Benefits of Physical Therapy for Patients with Scleroderma

Benefits of Physical Therapy for Patients with Scleroderma is presented by
Jessica Mandac, PT, DPT
Rehabilitation Institute of Chicago
Center for Pain Management

1. Benefits of Physical Therapy for Patients with Scleroderma Jessica Mandac PT, DPT Rehabilitation Institute of Chicago Center for Pain Management

2. What Physical Therapists Know About Scleroderma Systemic autoimmune disorder Rheumatic disease Fibrosis of organs Chronic Progressive 2 types: Diffuse Cutaneous Involvement Skin thickening proximal to elbows and knees Limited Cutaneous Involvement Either no skin thickening or thickness limited to distal extremities

3. Common Symptoms Reported Increased fatigue Pain Difficulty opening mouth/eating Joint Stiffness Ulcers Poor circulation to fingers/toes Weakness Hand, grip, legs, trunk Depression Anxiety Anger Frustration Physical: Emotional/Psychological

4. Body Systems Involved that are Addressed in Therapy Myositis Soft tissue restrictions Contractures Hands, wrists, hips/knees Joint restrictions Wrists, fingers, shoulders, hips, knees, ankles Spine Musculoskeletal:

5. Body Systems continued… Pulmonary hypertension Vasculitis Dyspnea Anemia Chest wall restriction Interstitial Lung Disease Poor Circulation Raynaud’s Pulmonary/Cardiac Systems:

6. Body Systems completed… Skin thickening Swelling Nervous System: Peripheral Nerve Entrapment Median nerve (carpal tunnel) Ulnar nerve Trigeminal nerve Integumentary & Lymphatic Systems: GI system: Stomach pain Constipation Diarrhea

7. Outcomes Assessed Activities of Daily Living Recreational activities Work activities Sleep Fatigue Depression/Anxiety/Mood Overall Health Pain Fear Outcome Assessment Tools: Health Assessment Questionnaire Short Form-36 Tampa Scale for Kinesiophobia Lower Extremity Functional Scale Visual Analog Scale

8. Health Assessment Questionnaire

9. Tampa Scale for Kinesiophobia

10. Lower Extremity Functional Scale

11. Visual Analog Scale

12. Strengthening/Stability: Core/ trunk Axioscap / shoulders How to Treat the Symptoms: Musculoskeletal Mobility : Gentle movement Active and Active Assisted Range of Motion Stretching Hips/ gluteals Ankles Joint mobilization/Passive Range of Motion Soft Tissue Massage Modalities: Ultrasound, Heat /Heating pad

13. Core/Trunk Hip/ Gluteals : L ying position

14. Core/Trunk Hip/ Gluteals : Seated Position

15. Axioscap /Shoulder Exercises

16. Ankle Stability Exercises

17. Stretching (Active): Lying position

18. Stretching (Active): Seated position

19. Oral/Facial Exercises (Active):

20. Chair Yoga

21. Chair Yoga cont.

22. How to Treat the Symptoms: Pulmonary/Cardiovascular Appropriate cardiovascular activity : Walking (treadmill or overground ) Cyling (stationary or outside) Elliptical Nustep Upper Extremity Ergometer (Arm Bike) Maintaining 60-80% of maximum heart rate Allows endorphin release for natural pain relief Strengthens heart tissue Increases blood flow allowing increased oxygenation to tissues

23. How to Find Target Heart Rate Zone 20-30 minutes within age adjusted target heart rate zone [Age] x 0.67 = ________ 206.9 - ___________ = _______ (number found (MAX HR) in step 1) 3 . [MAX HR] x 0.6 = ______ [MAX HR] x 0.8 = ______ Your target HR zone= [number found in Step 3] to [number found in Step 4] ____ bpm to _____ bpm

24. How to Treat the Symptoms : Integumentary/Lymphatic/Nervous/GI Integumentary/Lymphatic Systems: Manual lymph drainage techniques (LANA certified) Soft tissue massage Gentle range of motion Nervous System: Neural mobilization/flossing for specific structures involved Primarily median, ulnar, and trigeminal nerves Gastrointestinal System: Regular cardiovascular activity will assist with intestinal motility

25. Neural Mobilization/Flossing Median Nerve Ulnar Nerve

26. Neural Mobilization/ Flossing cont. Trigeminal Nerve

27. Aquatic Exercise Aquatic Exercise 98.6° Waist, chest, or shoulder level Water dumbbells Kickboard Pool noodles Ankle weights Benefits: Decrease swelling Decrease stiffness/Increase mobility Increase muscle strength Increase cardiovascular fitness Decrease pain Increase overall physical function

