Ilcoinvolgimentoarticolarenellemalattiereumatologiche:managementeterapia
LoredanaMAGGIMedicoFisiatra
UOCdiRiabilitazioneeMedicinaFisicaFondazionePoliclinicoGemelli-UCSC
ROMA
23Settembre2017
POLIARTRITICRONICHE
APPROCCIOMULTIDISCIPLINARE
The treatment approach for RAemphasizes the involvement of amultidisciplinary team, includingfamily physicians, specialists,and rehabilitation professionals(American 2002, Duff 1974, Glazier 1996,
Newcomer 1994).
IltrattamentodellepatologiereumatologicheèINTERDISCIPLINAREe
contemplaapproccifarmacologici,riabilitativiechirurgici
RIABILITAZIONE
Processo di soluzione dei problemi e di educazione nel
corso del quale si porta una persona disabile a
raggiungere il miglior livello di vita possibile sul piano
fisico, funzionale, sociale ed emozionale, con la minor
restrizione possibile delle sue scelte operative, pur
nell’ambito della limitazione della sua menomazione
RIABILITAZIONE
LaRiabilitazione cerca diprevenire/contenere erallentare
•leconseguenze della progressione della malattia adogni
stadio
•laprogressione deldanno
•di migliorare laqualità divitadei pazienti
Latipologiadeitrattamentiriabilitativivarianoinbaseallostato
funzionaledelpaziente,dell’età,delladuratadimalattia,dell’estensione
deldannomuscolo-scheletrico
ARMANAGEMENTv Farmacologico
Ø DMARDØ sintomatico
v MonitoraggioØ permalcardiovascolariØ osteoporosiØ complicanzeinfettive
v EducazioneØ Self managementØ InterventipsicosocialiØ Counseling dietico- nutrizionali
v RiabilitazioneØ EsercizioØ TerapiefisicheØ TerapiaoccupazionaleØ EconomiaarticolareØ Ortesi edausiliØ linfodrenaggio
OBIETTIVIDELTRATTAMENTORIABILITATIVO
Ø Controllodeldoloreedell’infiammazione
Ø Contenimentodeldannoarticolare
Ø RiduzionedellaperditadiROM
Ø Prevenzionedell’evoluzionedeformante
ØMiglioramentodellaperformancemuscolare
ØMantenimentodell’autonomiafunzionale
SINTOMIDolorearticolareTumefazionearticolareRigiditàarticolareInstabilitàarticolare
Limitazionefunzionale
sublussazione/Anchilosi
Debolezzamuscolare
DOLORE
Comportamentodievitamento
<mobilitàpaura/ansiadi
muoversiDebolezza
>DisabilitFatigue stanchezza
DepressioneIsolamentosocialeRidottacapacita
lavorativa
riposoIpotrofiamuscolare,retrazionecapsulari,
sofferenzacartilaginea
Terapiafarmacologica
Terapiaconmezzifisici
Massoterapia
Giusto equilibrio tra riposo nelle fasi di acuzie eun’attività ponderata
negli altri periodi
GESTIONEDOLORE
Radner H,Ramiro S,Buchbinder R,Landewé RBM,van der Heijde D,Aletaha D.Pain managementforinflammatory arthritis (rheumatoid arthritis,psoriatic arthritis,ankylosing spondylitis andother
spondyloarthritis)andgastrointestinal orliver comorbidity.CochraneDatabaseofSystematicReviews2012
Evenwithoptimaldisease-modifyingtreatmentandgoodcontrolofdiseaseactivity,
persistentpainduetostructuraldamageiscommoninpeoplewithinflammatory
arthritisandthereforeadditionaltreatmentforpainmightberequired……
Pain therapy comprised paracetamol,non-steroidal anti-inflammatory drugs
(NSAIDs),opioids,opioid-like drugs (tramadol)andneuromodulators
(antidepressants,anticonvulsants andmuscle relaxants
ESERCIZIOeDOLORECRONICO
Geneen LJ,MooreRA,ClarkeC,MartinD,ColvinLA,SmithBH.Physicalactivityandexerciseforchronicpaininadults:anoverviewofCochraneReviews.
CochraneDatabaseofSystematicReviews2017
Theavailableevidencesuggestsphysicalactivityandexerciseis
aninterventionwithfewadverseeventsthatmayimprove
painseverityandphysicalfunction,andconsequentquality
oflife
INATTIVITÀIpotrofia,Accorciamentomuscolareetendineo,retrazionecapsula/legamenti
INATTIVITÀRIDUCELACAPACITÀAEROBICA
OurstudyprovidesnoveldatasuggestingthatA-SLEandC-SLEpatientswith
mild/inactivediseasehaveimpairedaerobiccapacityandHRQOLwhen
comparedwithcontrolsmatchedbyphysicalinactivity,age,sex,andBMI.
