Rheumatoid Hand Management: A Physical Therapy Rehabilitation Protocol

Pathophysiology

Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disease characterized by inflammation of the synovial membranes, particularly affecting the small joints of the hands and wrists. This inflammation leads to synovial hyperplasia, pannus formation, and ultimately, cartilage and bone destruction. Common deformities in the hand include ulnar drift of the metacarpophalangeal (MCP) joints, swan neck deformities (hyperextension of the PIP joint and flexion of the DIP joint), boutonniere deformities (flexion of the PIP joint and hyperextension of the DIP joint), and tenosynovitis, particularly of the flexor and extensor tendons. Wrist involvement often leads to carpal instability and pain. The inflammatory process also affects surrounding ligaments, tendons, and muscles, contributing to weakness and loss of function. Early diagnosis and aggressive management are crucial to slow disease progression and preserve hand function. Patient education regarding joint protection principles and activity modification is paramount.

Phase I: Protection (Acute Inflammatory Phase)

The primary goals during this phase are to reduce pain and inflammation, protect the joints from further damage, and maintain range of motion (ROM) without exacerbating symptoms.

• Goals: Pain reduction, inflammation control, joint protection, maintenance of ROM, prevention of further deformity.
• Interventions:
• Rest and Splinting: Custom-made or prefabricated splints to immobilize and support affected joints, especially during periods of acute inflammation. Common splints include wrist cock-up splints, MCP ulnar deviation splints, and finger splints to address swan neck or boutonniere deformities. Splinting schedules should be individualized based on patient needs, but typically involve wearing the splint during periods of high activity or at night.
• Modalities for Pain and Inflammation: Cryotherapy (ice packs for 15-20 minutes several times a day) to reduce inflammation. Thermotherapy (warm water soaks or paraffin wax) may be used for pain relief and stiffness, but with caution to avoid exacerbating inflammation. Ultrasound or electrical stimulation may also be considered, as appropriate.
• Gentle Range of Motion (ROM) Exercises: Active assisted ROM (AAROM) and gentle active ROM (AROM) exercises within pain-free limits. Emphasis on composite fist, individual finger flexion/extension, thumb opposition, wrist flexion/extension, and radial/ulnar deviation. Exercises should be performed slowly and deliberately to avoid stressing the joints.
• Tendon Gliding Exercises: Promote tendon excursion and prevent adhesions. Exercises include straight fist, hook fist, full fist, table top fist, and straight finger fist. These should be performed gently and regularly.
• Joint Protection Education: Teach patients principles of joint protection, including using larger joints for tasks (e.g., using the shoulder to open a door instead of the wrist), avoiding prolonged gripping, using adaptive equipment, and pacing activities to avoid fatigue.
• Edema Management: Elevation of the hand, light compression gloves, and gentle retrograde massage.
• Precautions: Avoid aggressive stretching or strengthening exercises that could exacerbate inflammation or damage joints. Monitor for signs of increased pain, swelling, or warmth after exercise.

Phase II: Loading (Subacute Phase)

Once inflammation is controlled and pain is reduced, the focus shifts to gradually increasing strength and stability while continuing to protect the joints.

• Goals: Improve strength and endurance, increase joint stability, improve functional use of the hand, continue pain and inflammation control.
• Interventions:
• Progressive Strengthening Exercises: Isotonic exercises (e.g., using therapy putty, hand grippers, or light weights) to strengthen the muscles of the hand and wrist. Start with low resistance and high repetitions, gradually increasing resistance as tolerated. Focus on strengthening grip strength, pinch strength, and wrist extensor/flexor strength.
• Isometric Exercises: Isometric exercises can be used to strengthen muscles without putting excessive stress on the joints. Examples include gripping a ball and holding it for several seconds, or pressing the fingertips together.
• Functional Activities: Incorporate functional tasks into the rehabilitation program, such as grasping objects, manipulating small items, and performing simulated work or household activities. Modify activities as needed to minimize stress on the joints.
• Splint Weaning: Gradually reduce splint usage as symptoms allow. Encourage active use of the hand without splint support during low-stress activities.
• Proprioceptive Exercises: Improve joint awareness and coordination through activities such as ball tossing, pegboard exercises, and object manipulation with eyes closed.
• Scar Management (if applicable): If there are scars present (e.g., from surgery), scar massage and silicone gel sheeting can help to improve scar mobility and reduce pain.
• Precautions: Avoid activities that cause pain or swelling. Monitor for signs of joint instability. Progress gradually and avoid overexertion.

Phase III: Return to Function (Chronic Phase)

This phase focuses on maximizing functional independence and returning the patient to their desired activities. The goal is to maintain gains in strength and ROM, prevent recurrence of symptoms, and promote long-term self-management.

• Goals: Maximize functional independence, return to desired activities, maintain gains in strength and ROM, prevent recurrence of symptoms, promote long-term self-management.
• Interventions:
• Advanced Strengthening Exercises: Progress to higher-level strengthening exercises, such as using heavier weights or resistance bands. Focus on building endurance and power for demanding activities.
• Activity-Specific Training: Simulate and practice activities that are important to the patient's daily life or work. This may involve adapting tools or equipment to make tasks easier.
• Ergonomic Assessment and Modification: Evaluate the patient's work or home environment and make recommendations for ergonomic modifications to reduce stress on the joints. This may include adjusting chair height, using a wrist rest, or modifying tools.
• Self-Management Education: Teach the patient strategies for managing their symptoms, including pacing activities, using joint protection techniques, and recognizing signs of flare-ups. Emphasize the importance of regular exercise and adherence to medication regimens.
• Maintenance Program: Develop a home exercise program that the patient can continue independently to maintain gains in strength and ROM. Encourage regular follow-up appointments with the physical therapist as needed.
• Adaptive Equipment Training: Introduce and train the patient on the use of adaptive equipment to assist with daily tasks. Examples include jar openers, button hooks, and built-up utensils.
• Precautions: Monitor for signs of overuse or flare-ups. Encourage the patient to listen to their body and modify activities as needed. Emphasize the importance of long-term self-management.

Common Special Tests for Rheumatoid Hand

• Finkelstein's Test: Assesses for de Quervain's tenosynovitis.
• Phalen's Test: Assesses for carpal tunnel syndrome.
• Tinel's Sign: Assesses for nerve compression or irritation (e.g., carpal tunnel syndrome, cubital tunnel syndrome).
• Froment's Sign: Assesses for ulnar nerve palsy (specifically, the adductor pollicis muscle).
• Thumb Grind Test: Assesses for carpometacarpal (CMC) joint arthritis.
• Allen Test: Assesses for radial and ulnar artery patency.
• Bunnel-Littler Test: Differentiates between intrinsic muscle tightness and joint capsule tightness at the PIP joint.