|
 
 |
| CASE REPORT |
|
| Year : 2022 | Volume
: 10
| Issue : 3 | Page : 146-149 |
|
Post-viral polyarthritis: Case report
Rutuja Arulekar, Sandeep Babasaheb Shinde
Department of Musculoskeletal Sciences, Faculty of Physiotherapy, Krishna Institute of Medical Sciences “Deemed To Be University (KIMSDTU), Karad, Maharashtra, India
| Date of Submission | 25-Nov-2021 |
| Date of Decision | 23-Jul-2022 |
| Date of Acceptance | 06-Jun-2022 |
| Date of Web Publication | 21-Feb-2023 |
Correspondence Address:
Sandeep Babasaheb Shinde
Department of Musculoskeletal Sciences, Faculty of Physiotherapy, Krishna Institute of Medical Sciences “Deemed To Be University (KIMSDTU), Karad, Maharashtra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/DYPJ.DYPJ_66_21
Background: Viral infection is the infection caused by a virus in the human body. The immune response to a virus infection is attacking the body’s own cells. This causes stress and inflammation of tissues in the body and damage to the cells. Polyarthritis is one of the most common complications caused by viral infection. Post viral polyarthritis mainly affects the large joint such as the knee, but can affect several joints such as ankle, wrist. The full recovery time is still not sure, some studies have shown that it usually takes six weeks or it can even last for months or years. Case Description: A 15-year-old male complains of fever with dry cough for 2 days followed by Multiple joint pain and soft tissue pain since 2 months. Swelling was also noticed in both wrist and knee for a week. For assessment outcome measures like VAS, MMT, ROM were taken prior to the treatment. Patient underwent a 4 weeks physiotherapy rehab program and showed marked improvement in the pain, range of motion, muscle strength and functional activities. Result: When the post-assessment was done, patient showed significant improvement in the pain relief, showed improvement in range of motion of the joints, increase in the muscle strength and noticeable improvement in functional capacity. Conclusion: This concluded that starting physiotherapy management in the sub-acute stage of the condition is effective in reducing pain increasing mobility and increasing the strength and endurance. Keywords: Arthritis, case report, multiple joint pain, physiotherapy, Polyarthritis, viral infection
How to cite this article:
Arulekar R, Shinde SB. Post-viral polyarthritis: Case report. D Y Patil J Health Sci 2022;10:146-9 |
| Introduction | |  |
Viral infection is the infection caused by a virus in the human body. The virus which are freely circulating in the bloodstream are attacked by the immune system of the body which also attack the body’s own cells. This causes stress and inflammation of tissues in the body causing joint pain and swelling.[1] It is believed that these symptoms are caused by the early escape of the virus located inside the monocytes, with a consequent replacement within the synovial macrophages. This fact is documented by the observation of the persistence of the virus in muscle and joints.[2]
Studies say that viral arthritis peak incidence is in spring and winter seasons and is confirmed that it is a worldwide condition and not confined to any specific region of the world but depending on the virus it can vary. Common causative agents causing viral arthritis are parvovirus B19 which mostly affects young children, hepatitis B, HCV, HIV, alphavirus, HTLV-1 which is specifically found in Japan and Caribbean region.[3]
Even after the virus is not present in the body, it can continue to cause the pain and swelling.[1] Polyarthritis is one of the most common complications caused by viral infection. Main symptoms in the polyarthritis caused after virus infection is multiple joint pain, swelling, decreased strength in the muscles.[3] Post viral polyarthritis mainly affects the large joint such as the knee, but can affect several joints such as ankle, wrist and is accompanied by weight loss, fever, and swollen and/or warm joints.[5]
Arthritis is mainly divided into two categories that is inflammatory conditions and non-inflammatory conditions. The presence of joint swelling, erythema, prolonged morning stiffness (more than one hour), and symmetric pain even at rest tells us that it is inflammatory conditions.[4]
The duration of this post viral polyarthritis is still not certain, it can last for months or years too. The persistent symptoms may decrease with time. The full recovery time is still not sure, studies have shown that it usually takes six weeks for the symptoms to get completely vanished and does not leave any residual effect, and but some patients with osteoarthritis can still have the symptoms upto six to eight years after the infection, in which the polyarthritis considerably compromises the quality of life and functional capacity of the individual.[2]