ThesefindingsreinforcetherecommendationofphysicalactivityinSLE
treatment
PintoAJ.Reduced Aerobic Capacity andQuality ofLifeinPhysically Inactive Patients WithSystemic LupusErythematosus WithMild orInactive Disease.
Arthritis CareRes.2016
PERDITADIFORZA
• Inattività
• Inibizioneriflessadellacontrazionemuscolaredagonfiore
articolare
• Miositi
• Miopatiedasteroidi• Effettidirettidellapatologia(aumentodelcatabolismo
proteicoindottodaalcunecitochine,tracuiilTNFa)
MANOAR
SCLERODERMIA
PIEDE
AllucevalgoDitaamartelloDitaagriffeAvampiede triangolareDeviazioneacolpodivento
CarrollM,Parmar P,Dalbeth N,Boocock M,Rome K.Gait characteristics associated with thefoot andankleininflammatory arthritis:asystematic review andmeta-analysis.
BMCMusculoskelet Disord.2015.
ThegaitpatterninRAwascharacterisedby
• decreasedwalkingspeed
• decreasedcadence
• decreasedstridelength
• decreasedanklepower
• increaseddoublelimbsupportandpeakplantarpressuresattheforefoot
Walkingvelocitywasreducedinpsoriaticarthritisandgoutwithnodifferencesin
ankylosing spondylitis.
Nostudieshavebeenconductedinpolymyalgia rheumatica,systemicsclerosisor
systemiclupuserythematosus
PASSOAPROPULSIVO
Alterazionebiomeccanicaepiedeemuscoli
FATIGUEPersistentesensazionedistanchezza,debolezza,mancanzadi
energia,esaurimento,sensodisfinimentosiafisicochepsichico
Descrittanel40%-80%deipazienticonAR
Lepersonecheprovanofatigue nonhannoenergiaetrovanodifficoltosocompiere
quellesempliciattivitàquotidianechedinormasvolgonosenzaproblemi
InterventiPsicosociali
Cramp F,Hewlett S,Almeida C,etal.Non-pharmacological interventions forfatigue inrheumatoid arthritis.Cochrane DatabaseSyst Rev 2013
VariouspsychosocialinterventionscanbenefitpatientswithRA.
Asystematicreviewandmeta-analysisof13trials,involving1579patients,has
documentedthatpsychosocialinterventionscanmodestlyreducesymptomsof
fatigue
ØSostegnopsicologico
ØModificazioniorganizzativesullavoroeadomicilio
LESFATIGUEeESERCIZIOAvaux M,Hoellinger P,Nieuwland-Husson S,Fraselle V,Depresseux G,Houssiau FA.Effects of
two different exercise programs onchronic fatigue inlupuspatients.ActaClin Belg.2016
Mahieu MA,Ahn GE,Chmiel JS,DunlopDD,Helenowski IB,Semanik P,SongJ,Yount S,Chang RW,Ramsey-GoldmanR.Fatigue,patient reported outcomes,andobjective measurement ofphysical
activity insystemic lupuserythematosusLupus.2016
Oftheninestrategies,aerobicexerciseandbelimumab seemtohavethestrongestevidenceoftreatmentefficacy.N-acetylcysteineandultraviolet-A1phototherapydemonstratedlow-to-moderatelevelsofevidence.Psychosocialinterventions,dietarymanipulation(lowcalorieorglycemicindexdiet)aimingforweightloss,vitaminDsupplementation,andacupunctureallhadweakevidence
Yuen HK,CunninghamMA.Optimal managementoffatigue inpatients withsystemic lupuserythematosus:asystematic review.
