Læknablaðið : fylgirit - 01.07.1978, Page 89

W. Watson Buchanan
Karel de Ceulaer
Geza P. Balint
David G. Spencer
Myron E. Mavrikakis
and
W. Watson Buchanan
Centre for Rheumatic Diseases
University Department of Medicine,
Royal Infirmary,
GLASGOW, Scotland.
Time x Inflammation = Joint Damage
This equation presents the physician and
surgeon with his therapeutic dilemma in
the treatment of rheumatoid arthritis. As
all of us know only too well we cannot
influence time, and there is little evidence
that any drug or even synovectomy (Downie
et al 1973) can sufficiently alter synovial
inflammation to prevent joint damage.
Claims that gold (Sigler et al 1974,
Luukainen et al 1977) and cyclophosphamide
(Cooperating Clinics Committee of the
American Rheumatism Association, 1970)
significantly reduce radiological progression
of the disease remain to be confirmed.
It must not be forgotten when judging any
therapeutic claim in rheumatoid arthritis
that the prognosis is in general good.
Duthie et al (1964) in Edinburgh found
that 41 per cent of 307 patients admitted
to hospital seven years previously could
still manage some kind of modified
employment or housework, and 20 per
cent were fit for all normal duties.
These patients, it should be noted, had
only received salicylates and general
supportive measures.
R e st
Rest has been hallowed by tradition in
the treatment of inflammation. Lee et al
(1974) in Glasgow found significant
differences with hospitalisation and out-
patient treatment in terms of reduction of
pain and articular index of joint tender-
ness. However, although the hospitalised
patients fared better over the four week
period, 44 per cent showed no improve-
ment, and 50 per cent had still consider-
able disease activity at the end of the
in-patient period. One year later there
was no significant difference between the
two groups of patients. It seems, there-
fore, that hospitalisation does not confer
long term benefit. This is not only of
clinical but also of economic importance
in view of the high costs of hospital in-
patient treatment (Brooks 1969, Nuki,
Brooks and Buchanan 1973).
Physiotherapy and occupational
therapy.
Fortunately the role of the physio-
therapist in the management of rheumatoid
arthritis has changed in recent years.
No longer are such useless procedures as
wax baths being used, and physiotherapists
are now occupied in making proper splints
and in exercising joints following orthopaedic
surgery. There are now a number of new
splint materials available (Mowat 1970),
and seamless shoes (Tuck 1972), moulded
silastic foot supports (Shields and Ward
1968), "stretch" gloves (Askari, Moskowitz
and Ryan 1974) and "lively" or dynamic
splints for postoperative hand surgery
(Swanson 1968) have been introduced. It
is now recognised that too vigorous
exercises may be harmful (Castillo et al
1965).
Occupational therapy has now divested
itself of its diversional activities, such as
basket weaving and assumed a more active
role in assisting patients in daily living.
Innumerable aids and gadgets have been
introduced, but these still require proper
evaluation. In our experience (Baillie,
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