Arthritis is the leading cause of disability in adults.
Conservative management requires an understanding of: The disease process, specific conditions, potential deformities, and the patient’s individual needs.
A comprehensive holistic examination assists the therapist in appropriate goal setting and treatment planning.
The goals of therapy are to reduce inflammation, decrease trauma to the joints, decrease pain, facilitate proper joint alignment, and improve function in activities of daily living.
Nearly one in five adults in the United States has arthritis, and this number is anticipated to increase 40% by 2030. It is the leading cause of disability in adults. Approximately 294,000 children in the United States have arthritis or another rheumatologic condition. More than 100 different conditions make up these rheumatic and musculoskeletal disorders. Those that more commonly affect the hand include rheumatoid arthritis (RA); juvenile rheumatoid arthritis (JRA); osteoarthritis (OA); systemic lupus erythematosus (SLE); psoriatic arthritis (PA); and scleroderma, or systemic sclerosis (SS). It is clear that with this level of prevalence, many therapists eventually find these patients on their caseload and need to understand the disease process, how it can affect activities of daily living (ADL), current research, and current practice.
RA affects all racial and ethnic groups worldwide, with current U.S. estimates at 1.3 million adults. It is a chronic systemic disease characterized by synovial inflammation, and it affects individuals of any age. Hand involvement may be an early clinical sign and can include joint swelling and inflammation of the proximal interphalangeal (PIP) joints, metacarpophalangeal (MCP) joints, and the wrists. Particularly important in the management of RA is an understanding of the stages of the disease process, as well as potential deformities that result from it. This knowledge helps to determine the appropriate treatment options ( Table 103-1 ). It is important to note that the patient may return to earlier stages during the clinical course of the disease and may have remissions and exacerbations as the disease progresses.
|Stage||Symptoms||Radiographic Changes||Orthotic Positioning|
|Joint swelling; heat, redness, and pain are most severe||No destructive changes, but osteoporosis may be present||Resting orthoses as needed for pain|
|Night orthoses in an attempt to prevent potential deformity and to decrease pain|
|Joint deformity and soft tissue involvement||Bone, joint, and cartilage destruction, with osteoporosis||Night orthoses and functional day orthoses|
|Joint disorganization and severe deformities||Severe bone, joint, and cartilage destruction with joint instability, dislocation, and/or fusion||Orthoses at this stage cannot reverse deformities, but may provide joint stability during activities and comfort at night|
During the acute phase, or stage I as classified by Steinbrocker and colleagues, the patient demonstrates joint swelling and inflammation that is warm when palpated. Most patients present with symmetrical joint involvement, with the PIP, MCP, and wrist joints commonly involved. This is the most painful phase when most patients seek medical care.
The subacute, or stage II, phase often is marked by a decrease in symptoms. The inflammatory synovium forms a pannus that extends beyond the cartilage and invades ligament attachments and tendons. This results in joint damage, weakening of the supporting soft tissues, and adhesions. Nodules may be evident at the joint bursa, or along the tendons. Joint range of motion (ROM) is usually less painful, and there are no obvious deformities.
The destructive, chronic-active, or stage III, phase often is demonstrated by the patient reporting less pain, but irreversible joint deformities have progressed.
Stage IV has been called the chronic-inactive, or skeletal collapse and deformity, phase. In the chronic stages joint involvement is often symmetrical and bilateral, but the dominant hand can be more severely affected. Joint deformities are significant and may include instability, dislocation, spontaneous fusion, and bony or fibrous ankylosis. These joint deformities and others are discussed later in the chapter.
Juvenile Rheumatoid Arthritis
JRA is one of the most common chronic diseases in children. It is defined as persistent synovitis in one or more joints in a child younger than 16 years of age with symptoms lasting more than 6 weeks. Diagnosis is often a frustrating experience for parents seeking answers to their child’s pain, as there are no specific diagnostic laboratory tests. There are three types of JRA, including (1) polyarticular (more than five joints involved), (2) pauciarticular (four or less joints involved), and (3) systemic disease (variable joint involvement with prominent extra-articular manifestations). The wrist and hand involvement varies greatly in these children depending on the type of JRA. Wrist flexion and wrist ulnar deviation is a common deformity. Interestingly, some of these children may demonstrate wrist ulnar deviation and MCP joint radial deviation, which is opposite that of the more common MCP joint ulnar deviation seen in adult RA. Other children may demonstrate similar deformities to those for adult-onset RA. Care must be taken to consider all potential deformities when treating these children.
