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Aside from pain relief spasms poster order tizanidine with amex, physical activity may also contribute to spasms spanish buy tizanidine from india increased functional capacity (by increasing fitness) in these patients spasms small intestine purchase 2mg tizanidine fast delivery. Expectancies may affect pain (12) as may improvement in the state of mood (13) muscle relaxant anesthesia generic 2mg tizanidine overnight delivery, which further reduces the pain experienced. Accordingly, pain is a subjective experience that is not always related to the extent or even existence of tissue damage. Pain is a psychological phenomenon that must be described based on the behaviour and experience of the individual. Acute pain seldom gives rise to serious therapeutic problems and generally responds well to analgesics or cause-related treatment. Acute musculoskeletal pain usually responds well to analgesics or physiotherapy aimed at restoring function. Traditionally, the person administering the treatment (health profes sional) is normally active and the patient passive. Chronic non-malignant pain (defined as pain that persists 3 months or more) is more complex, however, and often very difficult to treat. In such cases, ideally the patient should play a more active role while the person administering the treatment should act as an adviser, including encouraging the patient to be more active. Complex regional pain syndrome is often characterised by allodynia, which is painful hypersensitivity to stimuli that should normally not cause pain. Pain tolerance is defined as the greatest level of pain that a patient is prepared to “tolerate”. Two individuals can have the same pain threshold but a different tolerance for the same painful event. These two definitions are critical in the pain analysis and for the treatment required. Pain impulses usually transpire through the activation of peripheral pain receptors (nociceptors, from the Latin nocere = to injure). This activates primarily myelinated (A-delta nerve fibres) and thinner unmyelinated (C nerve fibres) neurons. As a result, secondary neurons are activated and the pain signal is transmitted via the spinot halamic fasciculus up through the nervous system. Following a cortical processing, the activation typically gives rise to a sharp, well-localised feeling of pain (“it hurts”). This gives rise to the emotional components of pain (“discomfort”), which are very important from a clinical standpoint. In addition, there are a number of systems that process pain impulses before they give rise to the perception of pain. Opioids play a dual role in these systems by activating the descending pain-inhibiting systems and inhib iting the ascending pain impulses of the spinal cord. Opioids can also lead to peripheral modulation of pain at the receptor level in connection with inflammation. Psychological factors such as expectancies and experiences seem to influence the sensitisation of neurons (11) and, as a result, research into the mechanisms that underlie the placebo effect has intensified over the past few years. The difficulties with experimental studies on physical activity and pain are the various types of pain-inducing stimuli used and the individual differences in pain sensitivity. In addition, there are methodological issues regarding the type of physical activity, dura tion and intensity. For example, study subjects are usually less apprehensive/anxious since they know that the pain stimulation can be stopped at any time, which is not the case in real life situations. There are many indications that pain relief is an integral part of physical activity. In addition, the pressure receptors of the cardiovascular system appear to have an effect on the pain system (15). Experimental studies indicate that the pain threshold for different forms of pain stimulation increases during physical activity. For example, this applies to dental pain (16), electrically induced finger pain during a cycle test (17), and pressure-induced pain in the quadriceps muscle during static load (18). Evidence suggests that different forms of physical activity lead to pain relief using a broad range methods of assessment, as well as different pain stimuli. A high-intensity activity seems to increase the pain threshold, which then gradually decreases once the activity is finished (see “Prescription” below). In a trial using thermal provocation, the analgesic effect of 45 minutes of high intensity running corresponded to approximately 10 mg of intravenous morphine (19). Experimental studies on fibromy algia have shown physical activity to have the opposite effect. Unlike in healthy individ uals (in whom the pain threshold decreases), the sensitivity to pain was found to increase during and after physical activity (23). This may render it more difficult for patients with fibromyalgia to be physically active, as part of their everyday clinical treatment. Long-term effects Do physically active persons have a higher pain tolerance than inactive persons People who are physically active on a regular basis appear to have a higher pain tolerance. However, it does not necessarily mean that they have a higher pain threshold (24). Whether this poten tial difference in pain tolerance is due to the training itself, or simply individual/genetic, is currently subject to debate. However, the effect of physical activity on pain seems to be similar for both active sportsmen and untrained individuals (16, 20). A possible explanation