fundamentals of hand therapy || arthritis

Arthritis is the leading cause of disability in the United States.1 More than 100 diseases and conditions fall into the category of rheumatic diseases.2 The most common, osteoarthritis (OA), affects nearly 27 million Americans over the age

of 253 and is the most common joint disorder throughout the world.4 OA is associated with a defective integrity of the articular cartilage and changes in the underlying bone.5 Rheumatoid arthritis (RA) affects more than 1.5 million Americans6 and is a chronic, systemic, inflammatory, autoimmune disorder.7 The inflammatory process associated with RA manifests itself primarily in the synovial tissue.8 In addition to RA and OA, the therapist also may treat other rheumatic diseases, such as systemic lupus erythema-tosus (a systemic autoimmune disease characterized by inflammation and blood vessel abnormalities), gout (a disorder caused by uric acid or urate crystal deposition), bursitis (inflammation of the bursa), and fibromyalgia (diffuse widespread pain often with spe-cific tender points). 2, 3, 7, 8 In the United States nearly 50 million adults over the age of 18 report being told by a physician that they have some form of arthritis, and over 21 million adults have activity limitations attributed to arthritis.9 Clearly, with this level of prevalence, many therapists at some time will find these clients on their caseload, or be questioned about arthritis by colleagues and family. The therapist must have an under-standing of the disease process, potential deformities, and how it can affect the clients’ activities of daily living (ADLs). Client education about the disease and awareness of treatment options are also critical aspects of the treatment process.

Osteoarthritis

Pathology

OA is often called the wear-and-tear disease, but research demonstrates that the breakdown in the articular cartilage is due to both mechanical and chemical factors.10 Changes in the articular cartilage and the subchondral bone result from the chondrocytes failing to main-tain the necessary balance of the extra cellular matrix.11-13 Complex biomechanical factors appear to activate the chondrocytes to produce degradative enzymes.14, 15 This degradation then corresponds to failure of the articular cartilage to act as a shock absorber, resulting in progression of the disease. Mechanical factors, such as abnormal loading of the joint from trauma, heavy labor, joint instability, and obesity, can increase the risk of OA.16 Aging is also a risk factor, because aging cartilage contains less water and fewer chondrocytes, decreasing the capacity of the cells to restore and maintain the cartilage.13 Clients from all corners of the world report similar patterns of joint involvement12 including the distal interphalangeal (DIP) joints (35%) and the carpometacarpal (CMC) joint of the thumb (21%).9, 17-19 In addition, 50% of patients with DIP involvement also have proximal interphalangeal (PIP) joint involvement.20 Affected persons have a genetic susceptibility, and OA occurs more frequently in women over age 50 than in men of the same age. 13,18

In addition to the cartilage breakdown, new bone formation (or osteophytosis) can occur, resulting in pain and limitations of joint movement. Osteophytes, or bone spurs, occurring at the metacarpophalangeal (MP) joints can contribute to triggering (limited digital range of motion [ROM] caused by dragging of the tendon as it passes through a pulley) of the flexor tendons,4 or locking (the digit locks into flexion as the tendon fails to pass through a pulley). Nodules can occur with OA at the PIP joint and are called Bouchard’s nodes, and at the DIP joint they are called Heberden’s nodes.13 Deformi-ties as a result of this arthritic process include a mallet finger deformity at the DIP joint and lateral deviation or boutonniére deformities at the PIP joint.18 The client may also demonstrate reduced ROM, pain, crepitus (grating or popping as the digit flexes and extends), and signs of inflammation.9 In the lower extremity, the knees and hips com-monly are affected.

33Jeanine Beasley

Arthritis

PART 3 Clinical Reasoning and Treatment Guidelines for Common Diagnoses of the Upper Extremity458

Precaution. If the client needs to use a walker or crutches because of lower extremity pain, this can put additional stress on the joints of the hands.

Timelines and Healing

Currently, no cure is available for OA. Treatment is based on the specific needs of each patient and the stage of the disease. In the early stage, radiology reveals a reduction in the joint-spaces and swelling of the periarticular tissues; the moderate stage demon-strates osteophytes, subchondral sclerosis, and cysts. In the late stage, bone erosion, subluxation, and fibrotic ankylosis are com-mon.18 Regarding postoperative care, the timelines follow the phases of wound healing. This includes the inflammatory phase during the first few days after surgery. Healing continues to the proliferative phase or fibroplasia, which often lasts from 4 days to approximately 3 weeks after surgery and is when the fibroblasts lay beds of collagen. During this stage, many of the postopera-tive protocols incorporate a balance between specific orthoses and gentle exercise. Finally, the remodeling phase or maturation phase occurs, which often begins 3 weeks after surgery and can last several years with gradual increase in the tensile strength of the collagen fibers.21

Evaluation

The evaluation should include an assessment of pain, active range of motion (AROM), joint stability, joint inflammation, palpation, and ability to do ADLs. Pain can be measured at rest and with activities with a 10 cm visual analog scale (VAS), with 0 being no pain and 10 being severe pain.22 I have observed clinically that many clients with arthritis tend to underestimate their pain. Document areas of inflammation by specifying which joints are involved. If the joint is warm and red, it may be in an acute inflammatory stage, and this should be noted. The evalua-tion of ADLs should include home, work, and leisure activities, because clients often seek help when their meaningful activities are threatened. Standardized tests, such as the Canadian Occu-pational Performance Measure (COPM)23 and Arthritis Impact Measurement Scales (AIMS) health status questionnaire,24 can be helpful in determining areas of ADL limitations and set-ting goals in collaboration with the patient. In regards to the evaluation of the basal joint of the thumb with OA, the Eaton classification has been widely used to define severity as well as guide treatment.25 The stages are highlighted in Table 33-1. It is important to note that treatment should be based on the sever-ity of the symptoms reported by the patient and not simply on the radiographic stage.26

Precaution. Passive range of motion (PROM) measurements usually are not recommended, especially if there is a lack of joint sta-bility. Do not apply passive stretch to an OA joint that lacks stability, because this can be injurious.

Evaluate thumb joint stability by having the client attempt a tip pinch. Ligament stability may be questioned if the thumb MP and interphalangeal (IP) joints are unable to maintain a near-neutral position during pinch. Assessing lateral joint sta-bility of the digits is important at the PIP and DIP joints. Test the involved joint by stabilizing the proximal phalanx and gently moving the distal phalanx laterally in each direction. A greater degree of joint play is evident when joint stability is decreased. Lateral deviation of the IP at rest should also be

noted if evident. Document fixed deformities that cannot be corrected passively when gently positioned by the therapist. Fixed joint deformities in OA can include DIP flexion or angulation, CMC adduction, and thumb MP joint extension or flexion.

Grating or crepitus evident at a joint can indicate damaged cartilage. The grind test for degenerative joint disease at the CMC joint involves compressing the joint while gently rotating the head of the metacarpal on the trapezium27 (Fig. 33-1). Pain and crepitus at the CMC joint generally are considered positive findings.

Non-Operative Treatment

Non-operative treatment begins with a complete evaluation to determine the client’s specific needs. Treatment can include joint protection principles, modalities, exercise, orthoses, and adaptive equipment as outlined subsequently.

TABLE 33-1 Eaton Radiographic Classification for Staging Basal Joint Arthritis

Eaton Stage Radiograph

Stage I Normal appearance of articular surface and slight joint space widening.

Stage II Minimal sclerotic changes of subchondral bone with osteophytes and loose bodies less than 2 mm.

Stage III Trapeziometacarpal joint space markedly nar-rowed and cystic changes present. Subluxation of the metacarpal may have occurred. Osteo-phytes and loose bodies greater than 2 mm.

Stage IV Presence of scaphotrapezial joint disease with narrowing.

From Eaton RG, Glickel SZ: Trapeziometacarpal osteoarthritis. Staging as a rationale for treatment, Hand Clin 3(4):455-471, 1987.

FIGURE 33-1 The grind test as described by Swanson27 for crepitus at the carpometacarpal (CMC) joint involves compressing the joint while gently rotating the metacarpal at the CMC joint. (From Beasley J: Therapist’s examination and conservative management of arthritis of the upper extremity. In Skirven TM, Osterman AL, Fedorczyk JM, et al, editors: Rehabilitation of the hand and upper extremity, ed 6, St Louis, 2011, Elsevier, p. 1332.)

