Hallmarks of RA. Rheumatoid Arthritis

Transcription

1 Rheumatoid Arthritis Hand Therapy Review Course University of California, Irvine Medical Center Orange, CA February 24 26, 2017 ARTHRITIS AND JOINT RECONSTRUCTION IN THE HAND Vicky Adams OTR/L, CHT Chronic progressive inflammatory disease that is systemic and autoimmune in nature Three out of four cases occur in women 1 3% of the population affected Characterized by exacerbations and remissions May be accompanied by fatigue, fever, stiffness Onset usually between ages of Rate of progression is variable Hallmarks of RA Synovial lining becomes hypertrophic = (increased volume in cells increased cell count) Leads to articular, periarticular, and soft tissue inflammation, which destroys cartilage > bone Metacarpophalangeal joint and wrist involvement common in UE 3 Rheumatoid Arthritis Stage II Chronic inflammatory disease of the synovium proliferative phase: synovial swelling spreads into the joint cavity space across the cartilage producing pain limitation of movement nerve compression pannus = abnormal layer of granular tissue forming on the joint capsule pannus causes erosion of tissue, cartilage and bone Tenosynovitis > enlarges tendons increases drag reduces blood supply reduces ROM

2 Pannus Rheumatoid Arthritis Stage III IV III = cartilage destruction subchondral erosions loosening of ligamentous insertions impairment of tendon function joint disorganization fibrous ankylosis IV = reparative phase: synovial activity "burnt out"; fibrosis replaces inflammation may lead to auto fusion in joint / bony ankylosis Pathomechanics of deformity in hand and wrist fine balance between muscle and tendon system that exists in the normal hand is disrupted due to lengthening or destruction of restraining ligamentous structures of the joints, due to invasion of pannus (spreads in a tumor like fashion and erodes tissue, cartilage and bone) Common patterns of deformity Ulnar volar translocation of the carpus on the radius: ligamentous laxity at the wrist allows carpus to slip down volar slope of the radius away from the ulna results in pronounced ulna (Caput Ulna) Extensor Tendon Ruptures from attrition = (Vaughn Jackson Syndrome) FPL rupture over scaphoid = (Mannerfelt Norman syndrome) Common patterns of deformity wrist becomes radially deviated: may be further enhanced by volar displacement of ECU, which then becomes an additional flexor/deviation force RD at the wrist (carpals shift) + UD at the MP s = > zig zag deformity Common patterns of deformity ulnar deviation at MP joints due to: RD at wrist instability at collateral ligaments EDC decentralization Dorsal apparatus stretched out radial sagittal fibers and collateral ligaments become stretched imbalances in intrinsics (tightness) forces of ADL use/radial pinch.

3 Evidence for Orthosis at night time for RA CONCLUSION: The use of a night time hand positioning splint reduces pain, improves grip and pinch strength, upper limb function and functional status in patients with rheumatoid arthritis Rehabil Med Oct;40(9): Effectiveness of a night time hand positioning splint in rheumatoid arthritis: a randomized controlled trial. Silva AC, Jones A, Silva PG, Natour J. Rheumatology Division, Federal University of São Paulo, Brazil. Prefabricated wrist orthosis evidence CONCLUSION: Prefabricated wrist working splints are highly effective in reducing wrist pain after 4 weeks of splint wearing in RA patients with wrist arthritis. Arthritis Rheum Dec 15;59(12): Efficacy of wrist working splints in patients with rheumatoid arthritis: a randomized controlled study. Veehof MM, Taal E, Heijnsdijk Rouwenhorst LM, van de Laar MA. Evidence for Exercise CONCLUSION: A significant improvement in hand force and hand function in patients with rheumatoid arthritis was seen after 6 weeks of hand training; the improvement was even more pronounced after 12 weeks. Hand exercise is thus an effective intervention for rheumatoid arthritis patients, leading to better strength and function. Orthosis techniques for MP ulnar deviation and palmar subluxation J Rehabil Med Apr;41(5): A six week hand exercise programme improves strength and hand function in patients with rheumatoid arthritis. Brorsson S, Hilliges M, Sollerman C, Nilsdotter A. Common patterns of deformity Swan-neck deformity: PIP hyperextension with DIP extension lag Due to MP/PIP synovitis in combination with intrinsic muscle tightness 1. Chronic synovitis of the PIP puts stretch on volar plate leading to hyperextension 2. Extensor tendon becomes destabilized allowing the DIP to be pulled into flexion 3. Tight intrinsics weaken the forces of the intrinsics to straighten the PIP Early treatment: Rebalance with intrinsic stretches in early stages protect PIP from hyperextension with ring type splint Swan neck (can also start with MPJ subluxation flexion deformity)

