FUNCTIONAL EVALUATION OF HANDS IN PEOPLE WITH AND WITHOUT ARTHROPATHY OF JACCOUD ASSOCIATED WITH LÚPUS AVALIAÇÃO FUNCIONAL

| Introduction: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease of a diffuse nature, which causes, among other factors, joint involvement Jaccoud arthropathy (AJ) is a reversible deforming inflammation that occurs in the proximal joints, Frequently seen in upper limbs. The epidemiological prevalence of AJ is 5% for SLE patients. Poor alignment or loss of strength can limit movement, generate compensations and joint overloads. Early functional diagnosis may help reduce the installation of joint deformities. Objective: To compare the range of motion and palmar grip strength in people with and without AJ associated with SLE. Methods: A cross-sectional study where patients were allocated to two groups: diagnosed with SLE and diagnosed with SLE associated with AJ. The instruments used: dynamometer, finger goniometer and the universal goniometer. Results: 67 women with SLE participated in the study, of which 32 had AJ. The sociodemographic and clinical characteristics of the groups were considered homogeneous for the analyzed variables. A significant difference was observed between groups, except for the extent of interphalangeal extension of the first right mandibular (p = 0.073), distal interphalangeal of the fourth left (p = 0.083) and distal interphalangeal of the first left mandibular (p = 0.435 ). Conclusion: People with AJ associated with SLE had higher joint amplitude and lower palmar grip strength compared to those with SLE alone. These results suggest that there is still a need for complementary studies to observe the functionality of these people’s hands

Systemic lupus erythematosus (SLE) is an autoimmune, diffuse and chronic disease that causes joint involvement 1,2,3 .The most common signs and symptoms are joint pain, stiffness, non-erosive arthritis (Jaccoud arthropathy) or erosive (rhupus) 4 .Until an accurate analysis of the health condition is obtained, the individual may receive different diagnostic hypotheses, which often implies late treatment 5 .Jaccoud arthropathy (AJ) is a clinical manifestation that was primarily described in association with rheumatic fever, and been observed in connective tissue diseases, as SLE 6,7,8 , dermatomyositis 9 , Intestinal inflammations, psoriatic arthritis, among others 5,10,11 .
AJ is a non-erosive, reversible deforming inflammation that occurs in proximal joints, most often seen in upper limbs [6][7][8] .Commonly affects metacarpophalangeal (MF) and interphalangeal (IF) joints 5 .Epidemiological prevalence of AJ is 5% for patients with SLE 10,11 .AJ is a rare disorder, and there are some case reports with epidemiological and clinical data 5 .Imaging tests of the hand with AJ can be found three types of deformities 1 .Musculoskeletal manifestations characteristic of AJ are: swan neck, ulnar deviation, thumb subluxation and hallux valgus [6][7][8] .
Joint deformities generated by degenerative diseases lead to incapacities and functional dependencies, and thus generate economic costs for both the patient and society 12 .Therapeutic strategies must be preceded by a preliminary and detailed evaluation 13 .Few radiological and clinical studies in AJ 4,5 delineated the functional profile in this health condition, as recommended by the World Health Organization through the International Classification of Functioning, Disability and Health (ICF).
Measurement of manual grip strength and joint amplitude, which may contribute to the elaboration of more precise protocols for functional characteristics, which may contribute to the elaboration of evaluation protocols for monitoring clinical evolution and for responses therapeutic procedures.Lack of alignment or loss of strength can limit movement, generate compensations and joint overloads.Early functional diagnosis may help reduce the installation of disabling articular deformities for manual activities.This study aims to compare the range of motion and

INTRODUCTION
palmar grip strength in people with and without JA associated with SLE.