Arthritis CHAPTER 33 459

General Joint Protection PrinciplesJoint protection principles ideally are initiated early in the disease process in hope of decreasing stress and damage to the involved joints.28-30 This is completed through altered work methods to educate the client on proper joint alignment and the use of adap-tive equipment. Joint protection for OA should also take into account the specific deformity or potential deformity, which may include instability of the CMC joint and the deformities of the involved IP joints.29, 30 Common joint protection principles for both OA and RA are categorized by themes in Fig. 33-2. Because excessive pinching during ADL imparts large forces to the unsta-ble thumb CMC joint, educating patients in techniques that decrease pressure and force applied to the thumb CMC joint is important.31 There is moderate evidence to support joint pro-tection education and adaptive equipment for increased hand function and pain reduction in patients with OA.32 The Euro-pean League Against Rheumatism (EULAR)33 in their systematic

review recommended joint protection education combined with an exercise regimen for all patients with hand OA. Another sys-tematic review found moderate evidence to support combining joint protection with adaptive device provision for increased hand function and pain reduction.32 Adaptive equipment used in one study included enlarged writing grips, Dycem, an angled knife, a book holder, and other equipment based on the client’s ADL34 and resulted in improvements in grip strength and global hand function. Adaptive equipment that can help to increase leverage and also distribute the pressure in the hand includes larger-diameter pens, broad key holders, large plastic tabs on medicine bottles, and car door openers. As handle diameter increases, reduced digit force on a tool is needed. Basic science in tool design has developed in the engineering fields to accurately measure these forces. It is reported that in normal hands, the most comfortable handle is 19.7% of the user’s hand length35 and that the ideal tool handle design is a cylinder with a 33-mm

General Joint Protection Principles

Respect Pain Balance Rest and Activity

Exercise in a Pain Free Range

Avoid Positions of Deformity

Reduce the Effort and Force

Stop activities before the point

of discomfort

Decrease activitiesthat result in painlasting more than

1-2 hours

Avoid activities that put strain on

painful or stiff joints

Rest before exhaustion

Take frequent short breaks

Avoid activities that cannot be

stopped

Avoid staying in one position for

along time

Alternate heavy and light activities

Take more breakswhen inflammation

is active

Allow extra time for activities, avoid rushing

Wrist splints maydecrease pain

during activitieswith RA

Maintain muscle strength

Maintain joint ROM

Initiate warm water pool

exercise programs

Exercises are specific to each

potential deformity

AROM without pain

Use stable joint positions

Avoid bentelbows, knees,hips, and backwhile sleeping

Practice good posture during

the day

Use proper work heights

Avoid excessive loads with carts

Ask for help

Use appliances and assistive

devices

Keep items near where they are

used for easy flow

UseLarger/Stronger

Joints

Slide heavy objects on

kitchen counters

Use palms instead of fingers

to lift or push

Carry a backpack instead of a

handheld purse

Keep packages close to the body-

use two hands

Plan your day ahead of time

Eliminate unnecessary

activities

Use preparedfoods and freezeleftovers for an

easy meal

Avoid low chairs

Maintain proper body weight

Reduce trips upand down stairs-

complete work oneach floor

Use other parts ofthe body (example:foot pedal on trash

can)

Push doors openwith side of body

instead of thehands

Use energyconservationprinciples to

manage fatigue

Specific to each potential deformity

Thumb CMC splints may

decrease pain

FIGURE 33-2 Overview of joint protection principles. (Based on concepts by Cordery;29 Melvin;39 Meenan, et al.;24 and Hammond, et al.85 The concepts have been grouped into themes by this author. Chart is used with permission from Beasley J: Osteoarthritis and rheumatoid arthritis, J Hand Ther. 25(2):163-172, 2012.)


diameter.36 It has also been determined that to decrease the maxi-mum push pull force on a tool, a cylindrical handle must be parallel to the push/pull direction.37 It has also been reported that a handle design that reduces wrist ulnar deviation requires the least amount of grip force.38 Additional joint protection techniques include moving objects out of the hand (for example, using a shoulder strap tote bag instead of a brief case with a handle) to help distribute the pressure to larger joints when car-ried closer to the body. 28 Clients often place strong forces on the hands when lifting themselves from one position to another. In some cases, adaptive equipment can reduce the effort on the lower extremities (such as, a lift chair, a shower chair, or elevated toilet seat) by reducing the stress placed on the hands.

The therapist should also take into consideration the client’s sociocultural context. The client may or may not have insurance coverage or finances for adaptive equipment or orthoses. Care-fully discuss options with the client and weigh them in terms of cost versus value in meeting the client’s specific needs. The therapist should be aware of community resources, including civic, community, or religious organizations that may provide adaptive equipment (for example, grab bars and elevated toilet seats) for specific socioeconomic situations. For further informa-tion on joint protection, the reader is encouraged to review the work Adult Rheumatic Diseases (2000), by Melvin and Ferrel.39

ModalitiesModalities have a long history of use in the treatment of arthri-tis. Many patients with OA report beginning their day with a warm shower or bath as increased tissue temperatures result in temporary neuromuscular effects that decrease pain and muscle tension.40 Types of superficial heating agents include paraffin, Fluidotherapy, hot packs, microwave packs, hydrotherapy, and electric mitts. Decreasing pain and maintaining or improv-ing ROM is a primary goal in the application of these agents. Research continues to add to the body of knowledge concerning heat and other modalities for OA, including non-thermal ultra-sound, electrotherapy, cryotherapy, and low level laser therapy. 41 A systematic review by Zwang, et al.33 examined the benefits of heat and ultrasound and found predominantly only level IV evi-dence (expert opinion). According to the review by Valdes and Marik,32 there is weak to moderate level evidence supporting the use of heat modalities in decreasing pain and improving grip strength in patients with OA, and low level laser therapy was no better than the placebo.

Precaution. When clients benefit from superficial heat modali-ties and use them in their home exercise program (HEP), the thera-pist must instruct them carefully to avoid the possibility of burns.

ExerciseGeneral principles of exercise include avoiding painful AROM and PROM by working within the client’s comfort level. General AROM exercises for the hand include wrist flexion and exten-sion, gentle digit flexion and extension, and thumb opposition. There is moderate evidence to support hand exercises in OA for increasing grip strength, improving function, improving ROM, and pain reduction.32 Combining joint protection and pain-free hand home exercises were found to be an effective means to increase hand function, as measured by grip strength and self-reported global functioning in persons with hand OA.42 Exercise programs that utilize AROM as opposed to pinch strengthen-ing 32,43 were found to be more effective. One study that used

resistive pinch strengthening resulted in some of the participants leaving the study due to increased hand symptoms.44 For exam-ple, even light putty-pinching exercises impart large forces31 to an unstable CMC joint that may aggravate a potential deformity. Stability must not be sacrificed for a possible increase in strength. A stable pain-free thumb provides a post against which the dig-its can grip and pinch effectively. Stretching and massage of the first web space may help prevent the adduction contracture and subsequent MP hyperextension deformity.45 Thumb web space stretching or widening can be done by having the client grasp a one inch wooden dowel (Fig. 33-3) as part of the HEP, as well as techniques to relax the adductor pollicis (AP). Anatomically, strengthening the first dorsal interosseous may help provide sta-bility to the base of the CMC, because it originates at the base of the first metacarpal.45 In regards to the tendons, grip strength-ening is a common example of an exercise that can aggravate inflamed flexor tendons. A digit that is triggering or locking will not be improved with grip strengthening exercises, which can increase these symptoms.

Precaution. Therapy exercises should never create deforming forces or cause pain in the osteoarthritic client.

Research on overall body conditioning has been reported to result in decreased pain and increased static and dynamic grip strength.46 A study on low impact general conditioning dem-onstrated increased aerobic capacity, decreased depression, and decreased anxiety in patients with arthritis.47

Precaution. Keep ROM exercises pain-free to prevent stretching of joint structures. Use strengthening programs for the osteoarthritic hand with caution to avoid aggravation of deformities.

The Thumb

OA can affect all of the joints of the thumb with a swan neck deformity as one of the most common. It is often characterized at the CMC joint by metacarpal adduction and subluxation from the trapezium, MP joint hyperextension, and IP joint flex-ion (Fig. 33-4). Pinch is often painful because the CMC sublux-ation becomes more pronounced during heavy pinch activities.

FIGURE 33-3 Stretching and massage of the first web space may help prevent the adduction contracture and subsequent MP hyper-extension deformity.45 Thumb web space stretching or widening can be done by having the client grasp a 1-inch wooden dowel as part of the home exercise program (HEP).


The thumb IP joint sometimes assumes a flexed position. The Eaton classification has been widely used to define severity and guide treatment of this deformity through radiographs.25 The Eaton stages are highlighted in Table 33-1.When evaluating the thumb, determine the specific pattern of deformity so that treatment can be more specific in terms of orthotic support and therapeutic management.

Diagnosis-Specific Information that Affects Clinical Reasoning

If the orthosis fits well, the client will report decreased pain with pinch activities, because it is stabilizing the CMC joint in the proper position. Radiographs during active pinch can verify that the orthosis is properly maintaining the metacarpal on the trapezium.49

FIGURE 33-4 The type III thumb deformity involves subluxation of the carpometacarpal (CMC) joint, metacarpophalangeal (MP) joint hyperextension, and distal joint flexion. (From Terrono AL, Nalebuff EA, Phillips CA: The rheumatoid thumb. In Skirven TM, Osterman AL, Fedorczyk JM, et al, editors: Rehabilitation of the hand and upper extrem-ity, ed 6, St Louis, 2011, Elsevier, p. 1347.)

• What joints of the thumb are involved (as seen on theradiographs)?

• Istherealsojointinvolvementofthewrist?• Istheclientusinganymedicationsforthiscondition?

Questions to Discuss with the Physician

About the Condition“Here is a picture (radiograph) of a thumb with osteoarthritis. The problem often starts at this joint (the carpometacarpal). With wearing down of the cartilage and weakening of the joint ligaments and capsule, this joint has a tendency to dislocate or slide out of place. Over time, this results in a thumb that has difficulty abducting or moving away from the palm of the hand (at the carpometacarpal). The next joint of the thumb (metacar-pophalangeal) then has to do extra work, and it often stretches out and hyperextends.”

