111

Chapter 8

Physical therapies: treatment options

in rheumatology
Lindsay M. Bearne PhD MSc MCSP School of Biomedical and Health Sciences, Kings College London,
London, UK

Michael V. Hurley PhD MCSP Rehabilitation Research Unit, Kings College London, Dulwich Community Hospital,
London, UK

n Physical therapies are safe and popular with

CHAPTER CONTENTS powerful placebo effects and are useful in the overall
management of rheumatic conditions.
Introduction 111
The aims of physical therapies in rheumatic
diseases 111
Introduction
Electrophysical agents 112
Sensory stimulation for pain relief 112 Physical therapies are non-pharmalogical treat-
Transcutaneous electrical nerve stimulation 112 ments which are widely used by therapists in the
Interferential therapy 113 management of rheumatic diseases. This chap-
Motor stimulation of innervated muscle 114 ter briefly reviews the role of physical therapies
Low level laser therapy 114 (electrophysical agents (EPA), thermotherapy and
Ultrasound therapy 115 cryotherapy, manual therapy and acupuncture) in
Short wave therapy 115 common rheumatic conditions and discusses the
current evidence and recommendations for clinical
Acupuncture 115 practice for these therapies.
Thermotherapy and cryotherapy 116
Manual therapy 117 The aims of physical therapies in
rheumatic diseases
Massage 119
Conclusion 119 It is important our assessment and management
of patients with rheumatic disease is holistic. This
means therapists should consider the person with
the rheumatic condition rather than the structure
(e.g. synovial joint) or the pathological process (e.g.
Key points
rheumatoid arthritis) prior to selecting any therapy.
n Physical therapies aim to control pain, minimise This holistic perspective has been conceptualised
joint stiffness and limit joint damage with the least as the biopyschosocial model (see Chs 5 & 11) and
adverse treatment effects suggests there is far more than just the pathology or
n There is some evidence that TENS, thermotherapy structure which has an impact on the outcome of the
and acupuncture can relieve pain in some rheumatic disease. Therefore, a detailed subjective and objec-
conditions but insufficient evidence for the efficacy tive patient assessment, which includes psychosocial
of many electrotherapy interventions and manual factors (Kendall 1997) and health related quality of
therapy life, should be obtained (Ch. 4) and a collaborative

© 2010 Elsevier Ltd

DOI: 10.1016/B978-0-443-06934-5.00008-5
112 Rheumatology – Evidence-Based Practice for Physiotherapists and Occupational Therapists