4 Swan neck Deformity Intrinsic stretching Avoid function and activities in this position Common patterns of deformity Boutonniere deformity: PIP flexion contracture with DIP hyperextension contracture occurs due to synovitis causing destruction within the extensor system (central slip and lateral bands) central slip loses ability to extend PIP, lateral bands slide volar and become PIP flexors > taught ORL pip buttonholes dorsally Type I: Thumb deformities: Type I VI MP Flexion with IP hyperextension Type III: MP hyper extended with IP flexion and CMC flexed, adducted, and subluxed Type II: MP Flexion with IP hyperextension and CMC joint flexed and adducted Type III Thumb Deformities

5 Soft Splinting: Type III Thumb Deformity Type IV: CMC flexion and adduction with MP ulnar collateral ligament unstable Type V MP joint hyper extended due to a lax volar plate (leads to DIP flexion) Type VI Bone loss at any level Arthritis mutilans Psoriatic Arthritis Auto immune and chronic Inflammation of the skin and joints Sausage like digits Skin patches of thick red and scaly skin (psoriasis) Nails may be pitted Ages of Reduced motion > Spontaneous ankylosis of PIP and DIP joints Degenerative Joint Disease/ Osteoarthritis Common factor is deterioration of articular cartilage causing joint destruction and osteophyte formation etiology behind cartilage degeneration not fully understood primarily due to wear and tear and age

6 Degenerative Joint Disease Which is OA? Which is RA?????? Greater numbers of women affected than men may be genetic predisposition DIP joints and first CMC joints are most often involved due to stress/use incidence increases with age Secondary DJD may occur at any age etiologic factor is known (e.g. trauma) intra articular fracture General Therapeutic Intervention Based on the individual needs of patient Determined by the stages of the disease process Patient education!!! Goals of therapy: reduce inflammation and pain decrease trauma to the joints maintain or increase ROM facilitate proper joint alignment (thumb > circle position ) strengthen as tolerated to promote joint stability > isometrics Evidence CMC Orthosis Volume 23, Issue 4, Pages (October 2010) (JHT) A Systematic Review of Conservative Interventions for Osteoarthritis of the Hand Kristin Valdes, OTD, OTR, CHT, Tambra Marik, OTD, OTR/L, CHT The studies demonstrated that wearing a splint to immobilize the CMC joint of the thumb can improve hand function and decrease pain. Some studies established that subjects who received the CMC orthotic could postpone or avoid CMC surgery. Many of the subjects preferred the short flexible orthotic over the longer version. There is high to moderate evidence to support the intervention of orthotics. Evidence: prefabricated vs. custom CMC splinting CMC Orthosis / Splints Patients prefer prefabricated Custom does better job at reducing subluxation Better pain relief with prefabricated J Hand Ther Oct Dec;17(4): Splinting the degenerative basal joint: custom made or prefabricated neoprene? Weiss S, Lastayo P, Mills A, Bramlet D.