About Orthoses“We are going to try a couple of splints that may help to give the thumb some stability. We have several options, but we need to see what works best for you and your activities of daily living. Some people like one type of splint for night wear and a less restrictive splint for day wear.”

About Exercise“Heavy pinch activities and exercises put a lot of stress on this (the carpometacarpal) joint and can decrease joint stability. It is important that your hand exercises be pain-free. Exercises

What to Say to Clients

that can be helpful include a gentle stretching of the first web space (adductor pollicis) with massage, as well grasping a 1-inch dowel to gently wedge the web space. Strengthening the muscle (the first dorsal interossius) on the side of your index finger may help stabilize the base of your thumb. Pushing a glass sideways with your index finger (Fig. 33-5) with your hand stabilized is a nice way to activate this muscle. For your general conditioning, warm-water pool exercises may be helpful in managing your osteoarthritis.”

FIGURE 33-5 Having the patient push a glass with the index digit while the rest of the hand is stabilized can help strengthen the first dorsal interosseous muscle.

• Determinewhetherthethumbdeformityispassivelycorrectable. This involves gentle positioning opposite of the deformity; gently stabilize the base of the metacarpal on the trapezium, place the CMC in abduction and the MP in flexion (Fig. 33-6). This is the proper position for the orthosis.

• Determinehowthediseaseprocessisaffectingtheclient’s ADL and what the client is seeking regarding therapy. This allows you to determine whether the client will be compliant with the program.

Evaluation Tips

If the thumb deformity is not passively correctable, the orthosis can help provide support but cannot change the deformity.

Clinical Pearl


FIGURE 33-6 When the thumb deformity is passively correctable, the placement of the therapist’s hands often determines the forces that are needed to apply the orthosis correctly. (Concept courtesy of Judy Leonard, OTR, CHT. From Beasley J: Soft orthoses: indications and techniques. In Skirven TM, Osterman AL, Fedorczyk JM, et al, editors: Rehabilitation of the hand and upper extremity, ed 6, St Louis, 2011, Elsevier, p. 1614.)

FIGURE 33-7 The hand-based thumb spica orthosis for deformities that are passively correctable can help decrease pain. The orthosis places the metacarpal in gentle palmar abduction and the metacar-pophalangeal (MP) joint in slight flexion. The wrist strap gives the splint additional stability to stabilize the carpometacarpal (CMC) joint. (From Beasley J: Therapist’s examination and conservative man-agement of arthritis of the upper extremity. In Skirven TM, Osterman AL, Fedorczyk JM, et al, editors: Rehabilitation of the hand and upper extremity, ed 6, St Louis, 2011, Elsevier, p. 1339.)

FIGURE 33-8 Comfort Cool Thumb CMC restriction orthosis has an additional strap to support and gently compress the CMC joint. The splint also gently positions the metacarpal in abduction. (Photo and splint courtesy of North Coast Medical, Inc., Morgan Hill, CA. From Beasley J: Soft orthoses: indications and techniques. In Skirven TM, Osterman AL, Fedorczyk JM, et al, editors: Rehabilitation of the hand and upper extremity, ed 6, St Louis, 2011, Elsevier, p. 1614.)

The therapist has several choices when selecting the proper orthosis for the client. The orthosis can be custom fabricated of lightweight thermoplastics, or in some cases a soft material (for example, Neoprene) can be used, if the strapping is applied properly, to counteract the deforming forces (Fig. 33-7 through Fig. 33-9). There are also several prefabricated options available. This author has had good client acceptance and reported pain reduction with both the neoprene Comfort Cool Thumb CMC Restriction Splints (see Fig. 33-8) (available from North Coast Medical) and The Push MetaGrip (see Fig. 33-9) (available from HandLab). This acceptance is due to decreased pain and increased joint stability when using their properly fitted orthoses during pinching activities. Clients often misinterpret this as an increase in strength. A stable, pain-free thumb is important to hand function and provides a post to which the digits can grip and pinch effectively.

In some cases, the client has a large thumb IP joint that makes donning and removing the orthosis difficult. The or-thosis must be large enough to fit over this joint while provid-ing support to the proximal phalanx. One easy way to enlarge the orthosis thumbhole when it is nearly cool is to remove the orthosis from the client and then insert a closed scissors into the thumb portion of the splint and gently open the scissors (Fig. 33-10). Another technique is to pry open the seam that would be supporting the proximal phalanx after the orthosis has cooled. The unsecured seam then can be expanded partially when the orthosis is applied and secured with a Velcro® strap. An additional solution is an orthosis that does not include the MP or has a dorsal proximal phalanx flap (Fig. 33-11) to help

Tips from the Field

position the MP joint in flexion as described by Colditz.50 If the joints proximal to the trapezium are also involved, such as the scaphoid and trapezoid (this is referred to as pantrapezial arthritis), the orthosis may need to incorporate the wrist,51 requiring a forearm-based thumb spica orthosis (Fig. 33-12).


Operative Treatment

Therapy after Carpometacarpal Interposition Arthroplasty

CMC interposition arthroplasty involves resection of CMC joint that then allows the metacarpal to return to an abducted position.48 A donor tendon is rolled up and inter-positioned in

The client usually responds favorably to wearing the orthosis if it is comfortable and fits correctly. Many clients wear the soft orthosis during the day and the more rigid orthosis at night.49 Other clients feel that the rigid splint supports the thumb more completely, reporting decreased pain and rejecting the soft orthosis. In cases of bilateral involvement, only one rigid orthosis should be fabricated at the first visit to determine how the client responds. This assists the therapist in the decision making pro-cess. Once the client has decided on an orthosis for one hand, the client will have a preference for the other hand.

FIGURE 33-9 The Push MetaGrip from HandLab supports the carpometacarpal (CMC) with an imbedded contoured metal insert that assists in stabilizing the metacarpal on the trapezium.

FIGURE 33-10 One easy way to enlarge the orthotic thumbhole, when it is nearly cool, is to insert a closed scissors into the thumb portion of the orthosis and gently open the scissors.

FIGURE 33-11 This orthosis designed by Judy Colditz for carpo-metacarpal (CMC) joint subluxation has a metacarpophalangeal (MP) block to prevent MP hyperextension. This orthosis makes donning and doffing easier when there is a large thumb interphalangeal (IP) joint. (From Colditz J: Anatomic considerations for splinting the thumb. In Mackin EJ, Callahan AD, Skirven TM, et al, editors: Rehabilitation of the hand and upper extremity, ed 5, St Louis, 2002, Mosby, p.1870.)

FIGURE 33-12 A thumb spica orthosis for use when the arthritic process also involves the wrist.

• Themost troubling possible problemwith any orthosis is thedevelopment of pressure areas. The client should return for at least one follow-up visit to make any necessary orthotic adjustments.

• Remember,anorthosisthatiscleanisnotbeingworn.Usually,a clean orthosis is one that is uncomfortable to wear and needs adjustment. Some clients hesitate to ask for orthotic adjustment for fear of offending their therapist.

Precautions and Concerns


the joint space. The ligaments are usually reconstructed and help to provide the CMC joint stability. Hyperextension of the MP joint may be corrected as well. In most cases the client is in a cast for 4 to 6 weeks and then is referred for an orthosis. The postoperative course varies from surgeon to surgeon. When the surgeon allows CMC AROM, it is important to help the client learn how to move it properly. Frequently, these clients have been compensating before surgery by only moving their thumb IP and MP joints. One exercise technique for this is to have the client flex the thumb IP and MP joints (and try to keep them flexed) while moving the CMC joint in gentle flexion and exten-sion (Fig. 33-13). Techniques to restore the thumb web space and strengthen the first dorsal interosseous (see Fig. 33-5) may also be helpful in the promotion of CMC stability.45 The postoperative orthosis may be worn anywhere from 6 to 12 weeks from the date of surgery depending on the preferences and protocols of individual surgeons.

Precaution. Many surgeons recommend waiting at least 3 months before any heavy pinching activities are allowed.

A B

FIGURE 33-13 Clients with carpometacarpal (CMC) osteoarthritis (OA) have often been compensating before surgery by only moving their thumb IP and MP joints. One exercise technique for this is to have the client flex the thumb IP and MP joints (A) (and try to keep them flexed) while moving the CMC joint in gentle flexion and extension (B).

• May we see the client while they are still in the cast forthumb IP, digit, elbow, and shoulder AROM, as well as edema management?

• Whenwillthecastberemoved?• Atthetimeofcastremoval,shouldweapplyahand-based

or forearm-based orthosis?• AtwhatpointmaywebegingentleAROMof theCMC

joint?• Atwhatpointmaywediscontinuetheorthosis?• How longwould you prefer thatwe have the clientwait

before doing heavy pinch ADL?


About the Condition“The surgery helped to correct the joint deformities you were having as a result of your osteoarthritis. The two little scars on your arm (or leg) are due to the retrieval of the donor tendon graft. The tendon was rolled up and placed in the joint between the trimmed bones.”


About the Orthosis“Now that your cast has been removed (4 to 6 weeks after surgery), we need to make you an orthosis to maintain the proper position and stability of the joint that has been recon-structed. To get the best result, we need to maintain a good balance between mobility and stability. You will need to wear your new orthosis between exercise sessions and at night until discontinued by your surgeon. It is important that your orthosis be comfortable and not cause any pressure areas.”