Ther Clin Risk Manag.2014
EDUCAZIONE
WarsiA,LaValley MP,WangPS,etal.Arthritisself-managementeducationprograms:ameta-analysisoftheeffectonpainanddisability.ArthritisRheum2003;
Self-managementeducationalinterventionsforpatientswithRAorOAfoundaclinicallysmall,butstatisticallysignificant,beneficialeffect onbothpainanddisability
Ayear2004systematicreviewofpatienteducationinRAconcludedthatthereisevidenceforthesebenefits,atleastintheshort-term;however,evidenceoflong-termeffectsonoutcomesislacking
Niedermann K,Fransen J,Knols R,Uebelhart D.Gapbetween short- andlong-term effects ofpatienteducation inrheumatoid arthritis patients:asystematic review.Arthritis Rheum 2004
Patienteducationasprovidedinthestudiesreviewedherehadsmallshort-termeffectsondisability,jointcounts,patientglobalassessment,psychologicalstatusanddepression.Therewasnoevidenceoflong-termbenefitsinadultswithRA
Riemsma RP,Kirwan JR,Taal E,Rasker HJJ.Patient education for adults with rheumatoid arthritis.Cochrane Databaseof Systematic Reviews 2003
TERAPIAOCCUPAZIONALE
Steultjens EEMJ.Occupational therapy forrheumatoid arthritis.Cochrane DatabaseofSystematic Reviews 2008
aimtofacilitatetaskperformanceandtodecreasetheconsequencesofrheumatoidarthritisforADL,isconsideredtobeacornerstoneinthemanagementofRA
comprehensivetherapy,trainingofmotorfunction,trainingofskills,instructiononjointprotectionandenergyconservation,counseling,instructionaboutassistivedevicesandprovisionofsplints
Thereisevidencethatoccupationaltherapyhasapositiveeffectonfunctionalabilityinpatientswithrheumatoidarthritis
strongevidencefortheefficacyof“instructiononjointprotection”andthatlimitedevidenceexistsforcomprehensiveoccupationaltherapyinimprovingfunctionalability
38studies(1700p)
ObiettividellaT.O.SPECIFICIPERL’ARTOSUPERIOREeADL
üInsegnano esercizi ed attività
üEducano alla protezione articolare eall’autogestione
üConfezionano/individuano ausili ed ortesi
üistruiscono all’uso degli ausili
proteggere le articolazioni non significa risparmiarle attraverso l'inattività, bensì acquisire un diverso metodo di lavoro basato su semplici ma indispensabili accorgimenti che oltre a ridurre o evitare il dolore ritardano e evitano deformità
PROTEZIONE ARTICOLARE O ECONOMIA ARTICOLARE
strategie atte a svolgere un'attività con il minor sforzo possibile, utilizzando correttamente le articolazioni per evitare un sovraccarico o una sollecitazione errata delle strutture osteo-articolari
EconomiaarticolareØScaricarelearticolazionidoloranti
ØCaloponderale
ØBastoneantibrachialescaricodel25%
ØPromuovereunabuonaposturanelleattività
ØUsarelearticolazionimaggiori
ØConservareenergia(fatigue)
ØNoneccedereconitempidiattivitàintervallandoliconperiodi
diriposo
ØTutorieausili
RIPOSO(Funzionale)
1. Completo
2. Frazionatoinbreviperiodi(20-30min)
3. Parzialedi1opiùarticolazioni(tutori)
Riposoalettofaperdere5%algiornodiforzamuscolareKottke 1996
TUTORI
• Alleggerireilcaricoarticolare
• Ridurreilmovimentoarticolare
• Contenerelearticolazioniinposizionedimassimafunzionalità
• Aumentareilmovimentoarticolaresplint dinamici
Egan M.Splints andOrthosis fortreating rheumatoid arthritis.Cochrane DatabaseofSystematic Reviews 2010
insufficientevidencetomakefirmconclusionsabouttheeffectivenessofworkingwristsplintsindecreasingpainorincreasingfunctionforpeoplewithRA.
Similarly,preliminaryevidencesuggeststhatrestinghandandwristsplintsdonotseemtoaffectrangeofmotion(ROM)orpain,althoughparticipantspreferredwearingarestingsplinttonotwearingone.
moldedinsolesdecreasepainduringweight-bearingactivitiessuchasstanding,walking,andstairclimbing.Supportedinsolesmaybeeffectiveinpreventingprogressionofhalluxabductus anglebutdonotappeartohaveanyimpactonpain.
TUTORI
Plantarisumisura
Chalmers AC,Busby C,Goyert J,etal.Metatarsalgiaandrheumatoid arthritis--a randomized,singleblind,sequential trialcomparing 2types offoot orthoses andsupportive shoes.
JRheumatol 2000.
Reducerearfoot painafter3months,comparedwithdoingnothing,butdonotreducefootpainafter3years,comparedwithusingfake foot orthoses.
