Physical therapy in rheumatology

Reumatske bolesti su vodeći uzrok kronične nesposobnosti. Fizikalna terapija i rehabilitacija dio su strategije liječenja reumatskih bolesti sa ciljem održanja funkcije sustava za kretanje. Rano otkrivanje nesposobnosti omogućava efikasniju primjenu svih mjera fizijatrijskog liječenja. Vježbe su najvrijedniji oblik fizikalne terapije. Dugoročni efekt vježbi moguć je samo ako se postigne adherencija bolesnika za program. Upitnici aktivnosti svakodnevnog života ocjenjuju funkcionalni status bolesnika, mogu biti vodič za planiranje rehabilitacijskog programa i pokazatelj djelotvornosti terapijske intervencije. Metode fizikalne i rehabilitacijske medicine navedene su u svim objavljenim smjernicama za liječenje reumatoidnog artritisa, spondiloartritisa, osteoartritisa, osteoporoze, kronične križobolje, kronične nemaligne boli i fibromijalgije kao dio složenog terapijskog pristupa.Rheumatic diseases are the leading cause of chronic disability. Physical therapy and rehabilitation are an integral part of the strategy of treatment of rheumatic diseases in order to maintain the function of the musculoskeletal system. Early detection of disability provides a more efficient implementation of all measures of physiotherapy treatment. Exercises are the most important form of physiotherapy. Long-term effect of exercise is possible only if patients achieve adherence to the program. Questionnaires activities of daily living asses functional status of patients, can be a guide for planning the rehabilitation program and indicator of the effectiveness of therapeutic intervention as well. Methods of physical therapy and rehabilitation are part of all published guidelines for the management of rheumatoid arthritis, spondyloarthritides, osteoarthritis, osteoporosis, chronic back pain, chronic non-malignant pain and fibromyalgia

Pharmacotherapy for spondiloarthropathies

Spondiloartropatije (SpA) su donedavno bile terapijski zanemarena skupina reumatskih bolesti zbog ograničenih mogućnosti liječenja. Prikazane su osnovne smjernice pristupa bolesniku, a s naglaskom na ocjenu aktivnosti i lokalizaciju bolesti (periferni-aksijalni skelet). Nesteroidni antireumatici (NSAR) i fizikalna terapija su prva opcija osobito kod izoliranog spondilitisa. Sulfasalazin i metotreksat, a i drugi temeljni lijekovi (DMARD) dolaze u obzir kod afekcije perifernog skeleta. Anti-TNF preparati predviđeni su kod aktivne rezistentne bolesti s brzim protuupalnim efektom na sve manifestacije SpA. Lokalna aplikacija kortikosteroida je terapija izbora kod entezitisa i oligoartritisa, a sistemska primjena dolazi u obzir kod izražene upalne aktivnosti. Pamidronat i talidomid su nove potencijalne terapije za SpA.Since decade ago spondyloarthropathies (SpA) were neglected group of rheumatic disorders because of narrow therapeutic window. Main managing principles are described with emphasis to the assement of disease activity and distribution of pathological changes. Nonsteroidal antirheumatic drugs (NSAID) and physical therapy are still cornerstone for axial disease. Sulphasalzine and methotrexate are first choice considering peripheral arthritis. Biologic agents are effective in active vertebral and extravertebral disease. Local corticosteroid injection is favourable method for enthesitis and oligoarthritis and systemic treatment is indicated in patients during flare up of inflammation. Pamidronate and thalidomid are potential new agents for refractory cases

Treatment of Musculoskeletal Pain

Kronična mišićno-koštana bol globalni je javnozdravstveni problem s porastom prevalencije unatoč brojnim istraživanjima, sve većem broju farmakoloških i nefarmakoloških postupaka i osnivanju klinika za liječenje boli. Među rizicima od razvoja kronične boli u više su radova izdvojeni: trajanje i intenzitet boli do prvog pregleda, broj bolnih mjesta/regija, depresivno raspoloženje i životna dob. Već u akutnoj fazi valja prepoznati bolesnike s rizikom od kronične boli. Paracetamol, NSAR i tramadol standardna su farmakološka terapija boli. Formalna fizikalna terapija ima ulogu edukacije bolesnika, a kod rezistentne kronične mišićno-koštane boli indicirano je multidisciplinarno rehabilitacijsko liječenje. Mišićno-koštane bolesti najčešći su uzrok kronične nemaligne boli i nesposobnosti, a politopna distribucija boli direktno je povezana s gubitkom funkcionalne sposobnosti i kakvoće života.Chronic musculoskeletal pain is a global public health problem with an increasing prevalence in spite of numerous studies, a growing number of drugs, therapeutic procedures and the establishment of clinics for the treatment of pain. Among the risks for developing chronic pain, several factors have been identified: duration and intensity of pain until the first visit, number of painful regions/sites, depressed mood and life expectancy. The patients with a chronic pain risk should be recognized in the acute phase to prevent chronicity. Paracetamol, NSAIDs and tramadol are standard pharmacological therapies in pain treatment. The role of the supervised physical therapy is that of patient education, and multidisciplinary rehabilitation treatment is indicated in resistant chronic musculoskeletal pain. Musculoskeletal diseases are the most common cause of chronic non-malignant pain and disability, and distribution of pain is directly associated with the loss of functional capacity and reduced quality of life

Exercises in patients with myositis - active treatment intervention?

