Acute rheumatism—It’s problems and rehabilitation

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Acute Rheumatism—It’s Problems and Rehabilitation
By A. L. LOMEY , M.D., Ch.B., D .Phys. Med.(Rand)
Chief Specialist in Physical Medicine, General Hospital, Johannesburg, Head Sub-departments o f
Physiotherapy and Occupational Therapy, University o f the Witwatersrand, Johannesburg, South Africa.
September, 1961 PHYSIOTHERAPY Page 3
Acute rheu matis m, the sy non ym o f which is Rhe umatic
Fever, is an acute dise ase ch aracter ised by fever an d arth ritis,
with a special tendency to infla mm ation of the h eart valves
and hea rt muscle.
CONIC AL FEATU RES
Cause: The modern concept attributes the development
of rheumatic fever to a reaction on the pa rt of the patient
to a preceding infection with a haemolytic streptococcus of
the pharynx and the upper respiratory passages1.
Prevalence: The disease appears to be less com mon and
less severe than in the past, so much so that the present day
medical practitioner does no t often see a case2. The incidence
of sub-acute cases without a rthritis however, is probably not
less than formerly.
Amongst Bantu children in South Africa the disease is by
no means rare, and the impression gained is that it is as
frequent if not more so than in the European, and tha t it
occurs in a younger age group3. In 1956, 56 cases of rheu
matic fever and chorea were admitted to the children’s wards
at Baragwanath Hospital, and in 1958 the figure was 51.
With regard to the older age groups amongst the Bantu4,
of 1,100 cases of H eart disease adm itted to the medical
wards a t the same hospital in 1957, 246 were suffering from
rheumatic heart disease, so that acute rheumatism can be
considered a common disease in the African.
Race and Climate: All races are affected, but a tem perate
climate is more favourable.
Environmental Conditions: Adverse living conditions such
as overcrowding, poverty, exposure to cold and wet, favour
its occurrence or act as determining factors.
Age and Sex: It is essentially a disease of childhood, the
first attack usually occurring before the age o f 20 years,
although recurrences may take place well into middle life.
Males are more often affected in later years.
Heredity: It is not hereditary, although there is a here
ditary pre-disposition.
Recurrences: These are common and are due to sensitiza
ti on of the connective tissues of the body by a previous
ktreptococcal infection, e.g. from an inflamed tonsil. The
"disease can therefore be regarded as one o f the collagen
diseases5, and the characteristic pathological lesions, as
allergic responses to streptococcal infection. Once this
sensitization has occurred further streptococci will cause
further reactions and thus account for the occurrence and
frequency of the recurrent attacks.
Pathology: The essential lesion is characterized by an
exudation and proliferative process affecting a number of
tissues. In the heart the valves, particularly those of the
mitral, suffer an acute inflammation characterized by the
development at the edges of the cusps of minute pale vege
tations. Beneath the skin multiple discrete nodules the size
j pe^,are sornet*rnes found. These are called “Rheum atic
nodules” and consist of a fibrous matrix with an infiltration
of small round cells and larger mono-nuclear cells. They are
located most often over bony prominences, e.g. the wrists,
and knuckles, and are an indication o f severe infection,
accompanied almost always by cardiac involvement.
SY M PTOMS
Onset: This is usually abrupt and is ushered in with a
cnili and often w ith a sore throat and general malaise. A rise
in the temperature ranging between 102° and 104°F soon
occurs with an accompanying rise in the pulse rate.
Joints: Vague pains in the limbs are present at the onset,
soon however, pains in the joints develop, the larger joints
particularly the knees, ankles and wrists being the favourite
sites, the smaller joints usually rem aining unaffected. The
most characteristic feature o f the joint involvement is its
tendency to flit from joint to joint. An other is the fact that
the arthritis is always multiple. The joints themselves may
exhibit remarkably little evidence of involvement even in the
presence of the most acute pain, but some degree of swelling
due to an effusion of fluid, flushing of the over-lying skin,
and exacerbation of the pain of movement or palpation,
are fairly constant accom panying features present on
examination. Suppuration o f the fluid inside the joints
never occurs, but stiffness may ensure and may be trouble
some.
Skin: Sweating is usually profuse, the sweat having a
peculiar acid smell, and there may be an accompanying
diffuse erythema.
Heart: The heart is alm ost always affected, and it is this
which renders the disease so serious. In m ost cases some
degree of myocarditis is present, which m ay persist for
some time after the main symptoms o f the disease have
disappeared. In many cases signs o f definite endocarditis
affecting most commonly the mitral and less commonly
both the mitral and aortic valves, are also present. Peri
carditis too , may occur, particularly in severe cases, and in
recurrent attacks.
Blood: The blood shows a raised sedim entation rate, an
increased leucocyte count, and a moderate degree of hypo
chrom ic anaemia. The sedimentation rate parallels closely
the severity of the disease and is therefore of considerable
value in assessing progress.
Diagnosis: This is not difficult in the fully developed case,
but in the absence of noticeable arthritis as may happen
more especially in children, the diagnosis depends on the
development o f cardiac lesions. Generally the following
manifestations are helpful: carditis, polyarthritis, sub
cutaneous nodules, fever, raised sedimentation rate, positive
test for C-reactive protein, evidence of pre-existing heart
disease, or a history of past rheumatic fever. In children too,
the differentiation from acute osteomyelitis is important, as
an error may lead to serious consequences. T his can be
avoided if it is remembered that rheum atic fever should
never be diagnosed in a m ono-articular arthritis, that the
painful area in acute osteomyelitis is generally over the
lower end of the femur or tibia, and that this area is the
site of acute tenderness, and pitts on pressure.
