Physical therapy on inflammatory arthritis at Tiberius Hot Springs5

Therapy – potential benefits in psoriatic arthritis

Drd. Laviania Claudia
Dr. Virgil PATRASCU1,

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1University of
Medicine and Pharmacy Craiova, Romania



Keywords: Psoriatic
Arthritis Pain, SF-36; Physical Therapy


Psoriatic arthritis (PsA) is an autoimmune, seronegative,
chronic inflammatory disease of the osteo-articular system that affects people
with psoriasis (cutaneous, nail). Some patients have a mild illness that can
respond to therapeutic intervention, while others have erosive arthritis that
is often refractory to multiple treatments and potentially associated with
functional disability and poor quality of life1. The disability
effect of PsA was compared with that of patients with rheumatoid arthritis
(RA), and the results showed that function and quality were similar for both

Different approaches to kinesiotherapy have been proposed
and adopted for the different manifestations of PsA; some have been borrowed
from other types of inflammatory arthritis, such as RA and ankylosing
spondylitis (AS). Recently, the GRAPPA (Psoriasis and Psoriasis Arthritis and
Psoriasis Research and Assessment Group) proposed an evidence-based approach
and a basis for treatment guidelines. However, some proposed, after a
systematic review of the literature, a treatment algorithm in which
physiotherapy was the second line of therapy in PsA3.

I will in the following phrase a brief summary of kinesiotherapy in PsA after reviewing the literature identified on Medline, EMBASE, and CINAHL from 1996 to 2007, using key terms psoriatic arthritis, ankylosing spondylitis, psoriasis, spondylitis, peripheral arthritis, physiotherapy and kinesiotherapy. All articles that included data on this subject, as well as any summaries of the American College of Rheumatology and the European Rheumatology Congress, were considered. The search did not provide any study with level 1/A based evidence in PSA patients; It was only found minor studies on the role of physical therapies such as interferential current4, the beneficial effects of climate therapy on inflammatory arthritis at Tiberius Hot Springs5 and the effect of balneotherapy in the Dead Sea area for patients with PsA and concomitant fibromyalgia6.However, as mentioned above, a systematic review of the role of physiotherapy in patients with AS7 showed that these studies were considered appropriate for proposing an algorithm for joint involvement therapy in PsA3. In particular, physical therapy of the supervised group improved overall function, pain and health compared to individual home exercises7. Instead, as part of the rehabilitation program, patient education was evaluated in a PSA patient group through a self-administered questionnaire evaluating their level of knowledge and the results showed that the exercise was considered an important part of the plan treatment and a good approach to reduce the chances of joint deformity8.

Concluding, we can say that the main kinesiotherapy results in PsA are
summarized as follows:

 – Very little evidence is
available to evaluate the effectiveness of physical therapy;

 – Some data have been obtained
from studies on AS77;

 – Coverage of disease aspects
through standard operating measures presents difficulties.

In view of the above, I consider it necessary to implement a study
evaluating the effects of secondary kinetoprophyxia in Psoriatic Arthritis. In
this regard, I propose a multicenter, open, controlled study to compare the
effects of standard therapy (Group A) with the effects of standard therapy +
kinesiotherapy (Group B). The assessment of the effects will be done with the
help of quality of life questionnaires, VAS questionnaires for pain and
objective evaluation of the function of the locomotor apparatus according to
the European Society of Rheumatology guide. The study will follow the evolution
of patients for 3-6 months of therapy and will only address patients with PsA.


Subjects and methods

This was randomized, parallel trial. The subjects will
be assessed for eligibility at the screening visit within 2 weeks prior to
randomization. During this visit, all patients were assessed for eligibility
and were instructed in the use of the NPRS for pain intensity measurement and
other planned questionnaires. Before any study procedure, patients had to sign
the informed consent form. Treatment duration was be 28 days. Patients from one
group followed the physical therapy protocol and the other took their usual
treatment. During and after the treatment period, efficacy assessments was be
performed at different time points up to day 35, one week after finishing
treatment. Additionally, pain intensity was assessed daily by a diary since one
week before treatment start (day -7) to the final visit on day 35

Statistical analysis

The primary objective of this study was to describe the
pain release efficacy of the physical therapy and the impact on HRQOL in
addition to the regular pharmaceutical treatment in diabetic peripheral
neuropathy Romanian patients. For the primary objective, the statistical
analysis was basically descriptive, with continuous variables being expressed
as means, medians and modes, with point estimates, SD and two-sided 95% CIs and
qualitative variables (either dichotomous or ordinal) expressed as proportions
with 95% CIs. For continuous variables, subgroup analyses were performed by the
analysis of variance (ANOVA) in case of normal distribution, or non-parametric
Kruskal-Wallis test for non-normal distribution. Subgroup analysis were also
adjusted for covariates potentially influencing the outcome (age, gender,
domicile, duration of DM, level of HbA1c, obesity status, macro vascular
complications, retinopathy and therapeutic regimen) by use of ANCOVA. For
multiplicity correction of confidence intervals in ANCOVA model, the Bonferroni
method was employed. For sample-size estimation, although not formally
necessary, we assumed the prevalence of diabetes in Romania as being around 4%
out of the general population (including children), which gave us a total
estimation for diabetic population of around 850.000 patients. For a confidence
level of 95% and a pre-specified two-sided confidence interval of +/-5% for a
dichotomous variable (e.g. presence/absence of a certain factor), the number of
patients enrolled with usable data should be 384.

