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Management of three common

hand 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

RA Hand

Chronic, systemic,
autoimmune disease

Symmetrical peripheral
polyarthritis

Target hands and wrists

Joint destruction &


weakening of
periarticular structures

Irreversible hand
deformities

AHPA pre-conference February 13, 2013

VCH

Cima 2012; Carmona 2010

RA Hand

VCH

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
Akhavani 2011; Beenakker 2010; Sivakumar 2008

Common Areas of Synovitis

VCH

RA & Hand Deformity

70% report hand &


wrist dysfunction

90% develop hand


deformities

More effective RA
medications
severe hand
deformities

AHPA pre-conference February 13, 2013

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

VCH

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

RA & Hand Deformity

VCH

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

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

RA Hand

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

Period of time where


prevention may be
possible

AHPA pre-conference February 13, 2013

VCH

Cima 2012; Buljina 2001

RA & Hand Deformity

Understanding
pathomechanics &
early recognition of
deformities crucial for
proper management

RA individuals often
reluctant to report
hand-related problems
early

VCH

Madenci 2003; Eberhardt 1991

10

Common Hand Deformities in RA

VCH

VCH

Ulnar Drift Deformity


(UDD)

Swan-Neck Deformity
(SND)

44%

24%

VCH

Boutonniere Deformity
(BD)
24%

11

Johnsson 2009

Ulnar Drift Deformity


Ulnar Deviation

Volar Subluxation

VCH

12

AHPA pre-conference February 13, 2013

VCH

Johnsson 2009

UDD
Ulnar Deviation Pathomechanics

VCH

VCH

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

13

Akhavani 2011; Bielefeld 2005; Biese 2002; Abboud 2003

UDD
Volar Subluxation Pathomechanics

PP

CL
VP
EFF (FDS & FDP)

VCH

VCH

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

14

Bielefeld 2005; Abboud 2003

Functional Consequences of UDD

15

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

VCH

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

AHPA pre-conference February 13, 2013

Management of UDD

Splinting

Hand Exercises

16

Splints for UDD


Rennie 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

significantly ulnar drift in middle (p=0.0002),


ring (p<0.0001) & little (p<0.0001) fingers assessed by
radiography & goniometry

Splint

Tripod

pinch improved (p<0.0001)

No

significant improvement in grip strength, pain or


hand function

Limitation:

No control group

17

Splints for UDD


Formsma SA et al. Effectiveness of a MP Blocking
Splint and Therapy in RA: A Descriptive Pilot Study. J
Hand Ther 2008;21:347-353
Evaluated

effects of MCP blocking splint & hand


exercises in RA patients with intrinsic-plus posture &
movement patterns

Evaluated

strength, ROM, dexterity & pattern of hand

movement
Showed

significant improvement in dexterity (p=0.046)


and pain (p=0.043) measured by Sequential
Occupational Dexterity Assessment (SODA)

18

AHPA pre-conference February 13, 2013

Clinical decision tree for splinting in


UDD

19

Porter 2012

Hand Resting Splint for UDD


VCH

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

20

Functional MCP Splint for UDD


VCH

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

21

AHPA pre-conference February 13, 2013

Porter 2012

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 2004

23

Hand Exercises for RA


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

AHPA pre-conference February 13, 2013

Hand Exercises for RA

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 2012

25

Clinical decision tree for exercise


presciption in UDD

Porter 2012

26

Clinical decision tree for exercise


prescription in UDD

VCH

27

AHPA pre-conference February 13, 2013

Porter 2012

Tendon Gliding Exercise

1
4

1
3

Porter 2012

28

Isometric for Radial Interossei

VCH

Porter 2012

29

Radial Finger Walking


(Gravity Eliminated Position)

VCH

30

AHPA pre-conference February 13, 2013

VCH

Porter 2012

Radial Finger Walking


(Gravity Added Position)

VCH

VCH

Porter 2012

31

Interossei Stretch
(Passive)

VCH

VCH

Porter 2012

32

Lumbrical Stretch
(Active)

VCH

33

AHPA pre-conference February 13, 2013

Porter 2012

Summary of UDD Management

Porter 2012

34

Common Hand Deformities in RA

VCH

VCH

Ulnar Drift Deformity


(UDD)

Swan-Neck Deformity
(SND)

44%

24%

VCH

Boutonniere Deformity
(BD)
24%

35

Johnsson 2009

SND

VCH

SND MCPJ flexion, PIPJ hyperextension &


DIPJ flexion

Pathomechanics complex

Anatomical predisposition to hyperextension


accelerate deformity process

36

AHPA pre-conference February 13, 2013

Porter 2012

SND

VCH

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


Porter 2012: Biese 2002; Melvin 1989

37

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

38

Akhavani 2011; Tubiana 1998; Dreyfus 1983

SND Pathomechanics - MCPJ

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

DIPJ flexes in response


to tension on FDP
tendon

39

AHPA pre-conference February 13, 2013

Dreyfus 1983; Welsh 1977

Functional Consequences of SND


Difficulties with:
PIPJ

flexion initiation

Activities

requiring tip to
tip or tripod pinch

Activities

requiring
composite grip

Application

of pressure

at finger tip
VCH

Comprehensive

hand-

related tasks
van der Giesen 2010

40

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

AHPA pre-conference February 13, 2013

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<0.014) & passive DIPJ extension (p=0.010)