About Exercise“When it is approved by your surgeon, we will start gentle exercises of your new carpometacarpal joint. It is a joint that you have not moved in a long time. Before the surgery, you mainly moved the end and middle joints of your thumb. We will begin by gently trying to touch the tip of each finger and move your thumb in a small circle. I will show you an exercise where you try to keep your thumb end (interphalangeal) and middle joint (metacarpophalangeal) bent while you try to move the base of your thumb in and then away from your hand (carpometacarpal flexion, extension, and abduction) (see Fig. 33-13). We will also show you how to relax and massage the muscle at your thumb web (adductor pollicis). In addition, strengthening the muscle (the first dorsal interosseous) that moves your index finger to-ward the thumb can be helpful (see Fig. 33-5). We may have you doing grip-strengthening exercises that do not involve the thumb. The thumb is a stable post for the digits. We usually do not do pinch-strengthening exercises because they put too much stress on a repair that we want to be stable. Doing pinch activities too soon can compromise the surgical repair.”

• Manyclientswhoarrivefortherapyaresurprisedathowlong the recovery is for this surgical procedure.

• Mostclientsareusuallynotinmuchpain.Thosethathave pain may have had a tight cast or an irritation of the superficial branch of the radial nerve. These clients complain of burning pain and should be sent immedi-ately to the physician for a cast adjustment.

Evaluation Tips

Continued


Diagnosis-Specific Information that Affects Clinical ReasoningMost clients gain AROM quickly and want to resume activities as soon as possible. Many ADLs require a strong pinch and must be delayed until approved by the physician. Decisions to return to work depend on the type of activities that are done at work.

Therapy after Carpometacarpal FusionSee the Evolve website for information regarding therapy after CMC fusion.

Distal Interphalangeal Joint

Anatomy and Pathology

Clients with OA at the DIP joints often have enlargements called Heberden’s nodes.13 These nodes appear because of osteophytes or bony outgrowths near where the extensor tendon inserts on to the distal phalanx. When these nodes are present at the PIP joints, they are called Bouchard’s nodes.13


OA at the DIP joints can be painful initially, but pain usually decreases over time as they progress through the stages of OA.


Some clients are referred for DIP joint orthoses during this pain-ful time. The orthoses can help support the joints and are helpful in decreasing pain.55 The client may also be referred for joint protection and modalities. Other clients are referred to therapy for an orthosis that may help mimic a DIP fusion before a pos-sible surgery. This can assist the client to determine whether they would like to undergo a surgical fusion of the DIP joint. Another option is the application of various elastic tapes to the DIP joints, because this technique has been reported by some clients to be helpful in decreasing pain.

OrthosesThe orthotic tips previously outlined for the thumb spica or-thosis apply after surgery for CMC interposition arthroplasty. An additional area of concern following this surgery is that spe-cial attention should be paid to avoid pressure from the orthosis at the incision site and at the base of the thumb near the super-ficial branch of the radial nerve. This area can be very sensitive in some clients. In some cases the client may progress from a forearm-based to a hand-based orthosis during the postopera-tive program. Some clients after being cleared to return to work prefer a soft neoprene orthosis (see Fig. 33-8) to help make the transition. This orthosis supplies gentle support while allow-ing ROM after the rigid splint is discontinued. In clients with persistent pain from the superficial branch of the radial nerve, the same neoprene orthosis (see Fig. 33-8) can provide gentle padding and protection to the hand.52 This padding helps to prevent accidental bumping or irritation as the client’s activity level gradually increases.

Client ComplianceClient compliance is usually not an issue because this is an elec-tive surgery. A more common problem is that clients may do too much too soon after surgery. The therapist must stress the need for CMC joint stability to maximize the postoperative outcome.

Tips from the Field

• MovementoftheCMCjointisoftendifficult.Manyclients moved only the MP and IP joints before surgery. Therapy involves muscle reeducation to move the CMC into abduction without the MP and IP joints hyperex-tending.Precaution. When making the orthosis, take care to avoid

any pressure to the base of the thumb, which can irritate the sensi-tive superficial branch of the radial nerve.• Afterbeinginacastforseveralweeks,theskinwillbe

very dry, and the scars may be sensitive. The client will appreciate a gentle cleaning of the skin and an applica-tion of lotion. If the scars can tolerate it, initiate gentle scar massage. Show the client how to do scar massage a couple of times each day as part of their HEP.

• Beawareandlookforsignsofcomplexregionalpainsyndrome with this population (see Chapter 12).

Evaluation Tips—cont’d

• Avoid heavy pinch activities for up to 3 months after thissurgery.

• Avoidpressureareasfromtheorthosisespeciallyoverthebaseofthe thumb and incision sites.


• The orthosis should position the thumb opposite of the preoperative deformity but should not force the thumb into position.

• Bealertforsignsofcomplexregionalpainsyndrome,includingpersistent pain and heightened sympathetic nervous system responses.

• If the superficialbranchof theradialnerveis irritated, someclients report relief with a transcutaneous electrical nerve stimulation unit. A silicone gel pad also may be helpful.

• IstheclientacandidateforaDIPfusion?• AretheDIPorthosesforpainmanagement?

Questions to Discuss With the Physician

About the Condition• “The end joints of the fingers (distal interphalangeal) are

one of the most common sites of osteoarthritis.”• “These joints (distal interphalangeal) canbepainful for a

time, but usually the pain gradually goes away.”

About the Orthoses• “Ifyouarehavingpain,orthosesorelastictapeontheend

joints of the fingers (distal interphalangeal joints) can give some relief (Fig. 33-14). Most clients do not have pain for an extended period, but the orthoses or tape can be helpful during this temporary painful time.”




Orthoses are usually used only with clients who are in a painful acute inflammatory stage or those who are considering surgical fusion.

Rheumatoid Arthritis

RA is an inflammatory, systemic, autoimmune disorder.57 The inflammatory process associated with RA manifests itself pri-marily in the synovial tissue.58 Joint destruction occurs when the synovial pannus expresses enzymes allowing cartilage penetra-tion, cartilage damage, and joint erosion.57 RA is evident world-wide with prevalence rates at approximately 1% and varying among ethnic groups.59,60 The evaluation and treatment of the client with RA can be challenging for even the most experienced therapist. The disease can affect the intricate balance of the hand when joints and soft tissue structures become compromised.

Therapeutic treatment is individualized and specific to the client’s deformity or potential deformity, stage of the disease, and ADL needs. Only after a complete evaluation are goals and treatment methods selected to meet the needs and expectations

FIGURE 33-14 Orthoses to the distal interphalangeal (DIP) joints usually only are used with patients who are demonstrating a painful flare-up, those patients who are considering a surgical fusion, or fol-lowing surgical fusion.

FIGURE 33-15 Rheumatoid nodules near the elbow joint. (From Beasley J: Therapist’s examination and conservative management of arthritis of the upper extremity. In Skirven TM, Osterman AL, Fedorczyk JM, et al, editors: Rehabilitation of the hand and upper extremity, ed 6, St Louis, 2011, Elsevier, p. 1333.)

Determination of the client’s specific needs before providing treatment is important. Some clients do not wish to wear an orthosis, whereas others are at the clinic only for an orthosis. Be aware of the client’s ADL and the specific joint protection principles that may need to be recommended (see Table 33-1).

Evaluation Tips

OrthosesBecause of the presence of Heberden’s nodes and joint inflam-mation, orthoses to the DIP joints need to conform well and provide even pressure distribution. Thin or “light” orthotic materials are recommended, and the material should have ex-cellent drape characteristics, such as Polyform light or Orfit.

Tips from the Field

During an acute flare-up, the skin is very sensitive at the dorsal DIP level. Orthoses should conform well to prevent any pressure areas. Comfort is the key to splinting the DIP joints.

The orthoses should fit snugly so that they do not slide on the digit but should not be so snug as to feel constricting. The dorsal design allows the client to feel objects (meals, phones, keyboards, and so on) more easily on the volar surface.

Edema changes may necessitate orthotic modifications as the swelling decreases.


• “IfyouareconsideringasurgerytofuseyourDIPjoints,theorthoses may help you decide on this elective surgery.”

About Exercise• “Many clientswithmorning stiffness useheat to increase

mobility before exercise or before starting their day. They usually apply it for about 20 minutes when stiffness is a problem.”

• “Itishelpfultoavoidholdingobjectstightlywiththefingersfor a long time. This position keeps the joint bent, under stress, in a position of possible deformity, and can increase pain.”

These orthoses usually are made on the dorsal surface to allow for tactile input of the volar surface for ADLs (Fig. 33-14). To hold these splints in place, a non-adhesive wrap, such as Coban or Co-Wrap is recommended.

Client ComplianceClient compliance is good if the orthoses fits well and decreases pain during the acute inflammatory flare-up. Many clients re-ject the orthoses after the flare-up. Clients, who report they have no pain at the DIP joints but demonstrate joint inflammation during the evaluation, are less likely to wear the orthoses.


of these clients. Client education about the disease and treatment options is critical in the treatment process.