process used to develop realistic, achievable, meas- which have a morphine type inhibitory effect on the
urable patient orientated goals. As all patients C- fibre (nociceptor) system. Furthermore, activa-
with rheumatic disease are different, starting from tion of the A delta fibres may provoke impulses in
a different baseline and with different needs, the the mid brain which inhibit the neurons at the orig-
physiological and psychological impact of each inal site via stimulation of the descending inhibi-
physical therapy should be considered on an indi- tory pathways (Galea 2002). Thus, by changing the
vidual basis. sensory input the perception of pain may be altered
When considered in a biopyschosocial context, but not the underlying cause of the pain.
physical therapies predominantly address the ‘bio’
aspect and aim to control pain, minimise joint stiff-
Transcutaneous electrical nerve
ness, limit joint damage with the least adverse
stimulation
treatment effects. However, if applied judiciously
physical therapies help maximise function and Transcutaneous electrical nerve stimulation (TENS)
health-related quality of life. is an easily applied, non-invasive modality with
relatively few contraindications (Fox & Sharp 2007,
Robertson et al 2006) which can be readily adopted
as a pain management strategy for patients with
Electrophysical agents
rheumatic conditions. Small battery operated TENS
machines deliver an electrical impulse via surface skin
Electrophysical agents (EPA) are used by healthcare
electrodes (Fig. 8.1). Five parameters can be adjusted
practitioners to relieve pain, improve muscle function
to achieve most effective pain relief – waveform,
and reduce inflammation. An underlying premise of
pulse duration and frequency, intensity and electrode
all EPAs is that applying an external energy source
position. Therapeutic methods of applying TENS are
can beneficially alter physiological processes. In the
categorized into conventional, ‘acupuncture-like’,
management of rheumatic disease, electrical stimula-
burst, brief intense and modulation (Watson 2007).
tion, low level laser therapy, ultrasound therapy and
Selection is based on the underlying condition, sever-
short wave diathermy are most frequently used.
ity and duration of symptoms (Brosseau et al 2004)
(Table 8.1). Recent meta-analyses of six randomised
Sensory stimulation for pain relief controlled trials (RCT) involving 268 patients with
lower limb osteoarthritis (OA) suggest all modes
Sensory stimulation means applying electrical stim- of TENS improve pain, but not range of movement,
ulation with the intention of increasing the afferent function or strength regardless of the treatment pro-
nerve input. This effects a change at the spinal or tocol (Brosseau et al 2004). In patients with knee OA,
supraspinal level of the neurological system (cen- longer courses of treatment (4 weeks) and greater
trally), which can be used to alter pain perception. intensity protocols (high burst or low frequency)
The rationale for this treatment is provided by the may produce greatest pain relief (Osiri et al 2000).
pain gate theory (Melzack & Wall 1965). This the- In people with inflammatory disease, acupuncture-
ory proposes that pain perception is regulated by a like TENS reduces pain and increases muscle power,
‘gate’ at the level of the dorsal column of the spinal
cord, which may be opened or closed by means of
other inputs from peripheral nerves or the central
nervous system (see Ch. 5). Essentially, electrical
stimulation is aimed at modifying the peripheral
input (stimulation of the A beta mechanoreceptor
fibres at the skin) which inhibits nociceptor activ-
ity of C and A delta fibres (at the posterior horn)
thus changing the level of excitability of the central
components of the neurological system, e.g. central
nociceptive transmission cells, wide dynamic range
neurons (Robertson et al 2006).
Additionally, electrical stimulation is responsible
for releasing chemical mediators (e.g. encephalins), Figure 8.1 Example of a TENS machine.
 Chapter 8 Physical therapies: treatment options in rheumatology 113

whilst conventional TENS improves self reported dis- response (Robertson et al 2006). Clinically, medium
ease activity but not pain (Brosseau et al 2003a). frequency currents are applied which pass through
Clinical guidelines recommend acupuncture-like the skin more comfortably than a typical low fre-
TENS for improving pain, oedema and power in quency current (due to skin resistance). At the inter-
patients with RA, (Brosseau et al 2004) as a relatively section of the currents a beat frequency produces an
safe adjunct therapy for the relief of pain in patients effect similar to a low frequency current (Fig. 8.2).
with OA (Philadelphia Panel 2001) and for oste- Using appropriate frequencies, sensory nerve
oporotic (OP) patients with intractable pain especially
those with chronic low back pain and recent vertebral
A B
factures (Chartered Society of Physiotherapy 1999).

Interferential therapy
Interferential therapy (IFT) is an alternative method
of sensory nerve stimulation, which applies two alter-
nating currents of slightly different frequencies (kHz)
at right angles to each other in a continuous stream. B A
Theoretically, where the currents intersect an area
Current ‘A’ is at 4000 Hz and current ‘B’ is at 3900 Hz
of maximum stimulation is produced. However, as Interference current (beat frequency) generated in the
the spread of the current reduces the intensity in central zone at the difference between input currents
deep tissues the superimposed current may be less which would be 100 Hz
effective than immediately under electrodes and Figure 8.2 Diagrammatic representation of interferential
therefore may not achieve the desired therapeutic current (Watson 2000).

