Handedness and Hand Joint
Changes in Rheunlatoid Arthriti
(dominance, goniometry, deformity, joint protection)
Betty Risteen Hasselkus
This study investigates the rela-
tionship of hand use to the
deforming hand Joint changes of
rheumatoid arthritis. Measure-
ments of metacarpophalangeal
lateral mobility, loss of metacar-
pophalangeal hyperextension,
thumb metacarpophalangeal
range of motion, and lateral pinch
strength were statistically com-
pared across dominant and non-
dominant hands of 51 adult sub-
Jects who had definite or classical
rheumatoid arthritis. Incidence of
boutonniere and swan neck
deformities and distal Tadioulna
laxity was also recorded. Results of
a multivariate analysis of variance
of the difference scores between
dominant and nondominant mea-
sures were not significant. The
authors concluded that the rela-
tionship of hand use to Joint de-
struction is not yet clearly defined
and further study is needed. Impli-
cations for treatment principles of
Joint protection are presented.
K. K. Kshepakaran
ormal skeletal alignment and
N joint function in the human
body depend on the integrity of the
internal structures of the joint and
the balance of external forces acting
on the joint. The persistent in-
flammatory process of rheumatoid
arthritis (RA) is destructive to the
bony and soft-supporting intrinsic
structures of an involved joint. The
resulting pain and altered biome-
chanics predispose the joint to an
imbalance of its external muscle
forces (I, 2).
The synovial joints of the hands
are typically involved in rheuma-
toid arthritis and, in time, fre-
quently display characteristic joint
deformities and changes in func-
tional capacity. Bony erosions.
Betty Risteen Hasselkus, M.S.,
OTR, is Clinical Associate Profes-
sor, Occupational Therapy Pro-
gram, University of
Wisconsin-Madison.
K. K. Kshepakaran, M.Ed., OTR,
was formerly Assistant Professor,
Occupational Therapy Program,
Unwersityof Wisconsm-Madlson.
Margaret]. Safrit, Ph.D., is Pro-
fessor, PhYSical Education and
Dance, University of
Wisconsin-Madison.
The Amerzcan Journal of Occupational T erapy
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Margaret J. Safri t
weakening of the periart cular sup-
porting structures, and uscle im-
balance are all conseque ces of per-
sistent destructive syno itis in the
joints of the digits, the t umb, the
metacarpals, the carpal, and the
distal forearm.
A wide variety of a sessment
techniques has been us d to mea-
sure hand deformity nd joint
changes. The three mos common
measurements are grip strength,
range of motion, and pinc strength;
however, the kaleidosco e of other
assessments in the literat re include
roentgenograms, cada r dissec-
tions, measurements of and span
and thumb web angle, h nd profile
tracings, finger-palm pints, joint
circumference measurem nts, finger
flexor strength measures, nd dolor-
imeter measurements of ain (3-11).
A number of studies i clude test
items of function suc as tying
knots, cutting wire, and buttoning
(5, 12, 13). It is also ossible to
record categorical data s ch as pres-
ence of specific deformiti s, nodules,
tendon dislocations or r lUres, in-
trinsic muscle tightness, c epitation,
muscle atrophy, palmar erythema,
and triggering (5,9).
It has been suggeste that the
structural changes secon ary to RA
combine with the forces i volved in
the use of the hand t produce
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-
tigators. The presence or absence of
swan neck and boutonniere defor-
mities and distal radioulna joint
laxity was also recorded.
Lateral laxity of the MCP joints
was measured with a two-axis goni-
ometer as described previously by
Hasselkus, Kshepakaran, Houge, et
al. (26). Swezey states that collateral
ligament laxity is the primary com-
ponent of ulnar drift (I). The two-
axis goniometer enabled the investi-
gators to measure the passive range
of radial/ulnar movement at the
MCP joint while maintaining the
joint in flexion, that is, the joint
position in which the collaterallig-
aments are normally taut (14, 17,
19).
Loss of hyperextension at the
MCP Joints (defined as 20° of mo-
tion beyond 0°) and range of motion
of the thumb MCP were measured
passively with a small finger goni-
ometer that had been cut away to its
aXIs to facilitate better clearance
over bony prol u berances. An OSCO
pinch meter was used to measure
lateral pinch force (27).