7 Conservative Treatment Increase functional independence assistive equipment (jar openers, key turners) energy conservation/work simplification, joint protection Evidence Exercise(0A) Volume 23, Issue 4, Pages (October 2010) (JHT) A Systematic Review of Conservative Interventions for Osteoarthritis of the Hand Kristin Valdes, OTD, OTR, CHT, Tambra Marik, OTD, OTR/L, CHT Eight of the nine studies found that subjects who performed exercises demonstrated gains in grip strength ranging from 1.94kg to a 25% improvement from the baseline. The studies for the intervention of exercise were of moderate quality and provide moderate support for the intervention of exercise to increase hand strength and decrease pain. JOINT PROTECTION Maintain muscle strength, ROM, endurance Respect pain (especially during inflammatory stage) Use larger/stronger joints as able Avoid tight/prolonged grasp JOINT PROTECTION Avoid positions of deformity Avoid remaining in one position for a long time Balance rest and activity, conserve energy Use adaptive equipment and techniques as appropriate Evidence Joint Protection Pre operative Therapy Volume 23, Issue 4, Pages (October 2010) (JHT) A Systematic Review of Conservative Interventions for Osteoarthritis of the Hand Kristin Valdes, OTD, OTR, CHT, Tambra Marik, OTD, OTR/L, CHT The studies for the intervention of joint protection education and adaptive device provision were of fair to moderate quality and provide moderate support for this intervention. Patient education surgical goals/expectations Introduction to post op regimen Objective assessment Functional assessment Pre op splinting as indicated

8 Reconstructive Surgical Procedures and Therapeutic Management Treatment protocols may vary; those presented are guidelines only and need to be tailored to the patient's specific needs and the surgeon's philosophy of treatment Sx: Synovectomy (RA) Background: Synovitis tissue mass distends capsule and ligament mechanically may become trapped between bones, blocking motion. may restrict tendon gliding within flexor sheaths and pulleys causing decreased ROM, crepitus, triggering Synovectomy: general principles cannot prevent progression of disease can relieve symptoms/forestall joint destruction Surgical goals pain relief decrease inflammation return of ROM improve function through elimination of pain MP Joint synovectomy/ soft tissue reconstruction arthroplasty surgical procedure: extensor mechanisms incised along ulnar border ulnar intrinsics released if indicated joint capsules incised synovium removed capsules closed radial collateral ligaments may be repaired or shortened extensor tendons may be centralized MP Joint synovectomy/ soft tissue reconstruction arthroplasty Post op Therapy: early phase (0 2 weeks) gentle AROM PROM initiated if no extensor tendon reconstruction protective resting orthosis between exercises dynamic MP extension orthosis may be utilized if indicated intermediate/late phase ROM and strengthening exercises progressed as tolerated dynamic flexion orthosis as indicated goal is full ROM Metacarpophalangeal Joint Replacement Indications joints are fixed or stiff radiographic evidence of joint destruction or subluxation ulnar drift not correctable by soft tissue surgery alone pain due to destructive arthritis

9 Surgical Goals MPJ Arthroplasty Reduce pain Restore motion Restore more normal joint alignment Improve functional use Flexible Implant Resection Arthroplasty Basic Concepts "bone resection + implant + encapsulation = new joint" early guided motion essential biodynamics of scar formation balance of mobility and stability one piece silastic material of silicone and rubber bone resection + implant + encapsulation = functional joint Swanson Implant Correct surgical balancing of the soft tissue structures is required Controlled motion allows desired orientation of the collagen fibers Trained Capsular Fibrosis silicone elastomer with flexible hinge Metacarpophalangeal Joint Replacement (RA) surgical procedure transverse incision over dorsum of MP joints or dorsal longitudinal incisions between MC heads dorsal hood incised to displace extensor tendons metacarpal head excised implant inserted as joint spacer other reconstructions of soft tissue as indicated: intrinsic release, extensor realignment / decentralization, collateral ligament reconstruction, tenosynovectomy First Postoperative Week Note condition of incision at first dressing change Patients on steroids/ immunosuppressant's may need to have the splint application delayed