Diagnosis and Pathology

RA typically affects the joints symmetrically61 and hand involve-ment most commonly includes the MP, PIP, thumb, and wrist joints.58 Early symptoms include morning stiffness lasting more than an hour and fusiform swelling of the PIP joints.61 Flexor tendon tenosynovitis can reduce digit motion, strength, and in some cases result in a trigger finger if nodular thickening occurs.58 Deformities of the hand include MP joint ulnar deviation with palmar subluxation and radial deviation of the metacarpals or the zigzag deformity.58, 61 Other deformities include PIP swan neck and boutonnière deformities,58, 61 and a variety of thumb deformities.48 Rheumatoid nodules commonly occur over pres-sure areas at the elbows and digits.58, 61 Onset of symptoms can be abrupt, but more commonly a slower progression occurs over several weeks.

The therapist must have an understanding of the stages of the disease process, as well as potential deformities. This knowl-edge will assist in determining the appropriate treatment options. Recent medications for RA have altered the course of this chronic condition. The therapist also must note that the client may return to earlier stages during the clinical course and will have remis-sions and exacerbations as the disease progresses.

During the acute phase, or stage I, as classified by Steinbrocker, et al.,62 the client demonstrates joint swelling and inflammation that is warm when palpated. This is the most painful phase, and it is also when most clients 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.63 Nodules (small rounded lumps) may be evident at the joint bursa (a fluid-filled sac that decreases friction) or along the tendons. Joint ROM is usually less painful, and there are no obvious deformities. In the destructive, chronic active stage III, the client often reports less pain, but irreversible joint deformities have progressed. 62,63 Stage IV has been referred to as chronic inactive or skeletal collapse and deformity. The joint defor-mities are considerable and may include instability, dislocation, spontaneous fusion, and bony or fibrous ankylosis (stiffening of a joint). 62,63


Unfortunately, there is no cure for RA at this time. During the last decade, there has been significant progress understanding the molecular pathogenesis64 and role of the immune system in the arthritic process. The medical intervention of arthritis now includes early and aggressive treatments for greater control of inflammation and joint erosion.65 Despite these medical advances, it is important to understand that arthritis is still a chronic condi-tion,66 and these medical advances do not permanently change

the destructive behavior of the immune system.64 The therapist can help manage the symptoms as the disease progresses with client education, modalities, orthoses, joint protection, and adap-tive equipment. The postoperative timelines and protocols for specific surgeries follow.


Evaluation

A complete evaluation of the client is necessary and includes ROM, ADL, joint deformities, stage of the disease process, previ-ous surgeries, expectations of therapy, and pain.

Range of MotionMeasurements of AROM of the rheumatic hand varies daily with increased stiffness often noted in the morning.67 Goniometric measurement should be done when possible, but deformities make this difficult in the later stages. Measurements of composite digit flexion, active digit extension, and thumb opposition often give more functional information. Some clients are unable to perform palmar pinch and instead use a lateral pinch because of a pronation deformity of the index digit.68 The degree of ulnar deviation at the MP joints can provide helpful information for measuring progression of joint deformities. This measurement should be done with the digits in active available extension to avoid friction from a table, which can change the degree of ulnar deviation.

Loss of AROM can also be caused by tendon rupture. Rupture occurs as the tendon glides over roughened and irregular bone areas.

Precaution. The extensor pollicis longus and the extensor digi-torum communis tendons of the third, fourth, and fifth digits are particularly vulnerable to rupture.

The tendon, which may be weakened by the inflammatory synovium, can fray and eventually rupture, resulting in loss of motion.69 The extensor tendons are more vulnerable to rupture than the flexor tendons because of their proximity to the distal radius, ulna, and carpal bones. Extensor tendon rupture at the wrist level most often is seen with extensor pollicis longus at Lister’s tubercle (a boney prominence) and with extensor digi-torum communis at the distal end of the ulna. The extensor digiti quinti is often the first extensor to rupture and may signal the potential rupture of the other extensor tendons.70

StrengthAdams, et al.71 reported that hand grip strength acts as a reliable indicator of upper extremity functional ability. The Jamar dyna-mometer has demonstrated good reliability, 72 and measurements should be completed following the clinical recommendations of the American Society of Hand Therapists (ASHT). 73 In addition the B&L Engineering pinch gauge is considered the “gold standard”

With RA, the joint involvement is often symmetrical and bilateral.61

Clinical Pearl

Ulnar deviation often varies in MP flexion and extension because of ligament laxity, and therefore the position of the MP joint should be reported in combination with the ulnar drift measurements.

Clinical Pearl


when measuring pinch strength. 74 Joint instability, rather than weakness, is usually more problematic during ADLs. Even with adequate muscle strength, clients will be unable to maintain a grip on an object if their joints collapse into deformities.

Activities of Daily LivingEvaluation of the client’s functional level begins as the client enters the clinic. Observation as the client removes a coat and sits at a table can be invaluable in understanding their ability to pinch and grasp, complete simple functional activities, and even use the hand for mobility (such as, using crutches). Joint deformities can be observed and may be accentuated with simple activities. The speed by which the client enters the clinic often provides qualitative information as to the level of pain and the involvement of the lower extremi-ties. The therapist must gain an understanding of the client’s home and support system when planning the HEP and potential orthotic designs. For example, if the client is unable to don an orthosis inde-pendently, a caregiver will be needed. The therapist needs to evalu-ate the client’s goals for therapy carefully to make sure that they are realistic. A client diary, as described by Devore,70 can give insight into the needs of the client and make the client an active participant in the treatment process. The diary helps the client to determine problem areas with ADLs, including which joints are involved and also whether the joint difficulties are because of pain, power, or position. The diary can also assist with client “ownership” of the therapy program. This self-determination of problem areas facili-tates client goal setting and client follow through.

PainPain caused by acute inflammation is usually greater in the early stages of the disease than in the end stages when severe deformi-ties are evident. Pain analog scales can be used to determine the effectiveness of treatment, but clinical observation suggests that these clients, in the later stages, rate their pain much lower than anticipated by the therapist. Orthoses may be helpful in decreas-ing pain but should be balanced with the ADL requirements of each client. Rheumatoid nodules can be painful when palpated and should be noted in the evaluation, because they may affect orthotic design or strap placement (see Fig. 33-15). Pain and/or numbness from nerve compressions 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 be compressed at Guyon’s canal (a canal adjacent to the hook of the hamate) at the wrist and at the cubital tunnel (the groove between the medial epicondyle and the olecranon of the ulna) at the elbow.


Joint Deformities

Palpate joint deformities to help determine whether they are fixed or passively correctable, dislocated, or partially dislocated. Note this information in your evaluation. Common wrist and hand deformities are discussed as follows with orthotic and other treat-ment options in the non-operative section.

Swan Neck DeformityThe swan neck deformity is characterized by flexion of the DIP joint and hyperextension of the PIP joint (see Fig. 29-10). Synovitis of the flexor tendons can erode the PIP joint volar plate,

which normally helps prevent PIP joint hyperextension. The flexor tendon synovitis also limits PIP joint flexion and causes the client primarily to use the MP joints for digit flexion.63 This results in an intrinsic plus position (MP flexion with IP joints extended) during grasping activities, causing an altered pull of the intrinsic muscles. This altered pull tends to facilitate dorsal subluxation of the lateral extensor tendons and PIP joint hyper-extension. The DIP joint then flexes reciprocally by action of the flexor digitorum profundus tendon. The action of the extensor mechanism thus is concentrated at the PIP joint, resulting in PIP hyperextension, if the PIP volar plate (a thick fibrocartilaginous structure on the volar aspect of the PIP joint) is lax or disrupted. Studies that looked at orthoses for swan neck deformities at the PIP joint reported greater acceptance and tolerance with prefab-ricated orthoses75 than custom-made orthoses and also reported that Silver Ring Splints(orthoses) improved dexterity in selected patients with RA. 76

Boutonnière DeformityThe boutonnière deformity is characterized by PIP joint flex-ion and DIP joint hyperextension. Synovitis causes the central tendon to become weakened, lengthened, or disrupted from the bony and capsular attachments allowing the PIP joint to rest in flexion. The lateral bands then rest volar to the axis of the PIP joint, resulting in PIP joint flexion and DIP joint hyperextension (see Fig. 29-6). Orthotic techniques for the boutonnière defor-mity are outlined in Chapter 29.

Metacarpophalangeal Joint Ulnar Deviation and Palmar SubluxationThe MP joints, unlike the PIP hinge joints, have more planes of movement in that they also can abduct, adduct, pronate, and supinate. With this degree of mobility, the hand collapses into deformities if the restraining system of tendons, ligaments, or bony structures is disrupted by synovitis. Additional factors that can contribute to the development of the ulnar deviation defor-mity include an anatomic susceptibility and ulnar and volar forces applied during ADLs.63 The flexor tendons exert strong ulnar and volar forces at the MP joint. Lateral pinch activities, grip-ping an object, writing, and even gravity, tend to place ulnar and volar deviating forces at the MP joints (Table 33-2). The defor-mity also may include radial deviation of the wrist77 (Fig. 33-16). With ligament instability, the carpal bones can shift into a variety of deformities. Ulnar displacement of the proximal carpal row results in radial deviation of the hand.51 An orthosis can be used in the treatment of this condition. Steultjens, et al.78 reported in their systematic review that orthoses can decrease pain and improve grip strength but may decrease hand AROM. Another study compared groups of RA patients wearing soft and hard night resting orthoses and found that both groups had decreased pain.79 RA deformities can make proper fitting of an orthoses challenging. When fitting the RA hand with MP ulnar deviation and palmar subluxation, consider the position of the metacarpals, which are often in radial deviation. Aligning the MP joints in an anti-ulnar deviation position may contribute to the digit CMC radial deviation deformity. The orthosis should be designed to address all of the issues involved in the zigzag deformity.80

Ulnar deviation and palmer subluxation of the MP joints is the most common deformity seen in RA.

