeode, eroziuni marginale); artic MCF II si III

Stadializarea - funetie de st. anatomica, in stransa rei. cu aspectul Rx. Stadiul I. precoce: aspect Rx norm +/- osteoporoza. Stadiul II, moderat: osteoporoza vizibila rrx +/- distruetii osoase, posibila deteriorare a cartilajului articular; atrofie musc; limitarea miscarilor artic; abs. deformarilor articulare; +/leziuni de parti moi, noduli reumatoizi, tenosinovite.(3)

Stadiul III, sever : osteoporoza, distructiile osului si cartilajului evid. Rx;

deformare artic eu subluxatii, deviere ulnara sau hiperextensie, dar farà fibroza sau anchiloza;atrofie musc marcata si extinsa ;prez de noduli reumatoizi si tenosinovite.

Stadiul IV, terminal : criteriile stadiului III + fibroza articulara si anchilozanta.

Rezonanta magnetica nucleara ( RMN )

- evidentiaza precoce eroz. osoase, chístele osoase subcondrale, alterarea cartilajului artic, hipertrofia sinovialei, starea structurilor periartic, modificarile de la nivelul unor localizan mai greu de observât radiologie.

- cea mai buna modalitate de evaluare a eficientei unui tratament remisiv in stadiile clinice (monitorizarea distructiilor articulare)

TRATAMENTUL MAINII REUMATOIDE. Objective

* Conservarea capacitatii functionale a mainii reumatoide, in primul rand sub aspect musculoarticular

* Prezervarea capacitatii functionale restante (pentru flecare etapa in parte a bolii)

* Adaptarea la activitatile cúrente in functie de restantul functional real

* Mentinerea autonomiei functionale prin exploatare maximala a capacitatilor reale restante

Combaterea durerii si inflamatiei .Medicatie.Mijloace fizice - electroterapia de joasa freeventa - CDD in formula analgetica, curent galvanic, TENS - US, laser - caldura blanda in afara puseelor inflamatorii acute - masaj\Repaus - general (8h nocturn, Ih inainte si Ih dupa masa) - segmentar al mainilor (in puseu - maxim 3 saptamani, amelioreaza durerea si inflamada in fazele initiale, previne deformarea in fazele avansate)^ Postura (umar - in semiflexie si usoara abductie, cot - in semiflexie 80° si pozitie intermediara de pronosupinatie, pumn - in extensie 20-30°, degete - semiflectate ) Orteze statice / atele in perioadele de puseu inflamator - pansamente compresive, comprese aplícate in scop decongesti ve. Combaterea atrofiilor musculare; programul kinetic a dap tat, cal dura blanda uscata/umeda,masaj (bland, resorbtiv, ascendent),electroterapia de tip vasculotrofic muscular (curentii interferentiali, curent galvanic) Cresterea mobilitata articulare. Kinetoterapie pasiva/ activa ( ± hidrokinetoterapie1). Combaterea leziunilor secundare de parti moi periarticulare (tendinite, tenosinovite, bursiteìln stadiul acut - imobilizare, aplicatii de gheata, comprese reci cu solutie de sulfat de Mg, US cu hidrocortizon, laser.Masaj - o forma particulare masajul transversai profun dupa metoda Cyriax.Electroterapie antalgica.Kinetoterapia adecvata stadiului clinic, resurselor fiinctionale si posibilitatilor reale de compensare. Combaterea contracturilor musculare . Posturari. Caldura. MasajCurenti interferentiali aplicati in formula decontracturanta .Combaterea deforman lor articulare

In stadiile acute - imobilizari pe orteze de repaus.In stadiile subacute/ cronice - tonifiere musculara a grupelor hipotone, pentru a preveni contractia fais excesiva a antagonistilor (deformarile reversibile se corecteaza mimai activ, niciodata pasiv) + orteze de corectie

Combaterea modificarilor circulatorii ale extremitatilor => aparute datorita spasmelor vasculare, cu predilectie la nivelul circulatiei periferice prin procésele neurovegetative (in principal simpaticotonie), procésele inflamatorii spécifiée (vasculita reumatoida) Proceduri alternante de hidroterapie locala,, bai de C02/ mofete

Combaterea demineralizarii o-SOaseKinetoterapia activa, analitica, la limita durerii

MIJLOACE DE TRATAMENT .1. Medicamentos: terapia de fond, simptomatica, condroprotectoarell. Fizical- kinetic:aplicatiile de caldura cu urmatoarele efecte: diminuarea spasmului muscular si a durerii, cresterea extensibilitatii colagenului si a elasticitatii structurilor periarticulare, accentuarea resorbtiei infiltratelor sau edemelor; de regula se aplica umeda in PR, uneori sub forma de hidrokinetoterapie;balneo/hidroterapia,aplicatii de curent galvanic cu urmatoarele efecte: antalgic, miorelaxant, vasculotrofic; se aplica sub forma de bai galvanice, galvanizan, ionoforeza,electroterapie (inclusiv ultrasunetul) pentru efectele terapeutice deosebite analgetice, de asuplizare a structurilor periarticulare, decontracturant masajul folosit pentru efectele sale de crestere a circulatiei musculare si a tonusului muscular (combate atrofiileì.kinetoterapia - terapie de fond .III. Terapie ocupationala.IV. Terapii alternative.V. Psihoterapia.VI.Tratamentul chirurgical.In timpul puseelor de evolutivitate se indica:repausul articular, de regula ortezat - orteze de repaus - orteze de corectie (a deformatiilor) - orteze de functiune.Kinetoterapia este mimai activa si se efectueaza in limita functionala ,se lucreaza farà durere

