Rev Dor.

São Paulo, 2017 oct-dec;18(4):365-9 CASE REPORT

Physiotherapeutic intervention in pain and quality of life of women with

rheumatoid arthritis. Case reports
Intervenção fisioterapêutica na dor e na qualidade de vida em mulheres com artrite reumatoide.
Relato de casos
Caroline de Macedo Schnornberger1, Matheus Santos Gomes Jorge2, Lia Mara Wibelinger3

DOI 10.5935/1806-0013.20170131

ABSTRACT RESUMO

BACKGROUND AND OBJECTIVES: Rheumatoid arthritis JUSTIFICATIVA E OBJETIVOS: A artrite reumatoide é uma
is an autoimmune, chronic, idiopathic and inflammatory dise- doença autoimune, crônica, idiopática e inflamatória que atin-
ase that symmetrically affects the tissues, organs and peripheral ge simetricamente os tecidos, órgãos e as articulações periféricas
joints causing pain, swelling, stiffness and decreased the quality causando dor, edema, rigidez e diminuição da qualidade de vida.
of life. The objective of this study was to confirm the effects of a O objetivo deste estudo foi verificar os efeitos de um programa
physiotherapeutic intervention program on pain and quality of de intervenção fisioterapêutica na dor e na qualidade de vida de
life of women with rheumatoid arthritis. mulheres com artrite reumatoide.
CASE REPORTS: Study of a series of cases of five female pa- RELATO DOS CASOS: Estudo de uma série de casos de cinco
tients, with average age ± 54 years. The initial assessment con- pacientes do sexo feminino, com idade média de ±54 anos. A
sisted of data collection, pain assessment by visual analog scale avaliação inicial consistiu na coleta de dados, na avaliação da dor
and evaluation of the quality of life by the Medical Outcomes pela escala analógica visual e na avaliação da qualidade de vida
Study36 Item Short-Form Health Survey SF-36. After the initial pelo Questionário Medical Outcomes Study 36 - Item Short-Form
assessment, patients were subjected to a physiotherapeutic inter- Health Survey SF-36. Após a avaliação inicial as pacientes foram
vention program based on kinesiotherapy, which was conducted submetidas a um programa de intervenção fisioterapêutica base-
in groups, consisting of two sessions per week and duration of ado em cinesioterapia, que foi realizado em grupo, com frequên-
50 minutes per session, totaling 10 sessions. The pain showed no cia de duas sessões semanais e duração de 50 minutos por sessão,
statistically significant results when analyzed by the visual analog totalizando 10 sessões. Quando analisada a dor pela escala ana-
scale. However, when assessing the quality of life related to pain lógica visual não houve resultados estatisticamente significativos.
and vitality, there were statistically significant results (p≤0.05) in No entanto, na avaliação da qualidade de vida relacionada aos
post-intervention. domínios dor e vitalidade, verificou-se resultados estatisticamen-
CONCLUSION: The proposed intervention program has te significativos (p≤0,05) na pós-intervenção.
been effective in improving the pain and vitality domains CONCLUSÃO: O programa de intervenção proposto foi eficaz
regarding the analysis of the quality of life in women with na melhora dos domínios dor e vitalidade referentes à análise da
rheumatoid arthritis. qualidade de vida em mulheres com artrite reumatoide.
Keywords: Pain, Physical therapy, Quality of life, Rheumatoid Descritores: Artrite reumatoide, Dor, Fisioterapia, Qualidade
arthritis. de vida.

