il coinvolgimento articolare nelle malattie reumatologiche ... · alterazione biomeccanica e piede...

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

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