Module 5.2: Case study - Linda

Case study: Linda, 58 year old librarian

Hello, my name is Linda. I’m 58 years old and I work as a librarian in a community centre. I have been happily married for 25 years and I’m now a grandmother of 5 lovely children.

I was diagnosed with rheumatoid arthritis 12 years ago. After I was diagnosed I was started on a cocktail of drugs including methotrexate, prednisolone, folic acid, calcium and vitamin D. This mix of drugs has really helped me over the last 10 years, the feeling of tiredness and the aches in my hands, wrists, elbows and feet have improved greatly. Since I’ve had rheumatoid arthritis for such a long time, I now know how to listen to my body and change the way I do things. I’ve noticed my hands getting worse and find dressing and shelving books at work have become more difficult. I’m not sure if it is related to my hands looking more deformed.

Is there anything you can do to help me with my hands as I’m just getting slower and slower at work?

Linda, librarian.

Question 1

What would your assessment involve?
  • Observation of hand function with aggravating activities, including quality of movement of the more proximal joints of the upper limb.
  • Quantitative functional measures – dynamometry grip and fine pinch strength
  • Assessment of joint integrity of affected digits
    • Assess ligamentous stability or tendon dysfunction/rupture/attenuation.

Patients with rheumatoid arthritis may have overt deformities, yet manage to perform functional activities. However, difficulties often arise with task-specific skills, particularly fine motor or complex coordinated wrist and hand activities. Joint instabilities need to be identified and task analysis performed to assess force/stability discordance issues (task forces and anatomical instabilities) to best identify appropriate splinting/joint protection/task modification strategies.

Case continued

Another thing I want to talk to you about is this pain in my neck. Over the last 3 weeks or so, I’ve noticed this neck pain getting worse and awful headaches at the back of my head. I’m not sure if it’s related, but I’ve also noticed swelling in my hands and fingers. I’m feeling more tired and stiff than normal too and I have to rest every afternoon, which is unusual for me.

Linda, librarian

Question 2

What features may suggest Linda is experiencing a flare?
  • Swelling in her hands and fingers
  • Increased discomfort in her hands, fingers, neck and head
  • Feeling stiffer in the morning and more tired during the day

Patients with rheumatoid arthritis may experience an initial positive response to their pharmacologic management. It is not uncommon, as the disease progresses, to experience symptom reoccurrence or exacerbation.

Case continued

Linda was reviewed by her rheumatologist and her medication regimen has been modified. Currently the library is archiving books and journals as it transitions to electronic access. Linda needs to climb the ladder, transfer books into a trolley and transport them to the basement. Her knees are still sore going up and down the ladder and at times her legs feel weak, a symptom she attributes to the flare. Her neck is sore when she looks up at the books and even more so when she looks down to step down the ladder. She describes feeling slightly unbalanced doing this activity.

Question 3

What features of this presentation suggest this may be more than a flare?
  • Feeling of weakness in her legs
  • Feeling unbalanced
  • Neck pain with movement

Patients with rheumatoid arthritis usually report movement eases feelings of stiffness in joints. While Linda’s knees may indeed feel sore with repetitive ladder climbing, the reported feeling of lower limb weakness warrants further investigation to identify whether symptoms occur only during ladder climbing or during other activities, as this may indicate involvement of the peripheral or central nervous systems. Linda’s reported neck pain when looking down as she descends the ladder warrants further questioning, particularly with respect to reproduction of symptoms simultaneous with cervical flexion.

Case continued

Further questioning reveals Linda has experienced occasional jaw discomfort (which she attributes to clenching her teeth at night due to the stress associated with the library transition). She has noticed a “crunching” sound or “clunking” when she flexes her neck, however, has put that down to old age. She recalls a strange taste in her mouth, but thought the recent change in medication may have caused that.

Question 4

What further screening questions/assessments would you ask at this stage?

Symptoms of neck crunching and clunking and the strange taste that Linda is experiencing should alert the physiotherapist to possible cervical spine joint instability. Further appropriate screening may include:

  • A neurological examination to confirm/exclude any significant cord compression and establish any indications for further investigation
    • A neurological examination should include central and peripheral nervous system tests: specifically, upper and lower limb reflexes, muscle power and sensory tests (light touch, pin prick and thermal sensation), Babinski (plantar surface foot), Hoffman reflexes (thumb or index finger), clonus and cranial nerve assessment. These tests should be negative to support a diagnosis of normal nervous system function (cord involvement, neural compression, and possible peripheral neuropathy)
  • Gait and balance should be assessed – this may indicate involvement of the central nervous system or possible peripheral neuropathy associated with rheumatoid vasculitis.

Systemic inflammation associated with RA can degrade the integrity of the transverse and alar craniovertebral ligaments, leading to subsequent instability and osseous destruction. The transverse and alar ligaments stabilize the craniovertebral junction and prevent atlantoaxial instability. Note:

  • Atlantoaxial subluxation is reported on functional radiography in a sizable proportion of adult patients with rheumatoid arthritis.
  • The cervical spine is a common focus of destruction from rheumatoid arthritis, second only to the metacarpophalangeal joints. Joint, bone and ligament damage in the cervical spine leads to subluxations which can cause cervical cord compression resulting in paralysis and even sudden death. Because many patients with significant subluxations are asymptomatic, the key role of the physiotherapist is to recognize the clinically important clues to instability and refer on for further assessment and investigation
  • While active range of motion assessment is indicated, if there is a suspicion of cervical instability NO passive movements or techniques should be performed prior to further medical investigation.

Question 5

What would be your management plan for Linda?
  • If you are suspicious of possible cervical spine instability, with or without cord compression, referral to a medical practitioner for further assessment and radiological investigations is indicated prior to any physiotherapy intervention
  • Advise that a medications review by treating medical practitioner may be warranted
  • Education re avoiding extreme movements of the neck, particularly flexion
  • While evidence supports deep cervical flexor muscle retraining for the management of chronic neck pain (Jull et al. 2004), there is no evidence to recommend deep cervical flexor muscle (craniocervical flexor) exercises for the management of cervical spine pain or instability related to rheumatoid arthritis.

References

  1. Roche, C. J., Eyes, B. E., & Whitehouse, G. H. (2002). The rheumatoid cervical spine: signs of instability on plain cervical radiographs. [Review]. Clin Radiol, 57(4), 241-249. doi: 10.1053/crad.2001.0745 [PubMed]
  2. Osmotherly, P. G., & Rivett, D. A. (2011). Knowledge and use of craniovertebral instability testing by Australian physiotherapists. Manual Therapy, 16(4), 357-363. [PubMed]
  3. Jull, G., Falla, D., Treleavan, J. Sterling, M. O’Leary, S. A (2004). Therapeutic exercise approach for cervical disorders. In: Boyling, J., Jull, G. editors. Grieve’s modern manual therapy. The vertebral column. Edinburgh: Churchill Livingstone. pp 451-459.
  4. Slater, H., Briggs, A.m., Fary, R.e., Chan, M. (2013). Upper cervical instability associated with rheumatoid arthritis: What to 'know' and what to 'do'. Man Ther Feb 12 doi:pii: 51356-689X (13) 00006-4. 10.1016/j.math.2013.01.05 [Epub]