Table 8.1 Possible therapeutic methods and parameters for applying TENS (adapted with permission
from [Link])

Protocol Definition Possible pain relief Treatment parameters

mechanisms

Conventional High frequency 90-130 Hz Pain relief via pain gate Treatment time: at least 30 minutes but as
Pulse width 100 s mechanism long as needed
Intensity: definitely there but comfortable
Limited carry over effect
Acupuncture Low frequency -2-5Hz Pain relief via opioid Treatment time: at least 30 minutes but as
Pulse width 200  s mechanism long as needed
Intensity: definite/strong sensation
Positive carry over effect
Burst Low frequency 10 Hz Pain relief via all pain Treatment time: at least 30 minutes but as
Burst impulses – 2-3 per second mechanisms long as needed
Intensity: definite/strong sensation
Brief intense High frequency 80 Hz Pain relief via pain gate Treatment time: 15–30 minutes
Pulse width 150  s mechanism Intensity: close to tolerance
Indication: to achieve rapid pain relief
Modulation All characteristics are varied All pain relief mechanisms Treatment time: at least 30 minutes but as
throughout application may be stimulated long as needed
Intensity: strong/definitely there but
comfortable
Indication: suitable for long term
use as modulation diminishes the
accommodation effects of the sensory
nerves to a ‘regular’ stimulation pattern
114 Rheumatology – Evidence-Based Practice for Physiotherapists and Occupational Therapists

stimulation can be achieved, activating the pain muscle torque improved by 10% in people with OA
gate mechanism (between 80–130Hz) and opioid knee following muscle stimulation (Talbot et al 2003).
mechanisms (10Hz) associated with pain relief. Whilst not included in any clinical guidelines for
Evidence for the effectiveness of IFT in rheumatic patients with rheumatic disease, motor stimulation
disease is limited but it may reduce pain in patients should be considered as an adjunctive therapy for
with psoriatic arthritis (Walker et al 2006) and patients with gross muscle weakness secondary
when combined with ultrasound may reduce pain to rheumatic disease. However, the high ampli-
and improve sleep in patients with fibromyalgia tude needed to evoke a muscle contraction can be
(Almeida et al 2003). However, due to the size of uncomfortable and may diminish patient compli-
the apparatus, application of IFT is limited to use ance with the treatment.
within the healthcare setting and therefore encour-
ages reliance on healthcare practitioners rather than
promoting self-management. Whilst there is some
Low level laser therapy
evidence to support the efficacy of sensory stimu- Low level laser therapy (LLLT) utilises a pencil-
lation for pain relief no studies directly compare like beam of electromagnetic waves of a single
the clinical effectiveness of TENS and IFT. Without frequency and defined wavelength to promote tissue
evidence of superior efficacy of one form of sen- healing and pain relief in a broad spectrum of soft
sory stimulation, the small, battery operated TENS tissue injuries and diseases. The effects of LLLT are
machine offers a relatively safe, inexpensive, easily not thermal but photochemical reactions in cells,
self administered method of symptom control in termed photobioactivation. LLLT produces its physi-
patients with rheumatic diseases. ological and therapeutic effects by applying enough
energy to disturb local electron orbits, initiate chem-
ical change, disrupt molecular bonds and produce
Motor stimulation of innervated
free radicals at the cell membrane to control the
muscle
inflammatory response, promote healing and pain
Motor stimulation is the production of a muscle relief (Box 8.1) (Robertson et al 2006, Watson 2000).
contraction by electrical stimulation of the motor In patients with rheumatic disease the evidence for
nerves. It is used for; increasing muscle strength and the use of LLLT is mixed. In patients with OA, LLLT
endurance, re-education of motor control, oedema is ineffective for pain relief (Brosseau et al 2005).
reduction, increasing joint and soft tissue mobility However, LLLT is recommended in ­ clinical practice
and altering muscle structure and function (trophic guidelines for patients with RA as it improves pain
changes). Therapeutically it can be used as a sole and morning stiffness, but not ­ function, range of
treatment, (Bircan et al 2002) superimposed over an
active muscle contraction (Strojnik 1998) or as an
adjunct to an exercise regimen (Fitzgerald et al 2003).
Gradual onset short duration pulses may be
Box 8.1 The potential photobioactivation effects
selected at frequencies between 30-100 Hz with of low level laser therapy
on-off times and rate of ramping (progression)
varying with clinical considerations. The number Altered cell proliferation
of repetitions is defined by the training response Activation & proliferation of fibroblasts
required and the amplitude is set at maximum indi- Altered cell motility
vidual tolerance. A two second pulse, followed by Alteration of cell membrane potentials
four second rest with a one second ramp, mimics Activation of phagocytes
physiological muscle contraction although the com- Stimulation of angiogenesis
plexity of normal muscle group activity cannot be Stimulation of immune responses
simulated (Robertson et al 2006). Alteration of action potentials
In patients with rheumatoid arthritis (RA) with Increased cellular metabolism
secondary disuse atrophy of the first dorsal interos- Altered prostaglandin production
seous of the hand, muscle stimulation improves hand Stimulation of macrophages
function, strength and fatigue resistance of the first Altered endogenous opioid production
dorsal interosseus muscle (Oldham & Stanley 1989). Stimulation of mast cell degranulation
Similarly, functional performance and quadriceps
 Chapter 8 Physical therapies: treatment options in rheumatology 115

