Rheumatoid Arthritis

1987 Revised American Rheumatism Association Criteria for

- A disease in which inflammation happens in the Classification of Rheumatoid Arthritis
synovial membrane that lines the joint capsule of (Diagnosis is made upon presentation of four of the seven criteria for 6 weeks)

diarthrodial joints.
- In RA, synovial cells produce matrix degrading
[Link] In and around joints lasting >1hr before
enzymes that destroy the cartilage and bone
maximal improvement
- Joints affected are: PIP, MCP, thumb joints of Stiffness
the hand, wrist, elbow, ankle, MTP,
temporomandibular joints as well as hips, knees,
shoulder and cervical spine. 2. Arthritis of Soft tissue swelling of fluid as observed
by physician in at least 3 or more joint
three or more
areas simultaneously
Rheumatoid Nodule joint areas
- local swelling over bony prominences such as in
the tip of elbow, olecranon, DIP (Heberden’s 3. Arthritis of Wrist, MCP or PIP joints
Nodes), and PIP (Bouchard’s Nodes) hand joints

Rheumatoid factor
- autoantibody mostly relevant in RA
4. Symmetrical Bilateral, simultaneous involvement of
(approximately 70% of patients with RA) same joint areas
arthritis
- It is against the Fc portion of IgG, which is itself
an antibody. Both RF and IgG join together to
form immune complexes which contribute to the
5. Rheumatoid Subcutaneous nodules over bony
disease process prominences
Nodules
- Increased frequency of subcutaneous nodules,
vasculitis, polyarticular involvement

Joint damage begins at the synovial membrane, where 6. Serum Demonstration of abnormal amounts of
Rh factor
the influx and/or local activation of mononuclear cells Rheumatoid
and the formation of new blood vessels cause synovitis. Factor
Pannus
- osteoclast-rich portion of the synovial membrane 7. Radiographic Include erosion or unequivocal bony
- destroys bone decalcification localized in or almost
changes
most marked adjacent to involved joints

Enzymes
- secreted by synoviocytes and chondrocytes
- degrade cartilage Inflammatory process (4 stages)
1. Acute - limited movement, pain and tenderness
Clinical Features: at rest that increase with movement, overall
- Symmetric polyarticular pain stiffness, weakness, numbness, and red hot
- Swelling joints
- Morning stiffness 2. Subacute - Joints appear pink and warm and
- Malaise inflammation subsides with decrease in pain and
- Fatigue tenderness
- Depression 3. Chronic Active Stage -less tingling and pain and
tenderness, endurance low and increased
tolerance of activity
4. Chronic Inactive Stage - no signs of
inflammation, overall functioning decreased
because of fear of pain, limited ROM, muscle
atrophy, contractures

OT Implications
- Decrease in occupational functioning is due to:
 - Pain
- Joint changes Splinting
- Instability - Resting hand splints (acute inflammatory stage)
- Loss of motion - Worn during daytime and nighttime
- Change in living, social environment - Purpose: To increase ROM/ to prevent deformity
- To reduce pain when doing functional activities
- Prevent undesirable motion during occupational
performance
Classification Description
- To provide support for joints affected
- Position joints that will allow optimal
Class I Completely able to perform usual ADLs occupational performance
(self-care, vocational, avocational)
- Splint use should continue full time for at least 2
weeks after flare subsides to allow joints to
Class II Able to perform usual self-care and recover
vocational activities, but limited in - Recommended Joint position:
avocational activities - Slight wrist extension (0 to 20 degrees),
- Ulnar deviation (10 to 20 degrees),
Class III Able to perform usual self-care, but limited - MCP flexion (20-30 degrees),
in vocational and avocational activities - Slight PIP and DIP flexion (10-30
degrees) and
Class IV Limited in ablity to perform usual self-care, - Slight thumb extension
vocational, and avocational activities - CMC joint abduction
- Slight flexion of the MCP and IP joints
Table.1. The America College of Rheumatology Classification of
Global Functional Status in Patients with Rheumatoid Arthritis Commonly Used Splints for Arthritis
1. Resting Hand Splint
- Thorough OT evaluation of the ff. must be done: - Acute synovitis of wrist and hand
- Inflammation - Primary function: localize rest to involved joints
- Range of Motion - Relieve pain, decrease muscle spasm, protect
- Strength joints from contracture
- Hand function 2. Custom Fabricated Thermoplastic Wrist
- Stiffness Splint
- Pain - Wrist stability, decrease pain & improve function
- Sensation - Provide support allowing functional use of the
- Joint instability, deformity hand, and for fit and comfort
- Physical endurance 3. MCP ulnar deviation splint
- Relief of pain, stability, alignment, reduced
Intervention Objectives of OT stress on painful subluxed, or deviated joints
- Maintain or increase the ability to engage in - Slow progression of deformity
meaningful occupations - Infrequently used by clients because
- Maintain or increase joint mobility and strength immobilization may impede functional use of
- Maximize physical endurance hand and increase stress of PIP joints
- Protect against or minimize effect of deformities 4. Swan Neck Splint (PIP hyperextension block)
- Increase understanding of disease - Restrict unwanted PIP hyperextension motion
- Assist with adjustment to disability - Improve hand function
- Silver Ring Siris
OT interventions 5. Boutonniere Splint
- Rest - Block the PIP joint in extension and leave DIP
- Physical modalities joint free to flex
- Therapeutic Exercise and activity - Night splinting with PIP joint in maximal
- Splinting extension used to maintain ROM
- Occupational performance training 6. Thumb Splints
- Client education
 - Provide positioning of developing deformity in
early stages of disease
- Thumb Spica Splint leave wrist and IP joints free
and can be used for problems at MCP and CMC
joints
7. Dynamic and Serial Static Splints
- Used to regain ROM lost by shortening of
periarticular structures and to maximize motion
8. Silicone lined- Digital sleeves and Pad
- Protecting painful nodes from external trauma
References: Pedretti, L. W., Pendleton, H. M., & Schultz-Krohn, W.
(2006). Pedretti's occupational therapy:
Practice skills for physical dysfunction. St. Louis, MO: Mosby/Elsevier.

Multiple Choice Questions

1. Which commonly used splints is meant to
restrict unwanted PIP hyperextension?
a. Boutonniere splint
b. Swan neck splint
c. MCP ulnar deviation splint
d. Resting Hand splint
2. Which class, according to the American College
of Rheumatology, does a client belong to if she
is limited in ability to perform self-care,
avocational and vocational activities?
a. Class I
b. Class IV
c. Class II
d. Class III
3. What is the recommended joint position of the
MCP in splint fabrication for patients with RA?
a. 20-30 deg Flexion
b. 10-20 deg Flexion
c. 10-20 deg Extension
d. 20-30 deg Extension