for why certain runners are able to continue running despite an injury (1) could be that they have a high pain tolerance to begin with, which is then boosted by the extra physical load. Also, by focusing on other signals from the body, attention is diverted away from the pain. For example, it has been noted that the pain sensitivity of competi tive swimmers varies depending on the intensity of training during a season (4). When treating patients with chronic pain, increased physical activity is a key factor for improving the prognosis and alleviating the patient’s suffering. Aerobic fitness and quality of life is gradually reduced in patients with chronic pain, with the risk of social isolation. Activity-induced pain combined with the anxiety and uncertainty that comes with the possibly unknown cause of the pain often leads to a reduced level of activity. In a small number of cases, negative attributes such as pain communication, inadequate and increased pain distribu tion, as part of the so-called “somatoform pain disorder”, have developed. Increased physical activity has a significant effect on patients with chronic pain. Not only does it reduce pain, but it also positively influences the patient’s mood (13, 26), alle viates social isolation, and increases functional capacity (27). Physical activity may also lead to an improved perception of body image (28) and the person’s self image of being a healthy individual (29). These effects also increase the possibility of the patient being able to handle and cope with pain. Secondary muscle tension caused by pain can be reduced through physical activity and mobility training. Mechanisms Physical activity as pain relief Endogenous opioids the most favoured theory behind the effects of physical activity on pain relief is based on endogenous opioids (beta-endorphins; the body’s own opiates). The concentration of beta-endorphin in the blood increases with physical activity (30), although this is probably only partly responsible for the pain relief. According to a theoretical model, the activation of ergo receptors in major muscle groups during physical activity can lead to increased central opioid activity through the activation of A-delta fibres (31). However, for phys ical activity at lower intensities, such as aerobic endurance training with stable lactate levels, a long duration is required (> 1 hour) in order to obtain an increased release of beta endorphins (32). Some studies support the endorphin theory by showing that pain relief is reduced when patients are given naloxone (an antagonist to morphine and other opiates 528 physical activity in the prevention and treatment of disease and opioids that obstruct the analgesic effect of opiates by blocking their receptors) (19, 21), whereas other studies have been unable to confirm these findings (17, 21). Thus, there seems to be more than one explanation for the secondary effects that physical activity has on pain. Increased activity in non-pain transmitting sensory fibres Activation of large afferents (sensory fibres) could, in theory, lead to reduced pain via the activation of pain-inhibiting interneurons (Gate Control Theory) (35). Distraction A distraction or diversion has been proven to change the experience of pain (36) and can contribute to alleviating pain during and after an activity (37). A sports activity may distract an individual from pain, as also illustrated historically by injured and fleeing soldiers. Consequently, the analgesic effects of physical activity demonstrated in labora tory tests may be underestimated due to insufficient exterior influences (38).

The virus is present in saliva and is transmitted by bites or gas spasms discount tizanidine 2 mg mastercard, rarely muscle relaxant drug names cheap tizanidine 2 mg without a prescription, by contami nation of mucosa or skin lesions by saliva or other potentially infectious material (eg muscle relaxant on cns buy tizanidine 2mg on line, neu ral tissue) knee spasms pain cheap tizanidine 2 mg overnight delivery. Worldwide, most rabies cases in humans result from dog bites in areas where canine rabies is enzootic. Most rabid dogs, cats, and ferrets may shed virus for a few days before there are obvious signs of illness. No case of human rabies in the United States has been attributed to a dog, cat, or ferret that has remained healthy throughout the standard 10-day period of confnement. The incubation period in humans averages 1 to 3 months but ranges from days to years. Suspected rabid animals should be euthanized in a manner that preserves brain tissue for appropriate laboratory diagnosis. Virus can be isolated in suckling mice or in tissue culture from saliva, brain, and other specimens and can be detected by identifcation of viral antigens or nucleotides in affected tissues. Diagnosis in suspected human cases can be made postmortem by either immunofuores cent or immunohistochemical examination of brain tissue. Laboratory personnel should be consulted before submission of specimens to the Centers for Disease Control and Prevention so that appropriate collection and transport of materials can be arranged. Very few patients with human rabies have survived, even with intensive supportive care. Since 2004, 2 adolescent females and an 8-year-old girl, all of whom had not received rabies postexposure prophylaxis, survived rabies after receipt of a combination of sedation and intensive medical intervention. If the patient has bitten another person or the patient’s saliva has contaminated an open