Other conditions from which the disease may have to be
differentiated are other forms of arthritis, e.g. acute rheum a
toid arthritis, mono-articular or multiple arthritis occurring
in the course o f many diseases such as gonorrhoea, gout,
dysentry, pneum onia, etc. Pyrexia from other causes can be
differentiated by the absence of an adequate response to
full salicylate therapy.
Treatment: In view of the present concept that rheumatic
fever is an inflammation developing as a complication of
infection with H aemolytic streptococci, it is logical for
treatment to be directed at eradication of this organism.
The com mon practice therefore, is to begin treatm ent with a
course o f penicillin, employing large doses for a minimal
period of 10 days.
In order to suppress the inflamm atory process, such as
fever, tachycardia, joint pain, etc., two anti-inflammatory
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agents are employed, viz.: salicylates and steroids. The first
is the drug of choice, but the second has a place particularly
in patients with carditis. Sometimes both are used in com
bination.
There is no dou bt that absolute rest in bed is of the utmost
value as is careful nursing, in the warding off of the cardiac
affections so common in this disease. The rest prescribed
must be prolonged and thorough—several months being
often required in obvious cases of cardiac involvement.
For the sweating, when profuse nursing in between
blankets in preference to the usual sheets is advocated. A
flannel garment of ad equate length and with long sleeves is
also preferred for the same reason, and must be changed
as frequently as required.
The diet initially should be light, consisting largely of
milk and alkaline drinks. Later more substantial foods
including soup, oatm eal, jelly, fruit juice, etc. may be added.
Abundant fluid is allowed from the beginning to replace
that lost in the profuse sweats.
For the pain the additions of D over powder may be
necessary, and is often effective. The affected joints are sup
ported in the position o f most comfort, and the patient
himself is the best judge as to when and how much move
ment should be instituted—active movem ents being pre
ferred. Splints are often helpful in fixing the joints and giving
relief from pain, but in m ost cases wrapping the joints in
cotton wool held in place by a light bandage is sufficient
for this purpose.
It is important that the patient should be given plenty of
time to recover and convalescence should therefore be slow
and unhurried. Various forms of occupational therapy are
helpful to reconcile the child to prolonged periods of such
enforced rest.
Only when the acute inflammation has completely dis
appeared is physical treatment indicated. A table of gentle
movements for the affected joints is then instituted, this
being graduated carefully to avoid fatigue and over-strain.
Later still a course o f U.V.L. may prove beneficial and
aid recovery.
The Problems in Acute Rheumatism: In the m ain these
fall into two categories:
1. The prevention of the initial attack of rheumatic fever.
2. The prevention of recurrent attacks.
If both (1) a nd (2) above could be made more effective
the development of the serious and dangerous carditis so
comm on in the disease would cease to be a problem.
With regard to the first of these—all known or suspected
cases of streptococcal infection of the pharynx should be
treated by the administration of effective doses of penicillin
either by the oral or intra-muscular route. Sulphadiazine is
also effective, b ut it has been superceded by penicillin
because of the development of sulpha-resistant organisms,
and other disadvantages.
The prevention of recurrent attacks in patients who have
suffered previously from rheumatic fever also requires the
effective treatm ent o f streptococcal infection particularly
of the upper respiratory passages and pharynx6. Here too,
penicillin is the drug o f choice, and may be adm inistered
again by the oral o r intra-muscular route, whichever is
deemed perferable in any particu lar case. Th e dosage here
however, is much higher. Such prophylactic measures with
penicillin have to be continued for long periods o f time,
som e content permanently. Sulphadiazine given orally also
has a definite place in the treatment of these cases.
Rehabilitation in Acute Rheumatism: In general, such
patients are best advised to live in the country. They should
avoid any of the pre-disposing causes associated with the
disease such as maln utrition, cold and wet, overwork and
overcrowding.
As convalescence is necessarily so prolonged the establish
ment of special hospitals has been advocated to accommo
date long term cases for prolonged periods, such hospitals
to be conveniently situated, preferably also in the country.
Page 4 PHYSIOT
To meet the educational requirem ents of young patients
the provision of special schools and reasonable teaching
facilities follow as a necessity.
Follow ing recovery, a normal active life may be per
mitted, provided no cardiac lesion is present. In the presence
of such a lesion however, activity may have to be restricted,
bu t reasonable exercise within the patient’s tolerance is of
benefit.
Summary: A description of acute rheumatism is given.
This includes consideration o f the clinical features, diagnosis
and treatment. The problems to be faced in dealing with this
disease are discussed, and m ethods designed to alleviate
them detailed. Rehabilitation processes necessary to restore
these patients are briefly described.
I wish to express my sincere thanks to the following for
permission to publish this paper:
Dr. K . F. Mills, Superintendent, General Hospital,
Johannesburg.
Prof. J. H. Gear, Acting Head Dept, of Medicine, U ni
versity of the Witwatersrand, Johannesburg, South Africa.
RE FERE NCES
1. T albot, Jo hn H . and Lock ie, M axw ell, L. (1958),"
Progress in Arthritis, pp. 238-276, New York and London,
Gran e and Stratton.
2. Copem an, W. S. C. (1948). Textbook o f the Rheumatic
Diseases, p. 103, Edinburgh, E. and S. Livingston Ltd.
3. Ka hn , D r. E., Chief Paediatrician, Baragwanath
Hospital. Personal comm emoration.
4. Wilson , D r. V. H., Chief Physician, B aragw anath
Hospital. Personal commemoration.
5. Conybear, Sir J ohn and Ma nn, W. N. (1957).
A Testbook o f Medicine, 12th Edition, p. 62. Edinburgh and
London, E. and S. Livingstone Ltd.
6. British Medial Journal (1959), 5118, p. 351.
HERAPY September, 1961
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