Treatment for this condition is usually symptomatic as it is a self-limiting condition. along with the pharmacological treatment, physiotherapy treatment is also very important[6] Mainly in relation to the persistent arthritis (chronic), many individuals end up needing a physical therapy rehab program. Physical therapy management would help early recovery of those who are suffering from post-viral arthritis. The focus of the physiotherapeutic intervention is to decrease pain, regain functional capacity and, consequently, improve the quality of life.[2]
| Patient Presentation | | |
A 15 years old male who complains of fever with dry cough for 2 days followed by multiple joint pain and soft tissue pain since 2 months. Pain was sudden and dull aching in type. Swelling was also noticed in both wrist and knee joint for a week. No particular pattern of joint pain was noticed. Visual analog scale (VAS) was taken to check the pain intensity which was 9.2 Range of motion was assessed with a standardized Goniometer which was found to be in normal ranges for all the other joints except for wrist joint, metacarpophalangeal joint, knee and ankle joint. Wrist flexion (0–350) and wrist extension (0–400) ulnar deviation (0–10) radial deviation (0–5) MCP flexion (0–40) MCP extension (0–55) knee flexion (0–100) knee extension (100-0) ankle dorsiflexion (0–10) ankle plantarflexion (0–30) ankle eversion (0–10) ankle inversion (0–10). Manual muscle testing (MMT) for both wrist flexion and extension was found to be 3, elbow flexion was 4 and extension was 5. Knee flexion and extension both together were 4 and ankle dorsiflexion and plantar flexion were 4.
| Clinical Investigations | | |
Blood reports and urine tests were done which did not show any significant changes in the values. Erythrocyte sedimentation rate (ESR) and C-Reactive Protein (CRP) were also in the normal ranges. Rheumatoid factor and anti CCP (cyclic citrullinated peptide) antibody came negative. 2D echo was done to rule out Rheumatoid Heart Disease (RHD). Radio-graphic investigations also came out to be normal. Diagnostic measures did not give any significant relevance hence the patient was diagnosed with post viral poly-arthritis.
Drug history
Tab Azithromycin (dosage 1-0-1) for 4 days
Syp. Depura solution (once a week for 2 months)
Tab Solvin (dosage 1-0-1) for 10 days
Tab Myospas (dosage 1/2 - 1/2 - 1/2) for 10 days
Tab HCQS 200 mg (dosage 0-0-1) for 30 days
Tab Brufen (dosage 1-0-1) for one week
Tab Lanol ER (dosage 1-0-1) for one week
Along with the medications patient was also advised physiotherapy for the same.
| Clinical Examination | | |
Informed consent was taken from the patient before the treatment.
Pain assessment: Onset - sudden, Type - dull aching, Nature - continuous, Duration – acute, Site – knee joint, ankle joint, wrist joint and fingers. Visual analog scale (VAS) was taken which was 9.2. Aggravating factor - movement and doing something for longer period of time. Relieving factor – rest and medications.
Range of Motion (ROM): it was assessed with goniometer which showed full but painful range of motion of all the joints except for wrist joint, knee joint and ankle joint. Affected ranges for joints is shown in [Table 1].
Manual muscle testing (MMT): strength was assessed using manuals muscle testing and readings are mentioned in [Table 2].
Physiotherapy Intervention
Physiotherapy goals
- To reduce swelling at knee and wrist joint.
- To reduce pain for all the painful joints
- To increase the range of motion of the affected joint
- To maintain the range of motion of the unaffected joints
- To increase the strength of the muscles
- To increase the functional capacity
Treatment was started once the fever of the patient was subsided.
1–2 week
Educate the patient and the family members about the condition, prognosis of the condition and importance of physiotherapy in the respective condition.
Icing for 15 minutes was given for the swollen joints and reduction of pain
Hand pumps 10 times after every 3 hours to reduce the swelling with the help of gravity.
IFT (interferential therapy) for painful joints 15 minutes each.
Isometric exercises were started, 10 repetitions and 3 times a day.
Stretching was given to all joints 3 times each with 30 seconds hold.
Gentle mobilization grade 1 or 2 was given to the stiff joints.
General mobility exercises were given to all joints.
Grip strengthening was also started.
Brisk walking was advised daily for 15 minutes
Avoid heavy weight lifting and pushing activities.
2–4 weeks
Continue with the same protocol
Strengthening exercises with the help of theraband and dumbells were started.
Increase in the repetitions of general mobility exercises were given.
Brisk walking daily for 30 minutes.
| Result | | |
Assessment was taken 4 weeks after the treatment.
