Handedness and Hand Joint

Changes in Rheunlatoid Arthriti

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(dominance, goniometry, deformity, joint protection)

Betty Risteen Hasselkus K. K. Kshepakaran Margaret J. Safri t

This study investigates the rela- ormal skeletal alignment and weakening of the periart cular sup-
tionship of hand use to the
deforming hand Joint changes of
N joint function in the human
body depend on the integrity of the
porting structures, and uscle im-
balance are all conseque ces of per-
rheumatoid arthritis. Measure- internal structures of the joint and sistent destructive syno itis in the
ments of metacarpophalangeal the balance of external forces acting joints of the digits, the t umb, the
lateral mobility, loss of metacar- on the joint. The persistent in- metacarpals, the carpal, and the
pophalangeal hyperextension, flammatory process of rheumatoid distal forearm.
thumb metacarpophalangeal arthritis (RA) is destructive to the A wide variety of a sessment
range of motion, and lateral pinch bony and soft-supporting intrinsic techniques has been us d to mea-
strength were statistically com- structures of an involved joint. The sure hand deformity nd joint
pared across dominant and non- resulting pain and altered biome- changes. The three mos common
dominant hands of 51 adult sub- chanics predispose the joint to an measurements are grip strength,
Jects who had definite or classical imbalance of its external muscle range of motion, and pinc strength;
rheumatoid arthritis. Incidence of forces (I, 2). however, the kaleidosco e of other
boutonniere and swan neck The synovial joints of the hands assessments in the literat re include
deformities and distal Tadioulna are typically involved in rheuma- roentgenograms, cada r dissec-
laxity was also recorded. Results of toid arthritis and, in time, fre- tions, measurements of and span
a multivariate analysis of variance quently display characteristic joint and thumb web angle, h nd profile
of the difference scores between deformities and changes in func- tracings, finger-palm pints, joint
dominant and nondominant mea- tional capacity. Bony erosions. circumference measurem nts, finger
sures were not significant. The flexor strength measures, nd dolor-
authors concluded that the rela- Betty Risteen Hasselkus, M.S., imeter measurements of ain (3-11).
tionship of hand use to Joint de- OTR, is Clinical Associate Profes- A number of studies i clude test
struction is not yet clearly defined sor, Occupational Therapy Pro- items of function suc as tying
and further study is needed. Impli- gram, University of knots, cutting wire, and buttoning
cations for treatment principles of Wisconsin-Madison. (5, 12, 13). It is also ossible to
Joint protection are presented. record categorical data s ch as pres-
K. K. Kshepakaran, M.Ed., OTR, ence of specific deformiti s, nodules,
was formerly Assistant Professor, tendon dislocations or r lUres, in-
Occupational Therapy Program, trinsic muscle tightness, c epitation,
Unwersityof Wisconsm-Madlson. muscle atrophy, palmar erythema,
and triggering (5,9).
Margaret]. Safrit, Ph.D., is Pro- It has been suggeste that the
fessor, PhYSical Education and structural changes secon ary to RA
Dance, University of combine with the forces i volved in
Wisconsin-Madison. the use of the hand t produce

The Amerzcan Journal of Occupational T erapy 705

deformity 3, 14-19). Ellison, Flatt,
and Kelly ive equal weight to the Table 1
deforming forces of usage and to the Descriptive Data: Hand Changes and Dominance in Patients with Rheumatoid Arthritis
laxity of su porting joint structures Difference Max. MinI.
(18). Flatt ater states, "There must Variables' Between Means S.D. S.E.M. Difference Difference
be aberrati ns of structure or func- V1 .2373 5.9101 .8276 16.0000 -11.5000

