management of 3 common hand deformities in ra

AHPA pre-conference February 13, 2013

Management of three commonhand deformities in rheumatoid arthritis:

a clinical perspective

Asuko Brittain

B.Sc.PT, B.Sc.OT, CHT

AHPA Pre course February 13, 2013

Ottawa, Ontario

Mary Pack Arthritis Program

Objectives

To understand the pathomechanics of ulnar drift, swan-neck and boutonniere deformities

To understand the role of splinting and hand exercises in the management of these deformities

To be aware of future online resources available through CESEI

2

RA Hand Chronic, systemic,

autoimmune disease

Symmetrical peripheral polyarthritis

Target hands and wrists

Joint destruction & weakening of periarticular structures

Irreversible hand deformities

Cima 2012; Carmona 2010

VCH

3


RA Hand

Accelerated loss of muscle mass & strength compared to non-RA

IMs of RA hand, forearm, joint synovium & tenosynovium more hypoxic compared to non-RA

Hypoxia important factor contributing to intrinsic muscle dysfunction & tendon ruptures

VCH

Akhavani 2011; Beenakker 2010; Sivakumar 20084

Common Areas of Synovitis

VCH

5

RA & Hand Deformity

70% report hand & wrist dysfunction

90% develop hand deformities

More effective RA medications severe hand deformities

6

VCH

Chung 2011; Horsten 2010


RA & Hand Deformity

Presence is predictor of disease severity

Correlated with positive RF, active synovitis & disease duration

Intrinsic ms spasm common in first 3 years develop contractures

7

VCH

Akhavani 2011; Horsten 2010; Johnsson 2009; Madenci 2003; Eberhardt 1991

RA & Hand Deformity

More than one type can develop in same hand

No association with hand dominance

Impair hand strength, dexterity, mobility & efficient hand use

Functional consequences & impact QOL

8 Horsten 2010; Johnsson 2009; Adams 2008; Vliet Vlieland 1996; Eberhardt 1991

VCH

RA Hand

Occupational limitations & job loss common among active, working-age RA with hand deformities

Period of time where prevention may be possible

9 Cima 2012; Buljina 2001

VCH


RA & Hand Deformity

Understanding pathomechanics & early recognition of deformities crucial for proper management

RA individuals often reluctant to report hand-related problems early

Madenci 2003; Eberhardt 1991

VCH

10

Common Hand Deformities in RA

Ulnar Drift Deformity(UDD)

Swan-Neck Deformity(SND)

Boutonniere Deformity(BD)

Johnsson 2009

44% 24% 24%

VCH VCH VCH

11

Ulnar Drift Deformity

Ulnar Deviation Volar Subluxation

VCH VCH

Johnsson 200912


UDD Ulnar Deviation Pathomechanics

Chronic synovitis @ MCPJ weakens periarticular structures creating imbalance of passive & active forces

Attenuation of supporting structures (RCL & RSB) causes EDC tendon to displace ulnarly UD force

PP shifts ulnarly resulting in UD @ MCPJ

Akhavani 2011; Bielefeld 2005; Biese 2002; Abboud 2003

VCH VCH

13

UDDVolar Subluxation Pathomechanics

Chronic synovitis @ MCPJ weakens periarticular structures (CL & VP) normally responsible for resisting volar forces of EFF

Attenuation of periarticular structures causes volar displacement of EFF abnormal volar flexion force on PP

PP volarly subluxes relative to metacarpal head

PP

EFF (FDS & FDP)

VCH

Bielefeld 2005; Abboud 2003

VP

VCH

CL

14

Functional Consequences of UDD

Impairment of tripod pinch lateral key pinch UD (DI vs thenar / hypothenar)

Compromised power grip d/t involvement of ulnar digits ( hypoxia radial ulnar)

Inability to extend MCPJs impairment of grasp

Akhavani 2011; Johnsson 2009; Rennie 1996; Vliet Vlieland 1996

VCH

15


Management of UDD

Splinting

Hand Exercises

16

Splints for UDDRennie HJ et al. Evaluation of the Effectiveness of a Metacarpophalangeal Ulnar Deviation Orthosis. J Hand Ther 1996;9:371-377