Thisreviewshowsthatforpeopleyoungerthan60yearsofagewithpainfulhalluxvagus custom-madefootorthoses:Reducefootpainafter6monthscomparedtonotreatment,butmaynotreducefootpainafter6or12monthscomparedtosurgery
HawkeF,BurnsJ,RadfordJA,duToit V.Custom-madefootorthoses forthetreatmentoffootpain.CochraneDatabaseofSystematic Reviews 2008
ESERCIZIO
“un’attivitàfisicaprogrammata,strutturataeripetuta,attaa
migliorareemantenerel’efficienzafisica”
Klemz BN,Reis-NetoET,JenningsF,Siqueira US,Klemz FK,Pinheiro HH,SatoEI,Natour J,Szejnfeld VL,Pinheiro MM.Therelevance ofperforming exercise testbefore starting supervised physical exercise in
asymptomatic cardiovascular patients withrheumatic diseases.Rheumatology.2016
BENEFICIDELL’ESERCIZIOTERAPEUTICO• Mantenimentoemiglioramentodell’articolarità
• Potenziamentomuscolare
• Aumentodellaresistenzastaticaedinamica
• Miglioramentodellacapacitàlocomotoria
• AumentodellaBMD
• Riduzionedeldolore
• Riducel’infiammazione
• Miglioralacapacitàaerobica
• Miglioral’autonomiafunzionale
• Aiutaaridurreilpesocorporeo
• MiglioreilbenessereHoL
ESERCIZIOTERAPEUTICO• Prescrizioneindividualizzata• Salvaguardarelestrutturearticolariinfiammate• Programmaprogressivogestendoildolore• Migliorarelefunzioniimportantiperipaziente
Programmadieserciziodi1. Allenamentoaerobico2. Rinforzoneuromuscolare3. Resistenzamuscolare
Specificare1. muscoliinteressati2. tipo3. intensità4. durata5. frequenza6. eventualiprecauzioni
Unprogrammascrittoelosvolgimentoincompagniaoingruppomiglioralacompliance
o
TRATTAMENTOCHINESITERAPICO
• Mobilizzazionipassive• Contrazioniisometriche• Contrazioniisotoniche,controresistenza• Stretching• Rieducazioneposturale• FKTrespiratoria• Ginnasticadolce(Tai Chi,Yoga,Feldenkrais,QiGong)
LiL,JuddM,Pencharz JN.Comprehensive physiotherapy for rheumatoid arthritis.Cochrane Databaseof Systematic Reviews 2004,.
ESERCIZIO
lerecentilineeguidadellaBritish SocietyforRheumatology edellaBritish Health
Professionals inRheumatology edell’AmericanCollegeofRheumatology (ACR)
hannointrodottol’eserciziofisico(insiemeadaltre
tecnicheriabilitative)neltrattamentodell’artrite
reumatoide(AR)
1. Faseacutaeserciziisometriciedistretchingpermantenereiltonoeiltrofismomuscolareedimpedirelacomparsadiatteggiamentiviziatichepreludonoalledeformitàarticolari
2. Fasesubacutamobilizzazionepassiva(daeseguiresenzamaiforzarelearticolazioni)perevitarelarigiditàarticolare,mobilizzazioneattiva,conl’utilizzodiesercizisenzacarico,chenonprovochinodolorenéstanchezza,mentrepermantenereedincrementarelamotilitàarticolare
3. Fasediremissionemobilizzazioneattiva,conosenzaresistenza,perrinforzareedequilibrarel’apparatomuscolo-tendineo
Esercizi per la menomazione
Dolore Limitazione del ROM
Deficit muscolare
Attenzione ai segni di esercizi eccessivi o stressDolore durante l’attività o 1-2 ore dopo gli esercizi
gonfiore, affaticamento, debolezza
Illavorosaràeseguitoinscarico edinisometria,rispettandolasogliadolorosaLaresistenza,quandooccorre,saràmanuale
ESERCIZIOTERAPEUTICO
HakkinenA,Sokka T,Kotaniemi A,Hannonen P.Arandomized two-year study oftheeffects ofdynamic strengthtrainingonmuscle strength,disease activity,functional capacity,andbonemineral density inearly rheumatoidarthritis.Arthritis Rheum 2001
• EsercizidimantenimentodelROMpreservaomiglioralamobilità
articolare
• Eserciziperaumentarelaforzamuscolareeseguitiunaoduevoltea
settimanamiglioranolafunzioneeNONpeggioranol’attivitàdimalattia
ESERCIZIPERLAMANO
Inarandomizedtrialinvolving490patients,theadditionofatailoredstrengthening
andstretchinghandexerciseprogram(includingsixface-to-facesessionsandsupport
foradailyhomeexerciseprogram)tousualcare(adviceregardingjointprotectionand
generalexercise,andfunctionalsplintingandassistivedevices,asindicated)resulted
insignificantlygreaterimprovementinoverallhandfunctionatoneyearoffollow-up
comparedwithusualcarealone
Lamb SE,Williamson EM,Heine PJ,etal.Exercises toimprove function oftherheumatoid hand (SARAH):a RCT.Lancet 2015.
