SUBMISSION OF SYNOPSIS FOR THE REGISTRATION OF THE DISSERTATION FOR MASTER OF PHYSIOTHERAPY
SUBMITTED TO
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
SUBMITTED BY
SALVI SAGAR PRADEEP
NAVODAYA COLLEGE OF PHYSIOTHERAPY
P.B. NO. 26 MANTRALAYAM ROAD, RAICHUR
KARNATAKA
JULY 2013
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
ANNEXURE - II
1. / NAME OF THE CANDIDATE AND ADDRESS: / SALVI SAGAR PRADEEPNAVODAYA COLLEGE OF PHYSIOTHERAPY, MANTRALAYAM ROAD, RAICHUR.
2. / NAME OF THE INSTITUTION: / NAVODAYA COLLEGE OF PHYSIOTHERAPY,
MANTRALAYAM ROAD, RAICHUR.
3. / COURSE OF STUDY AND SUBJECT: / MASTER OF PHYSIOTHERAPY (MPT)
PHYSIOTHERAPY IN MUSCULO-SKELETAL DISORDERS AND SPORTS
4. / DATE OF ADMISSION TO COURSE: / 05/7/2013
5. / TITLE OF THE TOPIC:
“ A COMPARATIVE STUDY TO ANALYSE THE EFFECT OF ISOMETRIC STRENGTHENING EXERICISES WITH WAXBATH THERAPY ON GRIP STRENGTH AND HAND FUNCTIONS IN PATIENTS WITH RHEUMATOID ARTHRITIS OF HAND”
PROFORMA FOR THE REGISTRATION OF SUBJECT OF DISSERTATION
6. / RESEARCH QUESTION:Does isometric strengthening exercises and wax bath therapy has any effect on improving grip strength and hand functions in patients with Rheumatoid arthritis of hand?
6.1
6.2 / BRIEF RESUME OF THE INTENDED WORK:
Rheumatoid arthritis (RA) is an autoimmune inflammatory chronic systemic disease, which is particularly manifested at the synovial membrane of diarthrodial joints and can result in destruction of the involved joints, leading to severe disability and premature mortality. It is present in 0.5% to 1% of the general population, twice as often in women, and the age at disease onset is mainly between 45 and 65 years.1, 2
The etiology of RA is still unknown but complex genetic factors, as well as lifestyle and exposure factors are of importance. Given the presence of auto antibodies, such as rheumatoid factor (RF) and anti–citrullinated protein antibody (ACPA) (tested as anti–cyclic citrullinated peptide [anti-CCP]), which can precede the clinical manifestation of RA by many years; RA is considered an autoimmune disease. Autoimmunity and the overall systemic and articular inflammatory load drive the destructive progression of the disease.3
The pre-disposing factors are,2
· Genetic influence-More than 75% patients have positive family history. There is a strong association with HLA-DR4 immune response gene.
· Infectious agents
· Trauma, psychological factors
RA is a chronic polyarthritis. In approximately two-thirds of patients, the infectious agents such as the mycoplasam, Epstein Barr virus (EBV), cytomegalo virus (CMV), are situated locally. After the process of immune pathogenesis in response to the
antigen, The (HLA-DR) and (CD4 + T-cells) are activated to elaborate the cytokines (TNF-α, INF-γ, IL-1) which activates the endothelial cell, B-lymphocytes and macrophages and triggers the inflammation to damage the synovial membrane which leads to damage of the small blood vessels and collagen fibers and damages the bone and cartilage, leads to fibrosis and joint deformities. It begins insidiously with fatigue, anorexia, generalized weakness, and vague musculoskeletal symptoms until the appearance of synovitis becomes apparent. Specific symptoms usually appear gradually as several joints, especially those of the hands (proximal interphalangeal and metacarpophalangeal joints), wrists, knees, and feet, become affected in a symmetric fashion. 3
Pain, swelling, and tenderness may initially be poorly localized to the joints. Pain in affected joints, aggravated by movement, is the most common manifestation of established RA. Generalized stiffness is frequent and is usually greatest after periods of inactivity. Morning stiffness of less than 1-hour duration is an almost invariable feature of inflammatory arthritis. Clinically, synovial inflammation causes swelling, tenderness, and limitation of motion. Initially, impairment in physical function is caused by pain and inflammation, and disability owing to this is a frequent early feature of aggressive RA. Initially, motion is limited by pain. The inflamed joint is usually held in flexion to maximize joint volume and minimize distention of the capsule. Later, fibrous or bony ankylosis or soft tissue contractures lead to fixed deformities. Synovitis of the wrist joints is a nearly uniform feature of RA and may lead to limitation of motion, deformity, and median nerve entrapment (carpal tunnel syndrome).2
Characteristic changes of the hand includes (1) radial deviation at the wrist with ulnar deviation of the digits, often with palmar subluxation of the proximal phalanges (“Z” deformity); (2) hyperextension of the proximal interphalangeal joints, with compensatory flexion of the distal interphalangeal joints (swan-neck deformity); (3) flexion contracture of the proximal interphalangeal joints and extension of the distal interphalangeal joints (boutonnière deformity); and (4) hyperextension of the first interphalangeal joint and flexion of the first metacarpophalangeal joint with a consequent loss of thumb mobility and pinch. Later in the disease, disability is more related to damage to articular structures.2
According to the revised classification criteria of American College of Rheumatology (ACR) 4, 5 1987 have been used.