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tion to ini iate the deformity." (14, V2 - .1275 4.2812 .5995 12.0000 -13.0000
p 266) Hak tian and Tubiana, how- V3 .0784 5.0014 .7003 16.5000 -13.0000
ever, con ude that the external V4 .9314 7.5326 1.0548 20.0000 -19.0000
forces of and use are only sec- V5 4.9020 10.6212 1.4873 40.0000 -15.0000
ondary to issue destruction in the V6 4.5098 14.0205 1.9633 55.0000 -22.0000
productio of deformity in the V7 3.3137 12.3523 1.7297 60.0000 -30.0000
rheumatoi hand (19). V8 3.0980 9.5315 1.3347 50.0000 -13.0000
Anum r of investigators have V9 -5.0588 18.5477 2.5972 45.0000 -60.0000
addressed he relationship of hand V10 .2980 3.0887 .4325 11.5000 - 8.5000
use to joi t change in rheumatoid
N = 51
arthritis b comparing dominant
'V1 - V4 = MCP lateral mobility for digits 2-5
and nond minant hand data (3, 9,
V5 - V8 = limited MCP extension for digits 2-5
20, 21). T ey primarily studied the
V9 = Thumb MCP range of motion
developm t of ulnar drift at the
V10 = Lateral pinch strength
metacarpo halangeal (MCP) joints
in the rh matoid hand. Kemble
demonstra ed significantly larger that seek to reduce the joint stresses the assumption that the dominant
angles of Inar drift at the MCP of daily hand use are based on the hand is subjected to greater stress
joints of d minant hands than those theory that the forces involved in during daily activities than the
of nondo inan t hands, and further the use of the hand contribute to nondominant hand, this study was
stated, on the basis of X-ray data, structural joint changes and disease designed to test the hypothesis that
that hand ominance "determines activity, thus fostering deformity the dominant hand demonstrates
metacarpa head erosions and ulnar (16,17,22-24). However, the equiv- significantly greater clinically
drift defor ity." (3, P 240) (italics ocal results cited in the studies cited observable joint changes than the
for emphas' s) Fearnley earlier stated, above mandate the need to further nondominant hand in rheumatoid
"In other ise symmetrical cases clarify the issues involved in the arthri tis.
with ulna deviation more marked relationship between hand use and
on the rig t, the greater use of the hand joint changes in rheumatoid Methods
right han will explain the defor- arthri tis. Subjects for this study were 51 out-
mity." (20, 132) Treuhaft et al. (9). The purpose of this study was to pa tien ts who had defini te or classi-
however, oncluded that the joint investigate the effects of hand use cal rheumatoid arthritis as diag-
changes 0 each hand in their sub- on the deforming joint changes of nosed by a physician. Subjects had
jects were arly identical, and Lush rheumatoid arthritis. Clinically no other connective tissue disease
concurred that there "appeared to observable hand joint changes were and no history of upper extremity
be no corre ation between the degree statistically compared across domi- surgical procedures. Ages ranged
to which t e hand was used or the nant and nondominant hands of 51 from 22 to 79 with a mean age of
natureoft epatient'sworkandthe adult subjects who had definite or 54.15 years. There were 29 males
developme t of ulnar deviation." classical RA (25). In addition, cate- and 22 females.
(21, p 220) gorical data on digital deformities Measurement Criterza. An assess-
Occupa ional therapists have and dist al radioulna laxity were ment battery measuring lateral lax-
traditional y taught joint protec- obtained. Based on the theory that ity of the MCP joints in digits 2-5,
tion to R pa tien ts in an effort to the stresses involved in the use of the loss of hyperextension of the MCP
mmimize he dynamic deforming hand contribute significantly to joints in digits 2-5, thumb MCP
forces of t e diseased hand. Treat- joint changes and deformity in joint range of motion, and lateral
ment prin iples of joint protection rheumatoid arthritis, and based on pinch strength was administered to

706 Nov mber 1981, Volume 35, Number 11

Table 2
Correlation Matrix of Hand Measurements: Rheumatoid Arthritis
(N= 51)
ROM of Lateral
MCP Lateral Mobility Limitation of MCP Extension Thumb MC Pinch

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V1 V2 V3 V4 V5 V6 V7 V8 V9 V10

~
V1 oooo
V2 .3747 .0000
V3 .3068 I .3841 .0000
V4 .1794 .2363 .408 1.0000

~
oooo~
V5 .0756 .1455 -.0247 .2050
V6 .1747 .3265 .14023602 .6498
.0000
V7 .1750 .3270 .19323928 .6297 II .8091 .0000
V8 .1117 .2417 .15403454 .6953 .6910 .837 1.0000
V9 .0776 -.0646 .0349 -.0486 -.0662 -.2106 -.0799 -.0042 1.0000
V10 -.0163 .0761 -.0203 -.1793 -.0765 -.1892 -.1566 -.0167 -.1414 1.0000

