Yoga in rheumatic diseases.

Yoga is a popular activity which may be well suited to some individuals with specific rheumatic disorders. Regular yoga practice can increase muscle strength and endurance, proprioception, and balance, with emphasis on movement through a full range of motion to increase flexibility and mobility. Additional beneficial elements of yoga include breathing, relaxation, body awareness, and meditation, which can reduce stress and anxiety and promote a sense of calmness, general well-being, and improved quality of life. Yoga also encourages a meditative focus, increased body awareness and mindfulness; some evidence suggests yoga may help reduce inflammatory mediators including C-reactive protein and interleukin-6. Yoga is best learned under the supervision of qualified teachers who are well informed about the potential musculoskeletal needs of each individual. Here, we briefly review the literature on yoga for healthy, musculoskeletal, and rheumatic disease populations and offer recommendations for discussing ways to begin yoga with patients.

Yoga for rheumatic diseases: a systematic review.

OBJECTIVE: To evaluate the quality of evidence and the strength of recommendation for yoga as an ancillary intervention in rheumatic diseases. METHODS: Medline/PubMed, Scopus, the Cochrane Library and IndMED were searched through February 2013. Randomized controlled trials (RCTs) comparing yoga with control interventions in patients with rheumatic diseases were included. Two authors independently assessed the risk of bias using the Cochrane Back Review Group risk of bias tool. The quality of evidence and the strength of the recommendation for or against yoga were graded according to the GRADE recommendations. RESULTS: Eight RCTs with a total of 559 subjects were included; two RCTs had a low risk of bias. In two RCTs on FM syndrome, there was very low evidence for effects on pain and low evidence for effects on disability. In three RCTs on OA, there was very low evidence for effects on pain and disability. Based on two RCTs, very low evidence was found for effects on pain in RA. No evidence for effects on pain was found in one RCT on CTS. No RCT explicitly reported safety data. CONCLUSION: Based on the results of this review, only weak recommendations can be made for the ancillary use of yoga in the management of FM syndrome, OA and RA at this point.

Long-term benefits of radon spa therapy in rheumatic diseases: results of the randomised, multi-centre IMuRa trial.

In chronic rheumatic diseases, recent treatment regimens comprise multimodal concepts including pharmacologic, physical/exercise, occupational and psychological therapies. Rehabilitation programmes are used for long-term management of disease. Spa therapy is often integrated in various middle and south European and Asian countries. Here, we investigated radon spa therapy as applied in health resorts compared to a control intervention in rheumatic out-patients. Randomised, blinded trial enroling 681 patients [mean age 58.3 (standard deviation 11.1); female 59.7%] in 7 health resorts in Germany and Austria with chronic back pain (n 1 = 437), osteoarthritis (OA) (n 2 = 230), rheumatoid arthritis (n 3 = 98), and/or ankylosing spondylitis (n 4 = 39); multiple nominations in 146 cases). Outcomes were pain (primary), quality of life, functional capacity, and medication measured before start, after end of treatment, and 3 times thereafter in 3 monthly intervals. Adverse events were documented. To analyse between-group differences, repeated-measures analysis of covariance was performed in metric endpoints and Fisher's exact test in rates. Two-sided significance level of 5% was chosen. Until end of follow-up, superiority of radon therapy was found regarding pain relief (p = 0.032) and analgesic drug consumption (p = 0.007), but not regarding quality of life. Functional capacity was assessed specific to the underlying indication. Significant benefits were found in radon-treated OA patients until 6-month follow-up (p = 0.05), but not until end of study (p = 0.096). Neither the back pain sub-population nor the two smaller patient populations with inflammatory indications benefited significantly in functional capacity. Results suggest beneficial analgesic effects of radon spa therapy in rheumatic diseases until 9 months post-intervention.

[Special features of physical therapy for elderly rheumatic patients]. / Besonderheiten der physikalischen Therapie beim älteren Rheumatiker.