INTRODUCTION

Rheumatoid arthritis (RA) is an autoimmune, chronic, idio-

pathic and inflammatory disease that symmetrically affects
1. Universidade de Passo Fundo, Faculdade de Educação Física e Fisioterapia, Carazinho, tissues, organs and, especially, peripheral joints1. Its worl-
RS, Brasil.
2. Universidade de Passo Fundo, Faculdade de Educação Física e Fisioterapia, Soledade, dwide prevalence ranges from 0.5 to 1%, similar to Brazilian
RS, Brasil. literature, and may occur in all ethnic groups. It affects, es-
3. Universidade de Passo Fundo, Faculdade de Educação Física e Fisioterapia, Passo Fundo,
RS, Brasil.
pecially, the female gender in the age group between 20 and
60 years old2,3.
Submitted in February 03, 2017. The main features of RA are chronic synovial inflammation
Accepted for publication in October 27, 2017.
Conflict of interests: none – Sponsoring sources: none. and the presence of palpable rheumatoid nodules on physi-
cal examination, which conditions involve symmetrical joint
Correspondence to:
BR 285, Bairro São José edema, bone erosion, and joint cartilage destruction4,5. La-
99052-900 Passo Fundo, RS, Brasil. boratory tests evidenced the rheumatoid factor presence, and
E-mail: [email protected]
radiographic examinations evidenced erosions and/or periar-
© Sociedade Brasileira para o Estudo da Dor ticular osteopenia in hands and wrists joints5.

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Rev Dor. São Paulo, 2017 oct-dec;18(4):365-9 Schnornberger CM, Jorge MS and Wibelinger LM

Individuals’ clinical features present, mainly, strong morning (absence of pain) to 10 (worst pain imaginable), in which the
or night pain in the proximal interphalangeal joints of han- individual is asked to quantitatively indicate the pain present
ds, metacarpal and metatarsophalangeal joints in the wrists, at the time of evaluation15. Evaluator B performed the QoL
shoulders, and knees. Other symptoms accompany the pain- evaluation by means of Quality of Life Questionnaire - Medical
ful phenomenon, such as joint stiffness lasting at least one Outcomes Study 36 - Item Short-Form Health Survey (SF-36),
hour (morning or after long periods of immobilization), fati- gathering physical components (functional capacity, physical
gue, discomfort, decreased strength and muscular endurance aspects, pain and the general state of health) and mental (vita-
and physical deconditioning5-7. lity, social aspects, emotional aspects and mental health). The
Symptoms arising from the disease imply joint deformities final score of each domain ranges from zero (worse general state
and functional disability, which can lead individuals to func- of health) to 100 (best general state of health)16.
tional dependence and limitations of their daily living acti- After evaluations and initial data collection, the subjects perfor-
vities. The more advanced the disease stage, the shorter the med 10 sessions of physiotherapy in a group, with a frequency
survival becomes8. Pain and inflammation associated with of 2 times a week and average duration of 50 minutes. In total,
musculoskeletal disorders are the main factors responsible for including the initial and final meetings for evaluation and re-
the impact on the subject’s quality of life (QoL), both in phy- -evaluation, 12 meetings were held with the study participants.
sical aspects and in mental aspects9,10. The physiotherapeutic technique choice adopted in this study
Physical conditions presented imply the need to develop stra- was based on literature-referenced data10,17. Kinesiotherapy
tegies for RA treatment. Currently, several methods allow a was the technique chosen, and the intervention program was
satisfactory disease’s handling. Among these, physiotherapy, designed aiming its effects on pain and QoL of patients with
especially kinesiotherapy, becomes a beneficial and viable RA. Based on the foregoing, the exercises listed in this study
