Physiotherapy Management of the Rheumatoid Hand

PT Management of Hand Deformities in Rheumatoid Arthritis

Definition:

• Rheumatoid arthritis a chronic systemic disease primarily of the joints, usually polyarticular, marked by inflammatory changes in the synovial membranes and articular structures and by atrophy and rarefaction of the bones. In late stages, deformity and ankylosis develop.

• Rheumatoid arthritis (RA) is a chronic autoimmune disease that causes inflammation and deformity of the joints. Other problems throughout the body (systemic problems) may also develop, including inflammation of blood vessels (vasculitis), the development of bumps (called rheumatoid nodules) in various parts of the body, lung disease, blood disorders, and weakening of the bones (osteoporosis). [1]

1. Rheumatoid arthritis; Dorland’s Medical Dictionary, 27th Edn

What are the Causes of RA?

• exact causes – unknown

• genetic susceptibility

• most likely triggered by a combination of factors, including an abnormal autoimmune response

• some environmental or biologic trigger, such as a viral infection or hormonal changes

The Immune Response and Inflammatory Process

• Two important components of the immune system - B cells and T cells belong to lymphocytes.

• T cell- recognizes an antigen as "non-self,“ produces chemicals (cytokines) -cause B cells to multiply and release immune proteins (antibodies).

• antibodies recognize foreign particles and trigger inflammation- rid the body of the invasion.

• For reasons still not completely understood, both the T cells and the B cells become overactive in patients with RA.

Genetic Factors

• Main genetic marker identified with rheumatoid arthritis is HLA

• HLA-DRB1 and HLA-DR4 alleles are referred to as the RA-shared epitope because of their association with rheumatoid arthritis

• These genetic factors do not cause RA, but they may make the disease more severe once it has developed.

Environmental Triggers• Traces of E. coli have appeared in the synovial fluid of

people with RA. • may stimulate the immune system to prolong RA once the disease has started

• Other potential triggers include:– Mycoplasma– Parvovirus B19– Retroviruses–Mycobacteria, and– Epstein-Barr virus.

Who is Affected? • RA affects over 21 million people worldwide [2]

• There are about 3 million people living with RA in Europe [3]

• RA affects 3 times as many women as men [4]

• It can affect people of all ages but it is most common in the 30-50 age range [5]

2. United Nations World Population Database, 2004 revision.3. Weinblatt ME. Rheumatoid arthritis: treat now, not later. Ann Intern Med 1996;124:773-7744. Arthritis Research Campaign (http://www.arc.org.uk)5. Arthritis Care (http://www.arthritiscare.org.uk)

Disease Severity and Stages

Stage IEarly Acute Inflammatory

• Joint swelling• Heat• Redness• Severe pain

• Radiological Changes: osteoporosis may be present

Stage IIModerate Subacute Proliferation

• Synovium begins to invade soft tissues, leading to decreased mobility

• Tenosynovitis• Less pain

• Radiological Changes: may show slight bone and cartilage destruction

Stage IIISevere destructive, Chronic Active

• Joint deformity with soft tissue involvement

• Radiological Changes: bone, joint and cartilage destruction with osteoporosis

Stage IVSkeletal Collapse and Deformity

• Joint disorganization • Severe deformity• Muscle contracture

• Radiological Changes: severe bone, joint, cartilage destruction with Joint instability, dislocation and joint fusion.

ACR Criteria for Diagnosis• Four or more of the following criteria must be present:– Morning stiffness > 1 hour– Arthritis of > 3 joint areas– Arthritis of hand joints (MCPs, PIPs, wrists)– Symmetric swelling (arthritis)– Serum rheumatoid factor– Rheumatoid nodules– Radiographic changes

• First four criteria must be present for 6 weeks or more

Radiological Studies

• Plain Films– Bilateral hands & feet– Only 25% of lesions– Less expensive– Osteoporosis detection– Deformities

• Color Doppler U/S & MRI– Early signs of damage i.e. Erosions– Bone Edema - even with normal findings on radiography

Hand Deformities in RA

Swan-neck Deformity

• Flexion of DIP joint, hyperextension of PIP joint

• Flexor tendon synovitis- leads to use of primarily the MP joint for digit flexion

• ‘Intrinsic plus type position’ during activities

Boutonniere Deformity

• PIP joint flexion and DIP joint hyperextension• Synovitis causes central tendon to become weakened, lengthened, disrupted from bony capsular attachment, allowing PIP to rest in flexion.

MP Joint Ulnar Deviation

• Ulnar deviation of MP joint- most common• If restraining system of tendons, ligaments and bones are affected by synovitis, the hand collapses into deformity, as the MP joint has more degree of mobility.

• Also called as Ulnar drift.

Volar subluxation of the Carpus on the Radius

Ligament laxity due to chronic synovitis at the wrist+

Natural volar tilt/displacement of distal articular surface of the Radius

Lead to volar-subluxation of Carpus on the radius

Distal Ulna dorsal subluxation

• Normally, distal ulna is more prominent on pronation and less prominent in supination.

Arthritic degeneration, leads to weakened ligamentous structures.