wound or mucous membrane, the involved area should be washed thoroughly and postexposure prophylaxis should be administered (see Care of Exposed People, p 604). Education of children to avoid contact with stray or wild animals is of primary importance. Inadvertent contact of family members and pets with potentially rabid animals, such as raccoons, foxes, coyotes, and skunks, may be decreased by securing garbage and pet food outdoors to decrease attraction of domestic and wild animals. Similarly, chimneys and other poten tial entrances for wildlife, including bats, should be identifed and covered. International travelers to areas with endemic canine rabies should be warned to avoid exposure to stray dogs, and if traveling to an area with enzootic infection where immediate access to medical care and biologic agents is limited, preexposure prophylaxis is indicated. Exposure to rabies results from a break in the skin caused by the teeth of a rabid animal or by contamination of scratches, abra sions, or mucous membranes with saliva or other potentially infectious material, such as neural tissue, from a rabid animal. The decision to immunize a potentially exposed person should be made in consultation with the local health department, which can provide information on risk of rabies in a particular area for each species of animal and in accordance with the guidelines in Table 3. In the United States, all mammals are believed to be susceptible, but bats, raccoons, skunks, and foxes are more likely to be infected than are other animals. Coyotes, cattle, dogs, cats, ferrets, and other animals occasionally are infected. Bites of rodents (such as squirrels, mice, and rats) or lagomorphs (rabbits, hares, and pikas) rarely require prophylaxis. Additional factors must be consid ered when deciding whether immunoprophylaxis is indicated. An unprovoked attack may be more suggestive of a rabid animal than a bite that occurs during attempts to feed or handle an animal. Properly immunized dogs, cats, and ferrets have only a minimal chance of developing rabies. Postexposure prophylaxis for rabies is recommended for all people bitten by wild mammalian carnivores or bats or by high-risk domestic animals that may be infected. Postexposure prophylaxis is recommended for people who report an open wound, scratch, 1 Centers for Disease Control and Prevention. Immunization is discontinued if immunofuorescent test result for the animal is negative. Because the injury inficted by a bat bite or scratch may be small and not readily evident or the circumstances of contact may preclude accurate recall (eg, a bat in a room of a sleeping person or previously unattended child), prophylaxis may be indicated for situations in which a bat physically is present in the same room if a bite or mucous membrane exposure cannot reliably be excluded, unless prompt testing of the bat has excluded rabies virus infection. Prophylaxis should be initiated as soon as possible after bites by known or suspected rabid animals. Rabies virus transmission after exposure to a human with rabies has not been documented convincingly in the United States, except after tissue or organ transplanta tion from donors who died of unsuspected rabies encephalitis. Casual contact with an infected person (eg, by touching a patient) or contact with noninfectious fuids or tissues (eg, blood or feces) alone does not constitute an exposure and is not an indication for prophylaxis (see Care of Hospital Contacts, below). A dog, cat, or ferret that is suspected of having rabies and has bitten a human should be captured, confned, and observed by a veterinarian for 10 days. Any illness in the animal should be reported immediately to the local health department. Other biting animals that may have exposed a person to rabies should be reported immediately to the local health department. Management of animals depends on the species, the circumstances of the bite, and the epidemiology of rabies in the area. Previous immunization of an animal may not preclude the necessity for euthanasia and testing. Because clinical manifestations of rabies in a wild animal cannot be interpreted reliably, a wild mammal suspected of having rabies should be euthanized at once, and its brain should be examined for evidence of rabies virus infection. The exposed person need not receive prophylaxis if the result of rapid examination of the brain by the direct fuorescent antibody test is negative for rabies virus infection. The immediate objective of postexposure prophylaxis is to prevent virus from entering neural tissue. Prompt and thorough local treatment of all lesions is essential, because virus may remain localized to the area of the bite for a variable time. Quaternary ammonium compounds (such as benzalkonium chloride) no longer are considered supe rior to soap. The need for tetanus prophylaxis and measures to control bacterial infection also should be considered. After wound care is completed, concurrent use of passive and active prophylaxis is optimal, with the exceptions of people who previously have received complete immunization regimens (preexposure or postexposure) with a cell culture vaccine and people who have been immunized with other types of rabies vaccines and previously have had a documented rabies virus-neutralizing antibody titer; these people should receive only vaccine. Prophylaxis should begin as soon as possible after exposure, ideally within 24 hours. However, a delay of several days or more may not com promise effectiveness, and prophylaxis should be initiated if reasonably indicated, regard less of the interval between exposure and initiation of therapy. Physicians can obtain expert coun sel from their local or state health departments. Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies: recommendations of the Advisory Committee on Immunization Practices. Ideally, an immunization series should be initiated and completed with 1 vaccine product unless serious allergic reactions occur. Clinical studies evaluating effcacy or frequency of adverse reactions when the series is completed with a second product have not been conducted. Serologic testing to docu ment seroconversion after administration of a rabies vaccine series is unnecessary but occasionally has been advised for recipients who may be immunocompromised. Intradermal vaccine is not advised for postexposure prophylaxis in the United States, although for reasons of cost and availability, intradermal regimens are used in some countries. Because virus-neutralizing antibody responses in adults who received vaccine in the gluteal area sometimes have been less than in those who were injected in the del toid muscle, the deltoid site always should be used except in infants and young children, in whom the anterolateral thigh is the appropriate site. In adults, local reactions, such as pain, erythema, and swelling or itching at the injection site, are reported in 15% to 25%, and mild systemic reactions, such as headache, nausea, abdominal pain, muscle aches, and dizziness, are reported in 10% to 20% of recipients. All suspected serious, systemic, neuroparalytic, or anaphylactic reactions to the rabies vaccine should be reported immediately to the Vaccine Adverse Events Reporting System (see Reporting of Adverse Events, p 44). Although safety of rabies vaccine during pregnancy has not been studied specifcally in the United States, pregnancy should not be considered a contraindication to use of vaccine after exposure. Inactivated nerve tissue vaccines are not licensed in the United States but are available in many areas of the world. These preparations induce neuroparalytic reactions in 1 in 2000 to 1 in 8000 recipients. Immunization with nerve tissue vaccine should be discontinued if meningeal or neuroparalytic reactions develop. Corticosteroids should be used only for life-threatening reactions, because they increase the risk of rabies in experimentally inoculated animals. As much of the dose as possible should be used to infltrate the wound(s), if present. Passive antibody can inhibit the response to rabies vaccines; therefore, the recommended dose should not be exceeded.


A prospective spasms that cause shortness of breath quality tizanidine 2 mg, uncontrolled study of 316 infants with infantile colic showed a satisfactory result in 94% of cases receiving chiropractic care spasms in 8 month old purchase online tizanidine. Other authors have offered case reports of results obtained in patients with colic muscle relaxant magnesium buy genuine tizanidine online. In 1997 landmark research was published validating the role of the chiropractic adjustment in the care of children with otitis media spasms calf order generic tizanidine. This historic study of chiropractic adjustive care on children with this condition employed tympanography as an objectifying measure and studied 332 subjects. The results of this study indicate a strong correlation between the chiropractic adjustment and the resolution of this very common condition (Fallon, 1997). There is evidence that adjustment stimulates certain metabolic activity within some types of white blood cells (Brennan, 1990). There is also preliminary evidence suggesting a relationship between adjustment and serum beta-endorphin levels and other circulating pituitary hormones (Vernon, 1989). A randomized controlled study on a small number of patients with elevated blood pressure demonstrated a significant reduction in post-treatment blood pressure for subjects adjusted in the thoracic spine employing an Activator adjusting instrument (Yates, 1988). However, there is a great deal of overlap, and a number of techniques involve only minor modifications of others. Additionally, many named techniques have both analytical and therapeutic components. Analysis and other diagnostic considerations are discussed in other chapters (see History and Physical Examination, Diagnostic 252 Imaging, Clinical Laboratory, Clinical Impression, Frequency of Care, and Outcomes Assessment. However, many exercise and education protocols are in widespread use and considered standard approaches within the medical community (White and Anderson, 1991, Mayer and Gatchell, 1987). Physiotherapeutic modalities are relatively standardized (Schaefer, 1984, Stonebrink, 1990) and are generally used as ancillary procedures in chiropractic practice. Usually, patient functioning is verbally discussed between the patient and practitioner, but new questionnaire techniques may make such information more objective. Functional questionnaires seek to quantify symptoms, function and behavior directly, rather than to infer them from less relevant physiological tests. There are a large number of functional scales described in the scientific literature. Deyo (1990) presented an excellent review and summary of many functional assessments used in back pain research. Of particular note are the Pain Disability Index (Tait, 1987), the Million Disability Questionnaire (Million, 1982), the Oswestry Disability Questionnaire (Fairbank, 1980), the Roland Morris Disability