The demographic shift is leading to a rapid rise in the number of elderly citizens. Accordingly, the number of geriatric problems is also increasing within the population of rheumatic patients. Geriatric patients are characterized through the triad of high age, multimorbidity and functional deficits. Almost all will show signs of arthritis and other degenerative musculoskeletal illnesses. Inflammatory rheumatic diseases within the geriatric population are found to be mostly in the chronic stage or with defective conditions. Problems typical of this population, such as comorbidities especially in the cardiovascular sector, must be assessed prior to the application of therapeutic concepts. The focus is on activating therapies, such as physiotherapy and occupational therapy, where the functional usefulness is proven. The use of thermal therapy, especially applied in the form of heat, as well as electrotherapy and high frequency therapy are also useful when indicated. Balneotherapy and hydrotherapy, as well as massage therapy and lymphatic drainage, must be adapted to the cardiovascular function of geriatric patients; this applies especially to heart failure patients. Physical therapy concepts in elderly rheumatic patients should preferably be implemented and managed by a multidisciplinary geriatric team.

Study on the effectiveness of the kinetic method in patients with rheumatic diseases and temporomandibular joint dysfunction.

UNLABELLED: Selecting the appropriate treatment decision is essential for achieving optimal results in the management of algo-dysfunctional syndrome of the temporo-mandibular joint (TMJD). The study aims to decide on the most effective (symptomatic control, preserved motility) kinetic program in patients with TMJ involvement. MATERIAL AND METHODS: prospective observational study on 83 consecutive patients with rheumatic diseases and TMJ dysfunction. Clinical assessment (pain, noises, muscle spasm, range of motion, ROM) was performed at baseline and after 3 months of specific kinetic rehabilitation program. Change in clinical parameters and TM3 index was reported, p<0.05. RESULTS: over 45% TMJ involvement at baseline as defined by TMJ index (mean value of 13.56) and only 36.66% at 3 months (p<0.05). Significant improvement in pain (presence, severity) was demonstrated at 3 moths (p<0.05): 18.05% spontaneous pain, 75.9% provoked pain, with 12.11% respectively 2.41% decreased in nocturnal respectively diurnal pain. Significant decrease (p<0.05) in joint noises at movements: 27.71% when opening and 12.04% when closing the mouth, 8.43 at protrusion and 3.61% at retraction, while 18% at the side movements. CONCLUSIONS: Complex accurate kinetic reeducation is mandatory for achieving correct posture (head, neck and trunk), normal mastication, swallowing and respiration, as well as correction of neuromuscular imbalances in patients with TMJD secondary to rheumatic disorders.

An extraordinary testimonial of thermal rehabilitation: Giuseppe Garibaldi - 2011: 150th Anniversary of the Italian Unification.

On the occasion of the 150th Anniversary of the Italian Unification, the discovery of some letters by Giuseppe Garibaldi - referring to a period of thermal treatments at the Baths in Civitavecchia (Rome) - gave us the opportunity for writing a commentary about a not well known experience in the Two World Hero's life: the numerous treatments carried out at many Italian spa centres for treating a rheumatic pathology (probably a rheumatoid polyarthritis) and the outcomes of various war wounds, especially the famous gunshot-wound in his right ankle during the Battle of Aspromonte, in 1862.

Comprehensive rehabilitation of patients with rheumatic diseases in a warm climate: a literature review.

OBJECTIVE: To present the evidence for the efficacy of comprehensive rehabilitation in a warm climate of patients with a wide variety of rheumatic diseases. METHODS: A systematic review of the literature was undertaken, searching in PubMed, Cinahl, Pedro, SweMed and Embase from 1970 to 2010, and using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation system) criteria. RESULTS: Six studies met the inclusion criteria. For patients with rheumatoid arthritis, moderate evidence was found for reduction of disease activity, pain, fatigue, and global disease impact. The evidence was also moderate that comprehensive rehabilitation in a warm climate did not improve fitness or reduce activity limitation beyond levels reached by rehabilitation in Scandinavia. Among patients with ankylosing spondylitis, low evidence was found for reduction of disease activity, pain, joint range of motion, activity limitation, and global disease impact. In groups with mixed rheumatic diagnoses, low evidence was found for reduction of pain, activity limitation, global disease impact and improved health-related quality of life. No studies on psoriatic arthritis, osteoarthritis, fibromyalgia or osteoporosis were found. CONCLUSION: Well-designed studies to validate and improve the low-to-moderate evidence found for the efficacy of comprehensive rehabilitation in a warm climate among patients with inflammatory rheumatic disease are greatly needed.