movement, joint tenderness or swelling (Brosseau temperature by 3-7°C, muscle temperature by 2-6°C
et al 2004). (Robertson et al 2006) and intra-articular heating
has also been demonstrated (Oosterveld et al 1992).
Pulsed short wave diathermy (PSWD) or pulsed
Ultrasound therapy
electromagnetic energy (PEME) is an intermittent
In the management of rheumatic diseases, ultra- oscillating high frequency (27.12MHz) output. The
sound therapy (US) is commonly used as an mean power depends on the peak (pulse) power,
adjunctive therapy for its proposed effects on duration and frequency of the pulse. As a thermal
inflammation as well as for pain relief. It uses effect is only produced with outputs above 7 Watts,
sound waves at very high frequencies (0.5-5 MHz) the non thermal physiological effects of PSWD
to produce mechanical vibration within the tissues. are postulated to occur due to agitation of ions,
If applied in high doses absorption of US results molecules, membranes and perhaps cells which
in heating, which decreases pain and fluid viscos- accelerates membrane transport, phagocytic, and
ity, increases metabolic rate and blood flow (ther- enzymatic activity (Kitchen & Partridge 1992, Low
mal effects) (Nussbaum 1997). At lower doses of 1995, Robertson et al 2006).
US or following pulsed US non thermal, mechani- Brief, high intensity bursts of electromagnetic
cal effects such as stable cavitation (formation of energy:
gas bubbles in tissues), standing waves (reflected l increase the number and activity of cells in the
waves superimposed on incident waves) and acous- injured region
tic streaming (fluid movement which exerts pres- l improve re-absorption of haematoma
sure changes on a cell) occur (Maxwell 1992) which
l reduce oedema
cause membrane distortion, increased permeability,
l increase the rate of fibrin deposition
increased nutrient transfer and facilitation of tissue
repair (Mortimer & Dyson 1988). When applied to l increase collagen deposition and organisation
acutely inflamed tissues it encourages the inflam- l increase nerve growth and repair (Robertson
matory process to progress to the proliferation stage et al 2006).
(Watson 2000). Whilst based on reasonable biophysical evi-
Whilst there is evidence to support the physio- dence (Hill et al 2002), the evidence for the clinical
logical effects of US in laboratory or animal studies, effective of short wave therapy is mixed and some
(Mortimer & Dyson 1988) evidence for its clinical studies report no improvement of pain, stiffness or
effectiveness in people with rheumatic conditions disability in patients with lower limb OA following
is limited (Brosseau et al 2004, Zhang et al 2007) PSWD (Callaghan et al 2000, Klaber Moffett et al
and it is only recommended for those with arthritis 1996, Laufer et al 2005, Thamsborg et al 2005) whilst
of the hand (Casimiro et al 2002, Welch et al 2001). others conclude pulsed SWD may be beneficial
Moreover, a recent review concludes US may only (Van Nguyen & Marks 2002) after lengthy courses
be effective for people with carpal tunnel syndrome of treatment (Jan et al 2006). There is no evidence to
and those with calcific tendonitis of the shoulder suggest SWD may be beneficial for people with RA
(Roberston & Baker 2001) despite being a frequently and it is not included in guidelines for the manage-
used electrophysical modality in musculoskeletal ment of any rheumatic conditions.
conditions (Kitchen & Partridge 1996).

