Rehabilitation of patients with rheumatoid arthritis treated in stationary spa treatment

Introduction: Rheumatic diseases are nonsurgical diseases of the locomotor system and connective tissue. Rheumatoid arthritis (RA) is a systemic inflammatory disease of connective tissue of unknown cause, with progressive chronic or subacute course. The aim of the research is to determine whether stationary spa treatment leads to improvement of the functional status in patients with rheumatoid arthritis. Methods: We included 35 patients with diagnosis of rheumatoid arthritis, referred for treatment at the spa “ Ilidža “ Gradačac from February to April 2014. Patients not adhering to treatment protocols were excluded. We used Visual analogue pain scale (VAS), HAQ questionnaire and assessment of the clinical condition before and after the treatment based on the scores 1-5. Results: There were 32 female and 3 male patients. The average age was 62.28±8.31 years. Based on the HAQ, 12 patients had no difficulties, 9 of them perform activities with little difficulties, 10 with many difficulties, and 4 patients cannot perform certain activities. Before treatment VAS was 6.63±2.36, and after treatment the 2.51±2.27. Ratings of clinical condition before treatment was 2.38±0.74, and after the treatment 3.64±0.98. The most frequently used therapies were kinesitherapy, magnetotherapy and interferential electricity. Conclusions: Stationary treatment at the spa „Ilidža“ Gradačac leads to an improvement of the functional status in patients with rheumatoid arthritis.


INTRODUCTION
Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease which affects about 1% of the adult population, and up to now, genetic factors explain <50% of risks (1).The disease is present throughout the world, among all races, in all climate regions, in rural and urban environments.The prevalence varies in different surroundings from 0.5 to 1%.Rheumatic diseases are characterized by the presence of pain and functional disability, which can be alleviated by physical medicine and rehabilitation (2).
Highly destructive nature of the disease is manifested by the appearance of erosions in 10-26% of patients in the first 3 months of the disease, in > 60% within the first year, and as many as 75% of patients have erosive joint damages during the first 2 years (3).Rheumatoid arthritis has frequent deterioration, which leads patients to reduced work ability, which represents a loss for the individual, family and community.Cause of the disease is still unknown.It is assumed that a number of external factors are affecting the body and in genetically predisposed people result in immunological changes, which are important for the initiation and maintenance of inflammation.Numerous studies have shown that the stress on the physical and physiological level is essential in the development of autoimmune diseases, which means that it may enhance the development of the disease (2).A lot of environmental factors, including hormones, dietary factors, infections and exposure to tobacco smoke, as well as an interaction of genetic environments are associated with an increased risk for development of rheumatoid arthritis (4).Clinically dominate inflammatory changes of synovia, joint capsule and ligaments.The disease begins gradually and most often symmetrical peripheral joints of hands and feet first get affected, and later other large joints can get affected.Rheumatoid arthritis can affect any joint in the body.It can start on one side and in 1-2 months a pain and swelling can appear on the other.Duration of swelling on the joints is important.The swelling which lasts less than six weeks does not indicate rheumatoid arthritis, more likely it's some other disease (5).The disease may start with general weakness, mild fever, fatigue and vague pains, and afterwards pain and swelling in the joints occur (6).An important feature of rheumatoid arthritis is morning stiffness of the joints, which is especially expressed in the joints of the hands.The patient, after waking up, hardly moves joints, cannot do anything until stretching, and until a certain time passes.It takes time from one hour to several hours.Duration of morning stiffness depends on the degree of activity of the disease and is an important information for the physician in determining treatment for patient (2).
Diagnosis of the disease is often based on classification criteria.American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) announced in 2010 new classification criteria for rheumatoid arthritis by which patients with high risk for persistent, chronic and erosive arthritis should be defined and in that way fulfill the current definition of rheumatoid arthritis (Wollenhaupt and Krueger, 2012) (7).Usage of various physical modalities and kinesiotherapy is an integral part of the therapy of rheumatoid arthritis (2).
The aim of this study is to determine whether stationary spa treatment leads to an improvement of the functional status in patients with rheumatoid arthritis.

Study design
In the period of time from 01.02.2014 to 30.04.2014 retrospective -prospective research was conducted on 35 respondents who were staying in stationary treatment at the spa "Ilidža" Gradačac.All patients with rheumatoid arthritis regardless to gender and age were included in the research.
Examined variables that we have encompassed with this research were: age and gender structure of patients with rheumatoid arthritis, an employment status of respondents, assessment of activities of daily living based on Health Assessment Questionnaire (HAQ questionnaire), assessment of pain using a visual analogue pain scale (VAS) before and after the treatment, clinical condition of patients with rheumatoid arthritis before and after the treatment, modalities of the physical procedures in the treatment of patients with rheumatoid arthritis.Criteria for inclusion in the research were: diagnosis of RA, adherence to treatment protocol, agreement to participate in research.Criteria for exclusion were: discontinuation of rehabilitation treatment for any reason, non-adherence to treatment protocol.