Evaluated effects of MCP ulnar deviation splint on MCPJ alignment, hand function & pain

Splint significantly ulnar drift in middle (p=0.0002), ring (p


Clinical decision tree for splinting in UDD

Porter 2012 19

Hand Resting Splint for UDD

Purpose Pain & swelling minimize abnormal forces

Risk of intrinsic / extrinsic flexion contractures functional position

Design/Type Thermoplastic

Wear instructions

Night time use, periodically during day

Precautions Skin irritation, pressure points

Porter 2012

VCH

20

Functional MCP Splint for UDD

Purpose Pain Flexion force during grip Function by realigning fingers or prevent intrinsic-plus position

Design/Type Thermoplastic (see Appendix) Positions MCPJ in 300 flexion & neutral

deviation while keeping PIP & DIP joints free

Wear instructions Day time use

Precautions/ Contraindications

Skin irritation, pressure points Significant PIPJ synovitis or stiff PIPJ Interferes with composite grip

Porter 2012

VCH

21


Management of UDD

Splinting

Hand Exercises

22

Hand Exercises for RA

More research needed on benefits of specific hand exercises in the presence of hand deformities

Clinical practice guidelines advocate use of therapeutic exercises in the management of RA

Assumption: Hands response to exercise should be similar to other areas of body

Unclear whether whole body exercise guidelines / recommendations can be applied to RA hand

Beasley 2012; Porter 2012; Hurkmans 2011; Westby 2006; Ottawa Panel 200423


Wessel J. The Effectiveness of Hand Exercises for Persons with Rheumatoid Arthritis: A Systematic Review. J Hand Ther 2004;17:174-180

No strong evidence for the use of exercise in RA hand

No evidence of its effect on hand deformity

Appropriate long-term resisted exercises may prevent muscle atrophy & prevent or lessen severity of hand deformities

24



Exercise prescription requires knowledge of underlying pathomechanics of deformity

Type & intensity of exercises dependent on disease activity (tensile strength ), flexible or fixed, clients needs

Hand exercise should be painfree & should not promote progression of deformity

Initially monitor clients to avoid movement patterns that accentuate deformity

Beasley 2012; Porter 201225

Clinical decision tree for exercise presciption in UDD

Porter 2012 26

Clinical decision tree for exercise prescription in UDD

Porter 2012

VCH

27


Tendon Gliding Exercise

28

12

13

1

4

Porter 2012

Isometric for Radial Interossei

VCH

Porter 201229

Radial Finger Walking(Gravity Eliminated Position)

VCH VCH

Porter 201230


Radial Finger Walking(Gravity Added Position)

VCH VCH

Porter 201231

Interossei Stretch(Passive)

Porter 2012

VCH

VCH

32

Lumbrical Stretch(Active)

VCH

Porter 201233


Summary of UDD Management

Porter 2012 34





Johnsson 2009

44% 24% 24%

VCH VCH VCH

35

SND

SND MCPJ flexion, PIPJ hyperextension & DIPJ flexion

Pathomechanics complex

Anatomical predisposition to hyperextension accelerate deformity process

Porter 2012

VCH

36


SND

Can originate from MCP, PIP or DIP joints

MCPJ most frequent cause in adult RA PIPJ least common in adult RA DIPJ more common in JIA & PsA

VCH

Porter 2012: Biese 2002; Melvin 198937

SND Pathomechanics @MCPJ

Chronic synovitis / flexor tenosynovitis @ MCPJ weakens periarticular structures

Chronic inflammatory state triggers IM spasm

PP volarly subluxes overactivity of IM create excessive extensor force PIPJ hyperextension

Akhavani 2011; Tubiana 1998; Dreyfus 198338

SND Pathomechanics - MCPJ

Attenuation of transverse retinacular ligament dorsal migration of lateral bands PIPJ hyperextension

DIPJ flexes in response to tension on FDP tendon

Dreyfus 1983; Welsh 197739


Functional Consequences of SND

Difficulties with:PIPJ flexion initiationActivities requiring tip to tip or tripod pinchActivities requiring composite gripApplication of pressure at finger tipComprehensive hand-related tasks

van der Giesen 201040

VCH

Management of SND

Splinting

Hand Exercises

41

Splints for SND

Van der Giesen FJ et al. Effectiveness of Two Finger Splints for SND in Patients with RA: A Randomized, Crossover Trial. Arthritis Rheum 2009;611025-1031

Silver ring splint (SRS) and prefabricated thermoplastic splint (PTS) equally improved dexterity (P=0.05) and dexterity related pain (P=0.05)

Both types equally preferred by patients

42


Splints for SND

Zijlstra et al. Silver Ring Splints Improve Dexterity in Patients with Rheumatoid Arthritis. Arthritis Care Res 2004;51:947-951.

