Réadaptation en

cas d’altérations

inflammatoires de

l’appareil

locomoteur :

l’importance de

l’activité physique Rehabilitation bei

entzündlichen Veränderungen

am Bewegungsapparat,

Wichtigkeit der Bewegung“

Dr M Norberg

2 2 2

MENU

• Refresh: basics in

inflammation

• Lumbar pain: Modic

and inflammation

• AR

– rehabilitation

• SPA

– rehabilitation

3

Frequency

Literature suggests that 26% of patients with

rheumatoid arthritis were referred for

physical therapy and/or occupational

therapy Li LC, Bombardier C.. Physiother Can 2003; 55:23–30

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2004

Current Opinion in Rheumatology 2004, 16:130–131

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2008

Mayoux-Benhamou, Joint Bone Spine 75 (2008) 3-4

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2008

Current Opinion in Rheumatology 2008, 20:218–219

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2016

F. Gérald ,P. StéveninLa revue du praticien 2016 (66) , 631-2

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2017

Berdal et al, Disability and Rehabilitation, 2017 10.1080/09638288.2016.1275043

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Part 1: Basics

Physiology effects of exercise

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Exercise-induced cytokines in arthritis

model mice

•Exercise delayed the onset of arthritis and slowed

its progression

•Thickened articular cartilage

•↑the expression of IL-6, IL-10, IL-15,

•inhibited TNF-α expression.

•=>anti-inflammatory IL-6/IL-10, inhibited

the inflammatory activity of TNF-α

•=>delayed the onset of arthritis

•=>slowed its progression

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Kito et al Okajimas Folia Anat Jp 2016

The cells

•The leucocytes ↑ during exercise and ↓ after long standing exercises

•But neutrophiles ↑ during and after an intense exercise:

•*The reason is that the recruited cells come from mature cells and not from steam cells on maturation.

•During exercise the proportion CD4/CD8 ↓

since the > ↑ of TCD8+.

•NK CD94+ / - ↑

Nemet D et al Br J Sports med 2004; 38: 154-8

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The cytokine pathway

Physical exercise produces: ↑ IL1 and IL6.

During a marathon

↑ TNFα and IL1β (2x),↑ IL6 (50x).

↑ of IL1 RA,

↑ soluble receptors of TNF and the IL10 with

anti-inflammatoiry effects.

IL8, CCL3 and CCL4 ↑ after a marathon.

Chemokine (C-C motif) = Macrophage inflammatory protein

13

But if too intense:

Temporary negative incidence on immune function.

The ↓ in the immune function after exercise is more important...

•..when the exercise is more intense, longer ( > 1.5 h),

•..if it is done with medium or high intensity (55 to 75 % of the aerobic capacity)

•..without eating

Gleeson, M et al Exerc. Sport Sci. Rev. 2013 41:148-153. 14

Effects of physical activity on

inflammation

9 weeks of resistance training

•beneficial effects on circulating IL-8, IL-6.

•↑ anti-inflammatory cytokines sTNFR1 and

IL-1RA.

•resistance training has anti-inflammatory

effects in healthy young persons

Forti et al Eur J Appl Physiol 2017

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Part 2:

Back and the Modic change: 3 stages

MODIC CLASSIFICATION

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Back anatomy: importance VSB

VSB integrity, rather than the degree

of disk deg, determines the extent of

damage during compression

VSB vessels ensure cartilage endplate and

avascular–intervertebral- disk nutrition by

diffusion of dissolved molecules through

marrow contact channels C. Nguyen et al Osteoporos Int (2012) 23 (Suppl 8):S857–S860

VSB: Vertebral subchondral bone

17

But…

• Not all patients with

disc/endplate damage

develop MC.

• => related to the

inflammatory potential

of the disc and the

capacity of the BM to

respond to the

inflammatory

stimulus.

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Eur Spine J (2016) 25:3723–3734

Epidemiology of Modics

Prevalence is high in LBP : 43 % compared to 6 % in asymptomatic population.

• Jensen T et al Eur Spine J 2008,17:1407–1422.

MC1 more associated LBP than the others • Thompson KJ et al Radiology 2009 250:849–855

• Järvinen J et al BMC Musculoskelet Disord 2015; 16. 98

More prevalent and more severe at L4–S1 • Modic MT et al Radiology 1988 166:193–199

• Kuisma M et al Spine 2007 32:1116–1122 ,

More prevalent in the anterior third of vertebra • Chung CB et al Skeletal Radiol 2004 33:399–404

• Karchevsky et al Skeletal Radiol 2005 34:125–12913

Generally symmetric cephalad and caudad to a particular disc

• Kuisma M et al. Spine 2006 31:1714–1718

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BIOPSIES

• High bone turnover in

MC1,

– due to an

inflammatory process?

• reduced bone

formation in MC2

I II

Perilli E et al Euro Spine J 2014 24:1926–1934

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Risk factors for Modic I / II

M I

M I / II M I / II

21 Eur Spine J (2016) 25:3723–3734

Modic and possible changes

Nguyen C, et al. Ann Rheum Dis 2015

Genetics Auto immune

presuppose structural disc damage.