r of .273 significant at p ~ .05, df = 49

each of the 51 subjects by the i nves- formity was defined as 10° or greater on both hands of each of t e 51 sub-
tigators. The presence or absence of loss of extension of the proximal jects. Differences between group
swan neck and boutonniere defor- interphalangeal (PIP) joint in one means using all the varia bles were
mities and distal radioulna joint or more digits on the hand. Swan used to test for the main effect of
laxity was also recorded. neck deformi ty was defined as 10° or dominance.
Lateral laxity of the MCP joints greater hyperextension of the PIP Descriptive data from t e MAN-
was measured with a two-axis goni- joint in one or more digits. The OVA are presented in Tatle I. The
ometer as described previously by presence of radioulna joint laxity overall difference in clini ally ob-
Hasselkus, Kshepakaran, Houge, et depended on testing for the" spring- servable joint changes between
al. (26). Swezey states that collateral board" or "piano key" sign (24). dominant and nondomin" nt hands
ligament laxity is the primary com- Analysis and Treatment of the was not statistically Sl nificant
ponent of ulnar drift (I). The two- Data. The data were analyzed using (F(lO, 41 = 1.3037); P =.261). Thus
axis goniometer enabled the investi- a multivariate analysis of variance the joint changes measur d in the
gators to measure the passive range (MANOVA). The ten dependent dominant hands were no signifi-
of radial/ulnar movement at the variables were passive MCP lateral cantly different from those neasured
MCP joint while maintaining the mobility of digits 2-5, passive MCP 10 the nondominant ha ds. The
joint in flexion, that is, the joint hyperextension of digits 2-5, pas- hypothesis that the domin~nt hand
position in which the collaterallig- sive thumb MCP range of motion, demonstrates significantl greater
aments are normally taut (14, 17, and lateral pinch strength. The in- clinically observable join changes
19). dependent variable was hand dom- than the nondominant ~and 10
Loss of hyperextension at the inance. Difference scores between rheumatoid arthritis was not sup-
MCP Joints (defined as 20° of mo- dominant and nondominant mea- poned.
tion beyond 0°) and range of motion sures for each variable were used to The correlation matrix ( f the dif-
of the thumb MCP were measured test the hypothesis. Distal radioulna ferences bet ween the mea 1S of the
passively with a small finger goni- joint laxity and boutonniere and ten variables is presented ir Table 2.
ometer that had been cut away to its swan neck deformities of the digits With an r of .273, the trongest
aXIs to facilitate better clearance were descriptively analyzed. intercorrelations appear i 1 Trian-
over bony prol u berances. An OSCO gle II, that is, the measure of MCP
pinch meter was used to measure Results hyperextension in digits -5. The
lateral pinch force (27). The results of this study are based highest coefficient, .8377 f r V ,IV R,
The presence of boutonniere de- on the measurement of 10 variables indicates a very strong relationship

The American Journal of Occupational Ther py 707

between oss of MCP hyperexten-
sionindi it4anddigit5.Similarly, Figure 1
Digital deformities and radioulna laxity
the corre tion coefficient of .8091
for Vr/V indicates a strong rela-
:> :~:~:::NANT
tionship between hyperextension
measures in digits 3 and 4. In fact,
all coeffi ients in Triangle II are
12

I BILATERAL

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10
high, su gesting significant rela- (f)
f-
tionships between the loss of hyper- U
w
..., 8
extensio measures on all digits. CD
~
Triangle outlines the correlation (f)

coefficie ts for the measure of MCP ~ 6

0
lateral m bility in digits 2-5. The n::
w
highest c efficient in this group is CD 4
:2
.4083 for /V j, that is, the relation- ~
z
ship the b tween MCP lateral mobil- 2
ity meas rements in digits 4 and 5.
Freque cy of digital deformities
0
and dista radioulna joint laxity in RADIOULNA BOUTONNIERE SWAN NECK
dominan , nondominant, and bi- LAXITY

la teral ha ds is depicted in Figure I.

