Arthritis of the Hand
Background & Etiology
The hand and wrist is anatomically complex with 27 bones, 14 joints in the fingers alone, and a variety of joints where the palm meets the wrist and the wrist meets the forearm. The bones in the hand align precisely to provide a full range of motion and precision. When one of the bones is injured, it can force the entire hand out of alignment. One of the most common conditions to affect the hand is Arthritis, which can be severely debilitating.
Bone and Joint
There are 27 bones in the hand – eight in the wrist, called the carpals; five in the palm of the hand, called the metacarpals; and 14 bones in the fingers, called the proximal, middle, and distal phalanges. The two bones of the forearm, the radius and ulna also make up part of the wrist joint.
The joints in the fingers are the proximal interphalangeal (PIP) joints, located between the proximal and middle phalanges (finger bones), and the distal interphalangeal (DIP) joints, located between the middle and distal phalanges.
In addition to the joints in the fingers themselves, there are also metacarpophalangeal (MCP) joints in the hand where the proximal phalanges meet the metacarpal bones in the palm. In the wrist, each of the carpal bones has an associated joint – the radiocarpal, intercarpal, midcarpal, carpometacarpal, and intermetacarpal joints. There is also the distal radioulnar joint (DRUJ) between the radius and ulna (forearm bones).
In the hand, joints at the ends of the bones have a smooth shiny surface called joint articular cartilage that allows them to slide freely over each other. This allows the joints to move smoothly, controlling the motions of the hand. This articular cartilage can become damaged by arthritis. Arthritis is the wearing, degeneration or loss of articular cartilage in a joint. The three most common types of joint arthritis are osteoarthritis, rheumatoid arthritis, and traumatic arthritis.
Osteoarthritis typically effects weight bearing joints like the hip and knee, however in some cases it does effect the hand and most commonly the thumb carpometacarpal or basal joint. Osteoarthritis is a gradual wearing and degeneration of the joint surfaces or articular cartilage. Osteoarthritis is most common in people who are middle age and adults over the age of 50. Women are more likely to develop osteoarthritis.
Unlike other forms of arthritis, rheumatoid arthritis is a systemic autoimmune disease that is not caused by common wear and tear on the joint. This condition usually affects joints symmetrically (for example, both knees, both elbows, both wrists, both shoulders). Rheumatoid arthritis causes degeneration of the articular or joint cartilage. It can also affect the tissue that surrounds and lubricates the joint (synovium). If the joint surfaces and cartilage are not lubricated they can start to rub, causing wear.
Rheumatoid arthritis can affect other parts of the body including organs like the heart and lungs, and can even cause fatigue. The cause of Rheumatoid arthritis is not fully known. It is considered an autoimmune disease where the cells of the body attack themselves. Although it is a chronic condition, individuals can have periods of little to no symptoms mixed with acute or symptomatic periods. There can be a genetic component to this disease.
Traumatic arthritis occurs as a result of blunt, penetrating, or repeated trauma to a joint. Damage to the articular cartilage can occur when extreme force or pressure is exerted on a joint, causing the cartilage to tear or break off into small pieces. These pieces can become lodged in the joint, where they will rub against the other joint structures. This trauma can make the joint weak, causing the inflammation and pain associated with arthritis.
Common causes of arthritis of the hand include:
- Genetics and family history can predispose individuals to developing osteoarthritis and joint degeneration
- Ligament or meniscus damage can affect the stability and integrity of the hand joints placing more stress on the joint or articular cartilage. The increased stress and force placed on the joint surfaces can lead to wear and tear on the joint.
- Repetitive strain injuries to the hand can damage and accelerate wear on joint surfaces
- Diseases of the joint cartilage
- Excessive use of steroids or steroid medication can result in degeneration of the joint and cartilage.
- Previous trauma to a joint can increase wear and tear and the likelihood of developing arthritis.
- Severe pain and aching in the hand
- Loss of range of motion of the hand
- Swelling around the joint
- Increased size or visible deformity of the joint
- Weakness that makes daily activities difficult
- A sensation of “cracking” or “crunching” in the hand joints
- Stiffness, that can be extreme, causing tremendous difficulty moving the joint
Treatment of Hand Arthritis
Treatment of hand arthritis will depend on the severity of the condition. Some important guidelines should be followed at the onset:
The ideal treatment involves a combination of medication, rest, joint range of motion and strengthening exercises, joint protection strategies such as bracing and splinting and patient education. Restoring range of motion and strength is paramount to maintaining function. Protecting the joint through education about movement, bracing and splinting when necessary can help reduce further joint damage. Treatment is customized depending on the individual’s age, level of function, acute versus chronic flare up, pain level and general health.
- Rest: avoid the activities that produce the pain.
- Ice or moist heat: apply ice to the joint or area of pain or inflammation. It is one of the fastest ways to reduce swelling, pain and inflammation. Individuals with Rheumatoid arthritis may not tolerate ice well. The application of moist heat may be helpful with stiff joints. The application of ice or heat should be done at intervals for about twenty minutes at a time. Do not apply directly to the skin.
- Compression: when using ice, apply light compression. This is especially helpful if swelling is present.
- Elevation: elevate the area to help reduce swelling.
- Movement: keep your joints moving whenever possible. When pain occurs the tendency is not to move, but this will only result in further loss of motion and lead to increased pain and loss of function.
Mild: In mild cases rest, ice and medication may be all that is needed to reduce the pain and inflammation. Once the pain is reduced hand therapy is recommended to develop a series of stretching and strengthening exercises to prevent loss of motion, weakness and function. Individuals are advised to avoid becoming sedentary; however return to full activity should be gradual to prevent a flare up of symptoms.
