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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 27-32

Physiotherapy in psoriatic arthritis: A systematic review


Department of Musculoskeletal Sciences, Faculty of Physiotherapy, Krishna Institute of Medical Science, KIMSDTU, Karad, Maharashtra, India, KIMSDTU

Date of Submission25-Nov-2021
Date of Acceptance21-Jan-2022
Date of Web Publication19-Sep-2022

Correspondence Address:
Sandeep B Shinde
Department of Musculoskeletal Sciences, Faculty of Physiotherapy, Krishna Institute of Medical Science, KIMSDTU, Karad, Maharashtra
KIMSDTU
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/DYPJ.DYPJ_67_21

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  Abstract 

Psoriatic arthritis is an inflammatory joint condition. It is a chronic condition that includes pinkish-red plaque formation on the skin, leading to its changes. The purpose of this article is to review the literature on the role of physiotherapy in psoriatic arthritis. We performed a critical systematic review on the role of physiotherapy in psoriatic arthritis. The article selection process was systematic. The inclusion criteria of the review were (1) physiotherapy practice with psoriatic arthritis; (2) physical activity in psoriatic arthritis; and (3) chronic psoriatic arthritis and co-morbidities. The current review included 11 studies that fulfill these inclusion criteria. Evidence demonstrates that there is potential benefit of physiotherapy treatment and rehabilitation in psoriatic arthritis. Patients with psoriatic arthritis have impaired function and quality of life. It may involve co-morbidities such as obesity, musculoskeletal disease, cardiovascular disease, or fibromyalgia, which can be improved by non-pharmacological approach, such as aerobic exercise and cardiorespiratory exercise. Low level laser therapy increases not only self-repair activities of living tissues but also cell membrane permeability and metabolism, and education of patients is also necessary to improve clinical conditions. Hydrotherapy, resistance exercise, cryotherapy, and interferential therapy are also beneficial in psoriatic arthritis.

Keywords: Joint pain, joint stiffness, psoriasis arthritis, synovitis


How to cite this article:
Dhake P, Shinde SB. Physiotherapy in psoriatic arthritis: A systematic review. D Y Patil J Health Sci 2022;10:27-32

How to cite this URL:
Dhake P, Shinde SB. Physiotherapy in psoriatic arthritis: A systematic review. D Y Patil J Health Sci [serial online] 2022 [cited 2022 Oct 6];10:27-32. Available from: http://www.dypatiljhs.com/text.asp?2022/10/1/27/356518




  Introduction Top


Psoriatic arthritis is a complex inflammatory disease which differs from articular and extra-articular manifestation, and co-morbidities involve arthritis.[1] It mostly occurs in the adult age group. Joint pain in psoriatic arthritis can be monoarthritic, oligoarthritic, or polyarthritic. Polyarthritis is the most common manifestation pattern including oligoarthritis and arthritis mutilant. About 41% of distal interphalangeal involvement and distal arthritis in psoriatic arthritis involve toes and fingers; it mostly involves knee in psoriatic arthritis patients. There are various clinical types of psoriatic arthritis such as asymmetric mono- or oligoarthritis, symmetric arthritis, mutilating arthritis, spondylarthritis, SAPHO (synovitis, acne, pustulosis, hyperostosis, osteitis) syndrome, and psoriatic pachydermoperiostosis.[2]

In psoriatic arthritis, articular and extra-articular manifestation and co-morbidities are hallmarks, so it requires a “holistic” approach of physiotherapy to treat patients. But there are no studies showing holistic approach toward the treatment of psoriatic arthritis; however, there are studies with specific treatment, and the need for these is to collectively show all effective physiotherapy treatments for psoriasis arthritis. Only with physical therapy, hydrotherapy is beneficial for long-term effect with the help of home exercise.[3]

Psoriatic arthritis shows articular and extra-articular manifestation. Articular manifestation is the association of the presence of ductylitis, arthritis, and enthesitis with extra-articular problems and co-morbidities, which need a holistic approach of physiotherapy treatment. It combines with swollen joint on one side or on both sides of the body, morning stiffness, swollen fingers and toes, painful muscles and tendons, and fatigue; sometimes, spinal pain and stiffness can occur in psoriasis. Psoriasis typically causes scaly skin patches which worsen when joint pain flares up. In psoriasis arthritis, the characteristic features are “sausage” fingers and toes, caused by dactylitis. Painful manifestations are fibrocartilages, bursa, fat pad, and enthesitis. Pachydermoperiostosis is seen in enthesitis.[4]