Dorsal prominence of distal ulna, pain, crepitations with pronation and supination

Carpal translocation and Wrist radial deviation

• Ulnar displacement of the proximal carpal row results in radial deviation of the hand

• Digits may be secondarily affected, and deviated ulnarly.

Thumb deformities [6]

• Type I (Boutonniere deformity)• Type II (uncommon)• Type III (Swan neck)• Type IV (Gamekeepers)• Type V• Type VI (Arthritis mutilans)

6. Nalebuff, Philips: The rheumatoid Thumb. In Hunter JM, Rehabilitation of the Hand: surgery and therapy. Ed 3, Philadelphia, 1990, Mosby.

Type CMC Joint

MP Joint IP Joint

Type I (boutonniere)

Not involved

Flexed Hyperextended

Type II (uncommon)

CMC flexed, adducted

Flexed Hyperextended

Type III(Swan neck)

CMC subluxed, flexed, adducted

Hyperextended

Flexed

Type IV(Gamekeeper’s)

CMC flexed, adducted

MP hyperextendedUnstable ulnar collateral ligament

Not involved

Type V - Volar dislocation

Not involved

Type VI(Arthritis Mutilans)

Bone loss at any level



Swan-neck Thumb

Gamekeeper’s thumb

Other Features:

Synovitis

• Stage I; Redness and heat at the joints may be apparent, with swelling and tenderness at the joints

• Later stages: less or no synovitis, more of structural changes

• On Observation: location of swelling and presence of deformities, helpful to determine stage of the disease

Nodules

• Rheumatoid nodules develop in 50% of RA patients.

• Nodules-made up of granulomatous and fibrous tissue, may or may not be painful.

• Should not be confused with ‘nodes’(DIP- Heberden’s, PIP- Bouchard’s)

Crepitus

• Grating/Crepitus- a crunching or popping sound on performing AROM.

• Can be indicative of a damaged cartilage.• Grind test- compression of joint, while gently rotating Metacarpal over the Carpal.

• Positive sign- pain and/or crepitus

Skin Condition

• Evaluate- color, temperature and noted areas of swelling

• Initial stage- skin is red and warm• Later stages- skin may be very thin and bruise easily.

Range of Motion

• Increased stiffness, often noted early in the morning.

• Loss of AROM can be caused by tendon rupture.

• EPL and ED tendons are particularly vulnerable.

Strength

• Joint instability- rather than weakness, usually is more of a problem during ADL.

• Even with a good muscle strength, patients will be unable to maintain a grip on an object if their joints collapse into deformities.

Pain

• Pain caused by acute inflammation in the early stages of the disease is usually greater than in the end stages.

• Rheumatoid nodules can be painful when palpated- important to evaluate and note.

May affect splint design or strap placement

Management of Hand deformities

1. Protection principles:

Respect pain:

1. Stop activities before the point of discomfort2. Decrease activities that cause pain that lasts

for more than 2 hours.3. Avoid activities that put strain on painful or

stiff joints.

Balance rest and activity:

1. Rest before exhaustion.2. Take frequent short breaks3. Avoid staying in one position for a long time.4. Avoid rushing- plan ahead5. Alternate heavy and light activities.

Exercise in pain-free range:

1. Initiate warm-water pool exercises.2. Exercise should be specific to each deformity.

Avoid position of deformity:

1. Avoid bent elbows, knees, hips, and back while sleeping.

2. Splinting

Use the larger joints

1. Use palms rather than fingers to lift or push.2. Carry a backpack instead of a hand-held

purse.3. Push swinging doors open with side of body

instead of hands.

Use adaptive aids

• Use jar openers, button hooks, etc., that are specific to each patient’s needs.


2. Splinting

Splinting for MP Ulnar Drift and Palmar subluxation

• Resting Splint.• Hand-based hinged MCP joint splint

Splinting for Swan-neck deformity:

• Prevent PIP joint hyperextension, yet alow for flexion

• Example: • High-temperature plastic custom splint• Oval 8 splint• Silver-ring splint.

High-temperature plastic custom splint

Oval 8 splint

Silver-ring splint

Splinting for Boutonniere deformity:

• PIP joint in extension, DIP joint extension block.

• Many patients reject this splint during daily activities as it limits the ability to flex the PIP joint.

• Examples:– Silver-ring splint (reverse).

Splint for Volar subluxation of Carpus on the Radius:

• Soft, fabric splint with a volar rigid bar is used.

Splint for distal Ulna Dorsal subluxation:

• Provide gentle ulnar-head depression, often can decrease pain and increase stability.

Splinting the Rheumatoid Thumb:


3. Modalities

• Reduce pain, encourage relaxation: – Superficial heating modalities.• Paraffin• Hot packs• Hydrotherapy• Electric mitts.

• Acute inflammation: cryotherapy


4. Exercises:

A.ROM

• To work within the comfortable ROM.• Wrist AROM• Gentle digit flexion and extension• Thumb opposition• Shoulder and Elbow ROM in supine• Pool exercises- to reduce strain on weight bearing joints and also for conditioning.

Strengtheninig

• Strenthening should be done with caution- to avoid aggravation of deformity


5. Remedies

• Nutritional supplements• Diet plan• Topical medication• Patient education on disease progression and deformities.

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Health & Medicine

Physiotherapy Management of the Rheumatoid Hand