The presence of boutonniere de-
formity was defined as 10° or greater
loss of extension of the proximal
interphalangeal (PIP) joint in one
or more digits on the hand. Swan
neck deformi ty was defined as 10° or
greater hyperextension of the PIP
joint in one or more digits. The
presence of radioulna joint laxity
depended on testing for the" spring-
board" or "piano key" sign (24).
Analysis and Treatment of the
Data. The data were analyzed using
a multivariate analysis of variance
(MANOVA). The ten dependent
variables were passive MCP lateral
mobility of digits 2-5, passive MCP
hyperextension of digits 2-5, pas-
sive thumb MCP range of motion,
and lateral pinch strength. The in-
dependent variable was hand dom-
inance. Difference scores between
dominant and nondominant mea-
sures for each variable were used to
test the hypothesis. Distal radioulna
joint laxity and boutonniere and
swan neck deformities of the digits
were descriptively analyzed.
Results
The results of this study are based
on the measurement of 10 variables
on both hands of each of t e 51 sub-
jects. Differences between group
means using all the varia bles were
used to test for the main effect of
dominance.
Descriptive data from t e MAN-
OVA are presented in Tatle I. The
overall difference in clini ally ob-
servable joint changes between
dominant and nondomin" nt hands
was not statistically Sl nificant
(F(lO, 41 = 1.3037); P =.261). Thus
the joint changes measur d in the
dominant hands were no signifi-
cantly different from those neasured
10 the nondominant ha ds. The
hypothesis that the domin~nt hand
demonstrates significantl greater
clinically observable join changes
than the nondominant ~and 10
rheumatoid arthritis was not sup-
poned.
The correlation matrix ( f the dif-
ferences bet ween the mea 1S of the
ten variables is presented ir Table 2.
With an r of .273, the trongest
intercorrelations appear i 1 Trian-
gle II, that is, the measure of MCP
hyperextension in digits -5. The
highest coefficient, .8377 f r V ,IV R,
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-
onstrated radioulna laxity, 23 had
boutonni redeformities,and 14 had
swan nee deformities. No pattern
of domi ant side involvement
emerged; in fact, radioulna laxity
was clear y more prevalent on the
nondomi ant side.
Discussi n
The results of this study on the rela-
tionship between handedness and
hand joi t changes in RA did not
support he hypothesis that the
dominan hand demonstrates sig-
nificantl greater joint destruction
than the ondominant hand. Thus,
a clearcut elationship between hand
use and the clinically observable
jointcha ges measured in this study
was not monstrated.
It is ssumed, when using a
MANOV for analysis of data, that
the depe den t varia bles are rela ted
and that hey form a logical, con-
ceptually meaningful set. "Multi-
variate a alysis treats the data as a
whole a d considers correlations
among m asures," and the data are
handled s "related aspects of a sin-
gle response." (William C. Mann,
Multivariate Analysis Institute, 1980
AOTA Conference, 515 Stockton
Kimball Tower, Buffalo, New York
14214.) _ altered line of pull of the intrinsic
The dependent variables in this
study-MCP lateral mobility, loss
of MCP hyperextension, thumb
MCP range of motion, and lateral
pinch strength-were selected on
the basis of their logical inter-
relatedness in both the disease
pathology and the theoretical dy-
namic forces of deformity in the
rheumatoid hand. Smith et al. (16)
link loss of MCP hyperextension
and MCP lateral mobility together
via the flexor forces exerted by the
long finger flexors during hard
grip and pinch activities. In the dis-
eased hand, the flexor tendons tend
to bowstring volarly and ulnarly at
the mouth of the flexor tunnel at the
MCP joints. As the supporting lig-
aments become weakened and elon-
gated by the rheumatoid process,
the volar and ulnar pull of the long
flexors during hand use becomes
more and more forceful and the dig-
its gradually move into a subluxed
and ulnar-deviated posture. Ellison,
Flatt. and Kelly (18) also relate MCP
subluxation to ulnar drift, focusing
on the deforming forces of the
muscles and the extrinsic extensors.