Moderate to Severe: If the problem persists, consulting your health care provider should be the next step. Your physician and/or hand therapist will perform a thorough evaluation to determine the severity of the condition and the best course of treatment.
Hand Therapy Interventions
Hand Therapists are occupational therapists or physical therapists who, through advanced study and experience, specialize in treating individuals with conditions affecting the hands and upper extremity. A hand specialist may also have advanced certification as a Certified Hand Therapist (CHT). A qualified hand therapist is educated and trained to administer interventions. As stated in The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and goal of the patient or client.
- Your hand therapist will perform a thorough evaluation to assess and determine the following:
- Joint: a series of measurements will be performed to determine which joint is involved and the extent to which the inflammation is acute
- Splinting: determining the need for custom fabricated or pre-fabricated splinting to rest or assist the involved joint.
- Strength: resisted testing is performed to determine if there is associated weakness or strength imbalances
- Flexibility: range of motion measurements will be taken to determine if there is reduced joint movement
- Technique and ADL: the therapist will review what activities you have difficulty with and will help you make modifications in technique to reduce stress on the involved joint.
Hand therapy for hand arthritis must remain conservative at the onset to avoid aggravating the condition. Emphasis will be placed on rest, reducing the inflammation, protecting the joint and increasing the blood circulation for healing. Once the initial inflammation has reduced, a program of stretching and strengthening will be initiated to restore flexibility and improve strength to reduce stress on the joints of the hand.
Hand Therapy Treatment
Common Hand Therapy interventions in the treatment of Hand Arthritis include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, stretching and joint mobilization by a hand therapist to improve alignment, mobility and range of motion of the hand. The use of mobilization techniques also helps to modulate pain.
- Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen muscles of the hand and upper extremity to support, stabilize and decrease the stresses place on joint cartilage and the joints of the hand.
- Neuromuscular Reeducation (NMR) to restore stability, retrain the upper extremity and improve movement techniques and mechanics of the involved upper extremity to reduce stress on the joint surfaces in daily activities. Taping, strapping, splinting or bracing may be indicated for joint protection and promote healing.
- Modalities including the use of ultrasound, electrical stimulation, ice, cold, laser and others to decrease pain and inflammation of the involved joint.
Avoiding the activities that produce the pain or stress the involved joint is the first line of treatment.
- RICE: Rest, Ice, Compression, Elevation should be used to reduce the stress on the burse.
- NSAIDS (Non steroidal anti-inflammatory drugs) to reduce pain and inflammation.
- Immobilization, strapping or bracing may be beneficial to rest, protect the joint and promote healing.
- Injection of steroids may be indicated to reduce inflammation of the involved joint.
- Joint injections of hyaluronic acid preparations (synvisc or suparz) to facilitate joint cartilage repair and regeneration.
- In severe recurrent conditions surgery may be indicated. In less severe cases arthroscopic surgery to clean the joint surfaces (debridement) may be indicated.
Medical Management of Rheumatoid Arthritis
Early aggressive medical care is recommended for individuals with Rheumatoid Arthritis. Interventions may include the following:
- The use of DMARD (disease modifying anti-rheumatic drugs).
- The use of NSAIDS (nonsteroidal anti-inflammatory drugs)
- When indicated steroids in low doses will be prescribed to reduce joint inflammation.
- Physical and Occupational Therapy to develop a stretching and strengthening program.
- Bracing and splinting to protect and rest the involved joints
- Surgery may be indicated in severe cases. An arthroscopic procedure to remove an inflamed synovial lining is one surgical option.
Outcomes and prognosis for individuals with arthritis will depend on the severity of the joint degeneration, motion loss, weakness and age of the individual.
Mild: Individuals with mild degeneration respond well to conservative treatment including medication for pain and inflammation and a program of exercises for stretching and strengthening of the knee joint and surrounding muscles. Most patients show improvement in pain and function in 4-6 weeks.
Moderate: Individuals with moderate degenerative changes usually experience greater loss of motion, pain, weakness and loss of function. In some cases arthroscopic surgery may be required to clean or debride the elbow joint. Recovery may take from 6-9 weeks following surgery with emphasis on reduction of swelling, restoration of range, strength and function.
Severe: Individuals with severe joint degeneration have significant pain, stiffness, loss of motion and function. The cartilage on the joint surfaces has been eroded and X-rays reveal a loss of joint space and “bone on bone” contact. Joint replacement is the treatment of choice, however this is not available for many of the joints in the hand.
Once the pain and inflammation is reduced, and motion and strength are improved it is important that the patient returns to full activity gradually. Instruction in daily activities and a comprehensive home program are helpful for reducing a reoccurrence of flare-ups and slowing the degenerative process. As a preventive measure individuals should:
- Movement: keep moving and avoid a sedentary lifestyle. Joints are meant to move and depend on movement for lubrication. Remaining sedentary will reduce the joint’s available range of motion.
- Stretching: stretching regularly in addition to before and after activity will reduce the chances of developing joint stiffness and pain. Stretching will also improve and maintain the elasticity and flexibility of muscles and tendons of the joint. Hold stretches for 20 seconds and do not bounce. Remember, as joints age flexibility is lost. It is part of the aging process.
- Strength: performing a regular strength program will keep muscles strong enough to absorb the stresses placed on the joints. Weak muscles allow the stress and forces of every day activities to be transferred to the joint surfaces. Remember, as people get older weakness increases.
- Protection: Avoid activities that place increased stress on the hand.