strategy, aiming to relieve pain and combat inflammatory followed the order:
processes, to allow restoring articular movement amplitude 1. Slow and maintained muscle stretching in an active-assis-
and muscle activity, preventing new deformities onset, pro- ted or passive way of the main muscle groups of upper limbs,
moting physical, psychic and social well-being and, conse- lower limbs, and trunk (20 seconds for each muscle group);
quently, improving patients’ QoL10-14. 2. Strengthening of upper limbs (muscle groups: flexors,
This study aimed to verify the effects of a physiotherapeutic extensors and shoulder abductors and flexors and elbow ex-
intervention program in pain and QoL of women with RA. tensors) and lower limbs (muscle groups: plantiflexors, dorsi-
flexors, inversors and ankles evertors) with pink elastic band
CASE REPORTS progressing to green and blue (3 sets of 10 repetitions for each
muscle group);
It is a case-study that is part of a project called “Effects of 3. Pulmonary expansion exercise, in diaphragmatic pattern,
physiotherapeutic treatment in patients with rheumatic dise- with the aid of a stick (3 respiratory cycles of 5 repetitions);
ases,” approved by Ethics and Research Committee in Human 4. Strengthening of posterior trunk muscles with elastic bands
Beings of University of Passo Fundo (UPF) under Protocol No. in pink, green, blue or purple (3 sets of 10 repetitions);
348,381, which is in accordance with the Declaration of Hel- 5. Strengthening of muscles responsible for flexion, extension,
sinki of 1975. ulnar deviation and radial deviation of wrists with elastic ban-
Initially, the waiting list for ambulatory care in the UPF’s ds in pink, green or blue (3 sets of 15 repetitions);
Rheumatologic Physiotherapy Sector was consulted, which 6. Strengthening of hands and fingers with wrist and finger
included 12 individuals with RA. Were considered eligible strengthener, whose resistance varied from 1.4 to 4.1kgf (2
those with a RA clinical diagnosis, female, 18 years old or sets of 15 repetitions), and proprioceptive pellets with light
older, with physical and mental abilities to understand and and moderate resistance (3 sets of 20 repetitions);
perform the dynamics of the proposed physiotherapeutic 7. Fine-motor exercise with therapeutic masses of modeling,
exercises, that were not in an acute period of the disease, that where the patients performed tweezers movements with all
were not performing physical therapy or any other form of fingers (5 minutes performing this movement);
therapeutic intervention for at least three months prior to 8. Weight transfer exercise for upper limbs on a mat (3 sets of
data collection. 5 repetitions per side);
Among the individuals that were on the waiting list, only se- 9. Balance and proprioception exercises, by means of mini-
ven were able to integrate this study’s casuistry. Physiotherapy -squats in bipodal and unipodal support and displacement of
sessions were held at the Physiotherapy Clinic of the School body weight on the lower limbs, initially in soil and, later, on
of Physical Education and Physiotherapy of the UPF between destabilizing platforms (foam balance pad, rubberized balan-
May and June 2015. All participants signed the Free Infor- ce pad with disc shaped proprioceptive surface and trampoli-
med Consent Form (FICF), through prior explanation and nes) (3 sets of 10 repetitions);
clarification of doubts, agreeing to participate in the study. 10. Relaxation in 65cm Swiss balls, to lengthen the trunk’s
Evaluator A performed data collection and other information muscular chains and the neck’s muscles. Circulation move-
regarding disease conditions and pain assessment using visual ments of head and shoulders were also performed (20 seconds
analog pain scale (VAS). This is a numerical scale from zero each muscle group).