Clinical Pearl


Volar Subluxation of the Carpus on the RadiusLigament laxity caused by chronic synovitis at the wrist and the natural volar tilt of the distal articular surface of the radius can result in volar subluxation of the carpus on the radius (Fig. 33-17). An orthosis for this condition usually includes a volar component to support the wrist.81 The research on wrist orthoses is inconclusive at this time although one systematic review found that patients who wore wrist and resting hand orthoses preferred to use them.82

Distal Ulna Dorsal SubluxationInstability of the distal ulna is common in RA. The distal ulna is normally less prominent in supination and more prominent in pronation. The RA disease process often weakens the ligamentous structures causing dorsal prominence of the distal ulna, pain, and crepitation with pronation and supination.63 This instability and dorsal prominence of the ulna also may lead to extensor tendon disruption at the wrist level. Orthoses to provide stability to the distal ulna can be helpful in decreasing pain with pronation and supination (Fig. 33-18).52

Thumb DeformitiesTerrono, et al.48 have identified common patterns of thumb deformity in the rheumatoid thumb (Table 33-3). Type I is common with MP joint flexion and distal joint hyperextension (Fig. 33-19). Type III is also common with CMC subluxation, metacarpal adduction, MP joint hyperextension, and distal joint flexion (see Fig. 33-4). With the type III deformity the orthotic recommendations are comparable to the previously described osteoarthritic thumb deformity. The reader is referred to Terrono, et al.48 for further information on RA thumb deformities.

Crepitus

Grating or crepitation during AROM may be palpated or heard. It sounds like a crunching or popping sound. Volar inspection

FIGURE 33-16 The zigzag deformity with wrist radial deviation and metacarpophalangeal (MP) joint ulnar deviation. (Redrawn with permission from Melvin JL: Rheumatoid disease: occupational therapy and rehabilitation, ed 3, Philadelphia, 1989, FA Davis, p. 281.)

TABLE 33-2 Joint Protection Principles for the Metacarpophalangeal Joints with Rheumatoid Arthritis

Activities That Aggravate Metacarpophalangeal Ulnar Deviation Joint Protection Techniques

Closing a jar with the right hand Use the heel of the hand to close the jar or use a jar opener with two hands.

Smoothing a sheet with shoulder adduction Use shoulder abduction to smooth the sheet.

Stirring with a spoon using forearm pronation and lateral pinch on spoon

Stir with the forearm in neutral with the spoon head held on the ulnar side of the hand using a cylindrical grasp.

Resting the hand on the chin, with ulnar forces to the digits Avoid resting the hand on the chin or place the chin in the palm.

Lifting a cup of coffee Use two hands and a lightweight cup.

Cutting foods Use a knife with a 90° handle, a pizza cutter, or electric knife.

Lateral pinch to turn the key in the car door or ignition Use a built-up key turner.

Carrying a purse strap with a lateral pinch Use a fanny pack, back pack, or shoulder bag.

From Haviland N, Kamil-Miller L, Sliwa J: A workbook for consumers with rheumatoid arthritis, Rockville, MD, 1978, American Occupational Therapy Association; Cordery JC: Joint protection: a responsibility of the occupational therapist, Am J Occup Ther 19(5):285-294, 1965; Cordery, J, Rocchi M: Joint protection and fatigue management. In Melvin J, Jensen G, editors: Rheumatologic rehabilitation: assessment and management, vol 1, Bethesda, MD, 1998, American Occupational Therapy Association, pp. 279-322; Cooney WP, Chao EYS: Biomechanical analysis of static forces in the thumb during hand function, J Bone Joint Surg 59(1):27-36, 1977; Valdes K, Marik T: A systemic review of conservative interventions for osteoarthritis of the hand, J Hand Ther 23:334-349, 2010; Zhang W, Doherty M, Leeb BF, et al: EULAR evidence based recommendations for the management of hand osteoarthritis: report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT), Ann Rheum Dis 66(3):377–388, 2007; Melvin JL, Ferrel KM, editors: Adult rheumatic diseases, vol 2, Bethesda, MD, 2000, The American Occupational Therapy Association.


of the hand should include palpation of the first annular (A1) pulleys (at the volar aspect of the MP joints) as the client flexes and extends the digits. A thickening of the flexor tendons, trig-gering, or periodic locking of the digit in flexion indicates flexor tenosynovitis (inflammation of the synovial lining of the tendon sheaths).

Skin Condition

An evaluation of the skin condition should include color, tem-perature, and areas of swelling. In the initial stage, the skin often is red and warm. In the later stages the skin may be very thin and bruise easily, which may be due to the long-term use of steroids and/or anti-inflammatory medications. Fragile skin characteris-tics can affect postoperative healing and reduce tolerance to an orthosis.

Precaution. Skin tears may occur with only minimal shearing, such as rubbing from dressings or from the edge of a table.

FIGURE 33-19 The type I deformity with metacarpophalangeal (MP) joint flexion and distal joint hyperextension. (From Terrono AL, Nalebuff EA, Phillips CA: The rheumatoid thumb. In Skirven TM, Oster-man AL, Fedorczyk JM, et al, editors: Rehabilitation of the hand and upper extremity, ed 6, St Louis, 2011, Elsevier p. 1345.)

TABLE 33-3 Rheumatoid Arthritis Thumb Deformities

Type Also Called Carpometacarpal Metacarpophalangeal Interphalangeal

I Boutonnière deformity Not involved Flexion Hyperextension

II (Uncommon) Flexion and adduction Flexion Hyperextension

III Swan neck deformity Flexion, adduction, and subluxation

Hyperextension Flexion

IV Adduction and flexion as it progresses

Radially deviated and UCL unstable Not involved

V May or may not be involved Unstable volar plate, hyperextension Not involved

VI Arthritis mutilans Collapse resulting from bone loss at any level

UCL, Ulnar collateral ligament.Based on categories by: Terrono AL, Nalebuff EA, Phillips CA: The rheumatoid thumb. In Skirven TM, Osterman AL, Fedorczyk JM, et al, editors: Rehabilitation of the hand and upper extremity, ed 6, St Louis, 2011, Elsevier, p.1345.

FIGURE 33-17 The natural volar tilt for chronic synovitis can result in volar subluxation of the carpus on the radius. (Redrawn with permission from Melvin JL: Rheumatoid disease: occupational therapy and rehabilitation, ed 3, Philadelphia, 1989, FA Davis, p. 280.)

FIGURE 33-18 The rheumatoid arthritis (RA) disease process often weakens the ligamentous structures causing dorsal promi-nence of the distal ulna, pain, and crepitation with pronation and supination.63 This instability and dorsal prominence of the ulna also may lead to extensor tendon disruption at the wrist level. This orthosis (Count’R-Force Radial Ulnar Wrist Support, North Coast Medical) is padded at the dorsal distal ulna and volar distal radius to support and stabilize the ulna. Orthoses that provide stability to the distal ulna can be helpful in decreasing pain with pronation and supination.52



Joint Protection

The purpose of initiating joint protection principles early in the OA and RA disease process is to decrease joint stress and damage through altered work methods and to educate patients on proper joint alignment, and the use of adaptive equipment.29,30 Com-mon general joint protection principles for both OA and RA are categorized by themes in Table 33-2. For more complete informa-tion on specific principles and techniques as applied to specific deformities, the reader is referred to works by Cordery, Rocchi, and Melvin.29,30, 39 A systematic review found joint protection education beneficial for patients with RA.83 A randomized controlled trial of patients with early RA demonstrated that 8 hours of instruction in joint protection decreased pain, morning stiffness, and doctor visits, as well as improved grip strength and self-efficacy, and maintained function.84 Educational-behavioral joint protection programs that involve skill practice, goal-setting and HEPs were more effective than short instruction and/or information booklets. This was demonstrated by fewer defor-mities, less morning stiffness, improved ADL scores, and joint protection adherence.85 Additionally, a small study sample (n = 28) demonstrated that instruction in energy conservation with cogni-tive-behavioral strategies decreased pain and fatigue and increased physical activity.86

Joint protection principles for RA should address the specific deformity or potential deformity. For example, joint protection for a patient with a tendency to develop a swan neck deformity should avoid activities that place the PIP joints in full extension, such as holding a book. In contrast, if the patient has a tendency toward a boutonnière deformity, PIP flexion activities (such as, using a hook grasp to carry a bag) should be discouraged. Patients with MP joint ulnar deviation tendencies should be aware of activities that place ulnar deviating forces on the MP joints and use alterna-tive grasping techniques (see Table 33-2). With the thumb, joint protection principles focus on decreasing the amount of force used for pinching activities. The joint protection principles out-lined previously for the osteoarthritic client also apply to the RA client. In addition, a systematic review found moderate evidence that combining joint protection with adaptive device provision resulted in increased hand function and pain reduction.32

ModalitiesA variety of modalities have been used for the RA patient with unclear results.87-89 A systematic review found improved ROM, improved grip and pinch strength, and reduced pain and stiffness with paraffin wax baths.87 One review found that ultrasound was effective in increasing grip strength, decreasing morning stiffness, and reducing the number of swollen and painful joints.89 Trans-cutaneous electrical nerve stimulation (TENS) has been found to help decrease pain in RA.88 Another review found evidence that low-level laser therapy decreased pain and morning stiffness.90 Decreasing pain and maintaining or improving ROM are primary goals in the application of these agents. The stage of the arthritic process is also a determining factor.