OA affects more than 27 million Americans, most of whom are older than 45 years, and is the most common joint disorder throughout the world. Osteoarthritis is often called the wear-and-tear disease, but research demonstrates that the breakdown in the articular cartilage is due to mechanical, biochemical, and cellular factors. There is a genetic susceptibility, and OA occurs more frequently in women older than 50. In the upper extremity, the joints that are most symptomatic are the distal interphalangeal (DIP) joints and the first carpometacarpal (CMC) joint ( Fig. 103-1 ). In the lower extremities, the knees and hips are commonly affected. If the patient needs to use a walker or crutches due to lower extremity pain, this activity can put additional stress on the hands.
Systemic Lupus Erythematosus
SLE is one of the autoimmune connective tissue diseases characterized by inflammation, fatigue, and blood vessel abnormalities. In the United States it is estimated to affect 161,000 to 322,000 adults. Patients with SLE exhibit a characteristic rash, which can occur on the face (butterfly rash), between the interphalangeal (IP) joints of the digits, the trunk, and the upper extremities. There is also a tendency toward Raynaud’s phenomenon. The connective tissue involvement resembles RA in that it is symmetrical, with 10% developing nonerosive MCP joint ulnar deviation of the digits referred to as Jaccoud’s arthropathy.
PA is a condition that combines an inflammatory form of arthritis with psoriasis. Prevalence rates in the United States are estimated at 101 per 100,000. Clinically, PA may resemble RA but psoriatic skin lesions, nail changes (pitting), and DIP joint involvement assist in making the diagnosis. Moll and Wright categorized several clinical patterns of PA, which are outlined in Table 103-2 . Psoriasis precedes the arthritic symptoms in most of the cases. Some patients report a delay in obtaining a diagnosis that connects their psoriasis to psoriatic arthritis. A rare form of PA is arthritis mutilans, which can result in severe bone shortening and joint instability.
|Group I (Moll and Wright 1973)||Predominantly DIP Joint Involvement||Swelling of the DIP and Lifting of the Nail (Onycholysis)|
|Group II||Arthritis mutilans||Osteolysis (bone absorption) of the phalanges and metacarpals with shortening, telescoping of the digits, and instability|
|Group III||Symmetric polyarthritis||Similar to RA with the exception of a higher frequency of DIP joint involvement|
|Group IV||Oligoarticular arthritis|
|Group V||Axial involvement||Sacroiliitis and splondylitis|
Scleroderma, or Systemic Sclerosis
SS is an autoimmune disease characterized by degenerative, inflammatory, and fibrotic changes that affect multiple internal organs, muscles, joints, tendons, blood vessels, and the skin. Prevalence rates in the United States are currently estimated at 49,000. The first sign of progressive skin hardening or thickening is often noted at the digits. Ulcers can be evident at the PIP joints and at the tips of the digits. Hand deformities can progress to MCP joint extension with PIP and DIP joint flexion. Changes to the nail folds may include dilated capillary loops or small hemorrhages. The reader is referred to Chapter 111 , Chapter 112 for more complete information on this topic.
Examination includes inspection for the effects of the disease process on the arthritic hand and wrist with particular note made of joint deformities, skin condition, inflammation, and nodules and nodes. Also included is palpation to localize areas of tenderness and pain and to identify grating or crepitus; and an assessment of joint stability, ROM, and strength. Equally important is the assessment of how the arthritic condition has affected the individual’s occupational functioning. It is important to look at the client holistically and not just the hand in isolation when completing the examination.
Palpation and Skin Observation
Grating or crepitus evident with joint compression can be indicative of damaged cartilage. For example, the grind test at the CMC joint involves compressing the joint, while gently rotating the base of the metacarpal on the trapezium ( Fig. 103-2 ). Pain or crepitus at the CMC joint is generally considered a positive finding. Grating or crepitus during active range of motion (AROM) may be palpated or heard as a crunching or popping sound. Volar palpation of the flexor tendons at the A1 pulley while the patient flexes and extends the digits ( Fig. 103-3 ) may reveal tendon thickening, triggering, or periodic locking of the digit in flexion, which is indicative of flexor tenosynovitis. Examination of the skin’s condition should include color and temperature, and areas of swelling should be noted. Characteristic skin conditions vary with each condition and are outlined in Table 103-3 .