Improvement in dexterity (P=0.026) with SRS

For satisfactory results, careful patient assessment & optimal adjustment of SRS essential

43

Splints for SND

ter Schegget et al. A Study Comparing Use and Effects of Custom-made vs Prefabricated splints for SND in Patients with RA. Br J Hand Ther 2000;5:101-107

Both types of splint significantly improved finger stability (p


Resting Splints for SND

Purpose Pain Swelling Risk of intrinsic / extrinsic flexion

contractures

Design/Type Thermoplastic Supports PIPJ in 10-150 flexion

Wear instructions

Night time use

Precautions Skin irritation, pressure points Bulky may splay fingers

Porter 2012

VCH

46

3 Point Splints

Purpose Pain PIPJ hyperextension Hand function

Design/Type Positions PIPJ in 10-150 flexion prevents tightening of lateral bands; stretching of PIPJ volar plate, joint capsule & FDS

Prefabricated from thermoplastic Custom made from silver or thermoplastic Best applied during early stages

Wear instructions

Day time use

Precautions Skin irritation, pressure points, paraesthesia, synovitis, easy to lose

Porter 2012

VCH

47

Management of SND

Splinting

Hand Exercises

48


Clinical decision tree for exercise prescription in SND

Porter 2012 49


Porter 2012

VCH

50


Porter 2012

VCH

51


Active Extension of DIPJ(AROM)

VCH

Porter 201252

Active Flexion of PIPJ(AROM)

VCH

Porter 201253

Summary of SND Management

Porter 2012 54






Johnsson 2009

44% 24% 24%

VCH VCH VCH

55

Boutonniere Deformity (BD)(Buttonhole Deformity)

BD PIPJ flexion & DIPJ hyperextension In fixed BD, 20 changes MCPJ hyperextension

to achieve grasp

VCH

56

BDPathomechanics

Synovitis @ PIPJ

FDS unopposed PIPJ flexionProximal phalanx buttonholesdorsally between lateral bands

Disruption of central slip Stress on triangular ligamentLateral bands migrate volarly

(flexors @ PIPJ) Extensor force concentrated on

distal phalanx DIPJ hyperextension

PIPJ flexion DIPJ hyperextension

@ VCH

Hand Clinic

Hand Clinic

VCH

57


BDPathomechanics

Synovitis @ PIPJ

FDS unopposed PIPJ flexionProximal phalanx buttonholesdorsally between lateral bands

Disruption of central slip Stress on triangular ligamentLateral bands migrate volarly

(flexors @ PIPJ) Extensor force concentrated on

distal phalanx DIPJ hyperextension

PIPJ flexion DIPJ hyperextension

Hand Clinic

Hand Clinic

VCH

@ VCH

58

Functional Consequences of BD

BD demonstrate less functional impairment than UDD or SND

Often seek treatment for aesthetic / symptom relief rather than functional concerns

59 Chung 2011; Johnsson 2009; Tubiana 1998

VCH

Management of BD

Splinting

Hand Exercises

60


Splints for BD

Li-Tsang et al. The Effect of Corrective Splinting on Flexion Contracture of Rheumatoid Fingers. J Hand Ther 2002;15:185-191.

