1	Rehabilitation Considerations for Auto-immune Disease November 4, 2006
2	Auto-immune disease Secondary Sjogren’s Occurs 50% of the time in those with Sjogren’s (www.sjogrens.org) Polymyositis/Dermatomyositis Rheumatoid Arthritis (polyarthritis) Scleroderma Lupus (SLE)
3	What is Auto-immune? Group of diseases where the immune system attacks certain parts of the body Antibodies = body’s defense Antigens = intruders Body can’t tell the difference between normal tissue and Antigens. Body attacks itself with Antibodies
4	Secondary Sjogren’s (Polymyositis/Dermatomyositis) Inflammation of muscles/skin Attacks primarily proximally Weakness = chief complaint Flare = recent increase in weakness, fatigue, changes in the skin or arthritic pain Rehab is dependent on current state of muscles at the time of evaluation
5	Secondary Sjogren’s (Rheumatoid Arthritis) Extraglandular manifestation Chronic symmetric inflammation of the peripheral joints that progresses sequentially Complaints include Stiff, painful and tender joints Fatigue 4-6 hr after waking Morning joint pain lasting hours 60% cannot work 10 years after onset with loss of lifespan between 3-7 years –(Alan K. Matsumoto, M.D. John Hopkins)
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8	Secondary Sjogren’s (Scleroderma) Sclero = Hard Derma = skin Can be localized or systemic Restriction of movement Facial Extremities (arms, legs) Poor functional tasking Poor blood flow Joint swelling
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11	Secondary Sjogren’s (Systemic Lupus Erythematosus) Chronic inflammatory disease Affects skin, joints, blood, kidneys Types Discoid Systemic Drug induced Achy joints, fever, arthritic pain, fatigue are some chief complaints Flares – possibly sun or cold exposure, hormonal changes Has similar characteristics to fibromyalgia Keyser RE, Rus V, Cade WT, Kalappa N, Flores RH, Handwerger BS. Evidence for aerobic insufficiency in women with systemic Lupus erythematosus. Arthritis Rheumatology, 2003 Feb 15;49(1):16-22.
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14	Risks of Auto-immune (Common symptoms) Complaints: Fatigue Joint pain Muscle weakness Swelling Achiness Arthritic pains Restriction of movement Morning pain (hours) Numbness/Tingling
15	Physical Therapy According to the American Physical Therapy Association (2006), physical therapists (PTs) are health care professionals who diagnose and treat people of all ages who have medical problems or other health-related conditions that limit their abilities to move and perform functional activities in their daily lives. PTs also help prevent conditions associated with loss of mobility through fitness and wellness programs that achieve healthy and active lifestyles.
16	Physical Therapy Treatment is provided upon a doctor’s referral Treatment surrounds musculoskeletal, neuromuscular and cardiovascular limitations Exercise, modalities, and manual therapy is our foundation for intervention Goal is improvement of function, minimization of impairment and independence
17	Physical Therapy Evaluation Strength Endurance Range of Motion (ROM) Palpation for trouble areas Functional meaningful activity
18	Physical Therapy Evaluation: TMJ Temporomandibular Joint Disorders Characterized by pain with: Talking Yawning Chewing
19	Physical Therapy Evaluation: Foot dysfunction Plantar fasciitis Heel and toe pain Limping Poor striding Unequal leg lengths May benefit from orthotics
20	Exercise Management Types of exercise Range of motion(ROM)/flexibility Resistance training Cardiovascular training
21	Exercise Management Range of motion/flexibility Physiological movement helps: Maintain pliability of tissue Increase bloodflow Improve tissue remodeling Inhibit pain through joint receptor stimulation May include passive or active movement
22	Exercise Management Resistance training Isometric, Isotonic, Isokinetic Benefits include: Muscle strength improvement Endurance for functional tasks Increase in bone density Increase in balance Improved circulation
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24	Exercise Management Resistance training Free weights (dumbbells) Machine weights Cables (Bowflex) Thera-band Body weight (i.e. pushup)
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26	Exercise Management Cardiovascular/Aerobic training Benefits include: Weight control Increase metabolism Improved endurance Improved blood flow Decrease risk of cardiovascular disease Decrease in resting heart rate Improved lung efficiency and capacity
27	Exercise Management Aerobic training Dance Bicycling Cross Country Skiing In-line skating Fitness Walking Jumping Rope Running Stair Climbing Swimming
28	Exercise Management Other benefits of exercise Lessens depression Relieves stress Improves body image 23% less likely to get a cold Improves sleep patterns Boosts immunity???