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 Physiotherapeutic intervention in pain and quality of life Rev Dor. São Paulo, 2017 oct-dec;18(4):365-9
of women with rheumatoid arthritis. Case reports

After the sessions, the pain and QoL parameters were reasses- sessions. Thus, five women with RA (patients A, B, C, D, and
sed and the data collected in the pre- and post-intervention E) concluded the study. The average age of participants was
phases were cataloged in Windows Microsoft Excel 2013. 54.0±3.8 years, the diagnosis time of the disease was 15.0±2.9
Two patients initially selected were excluded. The first one was years, and the main complaint reported by them was a chronic
due to a surgical procedure performed during the physiothera- pain in the hands, where they had articular deformities. Selec-
peutic intervention (which was not related to the study) and ted patients’ characterization is described in table 1.
the second due not performing the 10 proposed physiotherapy Regarding the patients’ profile, it was observed that the majo-
sessions, both of which performed only seven physiotherapy rity of the sample had three or more children (60%) and was
single (60%). As for schooling and their work activities, the
Table 1. Selected patients’ characterization majority reported having elementary education only (60%)
Variables Representation
and being inactive in the labor market (60%). All patients
(n and %) used continuous drugs and reported having associated disea-
Schooling Elementary school 3 (60) ses. Moreover, the majority of the sample had a family history
of rheumatic disease (80%).
High school 1 (20)
Table 2 presents the data on pain measured by VAS, before
Higher education 1 (20)
and after the physiotherapeutic intervention.
Children No children 0 (20) Through VAS, it was observed that three patients (A, C and
1 - D) presented a decrease in pain intensity. Although two other
2 1 (20) patients (B and E) did not present a decrease in this parameter,
3 or more 3 (60) they did not present an increase in the symptomatic picture.
Marital state Married 2 (40) Table 3 presents the data regarding QoL according to SF-36,
pre- and post-intervention physiotherapeutic.
Single 3 (60)
In general, two patients (A and C) showed improvement in
Occupation Inactive 3 (60)
all QoL domains, two patients (B and D) presented improve-
Active 2 (40) ment of domains, with the exception of functional capacity
Drug use Yes 5 (100) (B), limitations by physical aspects (B) and social aspects (D),
No - and one patient presented QoL improvement in only three
Associated diseases Yes 5 (100) domains (E). Still, it is observed that only pain and vitality
No - domains showed improvement in all cases presented.
Family history of Yes 4 (80)
rheumatic disease DISCUSSION
No 1 (20)
n = absolute value; % = relative value.
RA is a disease with unknown etiology attacking women pre-
ferentially. Although it can start at any age, there is a predispo-
Table 2. Pain pre- and post-intervention physiotherapeutic sition to the onset of symptoms around 40 years old18. Pain is
Pre-intervention Post-intervention the most common complaint among the patients, manifested
Patient A 8 6 by acute polyarthritis (70% of cases) and persistent synovitis in
Patient B 6 6 hands (91% of cases), accompanied by edema of distal joints
Patient C 7 3
(proximal interphalangeal and metacarpophalangeal in more
than 90% of cases), by prolonged morning stiffness and mus-
Patient D 5 3
cle weakness1,19-21. In addition, individuals with RA have lower
Patient E 6 6
oxygen concentrations in the muscles of hands and arms, whi-

Table 3. Quality of life pre- and post-intervention physiotherapeutic

Patient A Patient B Patient C Patient D Patient E
Domains Pre Post Pre Post Pre Post Pre Post Pre Post
Functional capacity 35 45 05 20 25 50 10 25 65 60
Physical aspects limitation 25 100 0 0 25 100 0 100 0 0
Pain 10 20 20 61 30 51 31 41 10 20
General health status 40 55 40 57 55 67 32 35 45 0
Vitality 25 50 50 70 40 65 30 70 30 45
Social aspects 25 50 50 100 50 65.2 75 62.5 65.2 87.5
Emotional aspects limitation 0 33.3 100 66.6 33.3 100 0 100 100 66.6
Mental health 24 28 96 100 40 68 32 76 56 52
Pre = pre-intervention; Post = post-intervention.

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Rev Dor. São Paulo, 2017 oct-dec;18(4):365-9 Schnornberger CM, Jorge MS and Wibelinger LM