Kinetoterapia - Obiective: Prevenirea deformarilor si a atitudinilor vicioase

Deviatia cubitala a degetelor si radiala a carpului.Deviatia cubitala a degetelor si radiala a carpului.Tonifierea flexorilor comun profund si superficial al degetelor. Tonifierea apara tului extensor al degetelor Degetul in gai de lebada.Vrogram kinetic : - tonifierea flexor comun superficial degete . Deformatiti in butonierà - tonifierea extensorilor pumnului. Tonifierea fiexorului comun profund degete .Flexie-extensie la nivelul MCF.Nu se fac mobilizari in flexie a IFP (se evita alunecarea bandeletelor laterale ale aparatului extensor). Mis cari le active se realizeaza doar la o singura articulatie cu imobilizarea articulatiilor carenu trebuie sa participe la miscare.

Poticele in Z. In faza incipienta - mobilizarea policelui in abductie si opozitie + imobilizarea IF si MCF in rectitudine pentru a preveni hiperextensia F2

In faza tardiva - mentinerea pensei police-digitale prin mobilizarea articulatiei trapezo-metacarpiene si a indexului

Mentinerea sau cresterea mobilitàtii articulare.

Mobilizari active, eventual active ajutate, de preferinta in apa.Exercitiile pasive pot fi necesare pentru a atinge un maxim de amplitudine.Exercitii izotonice cu sau farà rezistenta moderata sau descrescanda la finalul miscarii pentru a nu fi activât antagonista. Tehnici de facilitare neuromusculara Kabat. Stretching activ si pasiv in faza subacuta si cronica

Cresterea fortei si rezistentei musculare.Un muschi nefolosit pierde 3% din masa sa intr-o saptamana

In faza acuta : exercitii izometrice, contractie máxima 1/zi.In faza subacuta : exercitii izometrice - 6 contractii/zi, izotonice cu rezistenta, scripeto-terapie cu rezistenta, terapie ocupationala.In faza cronica : ex izometrice, izotonice + hidroterapie, terapie ocupationala

ORTEZE -obiectivul terapeutic.Orteze de repaus si de protectie articulara - prin care se urmareste: pozitia de protectie articulara, e vitarea sau limitarea redorii,controlul durerii, controlul tendintei la deformari/deviatii articulare si periarticulare, asigurarea unei maini functionale. Orteze de corectie (rigide sau dinamice). Orteze de substitutie functionala (statice sau dinamice).Orteze de repaus. Orteze de corectie. Orteze dinamice(Nica)

TERAPIA OCUPATIONALA (Ergoterapia) .Objective generale:ameliorarea durerii si inflamatiei,combaterea/ ameliorarea atrofiilor musculare,ameliorarea/ compensarea limitarli mobilitàtii articulare,prevenirea/ compensarea contracturilor/ retracturilor (si a altor leziuni de parti moi),prevenirea/ compensarea deformarilor articulare,ameliorarea modificarilor circulatorii, combaterea/ ameliorarea demineralizarii osoase. Deviatia cubitala a degetelor Prevenirea ei se realizeaza primfolosirea prehensiunii bidigitale termino-terminale,evitarea prehensiunii termino-laterale si subtermino-laterala (accentueaza deviatia),in performarea prehensiunii polici-digito-palmare se va evita pronatia.Activitati recomandate: Scris cu inele corectoare.Confectionarea marge lelor din hartie.Rularea unei fesi sau a altor materiale in directie radiala

Deformatia degetelor " in gat de lebada"

Activitati recomandate :Cusut.Brodat cu acul.Impletit cu andrelele.Crosetat

Deformatia degetelor " in butoniera"Activitati recomandate :Insirarea margelelor pe ata.Insirarea margelelor de diferite dimensiuni.Cusut, brodat.Deformatia policelui " in Z"

- aceleasi activitati ca pentru deviatia cubitala.Terapia ocupationala trebuie sa asigure: Protectie articulara .Prudenta fata de durere - reducerea activitatii in functie de intensitatea durerii.Modificarea schemelor de miscare . Distribuirea greutatii pe mai multe articulatii : Se foloseste o arie maxima a palmelor pentru sustinerea unui obiect, cu degetele in extensie si articulatia radio-carpiana in extensie sau pozitie neutra cu cotul in unghiuri variabile de flexie,folosirea articulatiilor mari pentru anumite actiuni: Se foloseste palma sau marginea cubitala pentru impingerea unui obiect (nu se folosesc varfurile degetelor). Folosirea articulatiilor in pozitiile cele mai stabile si functionale. Reducerea efortului.Evitarea pozitiilor care favorizeaza deformarile. Conservarea energiei

Concluzii Tratamentul functional al mainii reumatoide: Trebuie sä fie precoce.Trebuie sä fie continuu. Trebuie permanent adaptât fazei evolutive a fiecarui pacient. Trebuie adaptât tipului de deformare existent. Trebuie adaptât restantului functional real de etapa

Trebuie adaptar necesitatilor functionale obiective ale subiectului

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