Precaution. During the acute inflammatory phase when joint temperatures are elevated, heat is contraindicated, because it can promote inflammation.

Cryotherapy, which lowers joint temperatures, reduces pain, and decreases inflammation, is more appropriate during the acute phase but many clients cannot tolerate cooling treatments.

During the subacute and chronic phases, heat may be more appli-cable to decrease pain, encourage relaxation, improve ROM, and increase functional use of the hand.

ExerciseGeneral principles of exercise include avoiding painful AROM and PROM and working within the client’s comfortable ROM. General exercises for the hand include AROM of the wrist, gentle digit flexion and extension, and thumb opposition. Keep ROM exercises pain-free to prevent overstretching of joint structures that may be vulnerable or distended by the inflammatory pro-cess. Shoulder and elbow AROM in the supine position is also beneficial for preventing stiffness. Clients often obtain increased shoulder motion in the supine position, because the effects of gravity are reduced in this position. Generalized conditioning for the patient with RA has been found to improve stamina and mus-cle strength and is recommended as routine practice in patients with RA.91 One study found low impact general conditioning utilizing walking or aquatics increased endurance and aerobic capacity in patients with RA.92 Clinically the psychosocial ben-efits of group exercise in a warm pool, tai chi, and other pain-free exercise programs have been reported by patients to this author as very beneficial.80

StrengtheningPrecaution. Strengthening programs for the rheumatic hand should be used with caution to avoid aggravation of deformities.

Stability must not be sacrificed for a possible increase in strength. Grip strengthening is a common example of an exer-cise that can place the digits in increased ulnar deviation during flexion if the position of the digits is left unchecked. A systematic review reported that there was not strong research evidence for or against hand exercises in the treatment of persons with RA.93

Precaution. Therapy exercises should never create deforming forces or cause pain.

RemediesMost therapists treating the client with RA are approached for advice on a variety of home remedies. These can include copper bracelets, magnets, nutritional supplements, diets, homeopathy, topical preparations, and many others. It is important that the therapist use care in addressing these questions. The therapist should scrutinize research on nontraditional treatments care-fully. As therapists, we cannot act as advocates, working outside our scope of practice, nor can we refuse to review nontraditional methods of treatment. When evaluating the effectiveness of any treatment, we should remember that RA is a disease of remissions and exacerbations. Many clients report improvement with a vari-ety of home treatments. Asking oneself whether the client might have improved even without the treatment is always reasonable. Of course, the therapist should advise the client against any non-traditional therapy that has the potential for harm.

Wrist and Metacarpophalangeal Joint Deformities

With ligament instability, the carpal bones can shift into a vari-ety of deformities. Ulnar displacement of the proximal carpal row results in radial deviation of the hand.94,95 The MP joints may be affected secondarily and demonstrate ulnar deviation (Fig. 33-20).


FIGURE 33-20 When splinting the zigzag deformity, the therapist needs to avoid forcing digits into alignment with an orthosis that leaves the wrist positions unchecked. The long lever arm involved in placing the digits into alignment can cause the wrist to go into additional radial deviation. This night orthosis helps to guide the wrist into gentle ulnar alignment and the metacarpophalangeal (MP) joints into radial alignment. This orthosis also is used at night following MP implant resection arthroplasty. (From Boozer JA: Splinting the arthritic hand, J Hand Ther 6:46, 1993.)

• Istheorthosisprimarilyfornightwear?• Arethereanytendonruptures?• Issurgeryanoptionforthisclientinthefuture?


About the Condition“Your hand is demonstrating a deformity in which the fingers go in one direction and the wrist goes in another. This can look like a zigzag deformity.”

“When you have rheumatoid arthritis, the lining of the joint becomes active and moves outside of the joints. This can dam-age the structures around the joint and including the cartilage, ligaments, joint capsule, tendons, and boney structures.”

About the Orthosis“The orthosis is designed to be worn at night to keep your fingers and wrist in good alignment. It should be comfortable and can help decrease your pain.”


“Some clients like to wear soft orthoses during the day for heavier activities. This keeps your fingers in position but lets you do some activities.”

About Exercise and Joint Protection“Learning ways that you can protect your joints and avoid positions of deformity can be helpful.”

“Sometimes adaptive equipment can be helpful to decrease the stress on the joints as you do some activities. I can help you determine the best options for you.”

“Any exercise that you do should be pain-free and should avoid positions of deformity.”

“It is important to be gentle with the exercises and not force the hand into uncomfortable positions.”

Even with severe deformities, clients are able to somehow do a great deal with their hands during their ADLs. Be sure to find

Evaluation Tips

Continued


Swan Neck Deformity

Swan neck deformity is characterized by flexion of the distal DIP joint and hyperextension of the PIP joint.

FIGURE 33-21 A soft neoprene anti-ulnar deviation orthosis is often helpful for day wear when a client with RA demonstrates MP ulnar deviation. (Rolyan Hand-Based In-Line Splint from Sammons Preston.)

OrthosesIf the digits alone are aligned radially in the orthosis without supportive correction of the wrist position, the wrist can be pulled into further radial deviation. This is undesirable be-cause the goal is to gently to position all involved joints. In the orthosis, a strap at the head of the metacarpals provides a necessary stop to counterbalance the long lever arm align-ment pull of the digital straps or spacers (see Fig. 33-20). The resting pan orthosis also places the MP joints in gentle exten-sion to decrease palmar subluxation of the proximal phalanx. The hand should never be forced into a position, because you cannot correct a severe deformity. Small foam spacers provide a soft but forgiving alignment to the MP joints and yield to changes in digit size caused by edema or inflammation. The spacers are cut from a sheet of self-adhesive Temper Foam. A second method for applying ulnar pull to the wrist meta-carpals is to secure a Beta Pile II or some other double-sided Velcro loop strap to the inside of the orthosis at the head of the metacarpals. The gentle pull of this strap helps keep the wrist from its tendency to follow the digits into radial positioning when aligned in the orthosis. Some clients also wear soft neoprene digit alignment orthoses during the day to protect their hands during more active ADLs. The gentle pull of the radial alignment strips can help to keep the digits in proper position, counteracting the ulnar deviation forces (Fig. 33-21).

Client ComplianceA client will wear an orthosis that fits well and is comfortable for an extended time. Some clients return for new orthoses every year because of wear and tear. If the client returns with a clean orthosis, it is most likely not being worn. Most clients need orthoses for both hands, which can make nighttime trips to the bathroom difficult. Alternating an orthosis on the right hand and the left hand every other night can be helpful in managing this situation.

Tips from the Field

The digits and wrist should never be forced into an aligned position.

According to Brand, et al.,18 it is important to avoid the use of the long lever arm of the digit to extend the MP joint. If the proximal phalanx tilts rather than glides into position, it can wear away at the dorsal lip of the phalanx. This results in an orthosis that actually increases pain and absorption of the joint surface.

Clients who are fitted with night orthoses should be made aware of proper application techniques to avoid this joint tilting, and the orthosis should be formed properly, allowing the joint to glide into position.


out if the client really wants, and will wear, an orthosis before fabrication. Adaptive equipment should also be used with the client’s individual needs and expectations in mind.

Evaluation Tips—cont’d

• Issurgeryanoptionforthisclientinthefuture?• What is the condition of the joints as observed on the

radiographs?


About the Condition“Rheumatoid arthritis can loosen the stability of your joints, ligaments, and tendons resulting in the fingers going into a swan neck deformity.”

“As you use your hand, the middle (proximal interphalan-geal) joints of your fingers tend to buckle backward and your end (distal interphalangeal) joints bend. This makes it difficult to grasp objects.”

About Orthoses“Orthoses can help keep the middle (proximal interphalangeal) joints flexed. This has a secondary effect on the end (distal in-terphalangeal) joints, helping them to straighten. This is the position opposite your deformity.”

“There are several styles of orthoses that can work for you. These orthoses allow your fingers to bend but prevent your middle joints (proximal interphalangeal) from buckling backward.”

“Some of the orthoses are made out of plastic, and some are made out of metal to look like special rings on your fingers.”

About Exercise“It is important that you maintain the bending ability (proximal interphalangeal flexion) of the middle joints. This is done by taking your other hand and gently bending it toward the palm.”

“Activities like holding a book or an electronic tablet can keep your middle joints straight while bending your knuckles (metacarpophalangeal). This can aggravate this deformity. You



should avoid activities that keep your middle joints straight for a long time.”

Take care to measure the AROM and PROM of the PIP joints and DIP joints. If the joints are passively correctable, the client is usually a good candidate for the swan neck orthosis.

Evaluation Tips

OrthosesIn clients demonstrating a swan neck deformity, orthotic tech-niques that prevent PIP joint hyperextension, yet allow flexion, are often effective. These orthoses are needed long term and

Tips from the Field

A B

FIGURE 33-22 A, A high-temperature plastic option, the Oval-8 splint, is available in a variety of sizes and can be obtained from 3-Point Products, Inc. (Stevensville, MA). This prefabricated orthosis is available in many sizes and is fitted in the clinic. B, Minor one-time changes can be made to this high-temperature plastic using a heat gun at the lateral central joint of the orthosis. For clients who are between sizes, the ring orthosis can be worn with the smaller ring placed proximally.