Acupuncture
Short wave therapy
Short wave diathermy (SWD) produces its physi- Acupuncture literally means ‘needle piercing’ – the
ological and therapeutic effects by rapidly alter- practice of inserting very fine needles into the skin
nating electrical and magnetic currents at short to stimulate specific anatomic points in the body
wave frequencies (27.12 MHz). Continuous SWD is (called acupoints or acupuncture points) for thera-
applied to tissues either inductively (metal cable, peutic purposes (Fig. 8.3). Heat, pressure, friction,
covered in insulating rubber, which is wrapped suction, or impulses of electromagnetic energy may
around the part to be treated) or capacitively (plate be used to stimulate the points.
or malleable electrodes placed next to the area to be Acupuncture is one of the more popular com-
treated), usually for 20–30 minutes. It increases skin plementary interventions for arthritis (Ernst 1997)
116 Rheumatology – Evidence-Based Practice for Physiotherapists and Occupational Therapists

There is no evidence that acupuncture interacts

with other treatments.
There is growing evidence that acupuncture
is beneficial for pain management in peripheral
joint osteoarthritis. A systematic review of 18 ran-
domized controlled trials (RCTs) of acupuncture
and electroacupuncture and a meta-analysis of data
from three studies suggests acupuncture relieves
pain in peripheral joint OA compared with sham
acupuncture (Kwon et al 2006). This is supported
by a recent systematic review and meta–analysis of
eight RCTs which concurs that acupuncture is supe-
rior to sham acupuncture or usual care and suggests
the effect size is comparable to that of nonsteroidal
anitiinflammatory drugs (NSAIDs) whilst having
fewer side effects (White et al 2007). However, the
addition of acupuncture to a course of advice and
exercise for osteoarthritis of the knee provided no
further improvement in function and pain (Foster
et al 2007) and whilst the National Institute of
Figure 8.3 Acupuncture treatment. Health and Clinical Excellence recommended acu-
puncture for low back pain, their osteoarthritis
guidelines do not (NICE 2008, 2009).
and it is gaining acceptance and utilization within In patients with RA acupuncture does not alter
western healthcare systems as a form of pain relief pain, medication use or disease activity (Casimiro
(Tindle et al 2005) where its effects are explained et al 2002). In patients with fibromyalgia, the evi-
through the pain gate theory (Melzack & Wall 1965) dence of effectiveness is mixed (Berman et al 1999,
and stimulation of the release of neurochemicals in Mayhew & Ernst 2007, Sim & Adams 2002); some
the central nervous system (Cheung & Pomeranz studies report short-lived, small beneficial effects
1979). In its traditional form (as a component of tra- (Deluze et al 1993, Guo & Jia 2005, Martin et al 2006)
ditional Chinese medicine) acupuncture points are and others report no positive effects of acupuncture
stimulated to balance the movement of energy (qi) (Assefi et al 2005, Sprott 1998). Consequently, acu-
in the body along energy channels (meridians) to puncture is only recommended for short-term pain
restore health and the production of acupuncture control in peripheral joint OA (Kwon et al 2006,
analgaesia is explained via neural, humeral and White et al 2007) and in osteoporosis (Chartered
biomagnetic mechanisms (Cao 2002). Society of Physiotherapy 1999) but not in fibro-
Acupuncture is used by many physiothera- myalgia (Mayhew & Ernst 2007) or RA (Casimiro
pists, often within the NHS, and the Acupuncture et al 2005).
Association of Chartered Physiotherapists is a
recognised special interest group within the pro-
fession. Many doctors have also been trained in Thermotherapy and cryotherapy
acupuncture, and there is a group of practitioners
who have trained in acupuncture and who mainly Thermotherapy (the therapeutic application of
work privately, sometimes also prescribing Chinese a heating agent) and cryotherapy (the therapeu-
herbs (see Ch. 14). tic application of a cooling agent) are widely used
Acupuncture needles can of course cause inju- treatments to reduce pain, oedema and muscle
ries, (for example, accidental penetration of the spasm, improve tissue healing and facilitate range
lung, which causes a pneumothorax or collapsed of motion and function. Clinically, superficial heat-
lung), but in the hands of a trained practitioner ing can be achieved by conductive methods, such
acupuncture is very safe (White et al 2001). The as heat pads or paraffin wax baths, by radiation
only contraindications are in patients who have an such as infra red light therapy and by convection,
undiagnosed bleeding disorder, or a fear of needles. such as sauna or steam room (Hicks & Gerber 1992).
 Chapter 8 Physical therapies: treatment options in rheumatology 117