Of the 51 ubjects, a total of 16dem- gle response." (William C. Mann, and ulnar-deviated posture. Ellison,
onstrated radioulna laxity, 23 had Multivariate Analysis Institute, 1980 Flatt. and Kelly (18) also relate MCP
boutonni redeformities,and 14 had AOTA Conference, 515 Stockton subluxation to ulnar drift, focusing
swan nee deformities. No pattern Kimball Tower, Buffalo, New York on the deforming forces of the
of domi ant side involvement 14214.) _ altered line of pull of the intrinsic
emerged; in fact, radioulna laxity The dependent variables in this muscles and the extrinsic extensors.
was clear y more prevalent on the study-MCP lateral mobility, loss Other studies provide further evi-
nondomi ant side. of MCP hyperextension, thumb dence for a strong relationship
MCP range of motion, and lateral between loss of MCP hyperexten-
Discussi n pinch strength-were selected on sion and ulnar drift (3, 6,14,20). In
The results of this study on the rela- the basis of their logical inter- addition, prolonged synovitis of the
tionship between handedness and relatedness in both the disease most commonly involved joint of
hand joi t changes in RA did not pathology and the theoretical dy- the thumb, the MCP joint, leads to
support he hypothesis that the namic forces of deformity in the joint instability and the classic
dominan hand demonstrates sig- rheumatoid hand. Smith et al. (16) thumb deformities described by
nificantl greater joint destruction link loss of MCP hyperextension Nalebuff (28). Laxity of the MCP
than the ondominant hand. Thus, and MCP lateral mobility together thumb joint and the laxity of the
a clearcut elationship between hand via the flexor forces exerted by the MCP joint of the index finger com-
use and the clinically observable long finger flexors during hard bine to result in a diminished pinch
jointcha ges measured in this study grip and pinch activities. In the dis- force (3, 4, 18). Thus the dependent
was not monstrated. eased hand, the flexor tendons tend variables chosen for this study did,
It is ssumed, when using a to bowstring volarly and ulnarly at in the authors' judgment, form a
MANOV for analysis of data, that the mouth of the flexor tunnel at the logical though unproven set.
the depe den t varia bles are rela ted MCP joints. As the supporting lig- The correlation matrix gives val-
and that hey form a logical, con- aments become weakened and elon- uable clues on why the test of the
ceptually meaningful set. "Multi- gated by the rheumatoid process, mean differences among all the var-
variate a alysis treats the data as a the volar and ulnar pull of the long iables between dominant and non-
whole a d considers correlations flexors during hand use becomes dominant hands was not statisti-
among m asures," and the data are more and more forceful and the dig- cally significant. The correlations
handled s "related aspects of a sin- its gradually move into a subluxed represc.1t the strength of the rela-

708 ember 1981, Volume 35, Number 11

tionship of the difference scores of loss of MCP hyperextension than weak pinch and finger flexion
between the dominant and non- ulnar deviation in his hand study, forces. Neither of these ariables
dominant hands for each variable. so that the two variables do not was considered in this st dy. The
With 49 degrees of freedom, a corre- necessaril y occur in concert. Res- use or nonuse of a cane or other
lation coefficient (r) of 273 is a nick (6) and Shapiro (15) both walking aid might have roved to
value significantly different from strongly implicate radial rotation be another important va iable in