28. Aquatic Exercise

29. Aquatic Exercise Cont.

30. Activity Pyramid

31. Multidisciplinary Treatment Promotes ACTIVE role in management: FUNCTIONAL RESTORATION Medication management/pharmacological interventions Learning emotional coping skills Relaxation techniques to decrease tension/stress Improving strength, mobility, endurance Improving physical activity tolerance Improving body mechanics, energy conservation, and work-related physical capacities Increasing education Assistance with returning to work Physicians Physical Therapists Occupational Therapists Psychologists Biofeedback Therapists Vocational Therapists Benefits Disciplines

32. Questions??

33. Thank You!!!

34. References A.A. Schouffoer , M.K. Ninaber , L.J.J. Beaart -Van de Voorde , F.J. Van Der Giesen , Z. De Jong, J. Stolk , A.E. Voskuyl , R. W. C. Scherptong , J.M. Van Laar , A.J.M. Schuerwegh , T.W.J. Huizinga, T.P.M. Vliet Vlieland . Randmonized Comparison of a Multidisciplinary Team Care Program with Usual Care in Patients with Systemic Sclerosis. American College of Rheumatology 2011; 63:909-917 L . Barker PhD, J. Talevski , R. T. Morello , C.A. Brand, A.E. Rahmann PhD, D.M. Urquhart PhD , Effectiveness of Aquatic Exercise for Musculoskeletal Conditions: A Meta-Analysis. Archives of Physical Medicine and Rehabilitation 2014; 95: 1776- 1786 B. Blom -Bulow, B. Jonson, K Bauer, Factors Limiting Exercise Performance in Progressive Systemic Sclerosis. Seminars in Arthritis and Rheumatism 1983; 13: 174- 181 C.P. Denton, C.M. Black, Scleroderma-Clinical and Pathological Advances. Best Practice and Research Clinical Rheumatology 2004; 18: 271- 290 G. Pizzo , G.A. Scardina , P. Messina, Effects of Nonsurgical Exercise Program on the Decreased Mouth Opening in Patients with Systemic Scleroderma. Clinical Oral Investigations 2003 J. Bidonde , A.J. Busch, S.C. Webber, C.L. Schachter , A. Danyliw , T.J. Overend , R.S. Richards, T. Rader , Aquatic Exercise for Fibromyalgia. Cochrane Database of Systematic Reviews 2014; Issue 10; Art No. CD011336 J.E Pope MD, Muscuoloskeletal Involvement in Scleroderma. Rheumatic Disease Clinics of North America 2003; 29: 391- 408 J. Sederstrom , Prevalence of Pain: Chronic Pain Often Requires a Multidisciplinary Approach to Care. Managed Healthcare Executive 2013; 23.9: 34 L.M. Benrud -Larson, J.A. Haythornthwaite , L.J. Heinberg , C. Boling, J. Reed, B. White, F. M. Wigley , The Impact of Pain and Symptoms of Depression in Scleroderma. International Association for the Study of Pain. Elsevier Science B.V. 2002; 267-25

35. References continued… L. Mouthon , C. Halimi , G.P. Muller, M. Cayre -Castel, T. Begue , A.C. Masquelet , L. Guillevin , Systemic Scleroderma Associated with Bilateral Ulnar Nerve Entrapment at the Elbow. Rheumatology 2000; 39: 682- 683 M. A. Ashburn MD, P.S. Staats MD, Management of Chronic Pain. The Lancet 1999; 353: 1865-1869 M. Hudson, B.D. Thombs , R. Steele, P. Panopalis , E. Newton, M. Baron, Quality of Life in Patients with Systemic Sclerosis Compared to the General Population and Patients with Other Chronic Conditions. The Journal of Rheumatology 2009; 36: 768- 772 M. Mondelli , C. Romano, P. Della Porta , A. Rossi, Electrophysiological Evidence of “Nerve Entrapment Syndromes” and Subclinical Peripheral Neuropathy in Progressive Systemic Sclerosi (Scleroderma). J Neurol 1995; 242: 185- 194 R . Casale MD, M. Buonocore MD, M. Matucci-Cerinic MD, PhD, Systemic Sclerosis (Scleroderma): An Integrated Challenge in Rehabilitation. Archives of Physical Medicine and Rehabilitation 1997; 78: 767-773 S. Maddali Bongi , A. Del Rosso , F. Galluccio , G. Tai, F. Sigismondi , M. Passalacqua , G. Landi , M.L. Conforti , I. Miniati , M. Matucci-Cerinic , Efficacy of a Tailored Rehabilitation Program for Systemic Sclerosis. Clinical and Experimental Rheumatology 2009; 27: S-44-S-50 T.A. Medsger Jr MD, Natural History of Systemic Sclerosis and the Assessment of Disease Activity, Severity, Functional Status, and Psychological Well-Being. Rheumatic Disease Clinics of North America 2003; 29: 255-273 U.K. Samuelson, E.M. Ahlmen , Development and Evaluation of a Patient Education Program for Persons with Systemic Sclerosis (Scleroderma). American College of Rheumatology 2000; 13: 141-148