Polimiozitis, dermatomiozitis i inkluzijski miozitis su rijetke idiopatske miopatije čija je zajednička klinička karakteristika slabost mišića. Bez obzira na farmakološko liječenje u većine bolesnika zaostaje mišićna slabost i nesposobnost za obavljanje dnevnih radnji. Donedavno je prevladavalo mišljenje da aktivne vježbe pogoršavaju upalnu aktivnost u mišićima, a danas se zna da aktivne i vježbe s otporom poboljšavaju mišćnu snagu i izdržljivost, aerobni kapacitet i ukupnu funkcionalnu sposobnost. Propisuju se prema aktivnosti bolesti, manualnom mišićnom testu/dinamometriji, opsegu pokreta, kardiorespiratornoj sposobnosti i općenito statusu sustava za kretanje. Na svaku od komponenata može se utjecati ciljano kreiranim vježbama koje bi trebale biti integralni dio terapije miozitisa.Polymyositis, dermatomyositis and inclusion body myositis are rare inflammatory myopathies characterized by muscle weakness. Regardless of pharmacological treatment in most patients remain muscle weakness and inability to perform daily activities. Until recently, the prevailing opinion was that active exercises can exacerbate the inflammatory activity in the muscles and is now known that active exercise and exercise with resistance improve strength and endurance of muscles, aerobic capacity and overall functional ability. Exercises are prescribed according to the disease activity, manual muscle test or dynamometer measurements, range of motion, cardiorespiratory capacity and clinical status of the locomotor system. Each of the components can be influenced by targeted exercises and should be a integral part of myositis therapy

Nonpharmacological treatment of osteoporosis

Vježbe i prevencija padova temelj su nefarmakološke terapije osteoporoze (OP). Mehanički podražaj ima osteogeno djelovanje, a treningom proporiocepcije poboljšava se ravnoteža. Intermitentni snažniji mehanički stimulus najbolje potiče adaptaciju kosti. Preporuka za vježbe je da, prema vrsti, budu aktivne dinamičke antigravitacijske i s otporom, prema frekvenciji valja ih provoditi najmanje 3x tjedno trajanja minimalno 20-60 minuta s 50-80% intenzitetom maksimalnih ponavljanja (RM). Ciljne skupine mišića za intervenciju su ekstenzori kralježnice i mišići kuka. Uklanjanjem rizika za pad i vježbama ravnoteže smanjuje se incidencija padova i prijeloma.Exercise and prevention of falls are the cornerstone of nonpharmacological treatment of osteoporosis (OP). Mechanical stress has osteogenic properties. Proprioceptive training can improve balance. Intermittent mechanical stimuli are most appropriate type of functional bone adaptation. Recommendations for exercises include type (aerobic, weight-bearing, resistance), frequency (minimum 3x weekly), duration (minimum 20-30 minutes) and intensity of 50-80% of repetitive maximum (RM). Target muscle groups for intervention are spine extensors and hip muscles. Eliminaton of risk of falls and proprioceptive exercises can reduce incidency of falls and related fractures

Early rheumatoid arthritis

Reumatoidni artritis (RA) je kronična multisistemska bolest s najtežim posljedicama na sustavu za kretanje. Pravilo dobre kliničke prakse je postaviti dijagnozu RA u preerozivnoj fazi i rano primijeniti diferentne lijekove. Rana dijagnoza RA postavlja se na temelju ciljane kliničke, serološke, imunogenetske i radiološke obrade. Klinički je potrebno precizno odrediti aktivnost bolesti na temelju definiranih parametara. Reumatoidni faktor i anticitrulinska protutijela (anti-CCP) su vrlo specifični serološki parametri. Genetski biljeg HLA-DRB1* znači predispoziciju i teži oblik RA. Magnetska rezonancija i ultrazvuk pružaju velike mogućnosti otkrivanja preerozivnih promjena na kostima (edem) i perzistirajućeg sinovitisa (debljina, prokrvljenost) kada su klasični radiogrami još uredni.Rheumatoid arthritis (RA) is chronic joint disease which if untreated leads to permanent structural damage and disability. Early diagnosis and therapy are the main requests for good clinical practice. Early diagnosis tools include specific clinical assesment, serological, immunogenetic and radiological evaluation. Disease activity score is cornerstone in clinical assesment, rheumatoid factor and anti-cyclic citrullinated peptide antibodies (anti-CCP) are very specific serological parameters. The shared epitope containing HLA-DRB1* alleles represent the most significant genetic risk for RA. Magnetic resonance and ultrasound imaging are very sensitive methods in early phase of disease

The treatment of rheumatoid arthritis

Danas je cilj liječenja reumatoidnog artritisa remisija aktivnosti bolesti koju bi trebalo postići kroz prvih šest mjeseci liječenja konvencionalnim sintetskim lijekovima koji mijenjaju tijek bolesti i redovitim učestalim kontrolama bolesnika na kojima se terapija prilagođava statusu bolesnika. Ako izostane remisija ili niska aktivnost bolesti, primjenjuju se biološki lijekovi. Prekid terapije ovisi o procjeni liječnika i bolesnika, a dolazi u obzir tek nakon najmanje šest mjeseci stabilne remisije.Today, the goal of the treatment of rheumatoid arthritis is remission of disease activity which should be achieved through the first 6 months of treatment with conventional disease modifying antirheumatic drugs and tight control principle. The treatment must be adjusted to the state of disease on each visit. In the absence of remission or low disease activity biological drugs are indicated. Tapering or withdrawal of any treatment depends on the judgment of the physician and the patient, and should be considered only after at least 6 months of stable remission