|Diagnosis||Common Skin Conditions||Treatment Considerations for the Hand|
|Systemic lupus erythematosus|
|Scleroderma||Initial edema that progresses to tight coarse thinning skin, fibrosis, loss of hair, reduced sweating, and digital ischemic ulcers|
Nodules and Nodes
Rheumatoid nodules develop in many patients with RA, and most commonly may be seen at the joints or along the tendons. The nodules may or may not be painful and are often largest near the elbow joint ( Fig. 103-4 ). Some patients report an abrupt appearance of nodules, whereas others have a more gradual onset. These nodules should not be confused with nodes, which are seen in OA due to a bony proliferation called osteophytes. This osteophyte formation at the DIP joint is called a Heberden’s node (see Fig. 103-1 ), and at the PIP joint it is called a Bouchard’s node. Patients can have RA in combination with degenerative joint disease, which explains the presence of these nodes in the RA population. Rheumatoid nodules can be painful when palpated and should be noted in the evaluation, as they may affect orthosis design or strap placement.
The presence of deformities should be documented and a notation made of whether the deformity is fixed or flexible and whether the deformity is accentuated during the performance of simple activities or whether the deformity prevents the activity. Chapter 102 includes a detailed description of common deformities in the arthritic hand and writst.
Pain is best measured with a 10-cm visual analog scale, with “0” being no pain and “10” being severe pain (see Chapter 16 ), to determine pain both at rest and with activities. Pain caused by acute inflammation in the early stages of the disease is usually greater than in the later stages. Pain from a nerve compression caused by synovitis also may be evident. Compression of the median nerve, or carpal tunnel syndrome , is one of the most commonly seen conditions at the wrist. The ulnar nerve can also be compressed at Guyon’s canal and at the cubital tunnel (see Chapter 11 , Chapter 47 , Chapter 48 , Chapter 49 , Chapter 50 , Chapter 51 , Chapter 52 ).
Range of Motion
AROM measurements of the arthritic hand vary. Increased stiffness or gelling, which is defined as difficulty in initiating joint motion after a period of inactivity, is often noted in the morning. Measurement of hand AROM has been shown to have poor reliability since measurements may vary by as much as 10 degrees with RA patients. Measurement of composite digit flexion, active digit extension, and thumb opposition often give more functional information. Passive range-of-motion (PROM) measurements using overpressure at the end of the available ROM are not recommended, especially if there is a lack of joint stability. However, it is important to note significant discrepancies between AROM and PROM at a joint or joints, which may indicate a tendon rupture or impending rupture.
Tendon ruptures cause loss of AROM in flexion or extension and occur secondary to attrition of the tendon as it glides over roughened and irregular bone areas. A lag is indicated when there is a discrepancy between AROM and PROM of the joint(s) that the tendon acts on. For example, in RA the extensor pollicis longus (EPL) and the extensor digitorum communis (EDC) tendons of the third, fourth, and fifth digits and the extensor digiti quinti (EDQ) are vulnerable to attritional rupture at the wrist level. The EPL can rupture at Lister’s tubercle on the dorsal aspect of the distal radius, and the EDC and EDQ can rupture over the distal end of the ulna. To test the EPL, the patient attempts to extend the thumb at all joints with the palm facing down; inability to fully extend the thumb through the available PROM may indicate a rupture or impending rupture of the EPL. To test the EDQ, the therapist should hold the MCP joints of the index, middle, and ring fingers in flexion and have the patient attempt isolated extension of the small finger. Inability to extend the small digit independently with no significant restriction in passive small finger extension may indicate a rupture of the EDQ. The patient often is unaware of this condition, but it should be brought to the attention of the hand surgeon and targeted for protection techniques in the therapy treatment plan.
The ROM of thumb pinch patterns should be evaluated and noted. Some patients are only able to complete a lateral pinch because of a pronation deformity of the index finger. Measurement of the degree of ulnar deviation at the MCP joints can provide helpful information for measuring progression of joint deformity. MCP joint ulnar deviation varies based on the MCP joint position (flexion or extension), and therefore the position of the MCP joint should be reported in combination with the ulnar drift measurement. This author recommends measuring ulnar deviation in the maximum available active MCP joint extension as this is the position commonly utilized in night positioning of the deformity.
Digit and thumb abduction should also be measured and can be especially limited in patients with SS. One method of measuring thumb and digit abduction is to trace on a piece of paper the hand with thumb and digits maximally abducted.