Subjects: Eligible subjects were
men or women, at least 18-year old, with PsA for at least 1 year and with drug
therapy started at least 6 months before the enrollment in the study. No change
in actual drug therapy for at least 3 months, except dose adjustments was
allowed. Exclusion criteria were: diabetic peripheral neuropathy pain history
of diabetic ketoacidosis, documented psychiatric diseases or major depression
and participation in other clinical trials.

Results A number of 374 eligible PsA
patients, enrolled in 4 centers were included in the study. The study
population was younger than general PsA (mean age 42.12 years, median 39
years), living predominantly in urban conditions (71.8%) and having generally
medium or high-level education (86.9% graduated at least high-school).
Retirement percent was high (66.4%). Approximately 50% of patients were obese,
as shown by median BMI of 30.5. Specific diabetes complications were not common
(most frequent was neuropathy -10.5%), as the median duration PsA
was 3 years. For the descriptive analysis of PROs, as many as 372 patients
completed the questionnaires and was included in the analysis. Physical Therapy
exerts an overall significant positive impact on quality of life with a mean
weighted ADAQoL score of 2.27 (95%CI: 2.57 -1.97). Every domain included in ADAQoL
questionnaire was positively and significantly impacted. The most positively
impacted domains were future worry and family life (mean scores 3.13 and
respectively -2.85), whilst lowest impact was on living conditions
(habitation), other people’s reaction and financial situation (0.78, 1.37 and
respectively 1.84) (Fig.1). Arthritis-dependent quality of life (AQoL),
measured by the single overview item, shows also a positive and statistically
significant impact, with a mean value of 1.52 (95%CI: 1.60 -1.43). Patients rated
their actual quality of life with a mean overall positive score of 0.80 (95%CI:
0.72 -0.88) (Fig.2). The SF-36 score showed also a significant positive effect
of the physical therapy. The Treatment Satisfaction score, Perceived Frequency
of Pain (“Pain Fear”) was assessed by PTSQs. Mean treatment satisfaction score
was 29.60 (95%CI: 29.07 -30.14) out of a 0-36 scale, indicating that patients
were generally satisfied with their physical therapy treatment. Most patients
perceived pain seldom, as 25.3%, 20.5% and 17.8% indicated their frequency as
never, very rarely or rarely, respectively. The EQ-5D descriptive component
showed significant increase in quality of life for all the five domains
assessed (mobility, self-care, usual activities, pain/discomfort and
anxiety/depression), mean values varying between 0.05 for self-care and 0.32
for pain/discomfort (out of a 0-3 scale).

3. 4. Discussions

question arises whether the improvement in measures of quality of life seen
with physical therapy is due to its effect as an antidepressant9
effect shown by the physical activity or due to a reduction in pain. In
addition, it is unclear how much pain reduction can be attributed to
improvements in mood and what effect on mood physical therapy may have on
patients who do not have MDD. For this reason, patients who met criteria within
the past year for the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV) Axis I diagnosis of MDD, dysthymic disorder, generalized
anxiety disorder, alcohol or eating disorders were excluded from enrollment in
the duloxetine studies of efficacy in diabetic peripheral neuropathic pain. To
screen for subclinical depression, changes in mood and anxiety were measured at
enrollment and at the end of the trials with either the Hamilton Rating Scale
for Depression (HAMD) or the Beck Depression Inventory-II and the Beck Anxiety
Inventory. It was found that there were no significant changes in mood or
anxiety to who undergone physical therapy. Interestingly, satisfaction
regarding therapy was generally deemed as good. In addition, patients did not
commonly experience feelings of fear of pain was rarely quoted as a serious
issue. The more general (and more insensitive) EQ-5D-3D tool showed slight
negative changes; with psychological aspects (pain and depression) being more
influenced than physical performances. There are some limitations of the
current study. Firstly due to the sample-size: the study was not powered for
showing small effects of factors on PRO outcome in multivariate analysis.
Secondly, the selection of a younger and predominantly urban PsA population
(which doesn’t completely reflect the demography of both general Psoriatic and
also of general Romanian population) could have interfered with the
generalizability of study results.

1 Individual sub-components of ADAQoL (n=372)       Fig. 2 Changes in SF-36 domanin scores groups

with bars depicting standard errors;                                                         according
to the extent of pain relief in patients

line represents
the mean value of ADAQoL(2,27)                  undergoing
physical therapy.



The current study, conducted in a young cohort of
Romanian type PsA patients, showed that physical therapy has a positive impact
on QoL in both overview measures and in every individual aspect specifically
assessed and by every specific tool used for evaluation (both ADQOL and EQ-5D).
Particularly positively impacted were future perspective and family life.
Further larger randomized studies are necessary for confirming the findings
from our limited research.


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