New drugs and small molecule drugs are evolving in recent years; the aim is to induce low disease activity.[5],[6],[7],[8] These new drug therapies show beneficial effects on low disease activity in some clinical trials, real-life experiences, and systematic review.[9],[10] Some study suggested that there is intolerance or non-response of pharmacological drugs. For example, in the study “Upadacitinib for psoriatic arthritis refractory to biologics: SELECT-PsA 2,” it was concluded that trial patients with active psoriatic arthritis had less response or intolerance to at least one biological disease-modifying antirheumatic drug and more than or equal to 3 biologics which ranged between 11% and 16%. Disease management issues are represented by some drugs. Therefore, there is a need to study non-pharmacological treatment for such patients who can have tolerance to pharmacological drugs to improve quality of life and functional activity.[11]

Effectiveness of new treatment approaches will reduce disease activity and increase quality of life shown by some clinical trials, real-life experiences, and some systematic reviews. The OMERACT-endorsed psoriatic arthritic core domain set included pain, function, fatigue, musculoskeletal problem, skin-related issues, and health-related quality of life.[12],[13] In psoriasis arthritis, some studies show how residual pain, impaired function, and decreased quality of life increase disease intensity.[14] In these contexts, pharmacological treatment, physical therapy, and rehabilitation all play a major role in treating psoriatic arthritis.

Physical exercises in psoriatic arthritis are important to improve quality of life, reduce disease intensity, prevent deformity, and improve skin conditions with dieting protocol to reduce obesity.

There is a positive role in physiotherapy and rehabilitation in various musculoskeletal problems, but there is less evidence of effectiveness of physiotherapy in psoriatic arthritis.

The aim of this article is to review the role of physical therapy, exercises, and rehabilitation in psoriatic arthritis.


  Materials and Methods Top


We performed a critical systematic review on the role of physiotherapy in psoriatic arthritis.

Search strategy

The article selection process was systematic. Articles selected relevant keywords in PubMed, Google Scholar, Medline, and CINAHL database up to September 2021. The search terms were “psoriasis,” “arthritis,” “psoriatic arthritis,” “psoriatic arthritis rehabilitation,” “physiotherapy in psoriatic arthritis,” and “co-morbidities in psoriasis arthritis,” and the search was limited to clinical human studies, clinical trials, reviews, and meta-analysis. We followed previous published studies for a systematic review.[13] The inclusion criteria of the review were (1) physiotherapy practice with psoriatic arthritis; (2) physical activity in psoriatic arthritis; and (3) chronic psoriatic arthritis and co-morbidities.

Study selection

A systemic review was undertaken. We included studies published in English till 2021, which focussed only on resistance exercises in the intervention. This study was a randomized, controlled, prospective study. The participant had to be above 18 years with psoriatic arthritis. The intervention included exercise, hydrotherapy, strengthening exercise, and laser therapy.

Data extraction

All steps in the selection and extraction processes were assessed independently by two reviewers. The titles and abstracts of the references are screened. The articles were reviewed according to the relevant topic and selected on the basis of inclusion criteria. The following data were extracted: study design, study population characteristics (inclusion/exclusion criteria), group(s) and sample size, resistance exercise intervention [e.g., specific exercises, number of sets per exercise, number of repetitions per set, intensity (load), frequency, and duration of training], selected outcome measures, and key findings. Summary of included studies is given in [Table 1].
Table 1: Summaries

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  Results Top




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This review represents the summary of 40 articles of physiotherapy treatment on psoriatic arthritis. The literature search produced 40 articles till the year 2021, where search is only limited for physiotherapy treatment on psoriatic arthritis.

A study by Elnaggar et al. shows the low level laser therapy positive effect on psoriatic arthritis, which shows a significant difference in physical functioning. Pre- and post-treatment mean values are recorded (P < 0.05). In psychological functioning, post-treatment values (P < 0.05) in Psoriasis Area and Severity Index (PASI) show a significant difference (P < 0.05); 6-min walk test shows significant differences after treatment (P < 0.05).

A study by Naldi et al. shows that there is an increase in body mass index (BMI), which will worsen the PASI shown which can be reduced by diet and exercise. Intention-to-treat analysis showed a median PASI reduction in dietary changes (P < 0.02) only in arm. The weight loss target was reached by 29.8% of the patients in dietary changes. Twenty-week dietary changes reduced weight by exercise and diet.

A study by Thomsen and Nilesh shows that after resistance training, regarding quality of life, the immunoglobulin (IG) improves pain and general health (P < 0.05). There is an increase in muscular strength, especially in biceps. Also the functional capacity was improved by resistance training.

A study by Lange and Uhlemann shows that in cryotherapy treatment, local and whole body cryotherapy was used to reduce pain and information shows that pain and inflammation activity score was significant (P < 0.05).


  Discussion Top


Psoriasis condition gets worse day by day and is becoming the major problem worldwide. Worldwide about 11.43% of the people are affected and psoriasis is becoming a serious global problem. When psoriasis condition gets worse, there are possible chances of arthritis.