The stability of the MCP and IP joints of the digits are frequently compromised by the arthritic disease process. Stability of the IP joints is tested by stabilizing proximally and then attempting to tilt or glide the joint laterally. Instability is apparent by excessive lateral play. Testing of MCP joint stability requires that the joint be positioned in flexion during lateral stress testing because in this position the collateral ligaments are tightened and normally there should be little lateral play. Thumb stability is further evaluated by having the patient attempt a tip pinch. If the thumb MCP and IP joints are unable to maintain a near-neutral position during pinch, ligament stability is questioned.
Philips reports that a grip of 20 pounds is necessary for most daily activities. The standard Jamar hydraulic hand dynamometer (Patterson Medical/Sammons Preston, Bolingbrook, IL) has good reliability, but is often painful for the rheumatoid hand. Sphygmomanometers are more comfortable for these patients, and a study by Agnew has determined correlations between the two instruments. Pinch strength can be obtained with a pinch meter; however, some patients are unable to complete a tip pinch or a three-jaw chuck pinch, and therefore perform many daily tasks with a key or lateral pinch. Joint instability, rather than weakness, can be more problematic during activities of daily living (ADL). Even with good muscle strength, patients are unable to maintain a grip on an object if their joints collapse into deformities. Another common area of weakness in the rheumatoid hand is weakness of the first dorsal interosseous muscle. This can be tested by having the patient attempt to abduct the index digit actively against resistance ( Fig. 103-5 ) to determine the appropriate muscle grade.
Activities of Daily Living
Examination of the patient’s functional level begins as soon as the patient enters the therapy clinic. The speed with which the patient ambulates can give information about the level of pain and the extent of lower extremity involvement. Observation as the patient unbuttons and removes their coat and sits at a table can be invaluable in understanding his or her ability to pinch and grasp, complete simple functional activities, and use the hand for mobility (e.g., using crutches). It is important to gain an understanding of the patient’s home situation and support system when planning the treatment program and potential orthosis designs. For example, if the patient is unable to don an orthosis independently, a caregiver must be available to assist. The patient’s goals for therapy need to be evaluated carefully, to ensure that they are realistic. A patient diary, as described by Devore, can give insight into the needs of the patient and encourage active participation in the treatment process. The diary helps the patient determine his or her ADL problem areas, including which joints are involved and whether the joint difficulties result from pain, power, or position. The evaluation of ADL should include home, work, and avocational activities. Many patients seek treatment when meaningful work and avocational activities are threatened or limited.
The therapist’s management of arthritis is individualized and specific to the patient’s condition, deformity or potential deformity, stage of the disease, and ADL needs. The patient’s personal goals should also be considered in determining the treatment plan. Patient education about the disease and treatment options is critical in the treatment process. The goals of therapy are to reduce pain and inflammation and to preserve and improve function. Methods of treatment include custom-fabricated orthoses and positioning, carefully prescribed exercise, patient education in joint protection and energy conservation techniques, ADL training with the use of adaptive aids and techniques, and physical agents.
Orthotic positioning is commonly used in arthritic conditions to decrease inflammation and pain, to improve function, and to minimize deformity. Although evidence in the form of published clinical studies is limited, expert opinion and practice clearly supports the use of custom-fabricated orthoses for the arthritic hand and upper extremity. A study by Callinan and Mathiowetz found that arthritis pain was considerably less with night positioning. In severe flexion deformities, night orthoses may be used to gently position the digits in comfortable extension, which can facilitate morning hand hygiene. Simple stretch gloves have been found to be helpful in decreasing morning stiffness and pain. Wrist or digit orthoses may be used to enhance joint stability during ADLs and thus improve function.
Orthotic Positioning for Deformities
It is important to note that although lasting correction of a deformity or of the subluxed, dislocated, or malaligned joint is not possible with orthotic positioning, it frequently is possible to fabricate an orthosis that gently supports the joint(s) in a position opposite of the deformity, thereby reducing pain, improving function, and maintaining soft tissue length. Of course, any attempt to realign the joints should be done gently. Orthotic positioning for common arthritic wrist and hand deformities is discussed later. The reader is referred to Chapter 102 for a detailed description of the pathoanatomy and pathomechanics of these deformities.
A swan-neck deformity is characterized by flexion of the DIP joint and hyperextension of the PIP joint ( Fig. 103-6 ), and can be seen in RA and SLE. The swan-neck deformity can originate from abnormalities at the DIP, PIP, or the MCP joints (see Chapter 102 ).