10 First post operative week Dynamic MP extension/alignment splint is applied post operative therapy dynamic extension orthosis allows patient to actively flex fingers with active assisted extension to neutral worn to retrain and protect healing structures for approximately 6 weeks active and passive ROM to MPs, PIPs and DIPs Daytime Outrigger Orthosis Night Orthosis Full (or nearly full) MP Extension Proper Alignment Wrist in Neutral or Slight Ulnar Deviation dynamic flexion may be initiated at 3 weeks post op if flexion remains tight daytime AROM exercises MP flexion to 45 degrees gentle opposition to each digit tip with the thumb radial finger walking PIP/DIP flexion and extension

11 Post operative therapy progress to intermittent protected ROM out of orthosis between 3 and 6 weeks limited functional strengthening, avoid ulnar deviating forces (especially lateral pinch) scar management, edema control ROM goals for the MP s: IF 0 45 degrees, MF 0 60 degrees, RF/SF 0 80 degrees (IF MP may be fused to protect other digits and allow functional, stable pinch) 6 8 weeks post surgery continue orthosis wear, and exercises increase MP flexion to 60 degrees in the dynamic orthosis resume light ADL while wearing the dynamic orthosis gradually increase light activity out of the dynamic orthosis under the supervision of the therapist 6 Weeks After Surgery 12 weeks post surgery therapy as required increase ADL outside of the dynamic orthosis Continue Night Splinting many protocols do not flex MP joints beyond 60 degrees for 1 year static night orthosis at least for one year and beyond to maintain digit alignment and extension Teach patient functional grasp avoiding the forces of radial pinch and gravity with forearm in neutral 3 Months After Surgery Scar management Joint protection Night splint continues Day soft alignment splint

12 Pyrocarbon Implants Metal based vs. traditional silicone Swanson type implants Need soft tissue and bone that can adequately stabilize the implant High Strength tested at 8 80 LB for 10 million cycles Material Biocompatability Anatomical design PyroCarbon MPJ Implant Rheumatoid Patient post op 4 days to 3 Weeks Post Surgery Plaster splint that places MP joints in full extension and slight radial deviation PIP and DIP AROM is allowed No MP AROM Wrist in 0 10 degrees of ulnar deviation More aggressive time frames with OA / trauma Begin therapy at 3 weeks with an MP dynamic extension orthosis Proximal Interphalangeal Joint Replacement indications pain due to destructive arthritis instability/subluxation of PIP joints stiffness and functional loss of PIP joints may be a component of swan neck or boutonniere reconstruction surgical procedure PIP Joint Replacement volar or dorsal access to PIP volar plate and collateral ligament may be released head of proximal phalanx resected; reaming of proximal and middle phalanges implant inserted capsular closure; extensor tendon reconstructed as indicated to balance tension between central slip and lateral bands in joints with collapse deformity, collateral ligaments reconstructed Postoperative Course Dependent Upon the Preoperative Condition Stiff PIP PIP with lateral deviation Boutonniere deformities Swan neck deformities (rarely) PIP with Lateral Deviation > delay motion until good stability achieved Immobilize in full extension with lateral stability Buddy tape through ROM Fit with a hinged orthosis for lateral stability Kinesio tape with lateral pull

13 Boutonniere Deformity continuous splint 4 6 weeks (DIP ROM ONLY) Emphasis initially on maintaining/maximizing PIP extension, developing stiffness and stability at PIP Swan Neck allow flexion immediately block extension PIP Joint Replacement post operative therapy 3 5 days AROM initiated * (MD may wait longer to initiate ROM, in order to gain greater stability) digital based extension orthosis (PIP immobilized in degrees flexion if swan neck reconstruction done) or buddy taping edema control wound care Proximal Interphalangeal Joint Replacement (OA) post operative therapy 3 4 weeks discontinue day splint if joint stable and minimal extensor lag continue at night 6 12 weeks discontinue night splint as indicated graded strengthening progressive increase in functional use incorporating joint protection principles AROM may be delayed if: Soft tissue reconstruction completed index and middle digits delayed 1 2 weeks as greater stability is needed Pyrocarbon PIP Implant Post operative Therapy Protocol: Generally used for OA Traumatic Arthritis RA patients may need up to 3 weeks of immobilization and follow an individualized program