Patients VAS (visual analog scale) was 9.2 before starting the physiotherapy treatment and post treatment after 4 weeks it was 4.5.
Patient’s range of motion and muscle strength showed massive improvement after the 4 weeks physiotherapy treatment sessions as shown in [Table 3] and [Table 4] respectively.
This showed regular physiotherapy sessions which included proper symptomatic treatment and strengthening exercises helped the patient to improve the condition. Daily activities of the patient is all improved. To maintain the obtained results patient is advised to continue the physical activity even after the physical therapy treatment protocol is completed.
| Discussion | | |
The long-lasting polyarthritis associated to the functional limitation is often considered one of the main problems of viral infection. Patients affected with polyarthritis after the viral infection usually suffer with multiple joint pain which worsens on movement and usually at night. swelling, erythema and warmth over the joint surface occurs usually because of the inflammatory changes in the body due to the response of the immune system to the virus. These symptoms affect the daily life of the patient in many factors due to which patients end up needing physiotherapy to improve the pain relief, muscle strength and the quality of life.[2]
In this case, the present patient was having polyarthritis which was causing pain and affecting the activities of day-to-day life like holding phone for longer period of time writing for longer durations, or regular basic bed transfer activities. Patients’ social life was also affected like he was not able to go out with his friends or was not able to play football like before. It was also affecting the academics as long duration writing was affected, concentration was disturbed so focusing was difficult. Getting affected by such condition in this very small age also reduces the self-esteem of a person and can push the person into depression. There are strong evidences that a rehab program is not only based on just exercise protocol but motivation, encouragement and orientation to self-care which can help patient gain his self-confidence back. The results of the present study show that starting physiotherapy in the subacute stage of the condition shows positive influence on several aspects of a patient life. Physiotherapy treatment has shown marked improvement and helped the patient mainly in the reduction of the pain, increase in muscle strength, increase in the range of motion; reduction of edema and improvement of the functional capacity.
Another study which was done on a 35 years old female patient with persistent polyarthralgia after chikungunya fever. She complained of severe joint pain at knee, wrist and ankle joint. Outcome measures like VAS, ROM with goniometer, sphygmomanometer test, and perimetry for assessment were taken. After physiotherapy treatment significant changes were noticed in the ranges, pain and strength of the patient. This study also revealed that physiotherapy treatment is useful in treating persistent polyarthralgia after chikungunya fever which also improves the subjective pain and functional capacity.
The treatment program proposed in the present study can benefit patients with post viral polyarthritis after the viral infection, decreasing the pain perception, increasing muscle strength and improving the functional capacity. We would we recommend that patients with no pharmacological treatment must be considered just to check the effect of physiotherapy management.[7],[8]
| Conclusion | | |
The case study showed that together with pharmacological treatment, Physiotherapy management is also very important and effective in reducing pain, increasing mobility, increasing the strength, endurance and quality of life. It also helps in early recovery of the patient with post viral polyarthritis.
Financial support and sponsorship
Not applicable.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Thiyagarajan S Post viral arthralgia-an insight to the physiotherapist. J Nov Physiother 2016;6:100.  |
| 2. | Oliveira AD, Silva JG Effect of a physiotherapy program in patient with persistent polyarthralgia after chikungunya fever. Case report. Revista Dor 2017;18:370-3. |
| 3. | Marks M, Marks JL Viral arthritis. Clin Med (Lond) 2016;16:129-34. |
| 4. | Pujalte GG, Albano-Aluquin SA Differential diagnosis of polyarticular arthritis. Am Fam Physician 2015;92:35-41. |
| 5. | Jagtap CS, Shinde SB Estimation of musculoskeletal impairments in post chikungunya viral infection. J Evol Med Dent Sci 2020;9:953-7. |
| 6. | Vaishya R, Agarwal AK, Singh SK, Vijay V, Sardana R Polyarthralgia in a young woman. BMJ 2017;358:j3561. |
| 7. | Rahman MH, Islam N, Haque M, Hossain M, Kakuli SA, Rashif NR Effectiveness of physiotherapy treatment for post chikungunya arthralgia. Edorium J Pub Health 2017;4:69-75. |
| 8. | Sales GMPG, Barbosa ICP, Canejo Neta LMS, Melo PL, Leitão RA, Melo HMA Treatment of chikungunya chronic arthritis: A systematic review. Rev Assoc Med Bras (1992) 2018;64:63-70. |
[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4]
|
Search Pubmed for