Compared dynamic and static splint for correction of flexion contractures

Both splints achieved similar extension gains but dynamic splint achieved better flexion

61

Clinical decision tree for splinting in BD

Porter 2012 62

Compression Dressings

Purpose Swelling by providing external compression to PIPJ

Design/Type Lightweight elastic material

Wear instructions

Day time use Leave tip open Apply wrap at angle with decreasing

pressure distally to proximally Should not block AROM

Precautions Skin irritation, pressure points Circulation must not be compromised

Porter 2012; Sorenson 1989

VCH

63


Gutter Splint for BD

Purpose Pain & swelling by providing local rest to PIPJ

Design/Type Thermoplastic Supports PIPJ in 00 extension

stress central slip; prevents tightening of ORL & lateral bands

Wear instructions

Night time use, periodically during day

Precautions Skin irritation, pressure points Bulky > 2 digits may splay fingers

Porter 2012

VCH

64

3 Point Splints for BD

Purpose Stress on central slip Risk of ORL & lateral band tightness

Design/Type Metal anti-boutonniere or reverse anti-swan neck splints

Thermoplastic hollow under PIPJ & dorsal strap

Wear instructions Metal day time use. Initially worn hour gradually to tolerance.

Thermoplastic night time use. Precautions / Contraindications

Skin irritation; pressure points; limit ADLs Metal 3 point splint contraindicated for

acutely inflamed PIPJ Porter 201265

VCH

Management of BD

Splinting

Hand Exercises

66


Clinical decision tree for exercise prescription in BD

Porter 2012 67

Clinical decision tree for exercise prescription in BD

VCH

Porter 2012 68

Active Flexion of DIPJ(AROM)

VCH

69 Porter 2012


ORL Stretch(Passive)

VCH

70 Porter 2012

Summary of BD Management

Porter 2012 71

CESEI

Centre of Excellence for Simulation & Innovation

Internationally recognized multi-disciplinary academic centre committed to achieving excellence in medical education, health care services and research through the use of simulation and other innovative technological means.

High tech classroom for physicians, health professionals and students

Supported & based at UBC and VCH

Numerous modules available

72


amrah

73

Take Home Message

RA hand deformities develop early in disease process impact hand function & QOL

Management complex no single approach Limited evidence to support or refute splinting

& hand exercise for deformities

More research required to guide clinicians on most effective approach to the management of hand deformities

Evidence-informed approach recommended

74

Questions

75


References

Abboud JA, Beredjiklian PK, Bozenthka DJ. Metacarpophalangeal joint arthroplasty In rheumatoid arthritis. J Am Acad Orthop Surg 2003;11:184-191.

Adams J et al. The clinical effectiveness of static resting splints in early rheumatoid arthritis: a randomized controlled trial. Rheumatology 2008;47:1548-1553.

Akhavani MA, Paleolog EM, Kang N. Muscle hypoxia in rheumatoid hands: does it play a role in ulnar drift? J Hand Surg Am 36(4):677-685. doi:10.1016/j.jhsa.2011.01.035.

Beasley J. Osteoarthritis and rheumatoid arthritis: conservativetherapeutic management. J Hand Ther 2012;25:163-172

Beenakker KGM et al. Patterns of muscle strength loss with age in the general population and patients with a chronic inflammatory state. Ageing Research Reviews. 2010; 9:431-436.

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References

Bielefeld T, Neumann DA. The unstable metacarpophalangeal joint in rheumatoid arthritis: anatomy, pathomechanics, and physical rehabilitation considerations. J Orthop Sports Phys Ther 2005;35:502-20.

Biese J. Therapists evaluation and conservative management of rheumatoid arthritis in the hand and wrist. In: Mackin EJ, Callahan AD, Skirven TM, et al, editors: Rehabilitation of the hand and upper extremity. 5th ed. St. Louis: Mosby Inc.;2002. pp. 1569-1582.

Buljina AI et al. Physical and exercise therapy for treatment of the rheumatoid hand. Arthritis Care Res. 2001;45:392-397.

Carmona L, Cross M, Williams B, et al. Rheumatoid arthritis. J Best Pract Res Clin Rheumatol 2010;24:733-45

Chung KC, Pushman AG. Current concepts in the management of therheumatoid Hand. J Hand Surg 2011;36A:736-747.

Dreyfus JN, Schnitzer TJ. Pathogenesis and differential diagnosis of the swan neck deformity. Semin Arthritis Rheum 1983;13:2:200-211.

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References

Eberhardt K, Johnson PM, Rydgren L. The occurrence and significance of hand deformities in early rheumatoid arthritis. Rheumatology 1991;30:211-213.