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The inflammatory potential of the disc

• Discs adjacent to MC produce more:

• cytokines – (IL-6, IL-8, TNF-a)

• osteoclastic factors – (RANKL, M-CSF,

NFATc1, RUNX1, OSCAR)

• than discs of the same degeneration degree without MC

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Eur Spine J (2016) 25:3723–3734

Hyp infection

* disc’s anaerobic: ↑potential for disc tissue damage,

↓ capacity for repair. =>low virulent skin microorganisms such as P. acnes

• Stirling A et al (2001) Lancet 357:2024–2025

Disc cells : ↑ IL-6, IL-8, PGE-2 after stimulation =>The persistent efflux of cytokines and bacterial metabolites cause inflammation of the adjacent BM .

• Wedderkopp N et al (2009). Acta Radiol 50:65–70.

C-reactive protein ↑ • Rannou F, et al (2007) Arthritis Rheum 57:1311–1315

Antibiotic treatment • Albert et al Eur Spine J (2013) 22:697–707

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7.5.2013

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Results

VAS

0

1

2

3

4

5

6

7

8

AB back pain

AB leg pain

Placebo back pain

Placebo leg pain

Roland-Morris

0

2

4

6

8

10

12

14

16

AB

Placebo

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Hyp: auto-immunity

•Nucleus pulposus (NP) no contact with the systemic circulation: no leucocytes contact.

• NP cells express Fas ligand, => apoptosis in infiltrating lymphocytes .

• Kaneyama S et al J Orthop Sci 2008 13:130–135.

•Endplate damage co-locates NP with BM leukocytes.

•↑ levels of Fas receptor in MC endplates, =>adaptive response to higher levels of Fas ligand, possibly from colocated NP .

• Wang F et al Injury 2011 42:790–795

•Peripheral disc damage expose the NP to the

immune system, => recognized as ‘‘foreign’’ and triggers an autoimmune response

• Dudli et al Eur Spine J (2016) 25:3723–3734

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Ann Intern Med. doi:10.7326/M16-1700_ 21.3.2017

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Results in VAS in Modic I patients

BUT…. 29

Secondary outcomes

And at 1/ 3/12 month after the intervention:

•No differences in

•QBPDS

•SF12

•HADS

•Analgesics / NSIAD

•work

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Part 3: AR and SPA

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Get moving! Dynamic exercise therapy

for rheumatoid arthritis

1) Getting our patients to move

2) Educating healthcare professionals

3) Educating rheumatoid arthritis patients

Mayoux-Benhamou, Revue du Rhumatisme 75 (2008) 5–7

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Aim rehab

↓pain

Prevent and treat deformations

Recover and stabilise articular mobility and

stability

Continuous muscular training ( aerobic

capacity)

Functional adaptations and capacity

Quality of life

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Pleasure and exercices

• enjoyment important

in motivating people

with arthritis to

exercise.

• advice regarding

feasible and

enjoyable exercise.

Kibblewhite et al Musculoskeletal Care 2016

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Therapeutic education

On a 3 days education programme

(sessions of education, individual and group

physiotherapy, exchanges) to obtain an

improvement in the patients personal

knowledge.

Sudre A et al. Joint Bone Spine 2012;79: 99–100

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Spondyloarthropathies (SpA)

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ACR 2015: SPA active

strongly recommend treatment with

physical therapy over no treatment with

physical therapy

conditionally recommend active physical

therapy interventions (supervised exercise)

over passive physical therapy interventions

conditionally recommend land-based

physical therapy interventions over aquatic

therapy interventions

Ward et al:ARTHRITIS & RHEUMATOLOGY 2016, 68, 2, 282–298

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ACR 2015: SPA stable

In adults with stable AS, it is strongly

recommend to treat with physical therapy

over no treatment

Ward et al:ARTHRITIS & RHEUMATOLOGY 2016, 68, 2, 282–298

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ASAS-EULAR 2016

van der Heijde D, et al. Ann Rheum Dis 2017;0:1–14. 39

Exercices

*Home exercises are efficacious and these

are therefore recommended to patients

*Physical therapy is proven to be

More efficacious than home exercises,

But more expensive and less feasible than

home exercises

May be required in some patients.

Dagfinrud H et al. Cochrane Database Syst Rev 2008

40

Exercices in SPA

• Several studies have showed that supervised group exercise provides superior results compared to an unsupervised HEP – Hidding A, et al. Arthritis

Care Res 1993

– Analay Y, et al. Clin Rehabil 2003

– Silva EM et al. Rheumatol Int 2012

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Ex and SPA

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Which exercices?

to maintain mobility and strength, as eccentric work of the erector spine muscle, the posterior muscle chain in the pelvic region, and the anterior chain of the scapular girdle

relieve symptoms,

prevent or limit spinal deformity,

long-term cardiopulmonary health,

improve quality of life.

behavioral interventions ↑ disease knowledge

↑ motivation for compliance

Millner et al.Sem Arthritis Rheum 2016

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Exercise and SPA: anti-inflammatory

effects? What is known?

the antiinflammatory effects of exercise have

attracted attention over the last decade • C. Kasapiset al J. Am. Coll. Cardiol. 45 (2005)

1563-1569.

