Case Study #4: Nina

Case Study #4: Nina

$1.25

Saturday, August 13, 2016

Vol XCIII, No. 311

What muscles are likely to be weak? Which are likely to be functional? What does MMT look like for Nina?

About Nina

Functional:

The muscles on the left side of the hand and forearm will remain functional because they will not become overstretched. For example, the extensor carpi ulnaris is inserted on the ulnar side of the hand. This muscle would be functional because the drift would not overstretch it. The fingers on the ulnar side will be more functional than the other fingers because the phalanges on the radial side will have stretched out muscles.

MMT:

• Manual muscle testing cannot be done on Nina normally.
• The break test is usually performed after full range of motion, yet with Nina, it needs to be done at the end of pain-free range of motion. By testing in a pain-free range, it will allow the therapist to be able to get a right grade and not have the patient inhibit their full potential because of pain.
• Pain may be common and if pain is experienced by the patient the therapist needs to stop testing. When it comes to testing the hand and grip strength, different tools may be used because of the hand being deformed.
• A blood pressure cuff can be used to test force and pneumatic bulb dynamometers for grip.
• The patient may not be able to position the hand in the right starting place, so the therapist needs to make note of that. When it comes to testing the hand, the therapist can observe the patient visually in their routine. Instead of applying resistance in all cases of MMT, different measures may need to be taken for a patient, like Nina, with RA.

Weak:

• When the RA flares up, the joints become inflamed which can rupture the tendons leading to the drifting of the fingers.
• Grip strength and straightening out the fingers become harder with this condition.
• Since the fingers are drifting to the ulnar side, it means the muscles on the radial side have become weak and overstretched. At the MCP joint the ligaments become ruptured which affects the whole hand creating part of the drifting. This in turn over stretches the muscles on the radial side.
• The palmar plate, transverse fibers, and oblique fibers rupture with the repetitive swelling.
• The Extensor Digitorum may be weakened, overstretched or even ruptured if the fingers are being pulled to the ulnar side. This muscle extends through the second through fifth fingers and crosses over the ruptured MCP.
• Any muscle that passes through the MCP joint can be affected by the swelling and rupture of the ligaments.
• The Extensor Indicis, Interossei, and lumbricals may be affected.
• The transverse fibers of the dorsal hood and radial collateral ligament rupture, also causing the drift. The radial collateral ligament prevents the wrist from drifting too far to the ulnar side, and once this is ruptured, there is nothing holding the wrist from drifting. This also causes overstretching of the muscles on the radial side.
• The Extensor Carpi Radialis Longus may be affected. Even though this muscle inserts at the base of the metacarpals, the rupture of the radial collateral ligament would cause the wrist to drift to the ulnar side, overstretching this muscle.
• The fingers seem to be the most affected at the MCP joint and the ulnar drift mostly takes places there. The muscles for the fifth phalange, such as the flexor digiti minimi brevis and opponens digiti minimi may be affected since these muscles cross over the MCP joint.

Nina also has a zigzag deformity of her thumb on her right dominant hand. This results in the ulnar ligaments rupturing and causing the thumb to become dislocated radially. The thenar eminence pulls the metacarpal radially yet the extensor pollicis longus tries to pull it back by pulling the proximal phalanx. The flexor pollicis longus becomes taut and overstretched since the metacarpal and proximal phalanx are being pulled. The FPL may become weak because it is being overstretched yet the EPL may remain functional by pulling on the phalange. The muscles in the thenar eminence may be affected since the metacarpal is being pulled into them. These muscles include abductor pollicis brevis, flexor pollicis brevis, opponens pollicis, and adductor pollicis which are all located in the thenar eminence. .

Who Is Nina?

Current ROM & Years Later

• Nina is a 52 year old lady who suffers from Rheumatiod Arthritis with active flare-ups for the past 5 years.
• She has ulnar drift in her bilateral hands as well as a zig-zag right thumb deformity.
• She has stiffness in her bilateral hips, shoulders, wrists, and digits.
• She lives with her husband in a two story home.
• She takes care of her house as well as her two grandchildren.
• She is an accountant and in her spare time she participates in church activities and attends her grandchildrens' events.

AROM:

• Active range of motion would most likely be done

- It is important to realize that performing PROM could cause more pain to the patient leading to an empty end feel

- When the arthritis is in its inflammatory phase, or flared up, range of motion would be difficult to perform

Now vs Then

Movement, Posture, & Balance:

• Joint movement would be compromised due the stiffness and pain

-Reduction in joint flexion, extension, rotation, and opposition

-Extension of the finger joints during work- accounting- might become more difficult

-Slower movements such as running or walking

Won’t be able to keep up as much with her grandchildren

Posture:

• Nerve damage could be a cause
• Slouching shoulders
• Pelvic tilt leading to slouching
• Shoulders become slouched forward, could lead to a kyphotic curve in the thoracic region of the spine

Balance:

• Standing upright can become difficult for Nina

-With a slouched posture, balance can also be compromised

-Example: when Nina needs to do household activities such as getting laundry from the washing machine- stiffness leads to inability of flexion at the hip which could make Nina lose her balance

5 Years After Flare Up:

• Pain in joints
• Some ease
• Slight stiffness during inactivity
• ROM might increase slightly but still not reach full potential
• Digits: range might increase slightly after exercise and how much pain she feels
• Wrists: Splint is used for the ulnar drift
• Shoulders: supine position to test flexion/extension and abduction/adduction of shoulder joint
• Bilateral hips: supine position

Immediately After Flare Up:

