History and present state
A 59 year old woman was diagnosed with rheumatoid arthritis 7 years ago. An exacerbation caused her to be hospitalised 3 months ago. Medication was revised, the signs of acute inflammation disappeared and her sedimentation rate was normalised. She has secondary osteoarthritis of ankles, knees and hips. She is referred for an out-patient aquatic therapy program.
Subjectively, she complains about pain in the feet, ankles and knees in rest and during activity between 4/10 and 6/10 on a visual analogue scale, decreased range of motion (ROM) in ankles, knees and hips, and a general stiffness of 4/10 on a visual analogue scale (ICF function level). She lists her 3 main functional complaints (ICF activity level) as restrictions in walking long distance outside, climbing stairs and maintaining balance while doing bimanual tasks at home
Objective assessment shows decreased ROM of both hips in internal rotation, abduction, external rotation and, to a lesser degree, extension. Knees (mainly the left) show a reduced ROM with flexion more than extension. Both ankles show a reduced ROM with plantar flexion more affected than dorsiflexion. There is a general loss of muscle power in the lower extremities, especially anterior tibialis, medial vastus (left and right) and all glutei. are weak around 4 at the MRC scale.
The Womac questionnaire (LK30 version) shows 43/68 in the physical function domain, 10/20 in the pain domain and 5/8 in the stiffness domain. Clinimetric tests like the Functional Reach shows 20 cm (normal value is 34 cm) and her Timed Up and Go test revealed a time of 25 seconds. Her physical capacity is very low in comparison with age-matched women: 16 ml/kg ffm / min as opposed to the norm of 31, based on the Åstrand test.
She has an adequate coping style: she is tiring quickly, however she knows why and really hopes to increase her present condition.
Overall Clinical Assessment Summary:
Impairments of joint mobility, joint stability, sensations of stiffness and sensations of pain, reduced mm power and mm endurance. Restrictions to maintain a steady position and to shift the COG
Aquatic Therapy Treatment Plan
Based on the analysis of the subjective and objective impairments and restrictions, the following objectives were formulated. (In order to keep this case simple, the SMART system of goal setting, goal attainment scaling, minimal clinically important improvement and patient accepted symptom state have not been used)
- to increase ROM of the lower extremities
- decrease the (sensation) of stiffness and pain
- to increase general muscle power of the lower extremities
- to increase muscle endurance of the LE
- to be able to change the COG while standing increasing her supportive leg functions
- to work on balancing and stabilising reactions during gait training
- to increase aerobic capacity
- to let her enjoy achievement of pain free movements
Amongst other aquatic therapy techniques like the Bad Ragaz Ring Method to increase muscle power, ROM and decrease stiffness, Clinical Ai Chi is used. This can be done individually, but can also be combined with attending a group, to be continued after the therapy goals have been met. The first session is partly used to introduce Clinical Ai Chi by focusing on breathing during the 5 initial katas. The sessions afterwards are focused on the objectives and therefore katas are chosen in which supportive function is exercised in standing and the trunk is in constant motion.
Gathering (fig 4a and 4b), freeing (fig 5a and 5b), shifting (fig 6a and 6b), accepting (fig 7a and 7b), accepting with grace (fig 8a and 8b), rounding (fig 9a and 9b), balancing (fig 10a and 10b), halfcircling (fig 11a and 11b), encircling (fig 12a and 12b). The program as used by Teixeira61 is modified in order to match the chosen katas with the available time.
|week||Exercise number, according to the pictures||Minutesof Ai Chi||Repetitions per kata||reps|
|1||4 – 7||8||3||20|
|2||8 – 12||8||3||15|
|3||4 – 12||15||3||15|
|4||4 – 12||20||4, with variations as suggested in the text||12|
|5||4 – 12||20||4, with variations as suggested in the text||10|
The Clinical Ai Chi session progresses to 20 minutes as a low level fitness “workout” at 40% VO2max or RPE 11/20 (some effort but not enough to speed up breathing) following the ACSM64 guidelines for arthritic patients. Muscular endurance fits training recommendations to achieve a high amount of repetitions with a low external load. The slow movements adequately address the connective tissue stiffness. The frequent change of the COG without using hands to additionally stabilize posture along with adaptations to decrease the base of support follow recommendations on balance training.30
Over the 5 week program the client progressively improved in hip, knee and ankle ROM, showed improvement of MRC muscle strength in both lower extremities to 4+/5, Her Timed Up-and-Go score improved by 7 seconds and her functional balance scores improved along with her subjective abilities to perform normal ADLs. She elected to continue with the independent group Ai Chi f