Rheumatoid Arthritis

(+) Hand Deformity

12 JANUARY 2018
Medical Background
 Related Anatomy
The wrist joint is a complex, multi articulated joint that allows wide range of motion in flexion,
extension, circumduction, radial deviation, and ulnar deviation.
A total of 27 bones constitute the basic skeleton of the wrist and hand
The hand is innervated by 3 nerves - the median, ulnar, and radial nerves — each of which has
sensory and motor components. The muscles of the hand are divided into intrinsic and extrinsic
groups.
Kinesiology
 Pathophysiology
External Trigger (Smoking, Infection or Trauma) → Autoimmune Response
→ Synovial Hypertrophy → Chronic Jt. Inflammation → Extra-articular
Manifestations (Cartilage and Bone Destruction)

CD4 T-cells, mononuclear phagocytes, fibroblasts, osteoclasts, and

neutrophils vs. B cells (produces autoantibodies such as rheumatoid
factors) - TNF-α, IL-1, IL-6, IL-8, TGF-ß, FGF, and PDGF
 Etiology
A. Genetic: 60% - Genetic Factor: HLA - DR4
B. Infectious agents: Mycoplasma organism, EBV, rubella virus
C. Hormonal Factors:
 Epidemiology
- Prevalent ampng adults
- 2-4x F > M
- White > african Americans
- MCP and PIP joints of hands & MTP of feet: 90%
- Knees,ankles and wrists: 80%
- Shoulders: 60%
- Elbows: 50%
- TM,AC & SC joints: 30%
 RISK FACTORS
- Gender: F>M
- Age: 40-60
- Genetics
- Smoking
- Environmental Exposures
- Obesity
 CLINICAL PRESENTATION
-Stiffness
-Tenderness
-Pain on motion
-Swelling
-Deformity (ulnar drift, boutonniere and swan neck deformity,
-Limitation of motion
-Extra-articular manifestations
-Rheumatoid nodules (Bouchard’s/Heberden nodes)
 Description of the dse
- A destructive chronic synovitis in multiple diarthrodial joints with a variety of systemic manifestation
- “autoimmune disease”
- Most commonly affects the joints: Hands, feet, elbows, knees and ankles
- Joint effect is “symmetrical”
- Hallmark feature: persistent symmetric polyarthritis (synovitis) that affects the hands and feet, through any
joint lined by a synovial membrane may be involved
- Radiographic hallmarks: Soft tissue swelling, Joint space narrowing, Marginal erosions and Extra-
articular involvements of organs Anti-cyclic citrullinated protein antibody (ACPA) and rheumatoid factor (RF)
is highly specific for this condition
Stages of RA
CLASSIFICATION & DIAGNOSTIC CRITERIA FOR RA (1987)
CLASSIFICATION CRITERIA FOR RA (ACR/EULAR) 2010
CLASSIFICATION FOR FUNCTIONAL STATUS IN RA
➢ Class 1: Independent in all ADLs (self-care, vocational, avocational)
➢ Class 2: (+) self-care and vocational, limited avocational
➢ Class 3: (+) self-care, limited vocational and avocational
➢ Class 4: limited in all ALDs (self-care, vocational, avocational)
Differential Diagnosis
General Information
Pt’s name: B.B.
Sex: F
Age: 60
Address: Dona Imelda, Quezon City
Civil Status: Married
Handedness: (R)
Occupation: Secretary
Referring Unit: OPD
Referring MD: Dr. M.C.
Rehab MD: Dr. D.O.
Date of Consultation: January 2, 2019
Date of Referral: January 30, 2019
Date of IE: January 31, 2019
MD Dx: Stage 3 Rheumatoid Arthritis
Subjective
HPI
Present condition started ~ 10mo. PTIE when pt noted swelling of PIP joints on B hands c accompanied
fatigue at about the end of the day. Pt. thought of it as signs of overworking and thus rested it out s any
intervention. This lasted for 3 months with the additional S/Sx noted throughout: frequent stiffness on B
PIP and MCP joints for ~1 hr upon waking up and intermittent dull pain (PS 7/10) on B hands upon
prolonged typing and writing during work. Pt took OTC pain meds to counter the pain and reported ¯ pain,
(PS 2-3/10) ~30min p intake. S/Sx still persisted for ~3 months with pt having increased difficulty in
performing daily activities such as cooking, cleaning, and doing the laundry d/t pain (PS 6-8/10) and
stiffness on B hand joints. Pt’s concern grew when for another 2 months, the symptoms continued to
persist until pt cannot work and perform ADLs s having to rest B hands for ~10mins, presence of nodules
on the dorsum of B MCP joints, hyperextension of PIP joints & flexion of DIP joints on B hands were also
noted.
Pt continued to alleviate the pain through rest and OTC pain meds (PS 8/10® PS 3-4/10). This prompted
pt to seek medical consult but d/t pt’s busy schedule, pt was only able to have a checkup p a month. Upon
MD evaluation, pt was prescribed c meds (see Meds taken) and was advised to have procedures done to
confirm Dx (see Ancillary Procedures); each procedure were done c a one week interval in accordance to
pt’s work schedule. Upon MD evaluation of procedure results, pt was Dx c RA on B MCP and PIP joints
and was then referred to PT rehab for further evaluation and management.
PMHx
(-) rheumatoid fever
(-) SLE
(-) trauma on B hands
(-) OA
(-) HTN
(-) DM
(-) CA
(-) cardiac disease
(-) respiratory disease
FMHx
PSHx
● Pt used to be a smoker ( 4 pack years)
● Pt drinks alcohol occasionally ( 3 bottles/day)
● Pt works as a secretary in a law firm for 8hrs a day
● Pts job consists of typing/writing documents continuously c 10 min breaks every hour
● Pt does the household chores such as cooking, cleaning the house and doing the laundry every
weekend

