Rheumatoid Arthritis

Question 1

RA Etiology+Presentation

Answer 1

-Autoimmune disease
-associate with antibody HLA-DR4

Diagnostic criteria for RA (4/7 for at least 6 weeks)

o Morning stiffness greater than 1 hour

o Arthritis of 3 or more joints

o Arthritis of hand joints
▪Wrist, MCP or PIP joints

o Symmetric arthritis

o Rheumatoid nodules

o Radiographic changes
▪ Including erosions or periarticular osteopenia in hands and/or wrist joints

o Serum rheumatoid factor

Question 2

RA deformity

Answer 2

▪ Hallux valgus: valgus deviation of great toe+varus deviation of first MT

▪ MTP subluxation: unopposed extensors pull PP into hyperextension–> lateral drift of toes

▪ Claw toe: MTP synovitis, MTP extension, PIP and DIP flexion, often all toes except big toe.

▪ Hammer toe: flexion of PIP and hyperextension of DIP (similar to boutonniere) (mostly 2nd toe

*Mallet toe: flexion of DIP, affects longest toe.

*Ulnar drift: MCP synovitis–>MCP subluxation–> pull of phalanges towards ulnar side of hand.

*Swan neck deformity: flexion of MCP (not always), hyperextension of PIP, flexion of DIP.

*Boutonniere deformity:MCP
hyperextension (not always), flexion of PIP, hyperextension of DIP.

Question 3

RA exercise CI

Answer 3

Acute stage:
-No gentle stretching
-No joint mobilisations

ALL TIME!!:
-No vigorous stretching
-No manipulative techniques

Question 4

RA Rx guideline

Answer 4

Acute stage: disease flare-up
-Protection: bracing during ADL, adaptive tools
-No heavy lifting/activities stress joint
No stretching/joint mob
-Gentle pain-free ROM
-Ice for inflammation
-Heat for morning stiffness

Chronic: no flare-up
-ROM ex: full and pain-free
-Increase cardiovascular training–>aquatic
-Strength: pain-free, low load, high reps
Use splint/braces when exercising
-Ice after activity for reducing inflammation
-Heat before activity

Question 5

Joint count Assessment

Answer 5

STOP
Swelling test–>Tenderness test–>Overpressure test

Swelling test:
2 fingers–>for small joint
4 fingers–>for PIP,DIPJ
bulging test–>for knee & elbow

stop as soon as +ve finding

Question 6

Bunnel littler

Answer 6

Testing structure:
-Tightness of intrinsic hand muscles

Procedures:
-1st: MCP in full Ext–>flex PIP to check ROM
-2nd: MCP in Flex–>flex PIP again

Finding:
ROM: 2nd>1st=intrinsic tightness
ROM: 1st=2nd=joint capsule tightness

**not valid if MCPJ subluxed/swan neck

Question 7

Test for subluxation of extensor digitorum

Answer 7

Testing structure:
-Ulnar subluxation of extensor tendons

Procedures:
-wrist in neutral+MCP in flexed–>resist finger extension

-actively made a fist

+Ve Finding:
extensor tendon drifts ulnarly over knuckle

Question 8

Collateral ligament test

Answer 8

Testing structure:
Integrity of collateral ligaments

Procedures:
-MCPJ to 90 deg–>grasp PP and apply ulnar/radial pressure

Finding:
-excessive laxity

Question 9

Central slip tenodesis test

Answer 9

Testing structure:
-Integrity of central slip of the extensor tendon

Procedures:
-wrist passive flex–>MCPJ passive flex–>observe PIPJ extend?

+ve Finding:
Failure of PIP to extend

Question 10

Piano key test

Answer 10

Testing structure:
-Distal radioulnar joint (DRUJ) instability

Procedures:
-pronated–>grasp radius & ulna with each hand–>push ulna down

+ve Finding:
Excessive motion of ulna and/or pain

Question 11

Crank test

Answer 11

Testing structure:
CMC arthritis

Procedures:
-Grasp 1st MC–>compress CMCJ–>grind perpendicularly up and down

Finding:
Crepitus and pain

Question 12

Grind Test

Answer 12

Testing structure:
CMC arthritis

Procedures:
-Grasp 1st MC–>compress CMCJ–>grind in rotation

Finding:
Crepitus and pain

Question 13

RA Specific Questionairre

Answer 13

Health Assessment Questionnaire (HAQ)
- Subjective measure of difficulty of ADL
- lower score–>less disability

MACTAR
- Pt picks specific activities for evaluation (Pt centered measure)
- Short Questionnaire administered by PT
- Better short-term vs long-term