Heating of the deeper tissues can be achieved by Box 8.2 The physiological changes in response to
short wave diathermy (electromagnetic energy) heat and cold therapy
and high doses of ultrasound therapy, which are
­discussed earlier in this chapter. Cryotherapy
includes the use of ice packs and ice baths, commer- Cryotherapy Thermotherapy
cially available gel packs or sprays and massage
with ice over acupuncture points or painful areas. Pain ↓ ↓
Prior to application of either therapy, skin test- Muscle spasm ↓ ↓
Metabolism ↓ ↑
ing to establish normal cutaneous sensation is rec-
Blood flow ↓ ↑
ommended as both heat and cold therapy have a Inflammation ↓ ↑
measurable effect on surface and intra-articular tem- Oedema ↓ ↑
perature of joints, skin micro-circulation and core Connective tissue
temperature (Oosterveld et al 1992) and patients with extensibility ↓ ↑
abnormal cutaneous sensation (e.g. diabetic neuropa-
thy) are at risk of damage (Fox & Sharp 2007).
Thermotherapy and cryotherapy produce anal-
gaesia via the pain gate theory (Melzack & Wall 1965) the management of patients with RA (Brosseau
and reduce muscle spasm. However, thermotherapy et al 2004), OA (Brosseau et al 2004, NICE 2008,
increases tissue temperature, blood flow, metabolism Zhang et al 2007) and osteoporosis (Chartered
and connective tissue extensibility, whilst cryop- Society of Physiotherapy 1999).
therapy decreases tissue blood flow by initially caus-
ing vasoconstriction followed by vasodilatation (the
‘hunting reflex’), reducing tissue metabolism, oxy- Manual therapy
gen utilization, inflammation and connective tissue
extensibility (Box 8.2). Whilst there are differences in Manual therapy is the skilled application of passive
physiological responses, both therapies can be used movement to a joint either within (‘mobilisation’)
in patients with rheumatic conditions and patient or beyond its active range of movement (‘manipu-
preference as well as physiological response should lation’). This includes oscillatory techniques, high
be considered when selecting which therapy to use. velocity low amplitude thrust techniques, sustained
Despite being used for years as a safe and effec- stretching and muscle energy techniques. Manual
tive symptomatic treatment of rheumatic conditions, therapy can be applied to joints, muscles or nerves
systematic reviews of thermotherapy and cryo- and the aims of treatment include pain reduction,
therapy highlight a lack of good quality research increasing range and quality of joint movement,
(Brosseau et al 2003b). In patients with RA, hot or improving nerve mobility, increasing muscle length
cold therapy has no effect on pain, swelling, ROM, and restoring normal function. There are three para-
strength or function (Dellhag et al 1992, Ivey et al digms for its therapeutic effects; physiological, bio-
1994, Kirk & Kersley 1968, Rembe 1970); whereas mechanical or physical, and psychological (Fig. 8.4).
ice massage improves pain, joint mobility and func- The physiological effects of manual therapy
tion in patients with knee OA (Yurtkuran & Kocagil include the reduction of pain via the pain gate the-
1999) and ice packs reduce swelling (Hecht et al ory (Melzack & Wall 1965) and stimulation of the
1983) and improve range of movement (Lin 2003) descending inhibitory tracts. Indirectly, manual ther-
but may not relieve symptoms in painful periph- apy can reduce pain via inhibition of muscle spasm
eral joint conditions (Clarke et al 1999). Similarly, which reduces tension on the periarticular struc-
short-term application of hot packs are not useful in tures, lowering intraarticular pressure, or reduces
peripheral joint osteoarthritis (Hecht et al 1983) but nociceptor activity (Zuzman 1986).
may control pain and improve disability if applied The biomechanical effects of manual therapy
for longer periods to patients with acute non spe- include altering tissue extensibility and fluid
cific low back pain (Nadler et al 2003a, 2003b). dynamics thus facilitating repair and remodelling.
Based on some evidence and anecdotal reports Temporary increases in tissue extensibility follow-
of effectiveness, thermotherapy and cryotherapy ing manual therapy occur through the mechanisms
are useful palliative self management therapies of creep (tissue lengthening following application
for rheumatic patients and should be included in of a constant force or load) and preconditioning
118 Rheumatology – Evidence-Based Practice for Physiotherapists and Occupational Therapists