LondonDA,Stepan JG,Calfee RP.Determining theMichiganHand Outcomes Questionnaire minimalclinicallyimportant difference bymeans ofthree methods.
Plast Reconstr Surg 2014.
EsercizioinCaricoPreliminaryevidencesuggestsaerobicweightbearing exercisemayhelppreventglucocorticoid-associatedosteoporosisinRAabenefitwhichstrengthtrainingaloneprobablydoesnotproduce
Exerciseprogramsshouldbeprescribedbyaphysicaltherapistandtailoredforeachpatient'sdiseaseseverity,bodybuild,andpreviousactivitylevel.High-intensityweightbearing exercisesmaynotbeappropriateforpatientswithpreexistingstructuraldamageoflowerextremityjoints.Lessintenseornon-weightbearingexercisesarealternativesforsuchpatients
Munneke M,deJongZ,Zwinderman AH,etal.Effect ofahigh-intensity weight-bearing exercise program onradiologic damage progression ofthelargejoints insubgroups ofpatients withrheumatoid arthritis.ArthritisRheum 2005;53:410.
Westby MD,Wade JP,Rangno KK,Berkowitz J.Arandomized controlled trialtoevaluate theeffectiveness ofanexercise program inwomen withrheumatoid arthritis taking low doseprednisone.JRheumatol 2000;27:1674.
RIEDUCAZIONERESPIRATORIA
Alterazionidellameccanicaventilatoria
Problematicheostruttiveorestrittive
• Infaseinizialedimalattia,halafunzionedimantenerelaresiduadinamicacostale
• Infasepiùavanzata,haloscopodiottimizzarelarespirazioneaddomino-
diaframmatica
RIEDUCAZIONERESPIRATORIA
Esercizidimodulazionedelflussoespiratorioperdisostruzionedellevieaereedistalioprossimali
EspansionetoracicalocalizzataRieducazionediaframmatica
Allenamentodeimuscoliinspiratori
Garrido M.Effects ofarespiratory functional trainingprogram onpain andsleep quality inpatients withfibromyalgia:Apilot study.
Complement Ther Clin Pract.2017
The8-weekbreathingexerciseinterventionreducedpainandimprovedsleepquality
ESERCIZIPEREQUILIBRIOPatients with RA may have an increased risk of
falls due to impairments in lower-extremity
joints, which may result in either mobility, or
postural stability problems. There is evidence
in the literature suggesting that balance,
agility and coordination training techniques
can induce changes in lower-extremitymuscle
activity patterns that result in improvement
in dynamic joint stability.
IDROCHINESITERAPIA
• MigliorailROM
• Camminoconminoreimpatto
sullearticolazioni
• Lapressioneidrostaticamigliora
ilritornovenosoegliedemi(Becker1997)
minorcaricogravitazionale
BALNEOTERAPIA
Verhagen AP,Bierma-Zeinstra SMA,Boers M,CardosoJR,Lambeck J,deBie R,deVet HCW.Balneotherapy (orspatherapy)forrheumatoid arthritis.
Cochrane DatabaseofSystematic Reviews 2015
Bagni inacque Minerali oTermali ,Fanghi
Overallevidenceisinsufficienttoshowthatbalneotherapy ismoreeffective
thannotreatment,thatonetypeofbathismoreeffectivethananotherorthat
onetypeofbathismoreeffectivethanmudpacks,exerciseorrelaxationtherapy
ESERCIZIOAEROBICOAttivitàdinamichediadeguataintensità,durataefrequenzatali
dastimolareilrinforzoelaresistenzamuscolare,lacapacità
cardiorespiratoria,laperditadipeso
ESERCIZIOAEROBICO
Nell’ARhadimostrato dimiglioramenti sull’autonomia funzionale
(DeJong2003;Macera 2003;Pate1995;VandenEnde 1996)
Riduceilrischiodimalattiecardiache,ipertensionearteriosa,diabete,tumorealcolon
ESERCIZIOAEROBICOAR
Sicuro
nonaumenta
• Ildolore
• L‘attivitàdimalattia
• Ildannoarticolare
(Hurkmans 2009;Gaudin 2007;Hakkinen2004;Stenström2003)
Programmi di esercizio aerobico e di tonificazione
Migliorano la forza muscolare e la propriocezione articolare
Riducono il dolore e migliorano la mobilità
ESERCIZIOAEROBICO
Hurkmans E,vander Giesen FJ,Vliet Vlieland TPM,Schoones J,Vanden Ende ECHM.Dynamic exerciseprograms (aerobic capacity and/ormuscle strength training)inpatients withrheumatoid arthritis.
