Psoriatic arthritis is a complex, chronically progressive inflammatory joint disease that can be associated with a number of extra-articular manifestations such as psoriasis. The clinical characteristic is the presence of peripheral and axial arthritis, dactylitis, enthesitis and psoriasis. Because of this complex manifestation, a holistic, multidisciplinary approach is required to successfully treat the condition.
Psoriatic arthritis is regarded as seronegative spondyloarthropathy. The fact that it is "seronegative" means that the blood will test negative for a certain factor that is present in rheumatoid arthritis.
Deep immersion in the spondyloarthropathy
In recent years, new drugs have revolutionized the management of the disease, but some patients either cannot tolerate it or unfortunately do not respond to treatment. For these patients physiotherapy plays a decisive role in the treatment of their symptoms . Even if patients respond to and tolerate pharmacological treatment, exercise should still be a central part of treatment plans. But what exercise is most effective in this population and what treatments should we use when patients are unresponsive to drug management?
A new narrative review aims to examine the evidence on the role of physiotherapy, exercise and rehabilitation in the treatment of PsA patients in each disease area.
Methods
Pubmed and the Cochrane Library were searched for relevant articles using the following search terms: psoriatic arthritis, psoriasis, psoriatic disease, synovitis, axial involvement, dactylitis, enthesitis, rehabilitation, exercise, physiotherapy, and comorbidities. The search was limited in time between January 1, 2000 and October 30, 2020. Human clinical studies, clinical studies, reviews, and meta-analyzes were included.
Results & clinical take-away
The narrative review has broken down the available evidence into sub-categories. Below is a roundup of everyone with Clincial Take Homes.
Skin involvement – lifestyle and exercise advice is the key
As the name of the disease suggests, psoriasis is an important extra-articular manifestation of the disease. Psoriasis is an inflammatory condition that has itchy, red, scaly plaques, and not everyone with psoriasis has psoriatic arthritis. However, it is an important symptom to be aware of. In general, psoriasis is mild in people with psoriatic arthritis. The condition can have a serious impact on the quality of life.
Obesity, alcohol consumption, smoking, poor sleep hygiene and a sedentary lifestyle have all been associated with worsening psoriasis, so a change in these behaviors has a positive effect on the disease. The same is true of stress, which is known to be a significant trigger for exacerbations in skin condition.
For this reason, it has been shown that relaxation, basic exercise, mindfulness and behavior and lifestyle modification therapies are effective in lowering the PASI values (Psoriasis Area and Severity Index). A multidisciplinary team approach is therefore clinically important for this group of patients. Include psychologists, nutritionists and occupational therapists early in your management plan for patients with psoriatic arthritis.
Peripheral involvement – dactylitis and axial involvement
The majority of patients with psoriatic arthritis suffer from erosive and osteoproliferative arthritis. Disease-modifying anti-inflammatory drugs (DMARDs) are of crucial importance here, as they change the course of the disease process and ultimately delay the destruction of the joint surfaces.
With respect to DMARDs, exercise and physical therapy should focus on various aspects of a patient's health in order to maximize the effectiveness of pharmacological therapy and reduce the burden of side effects, as well as increasing the potential potential ultimate duration of DMARD effectiveness as a whole.
Additionally basic exercise and physiotherapy treatment modalities should not be overlooked. Cryotherapy can help to relieve joint pain, swelling and tenderness and to improve the sensitivity of daily life. Splints and orthotics may be useful in reducing the risk of joint deformity, but the evidence is limited. Hydrotherapy can be a useful treatment option for those with high levels of pain and low self-confidence doing independent exercise.
Exercise is key to the lifelong treatment of the disease and is recommended by the EULAR guidelines for people with inflammatory arthritis, including psoriatic arthritis. This is general advice, however, and mostly stick with around 150 minutes of exercise per week with a mix of exercise types. This reflects the lack of research and evidence for specific exercise protocols and strategies in this patient population. There are new studies examining HIIT training in this population. However, the results did not show any change in the disease process, only improvements in fatigue.
The treatment of dactylitis in living people is psoiratoid arthritis, which follows recommendations similar to those for rheumatoid arthritis. Maintaining the function and range of motion of the small wrists is the central goal of treatment. This is complemented by helping patients find alternative, less painful methods of performing daily activities. Thermal modalities also help achieve these goals.
Axial diseases in psoriatic arthritis have some similarities with axial spondyloarthropathy, which is why the role of movement in the treatment of spinal symptoms has the same relevance and importance.
Enthesitis – difficult to handle
Enthesitis occurs in about 1/3 to 1/2 of people with psoriatic arthritis. According to this narrative overview, there is little evidence of physiotherapeutic treatment for this symptom. That being said, it is still a symptom that we as clinicians need to be aware of as it can be a significant barrier to participating in exercise due to the location and pain caused by movement.
Enthesitis typically shows up as pain, stiffness and tenderness of insertions without great swelling. However, swelling can also be a feature of larger lower limb insertions. Enthesitis is clinically diagnosed with pain caused by local pressure on the entheseal points or the use of imaging. Magnetic resonance imaging or ultrasound .
"The enthesis is a relatively avascular structure and therefore inflammation markers must not be increased in entheseal-related disorders"
Clinically, enthesitis can be difficult to recognize without swelling. The enthesis is a relatively avascular structure, so inflammation markers such as ESR or CRP cannot be increased in entheseal-related disorders . In addition, many insertions are either inaccessible to the examiner and have poorly localized pain.
Basic, regular stretching is a good place to start, especially before doing any exercise. There is little evidence of laser therapy and shock wave therapy, and this is not currently recommended, even considering that the self-repair activity of living tissue can theoretically be stimulated.
Comorbidities – reduction of the increased risk
Psoriatic arthritis is associated with several comorbidities due to the presence of the chronic underlying inflammation of the disease itself. It was assumed that patients have a 43% higher risk of developing cardiovascular diseases . This includes a 68% increased risk of a heart attack, a 22% increased risk of stroke, and a 31% increased risk of heart failure. It is important to note that this is a relative risk, not an absolute risk.
Due to the increased risk of cardiovascular diseases, exercise and a change in diet are crucial in order to reduce this increased risk. For this reason, the EULAR guideline for the treatment of psoriatic arthritis recommends not only exercising, but also treating cardiometabolic comorbidities.
Brief summary of the overview of physiotherapeutic treatments for psoritic arthritis
Rehabilitation and exercise are especially important for those who are inadequate to respond to pharmacological treatments
The involvement of dietitians, psychologists and occupational therapists is critical to facilitate lifestyle changes and manage the exacerbation of psoriasis
Enthesitis is a difficult symptom to investigate, so vigilance is required. Because of its irritability and location, it presents an obstacle to exercise and therefore ensures that basic treatments are considered
Exercise plays an important role in the treatment of axial / spinal symptoms
People with psoriatic arthritis have a 43% increased risk of developing cardiovascular diseases . Therefore, exercise and nutrition programs play an important role in reducing this risk
There is a lack of evidence for research into specific exercise protocols and regimes in this population to cope with joint erosion.
Overall, this review indicates that current findings confirm the potential benefits of exercise and physiotherapy in patients with psoriatic arthropathy. However, the scope and quality of the evidence is lacking, which means that exact treatment protocols are uncertain.