ch can lead to soft tissue changes, tendons degeneration and can be used in all phases of the disease, aiming to improving
deformities’ exacerbation22. Which is in line with the present joint mobility, muscle strength and coordination, flexibility, fa-
study, since the patients reported chronic pain in hands as the tigue resistance, aerobic capacity and, finally, preserving and/
main complaint, where they also presented deformities. or restoring general functional ability. In this sense, kinesiothe-
Chronic pain affects 54.2% of people between 60 and 64 years rapy uses the movement of the human body to provide such
old, 55.9% of people between 65 and 69 years old, 65.7% of benefits28,29. This suggests the idea of an alternative therapy es-
people between the ages of 70 and 74 and 62.5% of people tablishment, such as physical exercise (especially kinesiothera-
with more than 75 years old. In addition, 35% of people with py) in the daily life of the individual with RA, allowing him to
chronic pain report a moderate or severe disability and impact remain as functional as possible within the limitations imposed
mainly on domestic, leisure and occupational activities and by the disease.
sleep quality23. The chronicity condition persists beyond the It is recommended that physical exercise lasts for 20 minutes or
physiological recovery period of the injured tissue, generating more, being performed at least twice a week and leads to an in-
a negative impact on the individual’s physical and cognitive crease of 60% of the predicted heart rate for the age, to present
abilities, well-being and QoL. Chronic pain treatment, unlike positive clinical effects and without detriment to the disease,
the therapies for acute pain (rest and drugs), is composed of that is, without worsening the disease’s activity and without
physical exercise and multidisciplinary treatment4. causing pain. When the dynamic exercise is compared to the
It was observed that besides reporting the chronic pain as a conventional joint rehabilitation program, it can be observed
major complaint, the patients of this study were going to the that dynamic exercise significantly improves the QoL of indi-
third decade of life. Thus, it is possible to justify the physiothe- viduals with RA30,31. Although interventions were carried out
rapeutic intervention program proposal, which sought to keep with a frequency of two weekly sessions (averaging 50 minutes
them moving, as the painful condition seems to have exerted each), the present study used a rehabilitation program through
an influence on the QoL, since individuals who presented a physical exercise and found beneficial results on patients’ pain
decrease in pain had an increase in the scores of QoL’s domains and QoL, especially in the pain domains and vitality.
(A, C and D). Although patient B showed no decrease in pain This study’s results with regard to pain and QoL of RA pa-
by VAS, there was an increase in six domains of QoL, including tients submitted to a physiotherapeutic intervention program
the pain domain. based on kinesiotherapy agree with other reports presented in
As a complement to physical therapy, patients were taking the literature. A woman with RA was submitted to a physiothe-
methotrexate, one of the drugs most commonly used to tre- rapeutic intervention program based on kinesiotherapy with
at individuals with RA. It is a drug that modifies the disease elastic bands, hand strengthening, global stretching, joint mo-
course and is well tolerated by its patients, which in addition bilizations, and balance and proprioception exercises. After 15
to reducing the signs and symptoms of disease activity, blocks sessions of physiotherapy, there was a considerable decrease in
the radiographic lesions progression, and may help improve the pain and improvement or maintenance of QoL (especially in
functionality of its users24. the pain domain)10. Another case study involving a man with
According to the patients, the cold can act as an exacerbator RA revealed that after performing 15 sessions of kinesiothe-
of the painful symptoms. Numerous mechanisms and effects rapy, significant improvement of pain occurred, resulting in
may be influenced by cognitive, physical and behavioral artifi- improvement of QoL without worsening the clinical picture17.
ces during physical therapy, which may interfere with the tre- Twenty women with RA and those with deformities were sub-
atment of individuals with arthralgias25. The physiotherapeutic mitted to a protocol of muscle strengthening exercises. The
intervention was performed in late autumn and early winter study was randomized into an experimental group, which per-
in a region of southern Brazil, a cold place at this time of year. formed 20 physiotherapy sessions with muscle strengthening
Perhaps, this may justify the fact that there was no change in exercises, and in a control group. After physiotherapy sessions,
the pain intensity of B and E patients, and improvement of the experimental group achieved significant gains in the func-
most domains of QoL of patient E after the intervention. tionality and muscular strength of the studied individuals6.
Another factor that may have contributed to the pain of VAS not Since the patients in the present study had deformities, they
having decreased in B and E patients in the post-intervention chose muscle-strengthening exercises, allowing them to remain
phase would be the fact that joint and ligament instability are functional and in order to improve their QoL.
consequences arising from the painful situation and can have a
significant impact on the individual’s biomechanical and directly CONCLUSION
influence the rehabilitation process26. In addition, perhaps the
number of kinesiotherapy sessions performed may not have been The proposed intervention program was beneficial in impro-
enough to attenuate musculoskeletal instability and to obtain ving pain and QoL in RA women.
satisfactory results of these patients with exacerbated symptoms.
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