Assessment of pain
The measurement of pain is performed with a numerical rating scale (NRS) with ratings from 0 -no pain, to 10 -the worst possible pain, and between are ratings of gradation of pain: mild pain, moderate pain, moderately severe pain, and severe pain.

Assessment of activities of daily living
Health Assessment Questionnaire (HAQ questionnaire) of inflammatory rheumatic diseases is used for measuring a quality of life and an abilities to perform activities of daily living.

Condition of the patients before and after treatment
The clinical condition of patients before and after the treatment was verified by the following methodology: • Rating «1» -permanently incapable to work, capable to activities of daily living.By analyzing the employment status of respondents (Table 2) included in this research it was established that in the total sample there were mostly retirees (n = 20), followed by housewives (n = 12), and the lowest number was of employees total 3. Chi-square test showed that there is a statistically significant difference in the status of employment of respondents, and that retired people dominate.
Table 3 shows the incidence of obtained answers to the questions from HAQ questionnaire.The respondents did not have the most common problems during the getting up, reaching up and walking (climb up five stairs).Descriptive analysis showed that respondents were generally divided about answers to the questions from questionnaire, so 12 respondents on an average number of incidence of responses answered that had no difficulties, 9 of them that perform activities with some difficulties, 10 with many difficulties, and 4 of them cannot possibly perform certain activities.
Based on the numerical scale of responses (Table 4), respondents had the biggest problems during tasks around the house, such as vacuuming, gardening (1.62 ± 1.08); then climbing the stairs (1.57± 1.26), getting up from a chair without using a backrest (1.45 ± 1.6) and using the bathtub (1.48 ± 1.12).
By the statistical analysis of the value of VAS before and after the treatment (Table 5) it was found that an average value of VAS before treatment was 6.63 ± 2.36, and after the treatment a significant improvement has been noted so the value was 2.51 ± 2.27.By application of a paired t-test a statistically significant difference was found in the value of VAS before and after the treatment, which amounted 4.11 ± 1.65, t = 14 674; df = 34; p = 0.001.
From the total number of respondents included in this study, all patients were using kinesiotherapy, magnetotherapy and interferential electricity (Table 6).Among the other therapeutic procedures most frequently used were Diadynamic electricity (71.43%) and pool (51.43%).
By applying a rating scale of the clinical condition of respondents with rheumatoid arthritis before and after the treatment it was established that before the treatment four respondents had rating 1, rating 4 one respondent and rating 5 none of the respondents.After the treatment none of the respondents had rating 1, seven respondents had rating 4 and nine respondents had rating 5 (Table 7).Chi-square test showed the difference in the clinical condition before and after the treatment, and the improvement of clinical picture was noted (p <0.05).

DISCUSSION
Literature data show that women suffer three to five times more often than men, with the highest incidence of occurrence of rheumatoid arthritis between the fourth and sixth decade of life (4)(5)(6).From the total number of respondents included in our study, 32 (91.4%) were female, while only 3 (8.6%)were male, which correlates with study by Obradovic-Tomasevic B where female dominate (81.8 %: 18.2%), which was confirmed as a highly significant difference (p <0.001) (8).
In our study average age of respondents was In our study, Chi-square test showed that there is a statistically significant difference in the employment status of respondents and that retired people dominate.
In our study, respondents had the biggest problems during tasks around the house, such as vacuuming, gardening (1.62 ± 1.08); then climbing the stairs (1.57± 1.26), getting up from a chair without using a backrest (1.45 ± 1.6) and using the bathtub (1.48 ± 1.12).Functional ability of patients was reduced in all respondents (HAQ = 1.99) (10).In the study by Tomasevic-Todorovic an average values of the questionnaire index were 1.25 ± 0.70 (11), whereas in our study, an average value of the questionnaire index was 1.16 ± 0.99.In the study of 62.28 ± 8.31 years.By analysis of the age of respondents in relation to the gender structure of respondents, it was found that female respondents had on average 62.28 ± 7.96 years, and male respondents 74 ± 2 years.In the study by Obradovic-Tomasevic B. an average age of patients was 62.9 ± 10 years (9).

TABLE 1 .
Gender and age structure of respondents

TABLE 2 .
Employment status of respondents

TABLE 4 .
Average values of obtained answers from the HAQ questionnaire based on a numerical scale

TABLE 5 .
Analysis of the visual analogue scale of pain (VAS) before and after the treatment

TABLE 7 .
Comparison of the clinical condition before and after the treatment based on the scale of ratings

TABLE 6 .
Modalities of physical procedures in the treatment of patients with rheumatoid arthritis