Home situation
● Pt lives c her husband and child
● Pt has insurance which will help cover the expenses for her rehab
Environment Assessment
Home:
Pt. lives in a bungalow type house c ventilated and well lit rooms.
Using the main entrance as reference, the ff. measurements were noted:
● Bed room: ~15m
● Living room: ~ 5m
● Kitchen: ~8m
● Bathroom: ~7m

Using the floor as reference point, the following heights were noted:
Bathroom:
● Light switch = ~1.6 m
● Faucet = ~1.5m
● Shower knob = ~0.5 m
Living room:
● Coffee Table = ~0.5m
● Electric Fan = 1.8 m
● Bookshelf = ~ 2.5 m
● TV = ~ 1.5 m

Grip measurement:
● Remote = ~1.5 in
● Glass (cups) = ~2.5 in
● Eating utensils = ~0.3 in
● Cooking utensils = ~0.5 in
● Ball pen= ~0.2 in
● Lever type door knob = ~1 in
● Drawer handles = ~0.5 in
Work:
Pt spends most her time (~ 7 hrs) in the office, in front a table either typing or writing documents. Using the
floor as reference point, the following heights were noted:
● Chair = ~0.60 m
● Table=~ 1.6 m
● Bookshelf = ~ 2.5 m
Medications taken
Ancillary Procedures
C/C: Pt c/o intermittent pain and stiffness on B hands (7/10)
aggravated by prolonged typing , writing and by doing adls such
as cooking, doing the laundry and cleaning the house which is
alleviated by rest and medications.

Goal: " Gusto ko mawala na sana yung sakit para makatrabaho

nako ng maayos"
Objective
Vital Signs
BP: 110/80mmHg
HR: 88bpm
RR: 17cpm
Temp: 36.6C
SaO2: 99%

Findings: Results are WNL.

Significance: Results will be for baseline precaution to exercise.
OI
Amb s AD
Alert, coherent, cooperative
Ectomorph
(+) swelling on all MCP, PIP jt of B hands (See anthropometric measurement)
(+) redness on all MCP, PIP jt of B hands
(+) swan neck deformity on B hands
(+) postural deviation (see: Postural A:)
(-) ulnar drift deviation on B hands
(-) Bouchard & Heberden nodes on B hands
(-) ms atrophy on B UE
(-) wound/bruises on B UE
Palpation
Hyperthermic on all MCP, PIP jt of B hands
Gr. 1 Tenderness on all MCP, PIP jt of hands
Normotonic on B UE
(-) subluxation on B UE
(-) crepitus on all MCP, PIP jt of hands
(-) edema on B hands
(-) dislocation on B hands
ROM
Motion AROM PROM N Diff EF
All major joints of B
R L R L
UE/LE, neck and trunk
Wrist 0-70 0-70 0-70 0-70 0-80 R: 10/10 Firm
were actively and Flexion L: 10/10
passively assessed and Wrist 0-60 0-60 0-60 0-60 0-70 R: 10/10 Firm
are found to be WNL, Extension L: 10/10
pain-free and are Wrist Radial 0-10 0-10 0-10 0-10 0-20 R: 10/10 Firm
within N EF, except the Deviation L: 10/10
ff: Wrist Ulnar 0-20 0-20 0-20 0-20 0-30 R: 10/10 Firm
deviation L: 10/10
2nd-5th 0-70 0-70 0-80 0-80 0-90 R: 20/10 Firm
MCP flexion L: 20/10
2nd-5th 0-20 0-20 0-20 0-20 0-45 R: 25/25 Firm
MCP L: 25/25
extension
2nd-5th PIP -5-70 -5-70 -5-70 -5-70 0-100 R: 30/30 Firm
flexion L: 30/30
2nd-5th PIP 70-0 70-0 70-0 70-0 0-100 R: 30/30 Firm
extension L: 30/30
 2nd-5th DIP 10-50 10-50 10-60 10-60 0-90 R: 40/30 Firm
flexion L: 40/30
2nd-5th DIP 0-5 0-5 0-5 0-5 0-10 R: 5/5 Firm
extension L: 5/5

