Scleroderma Case Study

Author/s

Catelin Infante, Jessica Frederick, Kristin Casagrand, Jarrod Smith from the Bellarmine University Physical Therapy Program's Pathophysiology of Complex Patient Problems Project.

Patient Characteristics

• Demographic Information: (occupation/vocation, gender, age, etc.)                                                                                                       

Native American 

Female

Born and raised in Oklahoma 

Works in a factory 

Thirty-five years old 

Family history of rheumatoid arthritis on mother's side 

• Medical diagnosis if applicable

Scleroderma 

• Co-morbidities

Hypertension, Type II Diabetes 

• Previous care or treatment

Previous physical therapy for low back pain 

Examination

• Subjective

Ms. Smith comes into the clinic complaining of joint pain and muscle weakness, especially in her hands, hips and shoulders¹. She explains that she has been having trouble making it through a full day of work because her body feels limited and she just cannot reach as well for boxes at her job because "her arms won't go up that far". She also has noticed that she gets out of breath and sometimes has chest pain when she lifts a lot too quickly². Mrs. Smith indicates that her fingers often feel very swollen and stiff and sometimes feel "stuck" in a bent position¹. She reports that for several months she has been getting a really cold, numb feeling in her fingers throughout the day, especially when she is sitting in the air conditioning at her office³. Overall, she has just not felt well for the past few months either. When she eats, she has trouble fully opening her mouth to put food in². Then, when she lies down at night after dinner, she gets a feeling of heartburn and sometimes feels she has to vomit¹. However, she says she has been eating poorly lately, so it's probably her fault she hasn't felt well. Additionally, Mrs. Smith reports losing 20 pounds in the past month without any lifestyle changes. Her goals for therapy are to decrease her joint pain and to get her muscles stronger so she doesn't struggle at work any longer. Her focus is on getting her hands and arms "back to normal" because they are what she uses most in her job.

• Self-Report Outcome Measures

Health Assessment Questionnaire Disability Index (HAQ-DI)⁴: 1.1

Disabilities of Arm, Shoulder, and Hand Questionnaire (DASH)⁵: 34

Verbal Pain Intensity Scale: "Severe pain"

• Physical Performance Measures 

Grip strength (R)⁶: 20.7 kg

Grip strength (L)⁶: 19.18 kg

Pinch strength (R)⁶: 4.27 kg

Pinch strength (L)⁶: 3.98 kg

Oral aperture⁷: 28 mm

• Objective

MMT: WNL except for the following

4/5 finger and thumb abduction, adduction, flexion, extension

4/5 wrist flexion and extension

3+/5 shoulder flexion and abduction

3+/5 hip flexion and abduction

ROM: WNL except for the following

Decreased flexion and extension in all finger MCP and IP joints

Decreased wrist flexion and extension

Decreased hip extension and abduction

Reflexes: WNL

Sensation: Decreased facial sensation

• ICF Findings

Impairments^1,2,8

Patient has stiffening around fingers and what appears to be finger flexion contractures developing

Patient has noticeable hard deposits palpated around UE joints

Patient has slurred speech due to difficulty fully opening mouth. The skin around the face is thickened and has begun to cause puckering

Pt has dyspnea and chest pain upon exertion

Activity Limitations^1,2,8

Patient is unable to complete activities in supine secondary to reflux symptoms

Patient is unable to complete overhead activities due to decreased shoulder ROM

Patient is unable to complete more than 30 minutes of repetitive movements due to fatigue, muscle weakness and joint pain

Environmental Factors⁸

Patient is employed as a packer at a plastics company 

Patient is a smoker of 20 years 

Clinical Impression

• After Ms. Smith's assessment, we have determined that she has decreased range of motion in her fingers and wrists, decreased cardiovascular endurance, decreased muscle mobility, as well as increased muscle weakness and fatigue. All of these impairments have impacted her functional ability to do activities at home and in the work place. Physical therapy could benefit Ms. Smith by improving her impairments that were found and by providing patient education on management of her condition. The interventions during PT would include active joint range of motion, strengthening exercises and aerobic exercises to improve endurance, as well as education on a home exercise program and management of the symptoms of her condition. With the help of physical therapy, Ms. Smith would likely be able to reach her goals for improving her strength and endurance and decreasing her joint pain so that she can particpate in more activities at home, work and in the community.
  

Summarization of Examination Findings

Working Diagnosis and Targeted Interventions

Intervention

• Phases of Interventions

Edematous Stage:

Patient Education (About the disease; treatment of Raynaud's disease - dress in layers, monitor temperature changes, avoid air conditioning if possible, avoid things that cause vasoconstriction like smoking, cold temperatures and emotional stress)

Orthotic and adaptive equipment needs

Light range of motion exercises

Joint protection strategies (light weight splints)

Sclerotic Stage:

Paraffin/heat modalities for hands and fingers

Passive range of motion exercises progressing to active-assisted range of motion, then to active range of motion, can add a sustained stretch for five seconds at end range (finger flexion/extension and abduction/adduction, wrist flexion/extension - can use hand clasp with wrist extension stretch) 

Soft tissue mobilizations

Joint manipulations (Traction)

Kabat's method to improve mouth opening (activation of orbicularis oris, zygomaticus, levator labii, nasalis, frontalis and corrugator muscles by exaggerated facial movements) - progress from active-assisted ROM to active ROM

Soft tissue massage

Aquatic therapy (Upper and lower extremity range of motion and strengthening exercises, walking, squatting, marching, etc)

Atrophic Stage:

• Dosage and Parameters

SMART framework - combines physical therapy sessions with self-management of care through a home exercise program. The PT session focuses on designing an individualized program for each patient in order to treat their specific impairments and goals. The sessions are planned less frequently during the week, but spaced out over a longer period of time. This is to help shift the focus of the care to self-managed that way the patient can manage their condition for the long-term. The HEP uses exercises, self-stretches and paraffin to help the patient manage their condition at home. The patient is given 4-5 exercises that are performed 1-2 times per day, for 5 days per week.

• Rationale for Progression
• Co-interventions if applicable 

Occupational Therapy

Joint preservation principles

Devices for independent living

Medications

Disease modifying drugs (Penicillamine) - treatment of disease processes

ACE inhibitors - treatment of acute hypertension/pulmonary hypertension and renal complications

Nonsteroidal anti-inflammatory drugs (NSAIDs) - treatment of joint inflammation

Antibiotics/Oral Tetracyclines (Minocycline, doxycycline) - treatment for disease by reduction of pain, severity of condition and quality of life

Analgesics - treatment of pain

Calcium channel blockers - treatment of Raynaud's

Immunosuppressants - treatment during the acute phase of the disease

Outcomes

Findings Over time

Discussion

Summary Statement which should include related findings in the literature, potential impact on clinical practices

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