Cochrane DatabaseofSystematic Reviews 2009
Basedontheevidence,aerobiccapacitytrainingcombined
withmusclestrengthtrainingisrecommendedasroutine
practiceinpatientswithRA.
Theoptimaldurationoftheintervention,modeofdelivery,and
extentofsupervisionneedtobefurtherinvestigated.
ESERCIZIOAEROBICO
Frequenzacardiacamassima(HRMax)=220- età
Relazionetraintensitàeduratadell’allenamento
%diHRmax
60-70% esercizioaerobicoamodestoimpegnomuscolareConsumoereintegroenergeticorestainequilibrio,permettendoduratasenzaaffaticamento.Dopo25-30minlafonteenergetica>grassi
70-80%cardiofitness
esercizioaerobicoamedioimpegnomuscolare(comparsadifiatone)Fontienergetichemisceletragrassiezuccheri,miglioral’efficienzaACCRnelsostenerealungounlavoro
80-90%agonisti
Oltresogliaaerobicaridottacapacitàdisostenerealungoillavoro
>90% Esercizioanaerobicoaltatensionemuscolare–acidolattico
ESERCIZIOAEROBICO
Hurkmans E,vander Giesen FJ,Vliet Vlieland TPM,Schoones J,Vanden Ende ECHM.Dynamic exerciseprograms (aerobic capacity and/ormuscle strength training)inpatients withrheumatoid arthritis.
Cochrane DatabaseofSystematic Reviews 2009,
• Exercisefrequency ofatleast20minutestwiceaweek.•Duration ofexerciseprogramatleastsixweeks(duration<threemonthswasconsideredshort-term;duration>threemonthswasconsideredlong-term).•Exerciseprogramperformedundersupervision.•Aerobicexerciseintensity atleast55%ofthemaximumheartrate(HRmax);orintensitystartingat40%to50%ofthemaximumoxygenuptakereserve(VO2R)orHRmaxreserve(HRR).Furthermore,theintensityisincreasedupto85%duringtheintervention.•Progressivelystrengtheningexerciseloadsstartingat30%to50%andincreasingto80%ofmaximum(definedasthepercentageofeitheronerepetitionmaximum,onemaximumvoluntarycontraction,maximumspeed,orasmaximalsubjectiveexertion)(Pollock1998).
Nodeleteriouseffectsondiseaseactivity,self-reportedpain,orradiologicaldamagewerefoundinanyofthetrainingprograms.
20minutialmeno2volteasettimanaperalmeno3mesicontinuativiSottosupervisioneIntensitàtra55%HRMax 40-55%VO2RRinforzocon30
esercizio intensità quantità frequenzaflessibilità Più volte/die
TonificazioneIsometrica Bassa-moderata 40-
60% MCV
1-10 contrazioni submassimali
contrazionemantenuta 1-6 sec
quotidiana
isotonica Bassa 30% RMModerata 30-50% RMAlta > 80% RM
10-15 ripetizioni8-10 ripetizioni6-8 ripetizioni
2/settimana
Resistenzaaerobica
Bassa- moderata 40 -50% di VO2 max /HRmax
20 min/die 2/settimana
MCV massima contrazione volontaria RM ripetizione massimaleVO2 max massima capacità aerobica HRmax indice cardiaco età correlato
peralmeno3mesicontinuativiSottosupervisione
Hurkmans E,vander Giesen FJ,Vliet Vlieland TPM,Schoones J,Vanden Ende ECHM.Dynamic exerciseprograms (aerobic capacity and/ormuscle strength training)inpatients withrheumatoid arthritis.
Cochrane DatabaseofSystematic Reviews 2009,
ATTIVITÀFISICAeLES
O'Dwyer T,Durcan L,WilsonF.Exercise andphysical activity insystemic lupuserythematosus:Asystematic reviewwithmeta-analyses.
Semin Arthritis Rheum.2017
12weeksofanaerobicexerciseprogramthatissupervisedbyhealthprofessionalscouldreducefatigueandincreasevitalityforpatientswithSLE.SLEpatientswithmilddiseaseshouldbeginwithmoderateintensityforatleast20minutes,3daysaweek
Wu ML,Yu KH,Tsai JC. TheEffectiveness ofExercise inAdults WithSystemic LupusErythematosus:ASystematicReview andMeta-AnalysistoGuideEvidence-Based Practice.