Questionnaire (Roland, 1983), the Waddell Disability Index (Waddell, 1982), and the Dallas Pain Questionnaire (Lawlis, 1989). A modification of the Oswestry Questionnaire to make it useful for neck function was recently published by Vernon (1991). A very detailed discussion of the validity, reliability, responsiveness, relevance, feasibility, and safety of the many functional scales is beyond the scope of this chapter. For further information the book Measuring Health: A Guide to Rating Scales and Questionnaires (McDowell and Newell, 1987) is very useful. In general, while there may be some gaps in the research base for many individual functional questionnaires, the usefulness of these types of instruments is apparent. In terms of responsiveness, which is the ability of an instrument to document changes in health status, it is instructive to examine the clinical trials with respect to manipulative/adjustive care methods. In one meta-analysis (Anderson, 1992), the authors categorized the outcome assessments in 23 randomized trials into eight categories. The outcomes of health care may be characterized as falling into one of the following categories: death, disease, disability, discomfort, dissatisfaction, and destitution (Lohr, 1988). While easily understood in general, operational definitions and assessment procedures for outcomes of care that match the attributes mentioned above are more difficult to obtain. For this review, a citation search was derived from original research, review papers and books from the chiropractic, medical and scientific literature. A great deal of material was referenced from Interstudy, an organization devoted to the scientific 253 development of outcome assessments. Personal experience and opinions of those conducting clinical trials in the chiropractic community were also considered. The literature on outcome assessments can be divided into studies that have concentrated on the development of procedures, those that have tested procedures for validity and reliability, and those that have used the procedures in assessing the effects of care in randomized clinical trials. The literature review will be divided into five major subtopics, reflecting the nature of the outcome assessment procedures under discussion; (1) functional outcome assessments; (2) patient perception outcome assessments; (3) general health outcome assessments; (4) physiological outcome assessments; and (5) the subluxation syndrome as an outcome assessment. Disease-specific physiological measurements related to intervention outcomes number in the hundreds if not thousands, so only a small number of most relevant procedures deemed important to chiropractic practice are described here. The subluxation syndrome as an outcome assessment has elements of function, perception and physiology, but requires special consideration because of its importance to chiropractic clinical theory and practice. It is difficult to conceptually separate some of the physiological outcomes from those related more specifically to the subluxation syndrome. The argument exists because there are different opinions about just how comprehensive the definition of the subluxation syndrome should be in terms of encompassing different types of spinal and locomotor patho-physiology or dysfunction. Economic outcomes (assessing the costs and cost-effectiveness of care) are becoming increasingly important. Indeed, some have argued that cost accountability is more important to port of pain, overall clinical improvement assessed by the patient, overall clinical improvement assessed by the practitioner, range of trunk flexion, range of trunk extension, straight leg raising, work activities, and activities of daily living. Outcome assessments in the form of ranges of trunk motion did not indicate as much improvement on the average, although improvement was certainly demonstrated in a proportion of studies. Most clinical trial investigators created their own functional scales and so did not use standardized outcome assessments of known validity and reliability. Rasmussen (1979) used a measure of pain, spinal mobility, function and "fitness for work. Hsieh (1991) concluded that the Roland Morris Questionnaire and the Oswesyry Questionnaire gave consistent but slightly different results in a chiropractic clinical trial. Patient Perceptions Outcome Assessments Patient perceptions of pain and satisfaction have not traditionally been considered very important as outcomes in any quantitative fashion. This is probably because it was felt that patient perceptions were too subjective and variable to be of much use. This is despite the fact that clinical impressions of the value of treatments are most likely based on favorable comments by patients to their practitioners. Currently, however, health services researchers have discovered that patient perceptions, measured with appropriate procedures, may be an excellent way to measure many aspects of the quality of care (Donabedian, 1980; Cherkin, 1990). Pain upon palpation and motion tests directed by the doctor of chiropractic are important indicators of joint malfunction and malposition. Such tests are unique to chiropractic practice and are used not only to determine the articular misalignment but to determine techniques and need for adjustive procedures. In the assessment of a chiropractic case these assume an important analytical role. Low-back and neck pain probably represent about two thirds of all chiropractic patient concerns (Nyiendo 1989). There is a great deal