rheumatoid hand

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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 andrarefaction 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), thedevelopment 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 withrheumatoid 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 makethe 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 manywomen 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;124:773-774

4. Arthritis Research Campaign (http://www.arc.org.uk)

5. Arthritis Care (http://www.arthritiscare.org.uk)



Disease Severity and Stages



Stage I Early Acute Inflammatory

• Joint swelling

• Heat

• Redness

• Severe pain

• Radiological Changes: osteoporosis may be

present



Stage II Moderate 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 III Severe destructive, Chronic Active

• Joint deformity with soft tissue involvement

• Radiological Changes: bone, joint and cartilage

destruction with osteoporosis



Stage IV Skeletal 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 bepresent:

– 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 hasmore 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 articularsurface 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 JointType 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 hyperextended

Unstable ulnar

collateral ligament

Not involved

Type V - Volar dislocation Not involved

Type VI

(Arthritis Mutilans)

Bone loss at any level Bone loss at any level 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



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 discomfort

2. 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 breaks

3. Avoid staying in one position for a long time.

4. Avoid rushing- plan ahead

5. 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

S li i f MP Ul D if d P l



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

S li ti f B t i



Splinting for Boutonniere

deformity:

• PIP joint in extension, DIP joint extension

block.

•

Many patients reject this splint during dailyactivities 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, oftencan 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



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 weightbearing 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 anddeformities.



THANK YOU

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