1st CMC 0-10 0-10 0-10 0-10 0-15 R: 5/5 Firm

flexion L: 5/5
1st CMC 0-60 0-60 0-60 0-60 0-70 R: 10/10 Firm
Abduction L: 10/10
1st MCP 0-40 0-40 0-40 0-40 0-50 R: 10/10 Firm
flexion L: 10/10
1st IP 0-60 0-60 0-60 0-60 0-80 R: 20/20 Firm
flexion L: 20/20
1st IP 0-5 0-5 0-5 0-5 0-20 R: 15/15 Firm
extension L: 15/15

Findings: LOM on all wrist and hand joint 2 to pain and deformity.
Significance: Pt will have difficulty in doing ADLs such as self care activities and typing activities.,
 MMT
All major ms groups of B UE/LE, neck and trunk Ms group R L
were assessed and were found to be grade 5/5 Wrist extensors 4/5 4/5
except the ff: Wrist flexors 4/5 4/5

Ulnar Deviation 4/5 4/5

Radial deviation 4/5 4/5

2nd-5th MP flexors 3/5 3/5

2nd-5th PIP flexors 3/5 3/5

2nd-5th DIP flexors 3/5 3/5

Findings: Weakness on B wrist and hand ms
group. 2nd-5th MP extensors 3/5 3/5

2nd-5th PIP extensors 3/5 3/5

Significance: Pt may have difficulty in lifting and
2nd-5th DIP extensors 3/5 3/5
gripping objects when performing ADLs such as
eating, bathing/dressing. 1st MP and IP flexors 3/5 3/5

1st MP and IP extensors 3/5 3/5

Opposition 3/5 3/5

Grip A
Pt was assessed using hand dynamometer c the ff results:
Handedness: R
Sensory A
Anthropometric Measurement
Postural A
ADL A
Pt is completely independent in bed mobility and transfers, level and unlevelled surface
ambulation, eating, and self-care activities such as bathing, toileting, grooming and garment
dressing.
Activity Demonstration
Eating Pt requires assistance in preparing her food especially when cutting food since she has
moderate difficulty in using the utensils during eating. Pt usually puts the handle of the
spoon in between the index and the thumb. Pt has minimal difficulty in holding cups or
glasses c wide circumference.
Bathing/Toileting Pt uses the shower and has moderate difficulty in turning the knob of the shower. Pt holds
the shampoo bottle in between the thumb and the four fingers, forming a “c”. Pt also
holds the shower gel bottles this way since Pt has difficulty in holding bar soaps.
Grooming Pt holds the brush on its head instead on its handle when brushing her hair.
Activity Demonstration
Upper Garment Dressing Pt has no difficulty in putting on upper garments, whether it is a blouse or shirt. However, Pt has moderate
difficulty in buttoning up clothes. Pt has increased performance time in buttoning up or usually asks for an
assistance from her husband.

Lower Garment Dressing Pt has no difficulty in putting on lower garments, however, Pt has moderate difficulty in buttoning up jeans
and has increased performance time upon doing this task.

Cleaning the house Pt has no difficulty in washing the dishes or wiping the tables, however, Pt has increased performance
time in doing the task because of frequent rest periods. Pt has minimal to moderate difficulty in holding the
sponge and the plates: Pt holds the plates in between the thumb and the four fingers, forming a “c” while
pressing the sponge onto the plates c the use of her palm and doing circular motions. Pt usually uses a
glove-like cleaning tool to wipe the tables and other surfaces of their house.