Other studies provide further evi-
dence for a strong relationship
between loss of MCP hyperexten-
sion and ulnar drift (3, 6,14,20). In
addition, prolonged synovitis of the
most commonly involved joint of
the thumb, the MCP joint, leads to
joint instability and the classic
thumb deformities described by
Nalebuff (28). Laxity of the MCP
thumb joint and the laxity of the
MCP joint of the index finger com-
bine to result in a diminished pinch
force (3, 4, 18). Thus the dependent
variables chosen for this study did,
in the authors' judgment, form a
logical though unproven set.
The correlation matrix gives val-
uable clues on why the test of the
mean differences among all the var-
iables between dominant and non-
dominant hands was not statisti-
cally significant. The correlations
represc.1t the strength of the rela-

708 ember 1981, Volume 35, Number 11

tionship of the difference scores
between the dominant and non-
dominant hands for each variable.
With 49 degrees of freedom, a corre-
lation coefficient (r) of 273 is a
value significantly different from
zero. The higher the correIa tion, the
greater the evidence of a meaning-
ful strong relationship in the prac-
tical sense.
While a number of the variables
demonstrate high correlations (espe-
cially V j - V~), many do not. Most
surprising were the low intercorre-
lations between many of the mea-
sures of MCP lateral mobility and
those of loss of MCP hyperexten-
sion. Further, the authors had ex-
pected to find a strong correlation
between lateral pinch strength and
MCP lateral mobility, and these
coefficients were very low. Passiv
range of motion of the thumb MCP
did not correlate highly with any
other variable.
To investigate the effect of the
lack of relationship between many
of the variables on the overall F
value, twO separate MANOVAs were
run-one on the four variables that
measured loss of MCP hyperexten-
sion, and one on the four variables
that measured MCP lateral laxity.
The results of lhe tWO separate
MANOVAs were (F(4,47) = 2.6371);
P = .046) for the :VICP hyperrexten-
SlOn variable and (F(4,47) = .2571); P
= .904) for the Mep lateral mobility
variable. This suggests that domi-
nance is a major source of variance
in the loss of MCP hy! erextension,
although its role in Mep lateral
mobility continued to be statisti-
call y nonsignifical t.
Other Factors to Consider. While
a high correlation between M P
collateral ligament laxity and loss
of MCP hyperextension is supported
by a number of studies, the issue is
far from clear. l'reuhaft et al. (9)
demonstrated a higher perc ntClge
of loss of MCP hyperextension than
ulnar deviation in his hand study,
so that the two variables do not
necessaril y occur in concert. Res-
nick (6) and Shapiro (15) both
strongly implicate radial rotation
of the wrist in ulnar deviation of the
digits. Shapiro described the in-
creased ulnar-volar force of the long
flexors at the MCP joints with the
wrist in radial rotation and the
mechanical advantage this gave to
the ulnar intrinsics, upsetting the
normal delicate balance of the deep
muscles during hand activity (15).
Ellison, Flatt, and Kelly (18) cite
evidence tha t hernia tion of the pro-
liferating synovium first occurs at
the weakest anatomical pointof the
extensor expansion, that is, between
the extri nsic extensor and the radial
intrinsic insertion. Such a hernia-
tion changes the radial intrinsic
line of pull so that the radio/ulnar
balance is lost. The lumbricals are
all radial intrinsics and, according
to Eyler and Markee (29), the most
important function of the lumbri-
cals is to stabilize the MCP joint.
Habtian and Tubiana state that it
is conceivable that "capsular and
ligamentous attenuation without
involvement of the intrinsic mus-
cles could produce a hand with very
little ulnar-drift deformity." (19, p
314) Thus, the impact of persistent
synovitis on the integrity of the
intrinsic muscles and the sub-
sequent implications on develop-
ing deformity need further investi-
gatiol . A review of the factors that
contribute to ulnar drift, as well as
other hand deformities, is provided
by Swezey (I).