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zero. The higher the correIa tion, the of the wrist in ulnar deviation of the producing significant ha d defor-
greater the evidence of a meaning- digits. Shapiro described the in- mity; this information as not
ful strong relationship in the prac- creased ulnar-volar force of the long recorded. Further, one mig t specu-
tical sense. flexors at the MCP joints with the late that persons with rh umatoid
While a number of the variables wrist in radial rotation and the arthritis tend to shift muc of their
demonstrate high correlations (espe- mechanical advantage this gave to activity from a painful ommant
cially V j - V~), many do not. Most the ulnar intrinsics, upsetting the hand to a less painful non ominant
surprising were the low intercorre- normal delicate balance of the deep hand, thus somewhat e ualizing
lations between many of the mea- muscles during hand activity (15). the resulting stress during and use.
sures of MCP lateral mobility and Ellison, Flatt, and Kelly (18) cite A number of subjects co mented
those of loss of MCP hyperexten- evidence tha t hernia tion of the pro- on this phenomenon.
sion. Further, the authors had ex- liferating synovium first occurs at The Measure of Me Lateral
pected to find a strong correlation the weakest anatomical pointof the Mobility. In retrospect, th method
between lateral pinch strength and extensor expansion, that is, between used to measure MCP coli terallig-
MCP lateral mobility, and these the extri nsic extensor and the radial ament laxity may have co tributed
coefficients were very low. Passiv intrinsic insertion. Such a hernia- to the nonsignificant res Its. The
range of motion of the thumb MCP tion changes the radial intrinsic total range or arc of ra io/ulnar
did not correlate highly with any line of pull so that the radio/ulnar movement of the MCP jo'nt in the
other variable. balance is lost. The lumbricals are flexed position was recor ed as the
To investigate the effect of the all radial intrinsics and, according indication of collateral igament
lack of relationship between many to Eyler and Markee (29), the most laxity. The assumption w s that as
of the variables on the overall F important function of the lumbri- the arc of movement incr ased, so
value, twO separate MANOVAs were cals is to stabilize the MCP joint. did the angle of ulnar d ift. It is
run-one on the four variables that Habtian and Tubiana state that it possible that this is not so. t may be
measured loss of MCP hyperexten- is conceivable that "capsular and that the range of laxity eaches a
sion, and one on the four variables ligamentous attenuation without certain point and stabi izes, al-
that measured MCP lateral laxity. involvement of the intrinsic mus- though its anatomical position
The results of lhe tWO separate cles could produce a hand with very continues to drift ulnarw rd. A 30°
MANOVAs were (F(4,47) = 2.6371); little ulnar-drift deformity." (19, p arc of radio/ulnar move ent may
P = .046) for the :VICP hyperrexten- 314) Thus, the impact of persistent be positioned in the midi' e of the
SlOn variable and (F(4,47) = .2571); P synovitis on the integrity of the articulation, or it may be from 10°
= .904) for the Mep lateral mobility intrinsic muscles and the sub- to 40° of ulnar deviation. he total
variable. This suggests that domi- sequent implications on develop- arc of movemen t is the sa , bu t the
nance is a major source of variance ing deformity need further investi- second arc represents a ore ad-
in the loss of MCP hy! erextension, gatiol . A review of the factors that vanced stage of ulnar drift. n Lush's
although its role in Mep lateral contribute to ulnar drift, as well as study of ulnar deviation, 1J percent
mobility continued to be statisti- other hand deformities, is provided of the deviated digits could 10 longer
call y nonsignifical t. by Swezey (I). be pa. sivel y returned to th midline
Other Factors to Consider. While Kemble (3) found significantly (21). Fearnley (20), in outl ning the
a high correlation between M P larger angles of ulnar drift, greater thlee ·tagesofuJnardeviati n,stated
collateral ligament laxity and loss loss of M P extension, and weaker that the progression i toward
of MCP hyperextension is supported pinch in sero-positive hands than gradual loss of the abili ty t acti vel y
by a number of studies, the issue is ero-negalive hands, regardl ss of or passively correct to the midline.
far from clear. l'reuhaft et al. (9) dominance. f: e also found duration If su h is the case, a gre tel' degree of
demonstrated a higher perc ntClge of illness strongly correlated vith UII at leviation woulJ not necessar-

The Amnican Journal of Occupational The apy 709

ily be ref ected in a greater total arc Acknowledgments 14, Flatt A: Care of the Rheumatoid Hand,
of lateral movement. Theauthors gratefully acknowledge St. Louis: C,V. Mosby Co" 1974, 3rd
Impllc tions for Occupational the assistance and su pport of Walter Edition, Chap 10
15,Shapiro JS: A new factor in the etiol-
Therapy The results of this study R. Sundstrom, M.D., and Judy ogy of ulnar drift, Clin Orthop 68:32-43,
have im lications for occupational Spray, Ph.D. 1970
therapy ractice in rheumatology. This study was supported by the 16.Smith EM, Juvinall RC, Bender LF,
Pearson JR: Flexor forces and rheuma-
The theo ies of joint protection are following grants-University of

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toid metacarpophalangeal deformity.
based on linical observation, intui- Wisconsin-Madison: HilldaleTrust JAMA 198:150-154, 1966
logic. One concept im- Fund-School of Allied Health 17. English CB, Nalebuff EA: Understand-
ing the arthritic hand. Am J Occup
the principles of joint Professions; Graduate School Re- Ther 25:352-359, 1971
is that specificjoint stress search Fund #100099; Graduate 18. Ellison MR, Flatt AE, Kelly KJ: Ulnar
ily activity can result in School Academic Computer Funds drift of the fingers in rheumatoid dis-
ease. J Bone Joint Surg 53-A:1061-
increase disease activity and can #42009; Instrumentation Systems 1082,1971
foster joi t destruction and deformi- Center; Interdisciplinary Geriatric 19. Hakstian RW, Tubiana R: Ulnar devia-
ty. Patie t education includes in- Training Grant-CHS-VA #2C (75) tion of the fingers, The role of joint
structure and function, J Bone Joint
struction to avoid activities that IV -500406 Surg 49-A:299-316, 1967
require ard grip and pinch, that 20, Fearnley GR: UI nar deviation of the
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710 mber 1981, Volume 35, Number 11