Manual therapy

Psychological effects Biomechanical effects Physiological effects

Stimulation of Reduction
Muscle
gating mechanisms of nociceptor
inhibition
and descending activity
tracts
Alters tissue Alters fluid
extensibility dynamics
Reduced Reduction of
intra-articular periarticular
pressure tension

Positive Facilitates repair and

placebo response tissue remodelling Pain relief

Figure 8.4 Potential effects of manual therapy.

(elongation following repeated loading) (Panjabi & a­ ssociated with mild to moderate adverse effects
White 2001). More permanent length changes need (30-61% of all patients) and can result in serious
sufficient force, which are achieved in spinal man- complications such as vertebrobasilar artery dissec-
ual therapy (Harms & Bader 1997), to produce tion followed by stroke (Ernst 2007, Taylor & Kerry
microtrauma which elongates collagenous tissues 2005). Consequently, premanipulative testing pro-
(Threlkeld 1992). Repetitive movement of inflamed tocols attempt to identify patients at risk of verte-
joints alters fluid dynamics, reducing intra articular brobasilar artery insufficiency (Magarey et al 2004)
pressure (Jayson & Dixon 1996, Levick 1979, Nade & although the effectiveness of this screening has yet
Newbold 1983), increasing the rate of synovial to be established. All guidelines contraindicate the
blood flow and synovial fluid clearance (James et al use of manipulation in patients with RA due to the
1994) thus improving range and movement quality. risk of joint instability particularly in the upper cer-
The psychological effects of manual therapy or vical spine (Neva et al 2006) and caution should be
any therapy which has direct physical contact, such exercised when considering the use of manipulation
as massage, produces a response to the ‘laying on of in other inflammatory rheumatic conditions.
hands’. This placebo response (a response produced Whilst there is some evidence of the effectiveness
by a mechanism with incidental ingredients or com- of manual therapy in the treatment of acute and sub
ponents which have no remedial effect for the dis- acute spinal pain (Bronfort et al 2004, Ferreira et al
order but result in a positive effect of treatment) is 2006, UK BEAM trial team 2004) in patients with
enhanced by ‘learned expectancy’ (previous experi- peripheral joint disease manual therapy is often
ence of a stimuli establishes an habitual direction of combined with other therapies which makes the
response) and the therapeutic benefits of the patient – relative contribution of each therapy difficult to
therapist interaction and ­relationship (Roche 2002). determine (Deyle et al 2005). In patients with OA
Manual therapies are commonly used inter- knee, a combination of manual therapy and exer-
ventions regardless of reported non vascular and cise improves function and pain more than exercise
vascular side effects (Ernst 2007). Whilst mobilisa- (Deyle et al 2005). In patients with hip OA manual
tions (movement to a joint within its physiological therapy improves pain, range of movement and
range of movement) are not associated with seri- function more than exercise alone (Hoeksma et al
ous complications, manipulations (high velocity 2004). Those patients with the severest x-ray changes
low amplitude trust techniques applied beyond respond least to manual therapy although baseline
active joint range of movement) can have severe levels of function, pain and range of movement do
adverse reactions. Spinal manipulation, particu- not predict treatment response (Hoeksma et al 2005).
larly when performed on the cervical spine, is Consequently, evidence-based practice guidelines
 Chapter 8 Physical therapies: treatment options in rheumatology 119