29	Complications with exercise Soreness Muscle (D.O.M.S. vs. I.O.M.S.) Joint Avoid joint pain lasting 2+ Hr. Fatigue Co-morbidities Spinal stenosis, cervical spine instability, wrist, hand, and foot disease, hip necrosis
30	Research and Evidence Regarding Systemic Lupus: “There have also been a few studies done on the effects of exercise on people with lupus, specifically. One in particular looked at the effects of aerobic conditioning on people with lupus. It concluded that short term conditioning did not worsen joints or exacerbate the systemic disease. Another study found that in people with systemic lupus, fatigue is correlated with deconditioning, but with an 8 week supervised aerobic program, reconditioning and decreased fatigue could be achieved. Unfortunately, there is no evidence to suggest that exercise programs are being incorporated into routine practice.” -National Center on Physical Activity and Disability
31	Exercise Management Modes of exercise Land based Functional Higher impact Aquatic (88-92 degrees) Low weight environment Good for active assisted ROM Protect the eyes and skin Chlorine alternatives are Bromine, Ozone, Biguanides
32	Exercise Management Prescription of exercise “Get your feet under you” Understand energy conservation Set achievable goals Low impact at first Flexibility first 10% rule Perceived Exertion Scale (Borg) 12-15 Time vs. Distance
33	Exercise Management What if you have a flare? Fall back on flexibility and isometric exercise Learn to not “push” yourself Take 48-72 Hr. off Do you return to a baseline? Start back at 10-20% less than last bout of exercise
34	Helpful Resources www.arthritis.org (PACE) www.ymcaokc.org (Bethany) www.hopkins-arthritis.com (activity reminder) www.quackwatch.com (hoaxes)
35	Helpful Resources Paper vs. Video Home Exercises Paper Two dimensional Often requires further cueing Video Given in conjunction with PT visit Provides appropriate progression Easy to follow Personalized
36	Research and Evidence Schoster B, Callahan LF, Meier A, Mielenz T, DiMartino L. The People with Arthritis Can Exercise (PACE) program: a qualitative evaluation of participant satisfaction. Preventing Chronic Disease [serial online] 2005 Jul [date cited]. Available from: URL: http://www.cdc.gov/pcd/issues/2005/ jul/05_0009.htm. De Jong, Zuzana; Vliet Vlieland, Theodora P. M. Safety of exercise in patients with rheumatoid arthritis. Rehabilitation medicine in rheumatic diseases. Current Opinion in Rheumatology. 17(2):177-182, March 2005. Escalante A, Miller L, Beardmore TD. Resistive exercise in the rehabilitation of polymyositis/dermatomyositis. Journal of Rheumatology. 1993 Aug;20(8):1340-4. George A. Kelley1, Kristi S. Kelley1, and Zung Vu Tran. Exercise and bone mineral density in men: a meta-analysis, Journal of Applied Physiology, 88: 1730-1736, 2000. C. Raina Elley and Bruce Arroll (commentators) Aerobic exercise reduces systolic and diastolic blood pressure in adults. Evidence Based Medicine 2002;7:170
37	Research and Evidence Whelton SP, Chin A, Xin X, He J. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Annals of Internal Medicine 2002 Apr 2;136:493–503.