Wrist/Hand Rheumatoid Arthritis

Question 1

Inflammatory Stages of RA

What are the Characteristics of the Acute Stage of RA?

Answer 1

• Pain, swelling, warmth, and limited ROM

This is due to synovitis and tissue proliferation which occurs at the MCP, PIP, and distal radioulnar joint

The cycle of inflammation causes stretching and swelling within the joints. Then it heals and then its scarring results in damage to the periarticular tissues and surrounding soft tissue.
- These deformities ultimately lead to reduced hand and limb function
- Altough adaptations are helpful the disease progresses and accumulates to the point where simple ADLs become difficult.
- Pain and instabilites of the wrist may limit function in the elbow or shoulder

Question 2

Inflammatory Stages of RA

What are the Characteristics of the Chronic Stage of RA?

Answer 2

• There will be damages that include deformities, muscle weakness/imbalances, chronic pain, limited ROM or joint instability

Instability, subluxations and defromities occur in the later/more advanced stages of the disease

Common joint deformities include: Ulnar Drift, Boutonniere, Swan Neck, Z Deformity

Question 3

What is Boutonniere Deformity?

What can this result in?

Answer 3

This is damage to the Central Slip insertion of Dorsal PIP, causing the Lateral Bands to drift forward

AKA Buttonhole Deformity

This results in Flexion of the PIP and Hyperextension of the DIP

Question 4

What should be done for Interventions for Boutonniere Deformity?

Answer 4

Initial treatment: Splinting PIP in extension and still allowing for the DIP to flex. This is done for ~4 weeks.

• Begin AROM around 4-8 weeks
• Strengthening at 10-12 weeks

Question 5

What is Swan Neck Deformity?

Answer 5

This is Hyperextension of the PIP and flexion of the DIP

• This occurs from damage to the oblique retinaculular ligaments, which leads to Dorsal displacement of the lateral bands of the extensor mechanism

Question 6

What should be done for Interventions for Swan Neck Deformity?

Answer 6

Successful Treatment may include Figure-8 splint/bandage that prevents extension of the PIP

Question 7

What is Ulnar Drift a result of?

Answer 7

This is a result from damage to the collateral ligaments and extensor mechanism, resulting in an imbalance and pulling of the MCPs into ulnar deviation, pronation and in severe cases anterior subluxation

Question 8

What should be done for Interventions for pts with RA in the Acute Stage?

Answer 8

• Firstly we must Manage and control inflammation as a first line of treatment.
• Stretching is not approptiate in the acute stage
• If inflammation is well controlled, active exercise and isometric exercises are often well tolerated

Question 9

What should be done for Interventions for pts with RA in the Chronic Stage and Deformities are present?

Answer 9

Consider a resting hand orthoses to prevent further deformity or migration
- Focus on the entire joint system rather than isolated joints
For ex. if the pts. hand hurts, provide ROM, stretching or strengthening exercises as approptiate for neighboring joints to prevent additional impairments
- Joint Protection and Pain management are good interventions and educational tools to help patient manage the condition