[How to prescribe physical exercise in rheumatology]. / Come si prescrive l'esercizio fisico in reumatologia.

Physical exercise, aiming to improve range of movement, muscle strength and physical well being, lately substituted the immobilization previously prescribed in rheumatic diseases. International guidelines, recommendations of Scientific Societies, and structured reviews regard physical exercise as of pivotal importance in treating rheumatoid arthritis, ankylosing spondylitis, osteoarthritis, fibromyalgia syndrome, osteoporosis, and to be considered in connective tissue diseases. Therapeutic exercise should: aim to improve firstly local symptoms and then general health; respect the pain threshold; be a part of a treatment including pharmacological therapies and other rehabilitation techniques, be administered by skilled physiotherapist under the guide of a rheumatologist, be different according to different diseases, disease phases and patient expectations.

Efeito da música e de exercícios físicos num grupo de pessoas reumáticas: estudo piloto / Effect of music and physical exercises on a group of rheumatic patients: pilot study

A associação de terapias com música e exercícios físicos foi estudada com um grupo de indivíduos reumáticos (n = 17). Em cada sessão das terapias conjugadas, o participante era entrevistado quanto ao seu estado físico (sensação de dor e facilidade de se movimentar) e emocional. De modo geral, após 8 sessões, os participantes melhoraram nos aspectos avaliados. Considerou-se que a interação dessas áreas terapêuticas não só é possível, mas sobretudo, positiva. Desta forma, foram abertas perspectivas no campo terapêutico, principalmente, pela dimensão existencial que o processo alcança, uma vez que interfere, ao mesmo tempo, nos aspectos emocional, físico e social das pessoas reumáticas.

[Structures of acute rheumatic care]. / Strukturen der akutstationären rheumatologischen Versorgung.

Severe rheumatological systemic diseases demand high levels of diagnostic and therapeutic measures and differentiated and complex methods of care. In Germany, specialised rheumatologists and, if hospitalisation is indicated, specialised rheumatology hospitals or departments are responsible for the treatment of these patients. Early rehabilitation procedures, provided by a multidisciplinary therapeutic team, are an important component of the treatment concept in these facilities. Early rehabilitation is integrated into the patients acute medical treatment plan, with careful consideration of the patients current health problems and functional capabilities (body functions and structures, activities and participation as outlined in the ICF), thereby providing a comprehensive, integrated therapy strategy which has long been acknowledged as necessary for the successful treatment of rheumatoid patients. This article presents an analysis concerning the development, organisation, facilities and processes of the acute medical in-patient care for patients with rheumatological disorders in Germany. In total there are 4188 beds in 88 acute hospitals exclusively available for rheumatological in-patients in Germany at present. There is at least one facility specialised in rheumatology in every German federal state. The density of care in the German federal states varies between 131.8 beds per 1 million inhabitants in Bremen and 9 beds per 1 million inhabitants in Saxony. In most regions of Germany the acute in-patient care for patients with rheumatological disorders is provided by hospitals specialised in rheumatology. Rheumatological patients are treated in a variety of hospital departments. In the year 2000 only 47% of the inpatients with rheumatoid arthritis, 56% of those with ankylosing spondylitis and 28% of those with systemic lupus erythematosus were treated in a ward specialising in rheumatology. Rheumatoid arthritis, with a total share of nearly 30%, was the most frequently treated rheumatic disease in wards specialising in rheumatology, followed by soft tissue disorders (e.g. fibromyalgia), diseases with systemic involvement of connective tissue and inflammatory spinal disorders such as ankylosing spondylitis.

[Quality standards and certification of patient education in rheumatology]. / Qualitätsstandards und Zertifizierungen der Patientenschulung in der Rheumatologie.

Patient education includes much more than only explanation or information regarding illness. The intention of all is to have a positive influence on patients' behaviour and to deliver the capability of self-management. One has to understand that the development and the realization of those programme needs a high quality level to achieve a reasonable result. The quality standards have been worked out by the DGRh-commission "Patientenschulung"-demonstrating the different levels of patient education. These standards are the basics of certificate and also the prerequisite to negotiate about the costs of patient education with the health insurance.