SRS

preferred for cosmesis (p<0.0001) & scored


higher for comfort (p<0.011) than thermoplastic splints

44

Clinical decision tree for splinting in


SND

45

AHPA pre-conference February 13, 2013

Porter 2012

Resting Splints for SND


VCH

Pain
Swelling
Risk of intrinsic / extrinsic flexion
contractures

Purpose

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

46

3 Point Splints
VCH

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
Day time use
instructions
Precautions Skin irritation, pressure points,
paraesthesia, synovitis, easy to lose
47

Porter 2012

Management of SND

Splinting

Hand Exercises

48

AHPA pre-conference February 13, 2013

Clinical decision tree for exercise


prescription in SND

Porter 2012

49

Clinical decision tree for exercise


prescription in SND

VCH

Porter 2012

50

Clinical decision tree for exercise


prescription in SND

VCH

51

AHPA pre-conference February 13, 2013

Porter 2012

Active Extension of DIPJ


(AROM)

VCH

Porter 2012

52

Active Flexion of PIPJ


(AROM)

VCH

Porter 2012

53

Summary of SND Management

54

AHPA pre-conference February 13, 2013

Porter 2012

Common Hand Deformities in RA

VCH

VCH

Ulnar Drift Deformity


(UDD)

Swan-Neck Deformity
(SND)

44%

24%

VCH

Boutonniere Deformity
(BD)
24%

55

Johnsson 2009

Boutonniere Deformity (BD)


(Buttonhole Deformity)

VCH

BD PIPJ flexion & DIPJ hyperextension

In fixed BD, 20 changes MCPJ hyperextension


to achieve grasp

56

Synovitis @ PIPJ
PIPJ flexion
DIPJ hyperextension

@ VCH

BD
Pathomechanics

Disruption of central slip


Stress on triangular ligament
Lateral bands migrate volarly
(flexors @ PIPJ)
Extensor force concentrated on
distal phalanx DIPJ hyperextension

VCH

FDS unopposed PIPJ flexion


Proximal phalanx buttonholes
dorsally between lateral bands
Hand Clinic

Hand Clinic

57

AHPA pre-conference February 13, 2013

Synovitis @ PIPJ
PIPJ flexion
DIPJ hyperextension

@ VCH

BD
Pathomechanics

Disruption of central slip


Stress on triangular ligament
Lateral bands migrate volarly
(flexors @ PIPJ)
Extensor force concentrated on
distal phalanx DIPJ hyperextension

VCH

FDS unopposed PIPJ flexion


Proximal phalanx buttonholes
dorsally between lateral bands
Hand Clinic

Hand Clinic

58

Functional Consequences of BD

VCH

BD demonstrate less functional impairment


than UDD or SND

Often seek treatment for aesthetic / symptom


relief rather than functional concerns
Chung 2011; Johnsson 2009; Tubiana 1998

59

Management of BD

Splinting

Hand Exercises

60

AHPA pre-conference February 13, 2013

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
VCH

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
63

AHPA pre-conference February 13, 2013

Porter 2012; Sorenson 1989

Gutter Splint for BD


VCH

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

64

3 Point Splints for BD


VCH

Purpose

Stress on central slip


Risk of ORL & lateral band tightness

Metal anti-boutonniere or reverse antiswan neck splints


Thermoplastic hollow under PIPJ &
dorsal strap
Wear instructions Metal day time use. Initially worn hour
gradually to tolerance.
Thermoplastic night time use.
Design/Type

Precautions /
Skin irritation; pressure points; limit ADLs
Contraindications Metal 3 point splint contraindicated for
acutely inflamed PIPJ
Porter 2012

65

Management of BD

Splinting

Hand Exercises

66

AHPA pre-conference February 13, 2013

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

AHPA pre-conference February 13, 2013

Porter 2012

ORL Stretch
(Passive)

VCH

Porter 2012

70

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

AHPA pre-conference February 13, 2013

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

AHPA pre-conference February 13, 2013

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):677685. doi:10.1016/j.jhsa.2011.01.035.

Beasley J. Osteoarthritis and rheumatoid arthritis: conservative


therapeutic 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.

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 the


rheumatoid 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.

76

References

77

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 MPblocking 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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AHPA pre-conference February 13, 2013

References

Li-Tsang CW, Hung LK, Mak AF. The effect of corrective splinting on
flexion contractures of rheumatoid fingers. J Hand Ther 2002;15:185191.

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.

79

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 of


custom-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;23:835840.
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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AHPA pre-conference February 13, 2013

Appendix:
Functional MCP Splint for UDD

Index
Long

Web
space

A
B

Thenar

VCH

AHPA pre-conference February 13, 2013

VCH