Worldviews Evid Based Nurs.2017
Meta-analysessuggestthatexercisedoesnotadverselyaffectdiseaseactivity,
positivelyinfluencesdepression,improvescardiorespiratorycapacityand
reducesfatigue,comparedtocontrols.
TrainingcardiovascolareeLES
Abrahão MI,Gomiero AB,Peccin MS,GrandeAJ,TrevisaniVF.Cardiovascular trainingvs.resistance trainingforimproving quality oflifeandphysical function inpatients with
systemic lupuserythematosus:arandomized controlled trial.Scand JRheumatol.2016
Exercise intervention proved to be
better than not exercising.
CT cardiovascular training was
better than RT resistance training
in improving HRQoL.
FIBROMIALGIA
Strengthtrainingissafeandeffectiveintreatingpeoplewith,anda
significantdecreaseinsleepdisturbancesoccursafter8wks ofintervention
AndradeAWhatIstheEffectofStrengthTrainingonPainandSleepinPatientsWithFibromyalgia?AmJPhysMedRehabil.2017
Lowtomoderateintensityenduranceandstrengthtrainingarestrongly
recommended.
Winkelmann APhysiotherapy,occupational therapy andphysical therapy infibromyalgia syndrome :Updated guidelines 2017andoverview ofsystematic review articles.
Schmerz.2017
Bjersing JL. Benefitsofresistanceexerciseinleanwomenwithfibromyalgia:involvementofIGF-1andleptin.BMCMusculoskelet Disord.2017
FIBROMIALGIA
Whencomparedwithcontrol,moderate-qualityevidenceindicatesthat
aerobicexercise probablyimprovesHRQLandall-causewithdrawal,andlow-
qualityevidencesuggeststhataerobicexercisemayslightlydecreasepain
intensity,mayslightlyimprovephysicalfunction,andmayleadtolittle
differenceinfatigueandstiffness.Threeofthereportedoutcomesreached
clinicalsignificance(HRQL,physicalfunction,andpain)
Bidonde J. Aerobic exercise trainingforadults withfibromyalgia.Cochrane DatabaseSyst Rev.2017
SLERODERMIA
The current literature on rehabilitation techniques consists of studies evaluating the effectiveness of
• Paraffin wax treatment • Hand and face stretching exercises • Connective tissue massage and joint manipulation • Splints • Aerobic exercise and resistance training
Only 4 RCT were found and except for those studies, the majority of studies involved small sample sizes and no control groups.However, except for splints, these studies show improvement in joint motion, hand function, and cardiopulmonary endurance.
PooleJL.Musculoskeletal rehabilitation intheperson withscleroderma.Current OpinioninRheumatology.2010.
ESERCIZIOeDEPRESSIONE
KelleyExercisereducesdepressivesymptomsinadultswitharthritis:EvidentialvalueWorldJRheumatol.2016
exercisereducesdepressioninadultswitharthritis
andotherrheumaticconditions
YOGA
Noadverseeventswerereportedandattritionwascomparableorbetterthan
typicalforexerciseinterventions.Evidencewasstrongestforreductionindisease
symptoms(tender/swollenjoints,pain)anddisability,aswellasimprovedself-
efficacyandmentalhealth.
Haaz S.Yogaforarthritis:ascopingreview.RheumDisClin NorthAm.2011
TaiChieAR
HanA.Tai chifortreating rheumatoid arthritis.Cochrane DatabaseofSystematic Reviews 2004
Fourtrialsincluding206participants
TheresultssuggestTaiChidoesnotexacerbatesymptomsof
rheumatoidarthritis.Inaddition,hasstatisticallysignificant
benefitsonlowerextremityrangeofmotion,inparticularankle
rangeofmotion,forpeoplewithRA.
FIBROMIALGIA
Le ginnastiche dolci, che comportano un coinvolgimento
globale corpo-mente, particolarmente adatto alle
complesse alterazioni psicologico-funzionali
del paziente fibromialgico.
Haak T,ScottB.Theeffect ofQigongonfibromyalgia (FMS):acontrolled randomized study.Disabil Rehabil2008
Taggart HM,Arslanian CL,Bae S,Singh K.Effects ofTai Chiexercise onfibromyalgia symptoms andhealthrelated quality oflife.