recommend the use of manual therapy combined There is some evidence that thermotherapy, TENS,
with exercise for the reduction of pain in peripheral and acupuncture can relieve pain in some rheumatic
joint osteoarthritis (Brosseau et al 2005, NICE 2008). conditions but insufficient evidence for the efficacy
of many electrotherapy interventions and manual
­therapy. However, insufficient evidence of effectiveness
Massage should not be interpreted as ‘ineffective’ – it also indi-
cates an absence of evidence. Therefore clinical deci-
Massage has been used to reduce pain and oedema, sions should be made following a thorough assessment
increase circulation, improve muscle tone and of an individual’s symptoms and treatment based on
enhance joint flexibility for years. Its effect may be the available good quality evidence (basic principles
explained by the pain gate theory (Melzack & Wall and clinical effectiveness), practice guidelines, clinical
1965) but it is also likely to have a placebo response experience and patient preference (Jones 1995) until a
similar to other manual therapies. sufficient body of good quality studies are completed
Evidence of its efficacy in rheumatic patients is lim- to unequivocally direct the use of physical therapies in
ited; a course of massage improves function and pain the management of rheumatic disease.
in patients with OA knee (Perlman et al 2006) and
pain and quality of life in patients with fibromyalgia
(Brattberg 1999) although it is ineffective in patients
with neck pain (Ezzo et al 2007). However, a system- Study activities
atic review of nine studies suggests massage is benefi-
cial in patients with sub acute and chronic non-specific n Review the current guidelines for the management
low back pain especially when combined with exer- of rheumatoid arthritis (RA) on the NICE website
cise and education but it was no better than manipu- ([Link] and consider which
lation and inferior to TENS for back pain relief (Furlan physical modalities may be included in an evidence
et al 2003). Whilst massage is not often recommended based treatment programme for a patient with
in clinical guidelines, as it has high patient satisfaction moderate, well controlled RA.
and low adverse effects it is a viable adjunct to ther- n Access the ‘electrotherapy on the web – an
apy for patients with rheumatic disease. educational resource’ website ([Link].
org) and review the theories and evidence
underpinning the use of transcutaneous electrical
Conclusion nerve stimulation (TENS). Consider how you would
explain these concepts to a patient who is using
Physical therapies are often used in the management TENS for pain relief, within the biopyschosocial
of rheumatic conditions to relieve pain and improve framework.
function. Within the biopsychosocial model of health,
physical therapies influence the ‘bio’ element of this
framework but, if self administered, may enhance an
individual’s ability to cope with their condition, thus Useful websites
improving their quality of life. Whilst there is some
evidence for their efficacy (whether they work under [Link]/ accessed January 2009.
ideal, controlled circumstances), evidence to support [Link] accessed January 2009.
their clinical effectiveness (whether they work in [Link] accessed January 2009.
usual clinical practice) remains weak.

References and further reading

Almeida, T.F., Roizenblatt, S., Assefi, N., Sherman, K., Jacobsen, C., Berman, B.M., Ezzo, J., Hadhazy, V.,
Benedito- Silva, A.A., et al., 2003. et al., 2005. A randomised clinical et al., 1999. Is acupuncture effective
The effect of combined therapy trial of acupuncture compared in the treatment of fibromyalgia?
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