A B

FIGURE 33-23 A, Metal custom-sized splint, the SIRIS splint, is available from the Silver Ring Splint Co. (Charlottesville, VA). These orthoses are well tolerated by clients because they allow most activities of daily living (ADLs) and do not need to be removed for hand washing. In one study, dexterity was improved with selected clients with rheumatoid arthritis (RA) using the orthosis. 76 The Silver Ring orthoses have solder that is designed to tolerate multiple adjustments to account for digit swelling. If the rings are opened, it is tighter on the finger. Conversely, if the two rings are brought closer together, the orthoses is looser on the finger. B, The therapist measures for the SIRIS splint with a special tool, the EZ-Sizer that is available from the company.

therefore should be durable. Many of the low-temperature plastic splints can wear out and need to be replaced frequently. There is research evidence of greater client acceptance and tolerance for prefabricated swan neck orthoses.75 A high-temperature plastic option, the Oval-8 splint, is available in a variety of sizes and can be obtained from 3-Point Products, Inc. (Stevensville, Maryland). This is a prefabricated splint (Fig. 33-22, A) is available in many sizes and is fitted in the clinic. Minor one-time changes can be made to this high-temperature plastic using a heat gun at the lateral central joint of the ortho-ses (see Fig. 33-22, B). For clients who are between sizes, the ring orthosis can be worn with the smaller ring placed proxi-mally. Many clients may use this fit option with digit swelling fluctuations from day to day. A metal custom-sized splint, the SIRIS splint (Fig. 33-23, A), is available from the Silver Ring Splint Co. (Charlottesville, Virginia). The therapist measures these splints with a special tool, the EZ-Sizer (see Fig. 33-23, B), which is available from the company. These orthoses are


Operative Treatment

See the Evolve website for detailed information on postoperative care of MP implant resection arthroplasty.

CASE STUDIES

CASE STUDY 33-1 n Non-Operative Treatment of Rheumatoid Arthritis

B.L. is a 53-year-old nurse with RA. She works 40 hours a week on the cardiac care unit of a local hospital and reports that her pain is largely under control with medication. She has two children in college and likes to play the organ at church. She reports that with some activi-ties, such as playing the organ, her right PIP joints hyperextend at her right index and ring digits. This requires her to push even harder on the organ keys, which is sometimes painful. She would like some support that would give her index and ring finger (PIP) joints stability yet allow her to do her activities.

B.L. was fit with size 5 and 6 Oval 8 splints (from 3-Point Products, Inc.) because there is evidence of greater acceptance and tolerance with prefabricated orthoses75 than custom-made orthoses for this condition. She was shown the proper way to apply the orthoses to prevent PIP joint hyperextension yet to allow full PIP joint flexion. She was instructed that the orthoses would be tighter when applied in the opposite direction and that this might be useful if her swelling were to decrease. She was instructed in joint protection principles including avoiding the intrinsic plus position as she held a book or electronic tab-let. She was shown PROM to the PIP joints to help maintain PIP flexion.

B.L. returned to the clinic 1 week later with her husband. She reported increased stability as she played the organ. She felt the orthoses increased the stability of her PIP joints at work and during various other ADLs. Her husband had heard about the Silver Ring

splints and wanted to purchase a Silver Ring SIRIS orthosis for her ring finger with her birthstone for their anniversary. The therapist was aware of a study that found Silver Ring splints improved dexterity in selected patients with RA.76

She was measured for the Silver Ring splint using the EZ-Sizer. The correct size was determined and the form was completed. Her husband had purchased the birthstone previously, and this was included for placement on the ring with the order. The couple mailed in the form and the stone. The form stated the ring was to be delivered to the hand clinic for fitting by the therapist.

The Silver Ring SIRIS orthosis arrived 8 days later and was fit to the client. She was instructed in how to make adjustments to the orthosis fit by bending the rings together (for a looser fit) or apart (for a tighter fit). This would help the ring fit appropriately when there were edema fluctuations. B.L. continued to wear her Oval 8 orthosis on her index finger.

B.L. stopped by the clinic 2 weeks later. She had lost her Oval 8 splint. She reported decreased pain and increased stability with her orthosis and was wearing them day and night. They allowed full PIP joint flexion but prevented PIP hyperextension. She also felt she needed less pain medicine with the orthoses in place during activi-ties. Her lost Oval 8 splint was replaced, and she was encouraged to contact the therapist if further assistance was needed.

CASE STUDY 33-2 n Operative Treatment of Rheumatoid Arthritis

See the MP IRA case on the Evolve website.

CASE STUDY 33-3 n Operative Treatment of Osteoarthritis

N. B. is a 70-year-old female with CMC OA. She has been seeing the hand therapist for several years and has managed her pain with a hand-based thumb spica orthosis at night and a soft neoprene or-thosis during the day as needed. The orthoses have worked well in the past, but the pain has been increasing. She arrived in the hand clinic today in a cast and is 10 days post CMC interposition arthro-plasty. Her stiches had been removed that day by the physician’s office staff, and a cast had been applied. The client was referred to therapy for AROM of uninvolved joints and postoperative care.

N. B. is demonstrating significant pain at her wrist near the inci-sion site. She also has limited shoulder (80° flexion and abduction) and elbow (30°/100°) AROM. The client described her pain as burn-ing and radiating down to her thumb tip. She was immediately taken back to the physician’s office (located next door) where the cast was cut, spread, and rewrapped. This relieved pressure on the superficial branch of the radial nerve, and the client was comfortable in her cast. Returning back to therapy the client was instructed in AROM for the shoulder, elbow, and thumb IP joint (which was not supported in the cast). She was also instructed in elevation techniques and given suggestions for completing ADLs with one hand. She lives at home with her husband who attended the therapy session. Her husband reported that he could begin some simple cooking for N. B., but he would need her verbal guidance.

N. B. returned the following week for hand therapy reporting no pain. She now had full AROM of the shoulder, elbow, and thumb IP joint. Some edema was still evident and elevation techniques were reviewed, as well as gentle edema massage to the digits. An appointment was made for 4-weeks post-surgery for application of her thumb spica forearm-based orthosis. This was the same day as

Take care to ensure that the orthoses are not too tight or too loose. If they are too loose, the client often loses them; if they are too tight, they can cause pressure areas.

In the case of the Silver Ring splints, the client should have a good understanding of how to adjust the orthosis to account for changes in finger size from day to day.

Some clients with sensitive skin may react to the metal; if need be, a special coating is available from the manufacturer.


well tolerated by clients, because they allow most ADLs and do not need to be removed for hand washing. In one study, dexterity was improved with selected RA clients using the or-thosis.76 The Silver Ring orthoses have solder that is designed to tolerate multiple adjustments to account for digit swelling. If the rings are opened, the orthosis is tighter on the finger. Con-versely, if the two rings are brought closer together, the orthosis is looser on the finger.

Client ComplianceClient compliance with both of the aforementioned swan neck orthoses is typically excellent if the orthosis fits well, because it allows most ADLs.


her physician’s appointment for cast removal. She was instructed to contact the therapist if there were any concerns prior to that time.

N. B. returned after her physician’s appointment at the 4-week point and was fit with a forearm-based thumb spica orthosis. Her skin was cleaned due to post cast dryness, and lotion was applied. She was independent in donning and doffing the orthosis . Gentle AROM was initiated to the thumb including gentle opposition and flexion. N. B. had a tendency to move her MP and IP joints during the exercises and not her CMC joint. She was shown how to keep these joints slightly flexed during the CMC exercise to facilitate gentle movement and muscle reeducation. Gentle massage was completed to the thumb web space to decrease thumb metacar-pal adduction. Her husband was shown how to assist with this as well. Scar massage with the lotion of N. B.’s choice was initiated to the incision twice daily in her HEP after demonstration by the therapist.

N. B. returned to the hand clinic at 5 weeks post-surgery. She had 45° of CMC palmar abduction and could oppose all of the digit tips with her thumb. She was cautioned to wait one more week before removing her orthosis for ADLs and to avoid heavy pinch activities for at least 3 months post-surgery.

At 6 weeks post-surgery the thumb spica orthosis was discon-tinued. A soft neoprene Comfort Cool orthosis was applied for wear during some activities that N. B. felt might be problematic until her strength returned, such as cooking and making beds. She

demonstrated 30 lbs of grip strength at this visit. She was shown simple grip strengthening exercises with putty to be done two times a day, avoiding thumb pinch. Thumb pinch should be avoid-ed for the first 3 months post-surgery.

Vendor InformationAvailable from North Coast Medical (www.ncmedical.com)• Comfort Cool Thumb CMC Restriction Splints• Count’R-Force Radial Ulnar Wrist Support• Orfit

Available from Patterson Medical (www.pattersonmedical.com)• Rolyan Hand-Based In-Line Splint• Coban• Co-Wrap• Velcro• Polyform light• Temper Foam• Beta Pile II

Available from HandLab (www.Handlab.com)• The Push MetaGrip

Available from 3-Point Products (www.3pointproducts.com)• Oval-8 splint

Available from Silver Ring Splints Co. (www.silverringsplint.com)• SIRIS• EZ-Sizer

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http://www.ncmedical.com

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