Formsma SA, van der Sluis CK, Dijkstra PU. Effectiveness of a MP-blocking splint and therapy in RA: A descriptive pilot study. J Hand Ther. 2008; 21:347-53.

Horsten NC, Ursum J, Roodra LA et al. Prevalence of hand symptoms, impairments and activity limitations in rheumatoid arthritis in relation to disease duration. J Rehabil Med 2010;42:916-21.

Hurkmans EJ , Jones A, Li L et al. Quality appraisal of clinical practice guidelines on the use of physiotherapy in rheumatoid arthritis: a systematic review. Rheumatology (Oxford) 2011;50:1879-1888.

Johnsson PM, Eberhardt K. Hand deformities are important signs of disease severity in patients with early rheumatoid arthritis. Rheumatol 2009;48:1398-1401.

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References Li-Tsang CW, Hung LK, Mak AF. The effect of corrective splinting on

flexion contractures of rheumatoid fingers. J Hand Ther 2002;15:185-191.

Madenci E, Gursoy S. Hand deformity in rheumatoid arthritis and its impact on the quality of life. Pain Clinic 2003;15;3:255-259.

Melvin JL. Rheumatic disease in the adult and children: occupational therapy and rehabilitation. 3rd ed. Philadelphia:FA Davis;1989,pp.284-288.

Ottawa panel evidence-based clinical practice guidelines for therapeutic exercises in the management of rheumatoid arthritis in adults. Phys Ther 2004;84:934-72.

Porter B, Brittain A. Splinting and hand exercise for three common hand deformities in rheumatoid arthritis: a clinical perspective. Curr Opin Rheumatol 2012;24(2):215-221.

Rennie HJ. Evaluation of the effectiveness of a metacarpophalangeal ulnar deviation orthosis. J Hand Ther 1996;9:371-377.

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References Sivakumar B, Akhavani MA, Winlove CP et al. Synovial hypoxia as a

cause of tendon rupture in rheumatoid arthritis. J Hand Surg 2008;33A:49-58.

Sorenson MK. The edematous hand. Phys Ther 1989;69:1059-1064.

ter Schegget M, Knipping A. A study comparing use and effects ofcustom-made versus prefabricated splints for swan neck deformity in patients with rheumatoid arthritis. Br J Hand Ther 2000;5:101-107.

Tubiana R, Thomine JM, Mackin EJ. Examination of the hand and wrist. London: Martin Dunitz Ltd; 1998. pp. 102-105.

van der Giesen FJ, Nelissen RGHH, van Lankveld WJ et al. Swan neck deformities in rheumatoid arthritis: a qualitative study on the patients perspectives on hand function problems and finger splints. Musculoskelet Care 2010;8:179-188.

van der Giesen FJ, van Lankveld WJ, Kremers-Selten C et al. Effectiveness of two finger splints for swan neck deformity in patients with rheumatoid arthritis: a randomized, crossover trial. Arthritis Rheum 2009;61:1025-1031.

80

References

Vliet Vlieland TP, van der Wijk TP, Jolie IM et al. Determinants of hand function in patients with rheumatoid arthritis. J Rheumatol 1996;23:835-840.

Welsh RP, Hastings DE. Swan neck deformity in rheumatoid arthritis of the hand. Hand 1977;9:2:109-116.

Wessel J. The effectiveness of hand exercises for persons with rheumatoid arthritis: a systematic review. J Hand Ther 2004;17:174-180.

Westby MD, Minor MA. Exercise and physical activity. In Bartlett SJ, Bingham CO, Maricic MJ et al., editors. Clinical care in the rheumatic diseases. 3rd ed. Atlanta: ARHP; 2006. pp. 211-220.

Zilstra TR, Heijnsdijk-Rouwenhorst L, Rasker JJ. Silver ring splints improve dexterity in patients with rheumatoid arthritis. Arthritis Care Res 2004;51:6:947-51.

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Appendix:

Functional MCP Splint for UDD

VCH VCH

AB

Web space

Thenar

Index

Long

management of 3 common hand deformities in ra

Documents

hand strength

hand dominance

hand exercises

vch10common hand deformities

ra hand deformity presence

nonra ims of ra hand

cesei2ra hand chronic

report hand wrist dysfunction