14 Post op Management PIP dorsal block orthosis Short arc motion protocol avoid hyperextension 4 weeks post surgery increase PIP active ROM to degrees 6 weeks post surgery increase AROM to 0 75 degrees initiate PROM to increase flexion splint as needed if a deformity is evident light activities with therapist out of the splint Begin with AROM limit to degrees 6 weeks 3 months post PIP pyrocarbon implant surgery Goal is 0 75 degrees of AROM Splinting Light ADL Avoid hyperextension Evidence: 2 year follow up pyrolytic carbon implant PIP PIP avg. arc of motion = 47 deg Pain improved to 1/10 80% patient satisfaction rate 28% require second procedure to improve motion or decrease pain J Hand Surg Am Jan;32(1):1 11. Pyrolytic carbon proximal interphalangeal joint arthroplasty: results with minimum two year follow up evaluation. Bravo CJ, Rizzo M, Hormel KB, Beckenbaugh RD. Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA. CMC Joint Basal joint or TMC joint (trapeziometacarpal) most common joint affected by OA in hand females (especially postmenopausal) > males thumb 50% of hand function CMC inherently unstable joint due to shape forces of pinch translate through CMC Eaton classification based on radiographic changes with stages I IV Thumb Carpometacarpal Arthroplasty (OA) INDICATIONS localized pain and crepitation during passive circumduction with axial compression of the thumb (Watson's grind test) loss of motion with decreased pinch and grip strength radiographic evidence of arthritic changes persistent pain of the CMC joint that is non responsive to conservative management

15 Surgical Procedures root of most Tx is a trapeziectomy. either in isolation or combined with tendon interposition (TI), ligament reconstruction (LR), or ligament reconstruction and tendon interposition (LRTI) Surgical Procedures. LRTI Arthroplasty: anchor tendon (either FCR, PL or APL) and make a roll ( anchovy ) which is slid in the trapezial void = tendon interposition tendon becomes a soft spacer gold standard Hematoma Distraction Arthroplasty: 5 weeks of K wire immobilization in opposition and slight distraction scar becomes the soft spacer less complicated procedure Surgical Procedures» recent addition of using an Interface Screw and or a Mini Tight Rope support to maintain thumb and index metacarpals in proper relationship > stability > earlier mobilization? Post operative Therapy (approximate time frames) early phase (0 3/4+ weeks) immobilization in thumb spica cast or thermoplastic orthosis ROM to digits and proximal joints Anthrex» Artificial implants > rare due to failures» Studies show no one procedure is superior Intermediate phase (3 6 weeks) 3 4 weeks AROM may be initiated (may be delayed until 6 8 weeks with some procedures / surgeons orders. Radial Abduction avoided 6 weeks AROM/PROM Orthosis continued between exercises in most cases Some physicians progress to a hand based splint Post operative Therapy (varies widely) late phase (6-12 weeks) light functional use progressively increased, incorporating joint protection principles exercises to promote joint stability circle pinch with abduction and MP flexion gradual progressive grip and pinch strengthening, as tolerated (generally initiated at 8 weeks) goal: pain-free, stable joint for prehension

16 Rule of thumb question? Patient after CMC arthroplasty complains of inability to fully flatten hand on table. What should you do? Educate patient the surgery is designed to have a pain free stable joint for prehension. Avoid over stretching any ligament reconstruction of the joint capsule with forceful radial abduction. ARTHRODESIS Indications debilitating deformity mutilans deformity Goals of surgery relieve pain provide stability correct non functional deformity Joints commonly treated by arthrodesis wrist thumb MP joint PIP joints DIP joints Arthrodesis: Post operative therapy splint protection of fused joint until healed edema control scar management ROM to non involved joints Conclusion Postoperative Management The patient is an active participant Treatment is specific to the condition, postoperative week, stage of the disease process, and the deformity Treatment is individualized: understand the surgery, postoperative care and the individual functional needs Thank you & good luck! Vicky Adams OTR/L, CHT 91