This systematic review summarizes the current literature on physiotherapy practice in psoriatic arthritis. There is consistent evidence that weight management can improve skin condition in psoriasis; physical exercises, hydrotherapy, resistance exercises, aerobic exercises, and manual therapy will improve functional capacity, quality of life, and muscular strength. Hydrotherapy improves positive result in physical function, energy, sleep, cognitive function, ability to work in daily life. UV-B tends to clear psoriasis reliability.


  Physical therapy, exercise, and rehabilitation in psoriatic arthritis Top


Skin

In psoriatic arthritis, skin becomes itchy, pinkish-red with scaly plaques. Mostly involved areas are scalp, hands/feet, and genitals which have an important impact on quality of life.

In the studies of Paroutoglou et al.[15] and Fortes et al.,[16] it is suggested that bad lifestyle, for example, obesity due to unhealthy food, drinking, smoking, lack of sleep, and sedentary lifestyle, also worsens skin condition in psoriatic arthritis.

In studies by Stewart et al.[17] and Rousset and Halioua,[18] psychological stress is also responsible for worsening skin condition. About 31–88% of the studies reported that stress is a triggering factor for psoriasis. Stress management was also important to manage skin condition in psoriatic arthritis.

A study by Murray et al.[19] shows that there is correlation between BMI and extension of psoriatic arthritis, which concludes that obesity is also a well-known factor for worsening pain.

A study of Alotaibi[20] shows that increasing body weight is also one of the well-known factors of increasing skin psoriasis. Body weight management will improve the overall health of a person. Body weight management with the help of exercise could be important in the management of skin condition. By reducing body weight, reduced oxidative stresses will improve skin condition.

A study by Ko et al.[21] and Naldi et al.[22] was a randomized controlled trial in overweight and obese patients with psoriasis. They give 20 weeks of dietary plan with physical exercise for weight loss, which includes for weeks 1–12 they plan three main meals and maximum two snacks. Energy intake was set at 0.8 × resting metabolic rate. For weeks 13–20, they include 55% of carbohydrate, 30% of fat, and 15% of protein with 1.0× resting metabolic rate. Samples were instructed to perform 40 min of aerobic exercise. In aerobic exercise especially, they include walking exercise. Three times a week exercise was performed. Beneficial health effects can be obtained with the modest level of weight loss. Weight reduction goal is set up to 5% of total body weight. Outcome measure was recorded in 8, 16, and 20 weeks. Any percent of reduction of PASI score will be obtained. Some side effects of these studies due to reduction of calories include fatigue, nausea, and hunger. A study also shows that exercises, mostly walking exercises with dietary changes, will improve health and help to reduce scaly patches on skin. There is a positive impact of dietary and physiotherapy exercises in psoriatic arthritis.


  Joints and muscles Top


This literature review was aimed to identify a wide range of physiotherapy treatments in psoriatic arthritis. There is consistent evidence of physiotherapy for joints and muscles, which involves various approaches such as exercises, modalities, and rehabilitation. Modalities are mostly used to decrease pain. Thermotherapy, which includes cryotherapy and hot moisture pack, would reduce swelling and pain in hands and feet. Orthosis and splinting also reduce articular deformity.

A study by Thomsen et al.[23] concludes randomized controlled trials, which include inclusion criteria such as patients with psoriatic arthritis. Patients will perform high intensity interval training (HIIT) for 11 weeks, or a control group is instructed not to change their physical exercise habits. Intervention is given for 3 and 9 months’ period of time. With HIIT, the potential effect will sustain for a long period of time in psoriatic arthritis. The exercise intervention performed in HIIT is 10 min warm up, followed by 4 × 4 min exercise at 85–95% of maximum heart rate, with each 4 min period gap by 3 min of exercise at 70% of the maximum heart rate. HIIT does not show a clear effect on increased disease activity, but the intervention group reported less fatigue after the intervention period. HIIT exercises will improve physical activity and fatigue without deterioration of disease activity.

A study by Roger-Silva et al.[24] is to assess the effectiveness of resistance training in patients with psoriatic arthritis. Resistance exercise program in RCT with psoriatic arthritis patients is effective. The study is randomizing controlled trial with 41 patients between the age of 18 and 65 years, with diagnosis of psoriatic arthritis resistance exercise given twice a week for 12 weeks: Three sets of 12 repetitions twice a week for 12 weeks. Intensity of exercise is 60% of maximum repetition, and the interval between exercise is 1–2 min. The functional capacity is one maximum repetition test (1RM) for muscle strength. After completing 12 weeks’ protocol, there is improvement in muscular strength in almost all exercises, effective in improving functional capacity.

