Physical therapy on inflammatory arthritis at Tiberius Hot Springs5

PhysicalTherapy – potential benefits in psoriatic arthritisDrd. Laviania ClaudiaOCHIANA1, Prof.Dr.

Virgil PATRASCU1,1University ofMedicine and Pharmacy Craiova, Romania  Keywords: PsoriaticArthritis Pain, SF-36; Physical TherapyIntroduction Psoriatic arthritis (PsA) is an autoimmune, seronegative,chronic inflammatory disease of the osteo-articular system that affects peoplewith psoriasis (cutaneous, nail). Some patients have a mild illness that canrespond to therapeutic intervention, while others have erosive arthritis thatis often refractory to multiple treatments and potentially associated withfunctional disability and poor quality of life1. The disabilityeffect of PsA was compared with that of patients with rheumatoid arthritis(RA), and the results showed that function and quality were similar for bothgroups2.Different approaches to kinesiotherapy have been proposedand adopted for the different manifestations of PsA; some have been borrowedfrom other types of inflammatory arthritis, such as RA and ankylosingspondylitis (AS). Recently, the GRAPPA (Psoriasis and Psoriasis Arthritis andPsoriasis Research and Assessment Group) proposed an evidence-based approachand a basis for treatment guidelines. However, some proposed, after asystematic review of the literature, a treatment algorithm in whichphysiotherapy 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.

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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 aresummarized as follows: – Very little evidence isavailable to evaluate the effectiveness of physical therapy; – Some data have been obtainedfrom studies on AS77; – Coverage of disease aspectsthrough standard operating measures presents difficulties.

In view of the above, I consider it necessary to implement a studyevaluating the effects of secondary kinetoprophyxia in Psoriatic Arthritis. Inthis regard, I propose a multicenter, open, controlled study to compare theeffects of standard therapy (Group A) with the effects of standard therapy +kinesiotherapy (Group B). The assessment of the effects will be done with thehelp of quality of life questionnaires, VAS questionnaires for pain andobjective evaluation of the function of the locomotor apparatus according tothe European Society of Rheumatology guide.

The study will follow the evolutionof patients for 3-6 months of therapy and will only address patients with PsA. Subjects and methods This was randomized, parallel trial. The subjects willbe assessed for eligibility at the screening visit within 2 weeks prior torandomization. During this visit, all patients were assessed for eligibilityand were instructed in the use of the NPRS for pain intensity measurement andother planned questionnaires.

Before any study procedure, patients had to signthe informed consent form. Treatment duration was be 28 days. Patients from onegroup followed the physical therapy protocol and the other took their usualtreatment.

During and after the treatment period, efficacy assessments was beperformed at different time points up to day 35, one week after finishingtreatment. Additionally, pain intensity was assessed daily by a diary since oneweek before treatment start (day -7) to the final visit on day 35Statistical analysisThe primary objective of this study was to describe thepain release efficacy of the physical therapy and the impact on HRQOL inaddition to the regular pharmaceutical treatment in diabetic peripheralneuropathy Romanian patients. For the primary objective, the statisticalanalysis was basically descriptive, with continuous variables being expressedas means, medians and modes, with point estimates, SD and two-sided 95% CIs andqualitative variables (either dichotomous or ordinal) expressed as proportionswith 95% CIs.

For continuous variables, subgroup analyses were performed by theanalysis of variance (ANOVA) in case of normal distribution, or non-parametricKruskal-Wallis test for non-normal distribution. Subgroup analysis were alsoadjusted for covariates potentially influencing the outcome (age, gender,domicile, duration of DM, level of HbA1c, obesity status, macro vascularcomplications, retinopathy and therapeutic regimen) by use of ANCOVA. Formultiplicity correction of confidence intervals in ANCOVA model, the Bonferronimethod was employed. For sample-size estimation, although not formallynecessary, we assumed the prevalence of diabetes in Romania as being around 4%out of the general population (including children), which gave us a totalestimation for diabetic population of around 850.

000 patients. For a confidencelevel of 95% and a pre-specified two-sided confidence interval of +/-5% for adichotomous variable (e.g. presence/absence of a certain factor), the number ofpatients enrolled with usable data should be 384. Subjects: Eligible subjects weremen or women, at least 18-year old, with PsA for at least 1 year and with drugtherapy started at least 6 months before the enrollment in the study.

No changein actual drug therapy for at least 3 months, except dose adjustments wasallowed. Exclusion criteria were: diabetic peripheral neuropathy pain historyof diabetic ketoacidosis, documented psychiatric diseases or major depressionand participation in other clinical trials. Results A number of 374 eligible PsApatients, enrolled in 4 centers were included in the study. The studypopulation was younger than general PsA (mean age 42.

12 years, median 39years), living predominantly in urban conditions (71.8%) and having generallymedium 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 PsAwas 3 years. For the descriptive analysis of PROs, as many as 372 patientscompleted the questionnaires and was included in the analysis. Physical Therapyexerts an overall significant positive impact on quality of life with a meanweighted ADAQoL score of 2.27 (95%CI: 2.57 -1.

