Musculoskeletal Scenario 7

Musculoskeletal Scenario 7

Phillipa Hall is a 50 year old Medical Secretary who was diagnosed with Rheumatoid Arthritis 10 years ago. She had previously noticed an increasing ache in the hands and wrists which occurred intermittently. She experiences periods of worsening and improvement in pain but deteriorating function in terms of grip and wrist extension. She has also noticed a gradual decrease in strength affecting the muscles around her shoulder. She lives with her husband and teenage sons, but usually does all the domestic duties. She is finding this increasingly difficult due to her worsening condition and has consulted her GP for review of her medication. Currently she is taking DMARDS.

Important Points
• 50 years old
• Suffered from rheumatoid arthritis for 10 years
• Ache in hands (intermittent)
• Deteriorating function (grip and wrist extension)
• Decrease in strength around shoulder
• Taking DMARDS (disease modifying antirheumatic drugs)

Expectations from Subjective

Pain will most likely be intermittent
Pain will be an aching pain
Pain may be worse in cold conditions
More than one joint can be affected (shoulder in this case)
Difficulty in gripping (difficulty doing housework)
Poor mobility in extension and flexion
Worse symptoms in morning- increased stiffness

Easing factors: Resting hand and wrist
Heat
Ice to reduce swelling

Aggravating Factors: Activity of hand and wrist
Sleeping causes stiffness
Family history of RA?

Rheumatoid Arthritis Information

RA is a chronic, autoimmune disorder that most commonly causes inflammation and tissue damage in the joints.
RA of the joints is due to synovitis. As its name suggests this is the inflammation of the synovial membrane.
With time, RA can affect multiple joints (it is a polyarthritis). It most commonly affects small joints such as the joints of the hand which is relevant to this scenario.

Signs and Symptoms

• Swelling around the affected joint is commonly observed.
• RA causes joints to become tender and stiff reducing their movement and function.
• A warm sensation can sometimes be felt by the patient in the joint affected.
• Weakness in the joint and surrounding muscles can be observed
• Clicking and cracking noises can sometimes occur during joint movement.
• Tiredness
• Fever and feeling unwell
• Weight loss


Objective Assessment- Hand

• First observe the patient’s hand and note any deformity, swelling and bruising.
• Assess patients movement at hand. Active movements before moving to passive. Range of movement should be noticeably affected
• No special tests of the hand are really relevant here as the pathology has already been identified.
• Test power of the muscles and compare to opposite hand. Strength will be poor with extension.
• Test grip by holding your hands out with your palms flat. Ask patient to grip around the proximal phalangeal area. Too high or too low you may feel pain. Compare the two wrists

Objective Shoulder
• Oberve the shoulder. Look for bruising, swelling, redness, deformity
• Observe posture using the inferior angles of the scapulae.
• Look at active movements and compare to opposite shoulder
• Passively push past the limited range of movement to assess end feel and if more movement is capable
• Resisted tests to assess muscle power in shoulder. Resist all the GH movements. Compare to opposite shoulder

Special tests can be carried out should you feel necessary.

Due to symptoms it is most likely the rheumatoid arthritis that is affecting the shoulder as over time it can affect more than one joint. It is written in the scenario as a gradual decrease in strength of the muscles around the shoulder.


Normal Hand ROM

Wrist
Flexion 0-75
Extension 0-75
Radial Deviation 0-20
Ulnar Deviation 0-35
Pronation 0-75
Supination 0-80

Fingers
Flexion MP joints 0-90
Extension MP joints (active) 0-45
Proximal IP joint flexion 0-100
Distal IP joint flexion 0-80

Thumb
IP joint Flexion 0-80
IP joint extension 0-20
MP joint flexion 0-55
MP joint extension 0-5 passive

A noticeable decrease of mobility is a sign of RA and most movements will have decreased mobility depending on the affected joint.

Wrist Anatomy

She experiences pain when extending the wrist. Here are the tendons and muscles involved:

Extensor carpi radialis longus
Extensor carpi radialis brevis
Extensor digitorum
Extensor carpi ulnaris
Extensor indicis
Extensor pollicis brevis
Extensor pollicis longus
Extensor digiti minimi

She experiences pain and has noticed a decrease in strength when gripping so these are the muscles and tendons involved:

Flexor digitorum superficialis
Flexor digitorum profundus
Flexor digiti minimi brevis
Lumbricals

Diagnosis

Rheumatoid arthritis can be diagnosed in a number of ways. X rays can be taken of the affected joint to check for RA. However, X rays provide inconclusive evidence at the developing stages of the condition and other methods of diagnosis must be used.
When RA is suspected, blood tests can be taken to test for a specific RA antibody.

The treatment is not needed but I added it if you wanted to mention a few things in the exam

There is no cure for RA but it can be managed in several ways.
• Physiotherapy treatment will encourage exercising the affected joint in an aim to increase mobility. Exercise is a core treatment in RA irrespective of the age of the patient.

• Pain relieving drugs can be taken to reduce the pain sensation in the joints. Most commonly used are paracetemol, ibuprofen and in more severe cases codeine and tramadol.

• Anti-inflammatory drugs can also be taken to ease swelling around the joint capsule.

• Steroids can be taken to reduce swelling but it is not recommended for routine use due to the possible side affects. These include weakening of the bone marrow (osteoporosis), thinning of the skin, weight gain and muscle wasting.

• Disease modifying antirheumatic drugs (DMARDs) ease symptoms but also reduce the damaging effect of the disease on the joints. DMARDs can improve the prognosis of the patient after several weeks as they have little immediate effect. They are best taken at the early stages of RA.

• Certain food supplements can be taken to control RA. They do not work with all patients but some find it helpful. Glucosamine can be taken to slow the progression of joint degeneration. It can also relieve pain and improve function. Tropical capsaicin can also be taken to alleviate pain. Again the effects and success of taking the supplement can vary.

• Heat can be used to ease and relax the muscle tissue around the joint. This can ease pain for a short period of time but can also increase mobility slightly as the muscles involved are relaxed from the heat.

• Ice can also be used but it has a different affect to heat. Ice can reduce swelling around the affected joint to ease pain and improve function slightly.