• Pain in joints after overuse
• Joint stiffness
• Possible empty end feel
• Decreased ranges during ROM assessment- flexion/extension, rotation, opposition, radial and ulnar deviation
• Digits: flexion/extension will be difficult

- MCP flexion/extension and abduction/adduction will be painful

- PIP and DIP flexion

• Thumb: zigzag deformity
• Wrists: flexion: average range is 0-90, Nina would have a lower range depending on how much pain she feels
• Wrist ulnar deviation: due to ulnar drift
• Shoulders: flexion- 0-180, could vary according to pain
• Bilateral hips: rotation and flexion

Context & Treatment Plan

Compensatory Movements & RA and Joint Stability/Integrity

• She may have to ease back on the household work, hand over this role to her husband, or even hire somebody. On the other hand, because this is such a huge component in her life, she may be able to purchase assistive devices to help compensate for limited range of motion.
• Moreover, Nina lives an active lifestyle. It is to her benefit that she takes things one step at a time and that she takes breaks between activities.
• Attending Church activities and her grandchildren’s events also brings her joy. Unfortunately, pain and discomfort associated with arthritis can become overwhelming, and she may opt out of some of these activities.

RA and Joint Stability/Integrity:

• Due to Nina’s condition, her joints will cause her much pain and stiffness, therefore, her joint stability and integrity will be greatly weakened.
• The joints are often inflamed and result in swelling.
• This serves a great toll on Nina’s daily living because joints allow for movements to occur, and without certain movements, it becomes extremely difficult to perform many task.
• The inflammation that occurs from rheumatoid arthritis can damage cartilage of the joint, resulting in thinning of the bone.
• Rheumatoid arthritis manifests by inflammation of the synovial membrane that lines the joint capsule of diarthrodial joints (Pedretti, 1007).
• In addition, the joint capsule, ligaments, and tissues, also become damaged.
• Throughout the course of the rheumatoid arthritis, inflammation continues and the diseased synovial membrane destroys cartilage, bone, tendon, and ligaments.
• As a result, scar tissue is able to form in between the ends of the bone, causing affected joints to become rigid and immovable permanently.

• Nina states she has ulnar drift in her bilateral hands with a zigzag deformity in her right thumb of her dominant hand; Nina also has pain and stiffness in her bilateral hips, shoulders, wrists, and digits.
• Nina gave information on her primary roles, her job and her leisure activities to help make Nina’s treatment plan
• Nina lives in a large 2 story home- this can affect the treatment plan since Nina complains of pain and stiffness in her bilateral hips and also has rheumatoid arthritis, which can affect her feet, making stairs difficult
• Nina also has ulnar drift in her bilateral hands with zigzag deformity in the right thumb of her dominant hand. Not only can this affect her primary roles of managing the household and caring for her two grandchildren after school, she also works as an accountant which involves writing
• Knowing that Nina has ulnar drift in her bilateral hands and a zigzag deformity in her right thumb of her dominant hand means there is a possibility she is unable to drive or soon may be unable to. This can affect the care of her grandchildren and make her unable to get to her leisure activities of attending church and her grandchildren’s events

Intervention Plan:

• Knowing Nina’s primary roles, her career and what she enjoys doing would affect the treatment plan the occupational therapist decides to use. The Occupational therapist will have the client use an occupational therapy intervention plan, which includes sleep and rest, physical agent modalities, therapeutic exercise, therapeutic activity and splinting.
• Sleep and rest- This will help Nina reduce inflammation and pain; people who have arthritis are at risk for sleep problems due to pain and depression.
• Physical agent modalities- Using heat and cold as treatment have decreased pain and stiffness
• Heat increases blood flow, tissue elasticity and provides pain relief.
• Cold reduces inflammation and gives a decreased pain threshold. Therapeutic exercise is also used to keep joint and muscle functioning, improve ROM and maintain muscle strength.
• Exercises- The occupational therapist will teach Nina to perform exercises slowly, smoothly and with proper technique so it does not worsen the pain and inflammation.
• Therapeutic activity- The occupational therapist will find a therapeutic activity that Nina enjoys; these activities will be nonresistive, won’t overstress joints, avoid patterns of deformity and have enough repetition of movement to help improve ROM and strength.
• Splints- The occupational therapist may offer Nina splints; there are splints to help with her ulnar drift, zigzag deformity in her thumb and to help her wrists. Splinting helps to maximize function, increase ROM, reduce inflammation, decrease pain, properly position joints and support unstable joints.
• Rehabilitative approaches- There are several different tools Nina can use, for example, pencil grips or grasping tools that can help Nina perform activities around the house that are difficult to perform for a patient with Nina’s alignments.

Compensatory Movements:

• Due to Nina’s condition, she will have to compensate certain movements and actions when performing specific activities.
• Nina will have to compensate when it comes to holding and grasping onto items.
• The ulnar drift in her bilateral hands and the zigzag deformity in her thumb, along with the pain and stiffness in her wrists and digits, all have an impact on the tasks of grasping and holding.
• In order to successfully hold onto an item, Nina may have to utilize both hands, to ensure stability.
• Residing in a large two story home is one difficulty that Nina will have to confront.
• Being that she is presented with stiffness and pain in her bilateral hips, climbing up and down stairs will become burdensome because shifting weight from one leg to the other in order to maneuver steps is challenging.
• Nina may have to compensate by taking her time up the stairs, especially since holding onto a rail will also be difficult because of her lack in the ability to properly grasp onto things.
• Nina, by nature is a caregiver. She cares for her home and for her two grandchildren.
• Taking care of the home, such as gardening and cleaning, involves some degrees of kneeling and bending. The pain that arises when performing these activities may prevent her from continuing.