Criterion
1. Morning stiffness
2. Arthritis of three or more joint areas
3. Arthritis of hand joints
4. Symmetric arthritis
5. Rheumatoid nodules
6. Serum rheumatoid factor
7. Radiographic changes
* Criterion 1-4 must have been present for at least 6 weeks
According to the American college of Rheumatology the Revised Criteria for classsification of functional status in RA.6
Class I - Complete able to perform usual activities of daily living ( self care, vocational, avocational)
Class II – able to perform usual self care and vocational activities but limited in avocational activities
Class III- able to perform usual self care activities but limited In vocational and avocational activities
Class IV- limited in ability to perform usual self care, and avocational activities
Self care activities include dressing, feeding , bathing, grooming and toileting. Avocational (recreational and or leisure) and vocational ( work, school, home making) activites are pateint desired and age- and sex- specific.6
MANAGEMENT OF RA:
Medical management:
Medical management includes, disease modifying anti-rheumatic drugs (DMARDs), Non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids and immunosuppressant. Surgical treatment in early stage includes synovectomy and in later stages reconstructive surgeries like arthrodesis and total joint replacement 7, 8, 9
Physiotherapy management:
Physiotherapy management includes, wax bath therapy, Interferential therapy, transcutaneous electrical nerve stimulation, diathermy, and exercises. Exercises are strengthening exercises, flexibility exercises, free exercises etc.2
Diathermy: It increases blood flow in local arterioles and capillaries by producing sympathetic vasodilatation. It also accelerates the local metabolism. The increase in muscle blood flow is also associated with the removal of substances related to fatigue and pain-inducing substances within the muscle.8
Transcutaneous Electrical Nerve Stimulation (TENS) and Interferential therapy (IFT): It produces effects by activation of opioid receptors in the central nervous system. It reduces the excitation of central neuronsthat transmit the nociceptive information and activates the muscarinic receptors centrally to produce analgesia (by temporarily blocking thepain gate).10
Effects of wax bath therapy:
There is a marked increase in skin temperature in the 1st two minute, up to 12-13°c. Stimulation of superficial capillaries and arterioles cause local hyperemia and reflex vasodilatation.11 The hyperemia is due to response of the skin to its function of heat regulation. The effects of vasodilatation in the muscle are negligible, but then may be some reflex heating in the joints. Exercise after the wax is essential to increase the muscle circulation and sedative effect of heat to obtain more range of movement and muscle
strength. The most important effect of wax its marked sedative effect on the tissue.12 Wax leaves the skin moist, soft and pliable which is useful for stretching scar and adhesion before applying mobilization techniques. Overall, wax helps in reducing pain and stiffness of joints.11, 13
Effect of isometric exercises of hand:
Isometrics exercise helps in increasing joint flexibility and muscle strength.14 It helps to maintain bone and cartilage health, improves ability to perform daily tasks. Isometric exercises can help maintain strength to prevent injury or facilitate fatigue. According to Hettinger, daily isometric contractions of 10%-20% of maximum tension held for 10 seconds can maintain isometric strength. In RA patients, it has been shown that isometric strengthening can lead to ADL performance with reduced effort. Isometric strengthening exercises significantly improved grip strength and hand function in patients with RA.15, 16
HYPOTHESIS:
NULL HYPOTHESIS (H0):
There will be no significant effect on grip strength and hand functions followed by isometric strengthening exercises and wax bath therapy in patients with Rheumatoid arthritis of hand.
ALTERNATIVE HYPOTHESIS (H1):
There will be significant effect on grip strength and hand functions followed by isometric strengthening exercises and wax bath therapy in patients with Rheumatoid arthritis of hand.
6.3 / REVIEW OF LITERATURE:
1. Cima et al (2013)17 conducted study to evaluate the effects of an exercise program in improving the hand strength in individuals with hand deformities resulting from RA and to analyse the impact these exercises have on functionality.20 women of Group 1 (n=13) participating in the exercise program, Group 2 (n=7) with RA who received no treatment for their hands (control).The treatment program for hands consisted of 20 sessions, twice a week and at-home exercises. Both groups were submitted to Health Assessment Questionnaire (HAQ) and evaluation of HS and PS by means of dynamometry. Group 1 and after 2months in Group 2. After 20 sessions, Group 1 had a significant gain in HS and PS (p0.05) in addition to the improvement of functionality as assessed by HAQ (p=0.016). Group 2, no difference was found between (p0.05).They concluded that the strengthening exercises for individuals with RA hand deformity are beneficial to improve handgrip and pinch strengths as well as functionality.