of research in the scientific literature on pain measurement (McDowell, 1987; Melzack, 1983; Vernon, 1990). To discuss the entire range of potential assessment methods is again beyond the scope of this chapter, but details may be found in the references noted above and in other chapters. Pain has a number of dimensions including severity (intensity), duration, and frequency. Patients are asked to mark on the line a point that represents their perceived pain intensity. Numerical Rating Scales ask the patient to choose a number between 0-100 that represents their pain intensity. Another pain scale uses 11 ranked levels numbered 0-11 graphically depicted in boxes. The so-called "Behavioral Rating Scale" has six levels, each with a description such as for the third level, "pain present, cannot be ignored, but does not interfere with everyday activities. One commonly used scale from the McGill/Melzack Pain Questionnaire called the Present Pain Intensity scale uses the words, "none, mild, discomforting, horrible, and excruciating. Patients are instructed to daily indicate on a form the intensity, duration and frequency of their pain complaints. Parker (1978) used a patient report headache diary of severity, duration and frequency and a disability score calculated from it. Plain diaries may also be very useful for single-case time-series research designs (Keating, 1985).

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Osteoporosis is thought to spasms muscle generic tizanidine 2mg otc be a combined effect of the actual disease process spasms with cerebral palsy order discount tizanidine line, physical inactivity and spasms post stroke purchase generic tizanidine on line, if applicable muscle relaxant liquid form 2mg tizanidine sale, cortisone treatment. A reduced range of joint motion accompanies increased joint fluid, thickened joint capsules and changes in load conditions as a consequence of cartilage and bone destruction. The reduced muscle function is partly explained by muscle inflammation and partly by changes in the joints. This may lead to extended tendons, ligaments and joint capsules and as a result, joint instability, a reduced muscle mass and strength. The joint swelling will also have a direct impact on the ability of surrounding muscles to contract. The unfa vourable position of the joints restrains optimum muscle contraction and the impaired 43. A normative comparison of age-gender-matched data showed that 72 per cent had a reduced muscle function while 92 per cent had a reduced grip strength. Around 80 per cent of the women and 50 per cent of the men had a lower than average oxygen uptake capacity. Only around half (53 %) reported to have a suffi cient level of physical activity to maintain good health (6). At least four of the following seven criteria have to be fulfilled: Arthritis in the small joints of the hand and in at least three joints/joint areas, symmetry, morning stiffness, rheumatic nodules, decalcification of bone on joints or erosions (bone cavities) as shown on X-ray and finally, positive rheumatoid factor. Because of the large number of individual variations in disease manifestations and consequences, a functional classification system has long been used for rheumatoid arthritis (8). Prognosis the varied disease progression makes it difficult to establish individual prognoses. Even if the symptoms of rheumatoid arthritis may subside and fully disappear after a short period of time, the majority develop into chronic symptoms. However, alternating acute flares of the disease and calmer periods of remission usually lead to a gradual deteriora tion. Occasionally, the clinical picture presents severe, rapidly progressive joint destruc tion with system engagement. The treatment is usually administered by doctors, nurses, occu pational therapists, social workers and physiotherapists and aimed at alleviating inflam matory activity and other symptoms of the disease, preventing joint damage and potential disability as well as maintaining a good quality of life. However, treatment perceptions and objectives have developed significantly over the past few years with remissions or near remissions now being a realistic target (9). Treatment with inflammatory inhibitors should be administered effectively and as early as possible in the course of the disease so as to reduce future joint damage and functional disorders. Cortisone is an anti-inflammatory and effective medicinal product that is admin istered orally in tablet form or as an injection directly into the inflamed joint or tendon. Near total remission is obtained in many cases or at least a successful inhibition of the inflammation for the duration of the treatment. Modern biological treatment also seems to stop the bone and joint destruction identifiable on x-ray (10). All forms of rehabilitation should be implemented on the basis of team work in close collaboration with the patient, focusing on the goals of the patient. Patient education is a very important aspect of rehabilitation and includes informing the patient about the bene fits and prospects of physical activity. Pain relief, trying out various mobility aids, psycho logical and social support plus various forms of physiotherapy and physical exercise are also essential aspects of rehabilitation. This temporary pain increase is seen as a harm less soreness caused by joints and muscles being subjected to an unusual load. Long-term effects There are indications that regular and moderately intensive physical activity on a daily basis