Cooking Pt has moderate difficulty in holding on the handles while minimal difficulty in holding bottles being used
during the task. Pt also has moderate difficulty in putting on spices using her hand therefore Pt usually
uses a spoon to put on spices.
Activity Demonstration
Laundry Pt has moderate difficulty in doing the task, however, Pt has increased
performance time due to frequent rest periods. Pt hand washes their uniforms:
sitting on a low stool while scrubbing the clothes using a brush on a wooden panel
inside a pail or basin. Pt uses a brush c handle on its top, inserting only her four
fingers.
Typing/Writing Pt has moderate difficulty and has increased performance upon doing the task due
to frequent rest periods. Pt usually holds the pen in between her thumb and the
index finger.
Assessment
PTDx
MDDx of Rheumatoid Arthritis on B hands further defined by modified independence in ADLs that requires
the use of hands in manipulating objects such as in during eating, bathing, grooming, dressing, typing,
doing laundry secondary to intermittent pain and stiffness on B hands, LOM, decreased mm and grip
strength of B hands, swelling and redness over PIP, MCP joints of B hands along with evident swan neck
deformity,
PT Prognosis
Pt has fair prognosis as to going back to work in typing/writing s experiencing pain at all
since pt’s condition is a relapsing-remitting and a progressive one. Also, considering pt’s age
and that pt seek for rehab when her condition is in chronic stage wherein it’s considered as a
negative factor. Pt’s also presents c deformities that cannot be fully addressed c PT
management thus pt may be advised to look for work that will not aggravate her symptoms.
As for LOM, decreased mm and grip strength, swelling, pain can be addressed c PT
management along c medications that can also slow down pt’s condition.
Rehab potential
Pt has fair rehab potential d/t her busy schedule wherein she might have inconsistencies as to
attending PT rehab but she’s willing to undergo rehab. However, pt is supported by family and
insurances will shoulder rehab expenses.
Problem List
1. Minimal to moderate difficulty in ADLs that requires use of hands as manifested by modified
independence and decreased performance time during typing, doing laundry, eating, bathing
2. Decreased mm strength of B hands as manifested by 3-4/5
3. Decreased grip strength on B hands as manifested by less than normal value wherein (L)
hand is much weaker than ® hand
4. LOM of B hands (MCP, PIP, DIP joints)
5. Intermittent pain over B hands
6. Swelling on all MCP, PIP jt of B hands
7. Postural deviation
LTG
1. Pt will be able to independently modify writing/typing c minimal pain (along c intake of
medications), c rest intervals every after 30 minutes and c environmental modifications after 1
month of PT session.
2. Pt will maintain available ROM on B hands and wrists to prevent complications
STG
1. Pt will be able to perform ADLs c min difficulty as to grasping or manipulating objects after
2weeks of PT session
2. Pt will demonstrate inc in muscle strength on B hands by 1 grade p 1 month of PT session
3. Pt will demonstrate inc grip strength on B hands by 2kg p 1 mo of PT session
4. Pt will demonstrate dec pain on B hands from PS: 7/10 to PS: 2/10 p 3 weeks
5. Pt will demonstrate dec swelling on B hands as manifested by dec displaced water for ~ __
mL p 3 weeks of PT sessions
6. Pt will demonstrate inc kinesthetic awareness as to proper posture c dec visual, tactile and
verbal cues p 3 PT sessions
Plan
Pt will be seen 3x/week for 6 weeks
1. Paraffin on B hands and wrist x 20 mins to decrease pain and swelling
2. AAROMEs on B wrist, hand, and fingers x 10 reps x 1 set to maintain joint integrity
3. Stretching of B hands and fingers (MCP,DIP & DIP) on AP x 30 SH x 3 reps x 1 set to increase tissue
extensibility
4. Strengthening exercise on B hand using theraputty (color yellow) on B hands x 6SH x 10 reps x 1 set to
increase grip strength
5. Strengthening exercise on B hand using power web (color yellow) on B hands x 6SH x 10 reps x 1 set to
increase grip strength
Progression
1. AROMEs on B wrist, hand, and fingers x 10 reps x 1 set to maintain joint integrity
2. Self-stretching of B hands and fingers (MCP,DIP & DIP) x 30SH x 3 reps x 1 set to increase tissue
extensibility
3. Strengthening exercise using theraputty (color green) on B hands x 6SH x 10 reps x 2 sets to increase
grip strength
4. Strengthening exercise on B hand using power web (color green) on B hands x 6SH x 10 reps x 2 set to
increase grip strength

HEP
1. Self ROM exercise on B wrist, hand, and fingers on AP x 10 reps x 1 set to inc ROM and maintain joint
integrity
2. Grip strengthening ex using squeeze ball or water filled plastic bottle x 6 SH x 10 reps x 1 set to inc grip
strength
Pt Education
1. Respect pain
2. Teach the pt about her condition
3. Regularly drink her prescribed meds
4. Refer to OT for splint to address swan neck deformity
5. Joint conservation techniques :
● Monitor activities and stop when discomfort or fatigue begins to develop
● Modify or discontinue any activity or exercise that causes pain that lasts longer than 1 hour after stopping the activity
● Use frequent short episodes of exercise rather than one long session
● Avoid deforming positions or twisting and wringing motions with the fingers
● Avoid prolonged static positioning
● Use stronger, larger joints whenever feasible. For example, carry items in a shoulder bag or over the forearm or with
two hands rather than with one hand
● Cut food with the blade of the knife protruding from the ulnar side of the hand
● Stir food with spoon on the ulnar side of the hand
● Build up the handles of eating utensils
● Press water out of a rag by opposing the palms of both hands together