Orthop Nurs 2003
Almomento,cisonosoloalcuneevidenzescientifiche,chemostrano,comunque,risultatipromettentidialcunemetodiche,comeilQiGongeilTai Chi
Terapiefisiche
Termoterapia
Campimagnetici
Ultrasuonoterapia
Laserterapia
Elettroterapia
EffettianalgesiciRiduconolarigidità
Terapienoninvasivepochieffetticollaterali
US
CasimiroL.Therapeutic ultrasound forthetreatmentofrheumatoid arthritis.Cochrane DatabaseofSystematic Reviews 2010
Ultrasoundalonecanbeusedonthehand
§Toincreasegripstrength
§ Toincreasewristdorsalflexion
§ Decreasemorningstiffness
§ Reducethenumberofswollenjoints
§ Reducethenumberofpainfuljoints
2studies(80pz)continuous ultrasound applied inwater
LLLT
LLLTcouldbeconsideredforshort-termtreatmentforreliefofpainandmorningstiffnessforRApatients
LLLT• reducedpainby1.10points(95%CI:1.82,0.39)onVASrelativetoplacebo,• reducedmorningstiffnessduration by27.5minutes(95%CI:2.9to52
minutes)• increasedtiptopalmflexibilityby1.3cm(95%CI:0.8to1.7)
functionalassessment,ROMandlocalswellingdidnotdifferbetweengroups
howLLLT(wavelengthsfrom632nmto1064nm)effectivenessisaffectedbyfourimportantfactors:wavelength,treatmentdurationofLLLT,dosageandsiteofapplication(overnervesinsteadofjoints)?
Brosseau L.Low level lasertherapy (Classes I,IIandIII)fortreating rheumatoid arthritis.Cochrane DatabaseofSystematic Reviews 2010
Theeffectisnotthermal,butratherrelatedtophotochemicalreactionsinthecells
TENS
Brosseau L.Transcutaneous electrical nerve stimulation (TENS)forthetreatmentofrheumatoid arthritis inthehand.Cochrane DatabaseofSystematic Reviews 2010
ThreeRCTs,involving78people
• AL-TENS(lowfrequencyandhighintensity)isbeneficialforreducingpain
intensityandimprovingmusclepowerscoresoverplacebo
• C-TENS(highfrequency withlow intensity) resultedinnoclinicalbenefitonpain
intensitycomparedwithplacebo.HoweverC-TENSresultedinaclinicalbenefit
onpatientassessmentofchangeindiseaseoverAL-TENS.
ELETTROSTIMOLAZIONE
Pelland L,Brosseau L,Casimiro L,WelchV,Tugwell P,WellsGA.Electricalstimulationforthetreatmentofrheumatoidarthritis.
CochraneDatabaseofSystematicReviews2002
clinicallybeneficialeffectongripstrengthandfatigueresistanceforRApatientswithmuscleatrophyofthehand
OldhamJA,StanleyJK.RehabilitationofAtrophiesMuscleintheRheumatoidArthritisHand:AcomparisonoftwoMethodsofElectricalStimulation.
JournalofHandSurgery/BritishVolume1989
TERMOTERAPIA
WelchV,Brosseau L,CasimiroL,JuddM,Shea B,Tugwell P,WellsGA.Thermotherapy fortreatingrheumatoid arthritis.
Cochrane DatabaseofSystematic Reviews 2002,
Superficialmoistheatandcryotherapycanbeused
aspalliativetherapy
Księżopolska-Orłowska K.Complex rehabilitation andtheclinical condition ofworking rheumatoid arthritis patients:does cryotherapy always overtop traditional rehabilitation?
Disabil Rehabil.2016
Paraffinwaxbathscombinedwithexercises
canberecommendedforbeneficialshort-term
effectsforarthritichands
MAGNETOTERAPIA
magneticintensityof2mT andfrequencyof12Hzareusedinarthritis.Therecommendedtreatmenttimeisfrom15to30minutes,andthetreatmentsareperformed1–2timesperdayforseveralweeks
Themagneticfieldoflowfrequency(LF-EMF)iscommonlyusedinthetreatmentofpatientswithdiseasesoftheosteoarticular systemincludingRA
Zwolińska J.Theuseofmagneticfieldsintreatmentofpatientswithrheumatoidarthritis.Reviewoftheliterature.Reumatologia.2016
Despitethenumerousreportsshowinganimpactofmagneticfieldinsubjectswith
RA,theeffectivenessofmagnetotherapy hasnotbeenexplicitlyconfirmed
Modificare lo stile di vita
Attività fisica regolare
Interventi comportamentaliPer migliorare il livello di partecipazione
Migliora gli aspetti psicologici (motivazione, autogestione, consapevolezza, depressione)Le relazione interpersonali
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