Prospective controlled evaluation of the influence of an excursion to a health resort on medical students' opinion about chances for outpatient rehabilitation at a health resort.

OBJECTIVE: To assess the influence of an excursion to a health resort on students' opinion on the chances for outpatient rehabilitation at a health resort for cardiac and rheumatic diseases. METHODS: A group of 17 medical students went on a 1-day excursion to Bad Orb (near Frankfurt/M.) where mainly patients with heart diseases are treated. Another group of 44 students went on a 5-day excursion to Bad Gastein (Austria) where mainly patients with rheumatic diseases are treated. Before and after the excursion students completed a questionnaire asking their opinion on the chances for outpatient rehabilitation at a health resort for acute and chronic cardiac and rheumatic diseases. RESULTS: Students judged the chances for beneficial effects of outpatient rehabilitation at a health resort for chronic rheumatic diseases to be significantly better after the excursion to Bad Gastein than before, whereas there was no difference after the excursion to Bad Orb. CONCLUSION: Students' opinion of chances for outpatient rehabilitation at a health resort can be influenced by an excursion to a spa, but a single 1-day excursion may not be sufficient.

Osteopathic treatment considerations for rheumatic diseases.

Patients who receive medical care for musculoskeletal pain of rheumatic diseases often benefit from additional osteopathic manipulative treatment. This article offers a brief description of commonly used treatment modalities. It also includes discussion of indications as well as contraindications of operator-director versus operator-monitored techniques.

[Physical therapy with analgesic effects in inflammatory rheumatic diseases]. / Analgetisch wirksame Physiotherapieverfahren bei entzündlich rheumatischen Erkrankungen.

In praxis, one is not only concerned about the linear connection between rheumatic inflammation and pain therapy--pharmacological or physical treatment--but about an optimal connection of the whole spectrum of symptoms regarding the joint status with different options of actions on one hand, and the treatment procedure of choice beside pain therapy on the other hand. The understanding of the mode of action regarding physiotherapeutic methods with analgetic effects is due to the knowledge about the pathophysiologic relationship between inflammation and pain. On one hand, the information of pain from the periphery causes a sensibilisation of central nervous areas and therefore allodynia as well as irradiation of the painful area. On the other hand, biochemical processes lead to a neurogenic and alogenic inflammation due to the impact on the pain nerves. Beside the arthritis itself, the physiotherapy of a rheumatic-inflamed painful joint has to take into account the components arthralgia, irritation of the capsula, periarthropathia, and allogenic inflammation. Physiotherapeutic pain treatment has three modes of action: a causal effect on the structural level, suppression of over-excitation of the tissue as well as the central nervous transmission areas, and activation of the decelerating pain modulating systems. Each treatment procedure with analgetic effects like cooling, heating, localized mechanical methods, the activation techniques with proprio- and exteroceptive effects (TENS, Maitland-mobilisation), the electrotherapeutic option, and physical training therapy is characterized with its specific mode of action. The dosage of physiotherapeutic techniques has to be taken into account since it has to remain within physiologic limits and the tissue's irritability must not be reached.

[Occupational therapy in the diseases of the locomotor system]. / Ergotherapie bei Erkrankungen des Bewegungsapparates.

The spectrum of occupational therapy (OT) services in rheumatology includes the restoration of disturbed muscle function, psychosocial aspects, instruction and training in joint protection and manufacturing of orthotic devices as well as advice and training with technical aids and adapting the home and workplace according to the patient's disability. OT is especially indicated in inflammatory rheumatic diseases with polyarticular involvement, but also in degenerative joint diseases, various forms of soft tissue rheumatism and spinal disorders. It should be prescribed by a physician and functional therapist together with regard to the specific location of functional derangement and is to be dosed individually according to the work-load applied. A wide range of techniques involving different materials--including textiles, leather, wood, clay--enable individual joints or functional entities to be exercised specifically. Integration and coordination of OT with the other elements of multidisciplinary therapy, e.g. pharmacological treatment, physiotherapy, orthopedic surgery is the important task of the rehabilitation team. The objective measurement of therapeutic effects serve the purposes of demonstrating the quality of the results and also of motivating the patient. The methods used will depend on the clinical picture, the structures damaged, and the time available for the therapist.