• I.J. Kullo, et al , J. Appl. Physiol. 102 (2007) 1374-

1379.

contractile dysfunction in muscles is related

to TNF-a • M.B. Reid, Am. J. Respir. Crit. Care Med. 166

(2002) 479-484.

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SpA: Ex and IL-6

exercise induced IL-6 release from the

muscle tissue has an anti-inflammatory role

and inhibits TNF-a with a different receptor

pathway • R. Schindler et al, Blood 75 (1990) 40-47.

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SpA: Ex and cytokines

• Muscle derived IL-6

inhibits TNF-a by

activating TNF-a

receptor pathway: IL-

6 anti-inflammatory

during exercise.

• study:

• levels IL-6 stable,

• TNF-a levels ↓ during

the follow-up

46

Physical activity (PA)

PA may be

decreased (Swinnen et al PLoS ONE 2014 9(2))

no different (Plasqui G et al (Arthritis Care Res 2012) 4(1))

In the AS subtype, participants with high disease activity reported engaging in significantly less PA than respondents with low disease activity ( Fongen Clin Rheumatol 2013 32(12)), (Brophy et al Semin

Arthritis Rheu 2013 42(6)).

PA scores related to disease activity, physical function, and quality of life;

47

Compliance with PA

recommendations to achieve health-related

benefits vary across studies from

17 % (O’Dwyer T et al Rheumatology 2014, 53(10)) to

71 % (Manning et al J Clin Rheumatol Pract Rep Rheumat Musculoskelet Dis 2012 18(8))

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AR

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RA:Pathways activating macrophages

• RA synovitis :

• promoting cytokine

release:

– IL-6 , TNF

– probably GM-CSF,

• central importance :

clear therapeutic

benefits achieved

upon their inhibition.

Firestein, Immunity 46, February 21, 2017 50

Point of view of the physiotherapist

Musculoskeletal Care 2016

51

PTs reported:

•Lower degree of confidence and fewer roles

in managing RA compared with OA.

•good adherence to the national guidelines

for almost all the treatment modalities listed.

•a need for education, in chronic

inflammatory arthritis care.

Musculoskeletal Care 2016

52

Cochrane Database of Systematic Reviews

2009

53

Dynamic exercise therapy

Aerobic exercise and muscle strength training on land probably improve pain and physical function slightly in the short term.

It means activities with enough intensity, duration, and frequency to improve stamina or muscle strength. Exercise can be any activity that enhances physical fitness as aerobic exercise.

moderate evidence for a positive effect on aerobic capacity

functional ability and aerobic capacity

Cochrane Database of Systematic Reviews 2009 54

Balneotherapy

Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD000518

55

Effects

•Improved both pain and functional

impairments after 3 and 6 months.

•↓medication consumption.

•If patient education program delivered

during spa treatment: better in alleviating

fears and deleterious beliefs compared to

simple patient information

Forestier R. et al Joint Bone Spine 84 (2017) 9–13

56

But…

• Evidence insufficient

to show that

balneotherapy is

more effective than

no treatment, that one

type of bath is more

effective than another

or that one type of

bath is more effective

than mudpacks,

exercise or relaxation

therapy. Verhagen et al Cochrane Database of Systematic Reviews 2015,

57

AR

*benefits of exercise and physical activity

programmes regarding RA-related outcomes

is demonstrated

*enhancing the effectiveness of self-

management

-Duration at least 6 weeks;

-Explicit use of cognitive behavioural

approaches

Curr Opin Rheumatol 2011 23:259–264 58

AR and hand

• Appropriately hand

physiotherapy in

women with RA

contributed to the

improvement of its

function by:

– pain reduction,

– improved value and

quality of grip,

– increased

manipulative ability

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Reumatologia 2016; 54, 6: 285–290

AR and rehab.

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Results

• Team-rehabilitation in

a warm climate

resulted in clinically

meaningful

improvements in body

function, activities and

well-being, and

promoted physical

activity for up to one

year.

J Rehab 2016

61

Succes rehabilitation

“I need a doctor who will take care of my whole person not ‘just my painful joint’. “

Successful rehabilitation programs in rheumatic diseases require a working partnership:

the patient,

the rheumatologist, ev rehab MD

other health professionals.

Multidisciplinary care teams

Ton Nghiem,Donohue: Curr Op Rheumat, 2008, 20:218–219

62

Take home meassage

• Exercise is important:

movement more.

• Mobility stimulate

immune system: anti-

inflammatory effects,

IL 6, TNF

• No danger to move

• Supervised more

stimulating

www.mon-sport.ch

www.mein-sport.ch

63

Questions?

iohn.norberg@chuv.ch

64

Thank you for your attention: Go on training.

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