Occupational Therapy: Therapist’s Management of Rheumatologic Disorders of the Hand



Occupational Therapy: Therapist’s Management of Rheumatologic Disorders of the Hand


Aviva Wolff



Rheumatic diseases such as rheumatoid arthritis, osteoarthritis, and post-traumatic arthritis commonly affect the small joints of the hand, wrist, elbow, and shoulder. With these pathologies, the intricate biomechanics of the hand is altered, and hand function is affected. Therefore, the prevention of hand deformities, and the preservation or restoration of hand function are fundamental components of the treatment process. The form of therapeutic intervention that is crafted depends on the specific pathology, the deformity with which each patient presents, and one’s goals and functional needs. Hand therapy intervention in rheumatic disease falls into one of two categories, conservative treatment and postoperative management. Surgical intervention to correct hand deformities is performed to relieve pain, correct deformity, and improve function. Postoperative management of common hand surgeries is specific to the operative procedure performed and is beyond the scope of this manual. Common upper extremity surgeries performed for rheumatic disease include arthroplasties, fusions, synovectomies, and correction of deformities. This chapter will focus on the conservative management of rheumatic conditions of the hand.


GOALS

Hand therapy intervention has evolved over the years to accommodate new research, ideas, and information. The primary goal is to facilitate the performance of activities of
daily living (ADL) by overcoming barriers. This is accomplished by maintaining or improving abilities and compensating for decreased ability. Therefore, the goals of conservative management are as follows:



  • Increase functional abilities.


  • Correct and maintain joint alignment to reduce progression of deformity.


  • Reduce joint stress.


  • Reduce stiffness, pain, and inflammation.


  • Increase joint range of motion.


ASSESSMENT

Hand assessment includes physical examination, evaluation of symptoms, and the assessment of function. The International Classification of Functioning, Disability and Health (ICF) defines function as the ability to perform tasks by participating in activities within the environment. In recent years, health care providers have placed a strong emphasis on a person’s ability to function within his or her environment. Hand therapists have always focused on ability to function within the environment, and the hand assessment reflects this emphasis.


I. Physical examination

involves a detailed assessment of the nature of the anatomical abnormality, such as swan neck deformity or ulnar drift. Photographs and video imaging provide visual representation of the structural changes in the hand. Although the assessment of the anatomical position is important, the evaluation of function is critical. Often, what appears as severe deformity is not accompanied by great loss of function.


II. EVALUATION OF SYMPTOMS

Physical impairment measures of grip and pinch strength, range of motion (goniometric measurements), edema (circumferential and volumetric), and pain (visual analog scale) are used to quantify symptoms of weakness, stiffness, swelling, and pain. Administration of measures follows the guidelines described in the American Society for Hand Therapist’s (ASHT’s) Clinical Assessment Recommendations manual. Specific attention is given to the following aspects when measuring range of motion in the joints of the hand: degree of hyperextension; degree of ulnar drift; composite joint motion; whether the neutral or anatomic position of the joint can be obtained; and, if it cannot be obtained, the number of degrees by which it cannot. Although these measurements provide some useful information in assessing physical changes in the hand, they do not accurately assess functional ability or quality of life. Clinical studies have proven that decreased function is associated more with pain and discomfort than with stiffness and decreased motion.


III. FUNCTIONAL ASSESSMENT

Standardized outcome measures have been developed for arthritic conditions to assess the combined measurements of range of motion, strength, and functional tasks. These are useful tools of assessment for hand-related function in ADL in patients with rheumatic disease. In recent years, several additional tests have been developed, which are self-administered and allow the patients to report on their level of function. These instruments are standardized, well validated, and provide quantitative information. Following is a brief description of performance-based measures that are available for the assessment of hand impairment in rheumatic conditions. These instruments are particularly valuable in establishing a baseline and documenting change. Selection of the appropriate instrument is based on the relevant clinical characteristics of the patient.



  • Selected objective tests for the assessment of hand function



    • Hand functional index (HFI). The HFI assesses the movement and malpositioning of the thumb, fingers, and wrist by movement tasks. Each hand is assessed separately. Nine different movement tasks are included. This test can be administered in less than 1 minute.


    • Arthritis hand function test (AHFT). The AHFT assesses hand strength and dexterity by measurements of strength and functional tasks. Both hands are assessed together. Components of the test include five bilateral dexterity tasks, two bilateral strength tasks, three measurements of strength (grip,
      two point pinch, and three point pinch), and one measurement of dexterity (nine hole peg test).


    • Sequential occupational dexterity assessment (SODA). The SODA is a dexterity test that was designed specifically for patients with rheumatoid arthritis to measure bimanual hand dexterity. The SODA combines objective assessment with a self-report component. Four unilateral and eight bilateral ADL tasks assess dexterity. Patients rate their perception of difficulty and pain with each task. Estimated time of completion is 20 minutes. A short version of six items is also available.


  • Self-reported performance-based measures

Jul 29, 2016 | Posted by in RHEUMATOLOGY | Comments Off on Occupational Therapy: Therapist’s Management of Rheumatologic Disorders of the Hand
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