2. Dilek (2013)18 conducted RCT to evaluate the efficacy of paraffin wax bath therapy on pain, function, and muscle strength in patients with hand osteoarthritis. Patients were randomized into 2 groups- Group 1 (n=29) had paraffin bath therapy (5 times per week, for 3-week duration) for both hands. Group 2 (n=27) was the control group The primary outcome measure was pain (at last 48h) at rest and during activities of daily living (ADL), assessed with a visual analog scale (0-10cm) at 12 weeks. The secondary outcome measure was the Australian Canadian Osteoarthritis Hand Index (AUSCAN). At baseline, there were no significant differences between groups in any of the parameters (P>.05) When the 2 groups were compared, pain at rest, both at 3 and 12 weeks, decreased in the paraffin group (P<.05) Paraffin bath therapy seemed to be effective both in reducing pain and tenderness and maintaining muscle strength in hand osteoarthritis
3. Dogu et la (2013)19 conducted a RCT to evaluate the effect of 6-week-long isotonic and isometric hand exercises on pain, hand functions, dexterity and quality of life in women’s (age 40-70 years) diagnosed as RA. All patients were applied wax therapy in the first 2 weeks. The pain was assessed with visual analog scale (VAS), and their hand functions with Duruo¨z Hand Index (DHI) and hand grip strengthening.(HS) . VAS and DHI scores improved in both exercise groups (p = 0.002; p = 0.0001) while isometrics showed a significant increase in dominant HS (p = 0.029). Authors have concluded that isometric and isotonic hand exercises decrease pain and disease activity and improve hand functions, dexterity and quality of life.
4. Brorsson et al (2009)20 conducted study to evaluate the effects of hand exercise in patients with RA, and to compare the results with healthy controls. 40 women (20 patients with RA and 20 healthy controls) performed a hand exercise programme. The results were evaluated after 6 and 12 weeks with hand force measurements. Hand function was evaluated with the Grip Ability Test (GAT) and with patient relevant questionnaires (DASH and SF-36). The extension and flexion force improved in both groups after 6 weeks (p < 0.01). Hand function (GAT) also improved in both groups (p < 0.01). The rheumatoid arthritis group showed improvement in the results of the DASH questionnaire (p < 0.05). They have concluded that hand exercise is an effective intervention for RA patients, leading to better strength and function.
5. Bastiana et al (2008)21 conducted an experimental study to evaluate the effect of range of motion (ROM) and muscle strengthening exercises for 6 weeks on grip strength and hand function in RA patients. 17 patients with chronic RA were randomly assigned to a treatment group A (n=8), muscle strengthening exercises and paraffin baths 3 times a week and ROM exercises once a day at home for 6 weeks) and a control group B (n=9), was treated paraffin baths 3 times a week). After 6 weeks, there were significant differences in hand function (p=0.003), and bilateral hand strength (p=0.000 and p=0.001). ROM and isometric strengthening exercises significantly improved grip strength and hand function in patients with RA, while no
Impact was found when the patients were given paraffin baths only.
6. Ronningen et al (2008)22 conducted a RCT to test the effect of an intensive hand exercise programme in patients with RA. The first 30 participants received a conservative exercise programme (CEP), while the next 30 received an intensive exercise programme (IEP). Outcomes were assessed at baseline, and after 2 and 14 weeks. Hand strength, measured as grip strength and pinch strength, was the primary
Outcome variable. Secondary outcomes were joint mobility, hand pain, and functional ability. After two weeks, there were significant differences between the groups in favor of the IEP in pinch strength in the dominant hand (p=0.01), as well as grip and pinch strength in the non-dominant hand (p=0.04 and 0.05). Authors have concluded that an intensive hand exercise programme is well tolerated and more effective in improving hand function in patients with RA.
7. O’Brien et al (2006)23 conducted RCT to evaluate the effectiveness of three different physiotherapeutic approaches in the management of the RA in 3 groups. Group 1 participants received a set of additional hand- strengthening and mobilizing home exercises, group 2 a different set of additional hand-stretching exercises and group 3 the JP information alone. Analysis was by intention to treat group (1) n=21, group (2) n=24 and group (3) n=22. A 78% follow-up was achieved at 6 months. In groups 2 and 3 there was a mean increase in Arthritis Impact Measurement Scales (AIMS) II scores of 0.18 (1.54) and 0.30 (1.22). The differences in AIMS change scores between group 1 and groups 2 and 3 were statistically significant (P=0.007) and remained so after adjustment for multiple testing (P=0.012).They have concluded that the significant improvements in arm function have been demonstrated following a program of home-strengthening hand exercises in RA patients.