results in improved muscle function and a better quality of life in patients with early rheumatoid arthritis (11). Just like healthy patients, patients with rheumatoid arthritis are able to improve their aerobic capacity, muscle function, bone density, daily activity performance and quality of life with the implementation of physical activity (15–19). Recent studies of moderate to high-intensity exercise indicate that, regardless of whether the patient’s disease status is stable or active, previous concerns over increased disease activity were unwarranted (12, 16, 20). The few studies that have examined the effects of moderate-intensity exercise on the progression of joint destruction showed no negative effects (15, 21). However, long periods of high-intensity exercise appeared to accelerate joint destruction in individuals with an initial destruction of large joints, particularly the shoulder joints and subtalar joints of the foot (22). Also, as mentioned above under “Pathophysiology”, it is recommended that joint flexibility, strength and aerobic training programmes are adapted to the individual patient with the aim of main taining optimal biomechanical properties and preventing a gradual decline in aerobic capacity. Physical activity can also help reduce symptoms of stress, anxiety and depres sion and stop social isolation. Also, it is important to discuss how physical activities can be incorporated into the daily life of the patient. Because of the inconsistent progress of the disease, every organised physical exer cise should be adapted to the individual patient for the purpose of improving bodily func tions. It is recommended that the joint range of motion is monitored and exercised, especially in case of an active disease status and threatening contractions. In order to increase oxygen uptake capacity, muscle function and ability to carry out daily chores, the patient needs to perform moderate to high-intensity exercise for 30 minutes at least 3 times a week. The prescription specified in Table 1 is based on a systematic review of randomized controlled studies on physical exercise (15), but is not much different from general exer cise recommendations. Due to the intermittent nature of rheumatoid arthritis, it is not possible, as with other diseases, to consistently upgrade the exercise, but rather it must be adapted to the varia tions of the disease. Specific attention paid to a possible increase in the initial pain will facilitate continued exercise. However, it is still common for the so-called 24-hour rule to be applied and the load temporarily reduced if the increase in pain continues for more than 24 hours after exercise. Exercising in a heated swimming pool can be very beneficial as the water offloads the body weight at the same time as it is provides a gentle and even resistance to movement. Submaximal cycling or treadmill tests are used to assess the level of aerobic fitness while strength levels are assessed using various types of weight-lifting equipment. Interactions with medical treatment Cortisone is a catabolic steroid with alleviating effects that reduces the connective tissue strength in for example ligaments and tendons with an increased risk of rupture. Consequently, extreme physical activity is not recommended in connection with a corti sone treatment. It is recommended that patients undergoing a course of intra-articular cortisone injections should be prescribed rest, preferably bed rest, for the first 24 hours followed by at least one week of refraining from pronounced physical activity or exercise. When injections are given directly into muscular attachments or around tendons, the risk of rupture will remain for far longer, sometimes several months, and as a result, large physical loads should be avoided for a relatively long time. In the event of a long-term low-dose peroral cortisone treatment, the benefits of physical activity and exercising may surpass potential risk factors although this requires an individual assessment. This will not negatively affect the movement organs, at least not in the short term. The conditions described below are all perceived as relative contraindications requiring specialist care. Patients with these types of complications require special training and guidance by healthcare professionals. However, it is important not to forget the increased risk of fractures and conse quently, the necessity of being extra aware and cautious to prevent falls or similar acci dents from happening. Patients suffering with large joint destruction should be advised to weigh up the bene fits of high-intensity training over the risk of an accelerated joint destruction. Exercise programmes designed for patients with large joint destruction should to the greatest extent possible protect shoulder joints and subtalar joints. Caution should also be observed in the event of joint replacement surgery, especially in association with heavy-load strength training. However, physical activity and exercise is normally beneficial to maintain maximum muscle function and mobility before and after joint replacement surgery. Threefold increased risk of hip fractures with rheumatoid arthritis in central Finland. Increasing evidence for the role of rheu matic disease in the cardiovascular mortality of rheumatoid arthritis. Physical activity, physical fitness and general health perception among individuals with rheumatoid arthritis. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis.

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