Kemble (3) found significantly
larger angles of ulnar drift, greater
loss of M P extension, and weaker
pinch in sero-positive hands than
ero-negalive hands, regardl ss of
dominance. f: e also found duration
of illness strongly correlated vith
The Amnican Journal of Occupational The apy
weak pinch and finger flexion
forces. Neither of these ariables
was considered in this st dy. The
use or nonuse of a cane or other
walking aid might have roved to
be another important va iable in
Downloaded from http://research.aota.org/ajot/article-pdf/35/11/705/50895/705.pdf by VA Library Network, Huertas College on 10 April 2024
producing significant ha d defor-
mity; this information as not
recorded. Further, one mig t specu-
late that persons with rh umatoid
arthritis tend to shift muc of their
activity from a painful ommant
hand to a less painful non ominant
hand, thus somewhat e ualizing
the resulting stress during and use.
A number of subjects co mented
on this phenomenon.
The Measure of Me Lateral
Mobility. In retrospect, th method
used to measure MCP coli terallig-
ament laxity may have co tributed
to the nonsignificant res Its. The
total range or arc of ra io/ulnar
movement of the MCP jo'nt in the
flexed position was recor ed as the
indication of collateral igament
laxity. The assumption w s that as
the arc of movement incr ased, so
did the angle of ulnar d ift. It is
possible that this is not so. t may be
that the range of laxity eaches a
certain point and stabi izes, al-
though its anatomical position
continues to drift ulnarw rd. A 30°
arc of radio/ulnar move ent may
be positioned in the midi' e of the
articulation, or it may be from 10°
to 40° of ulnar deviation. he total
arc of movemen t is the sa , bu t the
second arc represents a ore ad-
vanced stage of ulnar drift. n Lush's
study of ulnar deviation, 1J percent
of the deviated digits could 10 longer
be pa. sivel y returned to th midline
(21). Fearnley (20), in outl ning the
thlee ·tagesofuJnardeviati n,stated
that the progression i toward
gradual loss of the abili ty t acti vel y
or passively correct to the midline.
If su h is the case, a gre tel' degree of
UII at leviation woulJ not necessar-
709
ily be ref ected in a greater total arc
of lateral movement.
Impllc tions for Occupational
Therapy The results of this study
have im lications for occupational
therapy ractice in rheumatology.
The theo ies of joint protection are
based on linical observation, intui-
logic. One concept im-
the principles of joint
is that specificjoint stress
ily activity can result in
increase disease activity and can
foster joi t destruction and deformi-
ty. Patie t education includes in-
struction to avoid activities that
require ard grip and pinch, that
subjectj intligamentsand tendons
to twisti g and stretching, that
longed tension around a
that rota te the digi ts in an
ulnar di ection. Resting splints,
adapted elf-care equipment, pre-
scribed r st and exercise, and work
simplific tion are all modes of
treatmen that are employed in oc-
cupation I therapy (22-24, 30, 31).
The st dy was done in an attempt
to test th s theory of joint stress-
that is, to explore the predIctability
of joint estruction and deformity
and to scertain to what degree
actual da a confirm or fail to con-
firm the heory. The data in this
study fail d to support the hypothe-
sis, there y failing to support the
theory th t links joint stress and
hand c anges in rheumatoid
arthritis.
The i terrelationships between
the forces involved in the use of the
hand an the joint changes of
rheumato'd arthritis are very com-
plex and need more precise and
careful st dy to become better de-
fined, bot operationally and con-
ceptually. Although the pnnClples
of hand j in t protection make sense
logically nd intuitively, they are
not yet str ngly supported by clear-
cut empir cal data.
710 mber 1981, Volume 35, Number 11
Acknowledgments
Theauthors gratefully acknowledge
the assistance and su pport of Walter
R. Sundstrom, M.D., and Judy
Spray, Ph.D.
This study was supported by the
following grants-University of
Wisconsin-Madison: HilldaleTrust
Fund-School of Allied Health
Professions; Graduate School Re-
search Fund #100099; Graduate
School Academic Computer Funds
#42009; Instrumentation Systems
Center; Interdisciplinary Geriatric
Training Grant-CHS-VA #2C (75)
IV -500406
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