97). Every domain included in ADAQoLquestionnaire was positively and significantly impacted. The most positivelyimpacted domains were future worry and family life (mean scores 3.13 andrespectively -2.85), whilst lowest impact was on living conditions(habitation), other people’s reaction and financial situation (0.78, 1.

37 andrespectively 1.84) (Fig.1). Arthritis-dependent quality of life (AQoL),measured by the single overview item, shows also a positive and statisticallysignificant impact, with a mean value of 1.52 (95%CI: 1.

60 -1.43). Patients ratedtheir 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 effectof the physical therapy. The Treatment Satisfaction score, Perceived Frequencyof Pain (“Pain Fear”) was assessed by PTSQs.

Mean treatment satisfaction scorewas 29.60 (95%CI: 29.07 -30.14) out of a 0-36 scale, indicating that patientswere generally satisfied with their physical therapy treatment.

Most patientsperceived pain seldom, as 25.3%, 20.5% and 17.8% indicated their frequency asnever, very rarely or rarely, respectively. The EQ-5D descriptive componentshowed significant increase in quality of life for all the five domainsassessed (mobility, self-care, usual activities, pain/discomfort andanxiety/depression), mean values varying between 0.05 for self-care and 0.32for pain/discomfort (out of a 0-3 scale).3.

4. Discussions Thequestion arises whether the improvement in measures of quality of life seenwith physical therapy is due to its effect as an antidepressant9effect shown by the physical activity or due to a reduction in pain. Inaddition, it is unclear how much pain reduction can be attributed toimprovements in mood and what effect on mood physical therapy may have onpatients who do not have MDD. For this reason, patients who met criteria withinthe past year for the Diagnostic and Statistical Manual of Mental Disorders, FourthEdition (DSM-IV) Axis I diagnosis of MDD, dysthymic disorder, generalizedanxiety disorder, alcohol or eating disorders were excluded from enrollment inthe duloxetine studies of efficacy in diabetic peripheral neuropathic pain. Toscreen for subclinical depression, changes in mood and anxiety were measured atenrollment and at the end of the trials with either the Hamilton Rating Scalefor Depression (HAMD) or the Beck Depression Inventory-II and the Beck AnxietyInventory.

It was found that there were no significant changes in mood oranxiety to who undergone physical therapy. Interestingly, satisfactionregarding therapy was generally deemed as good. In addition, patients did notcommonly experience feelings of fear of pain was rarely quoted as a seriousissue. The more general (and more insensitive) EQ-5D-3D tool showed slightnegative changes; with psychological aspects (pain and depression) being moreinfluenced than physical performances. There are some limitations of thecurrent study. Firstly due to the sample-size: the study was not powered forshowing 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 andalso of general Romanian population) could have interfered with thegeneralizability of study results.Fig.1 Individual sub-components of ADAQoL (n=372)       Fig. 2 Changes in SF-36 domanin scores groupswith bars depicting standard errors;                                                         accordingto the extent of pain relief in patients line representsthe mean value of ADAQoL(2,27)                  undergoingphysical therapy.  ConclusionsThe current study, conducted in a young cohort ofRomanian type PsA patients, showed that physical therapy has a positive impacton QoL in both overview measures and in every individual aspect specificallyassessed 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 findingsfrom our limited research.Bibliografie:1.

            Kavanaugh A, Ritchlin C,and the GRAPPA Treatment Guideline Committee. Systematic review of treatmentsfor psoriatic arthritis: an evidence based approach and basis for treatmentguidelines. J Rheumatol 2006;33:1417-21.2.

            Sokoll KB, Helliwell PS.Comparison of disability and quality of life in rheumatoid and psoriaticarthritis. J Rheumatol 2001;28:1842-6.3.            Nash P. Therapies foraxial disease in psoriatic arthritis.

A systematic review. J Rheumatol2006;33:1431-4.4.            Walker UA, Uhl M, WeinerSM, et al. Analgesic and disease modifying effects of interferential current inpsoriatic arthritis.

Rheumatol Int 2006;26:904-7.5.            Hashkes PJ. Beneficialeffect of climatic therapy on inflammatory arthritis at Tiberias Hot Spring.

Scand J Rheumatol 2002;31:172-7.6.            Sukenik S, Bardin R,Codish S, et al.

Balneotherapy at the Dead Sea area for patients with psoriaticarthritis and concomitant fibromyalgia. Isr Med Assoc J 2001;3:147-50.7.

            Dagfinrud H, Kvien TK,Hagen KB. Physiotherapy interventions for ankylosing spondylitis. CochraneDatabase Syst Rev 2008;Jan 23: CD002822.8.            Lubrano E, Helliwell P,Parsons W, Emery P, Veale D. Patient education in psoriatic arthritis: a crosssectional study on knowledge by a validated self-administered questionnaire. JRheumatol 1998;25:1560-5.

9.            Ryan MP,The antidepressant effects of physicalactivity: mediating self-esteem and self-efficacy mechanisms, PsycholHealth. 2008; 23(3):279-307