A study by Lindqvist and Gard[25] shows that physical therapy is an essential part of management of psoriatic arthritis. Group training and swimming are especially for axial disease. The study includes 10 participants: 8 are women and 2 are men with psoriatic arthritis diagnosed last one year at least. From 18 years onward, 10 or more sessions are required and the treatment period is not more than 3 months. Hydrotherapy is performed in warm water, i.e., 35% of warm water, with coach performing hydrotherapy with a physical therapist. Hydrotherapy is also beneficial in psoriatic arthritis; it will improve physical function, ability to work, energy, sleep, cognitive function, and participation in the activities of daily living. Hydrotherapy increases physical capacity by decreasing morning stiffness in general; decrease in pain during physical activity improves way of walking. Also a positive effect on pain is experienced. These positive effects of hydrotherapy last 2 months.

A study by Wollina et al.[2] shows that psoriatic arthritis is mostly seen in the adult age group. Joint affection can be monoarthritic, oligoarthritic, or polyarthritic. Polyarthritis is the most common arthritis in psoriasis, followed by oligoarthritis and arthritis mutilates. In these articles about kinesiotherapy, manual therapy, thermotherapy, cryotherapy, electrical stimulation, and ultrasound, massage therapy is useful in psoriatic arthritis.

A study by Harjacek et al. shows[26] that low level laser therapy (LLLT) and extracorporeal shock wave therapy (ESWT) show efficiency in enthesitis in patients with juvenile psoriatic arthritis. It promotes tissue healing increasing the formation of new vessels.

A study by Lange et al.[27] includes 10 patients with different rheumatic diseases (rheumatic arthritis, ankylosing spondylitis, and psoriatic arthritis). They undergo nine sessions of whole body cryotherapy for 5 days for short time period—at first 90 s and gradually increase by 2.5 min. Cryotherapy decreases pain and disease activity score.

Some drugs like adalimumab improve joint and skin manifestation,[28] with that treatment symptoms occur like co-morbidities, enthesitis, and pain, which will be managed by using balneotherapy in chronic inflammatory disease. It is beneficial to reduce pain and improve quality of life.[29]

Axial disease involvement in psoriasis arthritis is ankylosing spondylosis; the prevalence rate for axial involvement is 40–74%, which depends upon criteria for diagnosis.[30],[31] In psoriatic arthritis, enthesitis is hallmark.[32] The study shows beneficial effect of exercises in psoriatic arthritis],[ and it will improve quality of life.[33] One development and initial validation of the questionnaire to assess facilitators and barriers activity for patients with rheumatoid arthritis, axial spondyloarthritis, and/or psoriatic arthritis shows that there are three most reported categories of barriers, which were symptoms (8/100), beliefs, fear, and loss of motivation (7/10), and lack of support, exercise knowledge, confidence, and conflict in advice from health care (4/10).[34]

In psoriatic arthritis, patients can develop cardiovascular events during the course of their disease and can increase cardiovascular risk in psoriatic arthritis.[35],[36] Physical activity in psoriatic arthritis reduces chances of cardiovascular risk.[37]

Severe conditions of psoriatic arthritis may create complicated problems to the major joint of the body, mostly body weightbearing joint such as knee is mostly affected. Due to that, there may be chances of total knee replacement. In one thesis, it is reported that rehabilitation shows improvement in total knee replacement in psoriatic arthritis.[38]

Studies showing physiotherapy treatment in psoriatic arthritis are very less. There is need who shows more studies about physiotherapeutic treatment in psoriatic arthritis. Currently, very less studied are showing result about physiotherapy treatment in psoriatic arthritis. There is only one study on hydrotherapy treatment, resistance exercises, interferential therapy (IFT), and cryotherapy studies in psoriatic arthritis. In physiotherapy treatment, various modalities are used for pain relief, but there is only IFT study for pain management. More research is required for physiotherapy treatment, especially modality treatment.


  Conclusion Top


The systematic review has provided an overview of the various physiotherapy treatments patients undergoing in psoriatic arthritis. Evidence demonstrates the potential benefit in psoriatic arthritis by giving physiotherapy treatment and rehabilitation; there are very less articles on the physiotherapy effect on psoriasis arthritis. Patients functional and quality of life are impaired in psoriatic arthritis. It may involve co-morbidities such as obesity, musculoskeletal disease, cardiovascular disease, or fibromyalgia. This can improve benefits of non-pharmacological approach, such as aerobic exercise and cardiorespiratory exercise; low level laser therapy that increases self-repair activities of living tissues and also increases cell membrane permeability and metabolism; and education of patients will improve clinical conditions. There are very less articles on physiotherapy in psoriatic arthritis. There is only one article about hydrotherapy which shows positive effect for long term; it requires more study on hydrotherapy. Also there is only one article showing IFT positive effect, but other physiotherapy modalities can also show beneficial effect on psoriasis arthritis. There are various studies that are required on psoriatic arthritis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  References Top




 
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