MATERIALS AND METHODS
Cross-sectional study.Fulfilled in outpatient clinics of Bahiana School of Medicine and Public Health (ADAB), situated in Brotas, Salvador, Bahia.Data collection occurred from September to December of 2014.ADAB comprises two units in Brotas and Cabula, providing private and public services, in addition to having an association with the Salvador Municipal Health Department and Unified Health System.Inclusion criteria's were selected people who were in regular follow-up in SLE outpatient clinic, met classification criteria's of SLE proposed by American College of Rheumatology 2 and JA according criteria's proposed by Santiago 14 who were on medication in use stabilized for at least six consecutive months.Exclusion criteria's were pregnant patients; with poor understanding of the underlying disease or evaluation tools and patients with rhupus.
Predictor variables were age, time of disease, occupation and dominance; The occupation was divided into light: retired, unemployed, clerk, beneficiary, disability; moderate: community agent; High: student, housewife, administrator, laundress, artisan, secretary, drawer, farmer and teacher.Outcome's variables was joint amplitude and palmar grip strength.Data were from a primary source, collected in a previously reserved room where the physical evaluation.
Individuals were allocated into two groups: those diagnosed with SLE and those diagnosed with SLE associated with JA.To reduce the risks of bias, the interviews and the structuring of the database were done by an independent examiner.Instruments used were: manual hydraulic hydraulic dynamometer JAMAR®; finger goniometer Inches® and universal goniometer Carci®.
Before measurement of palmar grip strength, an evaluation of the range of joint motion, by same examiner, and patients were placed in a blood collection chair, So that there was minimal musculoskeletal compensation during data collection.Articular amplitudes evaluated were ulnar deviation of the wrist, with goniometer fulcrum located in middle of the dorsal face of wrist, In radio's lister tuber.Fixed arm alignment was the forearm and movable arm was third metacarpal's dorsal midline 15 .Fingers ulnar deviation was also evaluated, where fulcrum of movement was located in hands extensor musculature's tendon, in third metacarpus's head region.Joint examination's second part consisted on measurement of bilateral fingers.Inches finger goniometer was used, the extent of proximal IF joints was measured and distal regions of II, III, IV and V fingers.Forearm at 0º of supination and pronation.Flexion, extension, radial and ulnar deviations of the wrist at 0º. Flexion, extension, abduction and adduction of 0º MF joint.Movement fulcrum was situated in the center of each joint, fixed arm, aligned with proximal and medial phalanx, respectively, and movable arm followed median phalanx and distal phalanx of each finger evaluated 16 .
Then, IF joint of 1st finger was evaluated.Forearm in total supination, wrist with ulnar and radial deviation, flexion and extension at 0 degrees.Carpometacarpal joint in 0º of flexion, extension, abduction, adduction and opposition.MF joint in 0º of flexion and extension 17 .
For security measure, and to ensure statistical reliability, the complementary angles for extension were described, since negative signal, commonly designated to describe extension, was not used.This influenced measures normally used as standard joints references.Measurement of muscle strength was performed by American Society of Hand Therapists (SATM) and American Society of Hand Surgery (SACM) positions recommended.Jamar brand analog hydraulic dynamometer was considered a validated, reliable and gold standard instrument in the literature 20 .
A room without noise and ambient light was reserved previously.Before starting, was demonstrated through a simulation how evaluation would be and any doubts were taken 15 .
During assessment no verbal commands were given nor mentioned.Patients sat in a plastic chair without arms where and angle of hips and knees were approximately 90º, and feet supported on floor.Was certified if feet were supported the ground when compared to height of seat, for those who did not lean was placed books, according to patient height.Patients were instructed to make a shoulder adduction, a 90º elbow flexion, forearms in a neutral position.It is recommended wrist extension of 0º-30º and adduction of 0º-15º to evaluated upper limb.When was ready, the subject had tightened dynamometer with maximum isometric effort, which is held for about three seconds, three consecutive times with a thirty-second interval between each hold.Started with right hand and then, left hand 15,18,19 .
Patients were corrected for placements if there was a need and were instructed to remove objects that could influence the evaluation such as watches, rings, bracelets.Was performed three times and remained the highest value.
Collected data were inserted in software IBM Statistical Package for Social Sciences (SPSS v.21).Stored on a computer in a confidential way with a password, so that there was no change of data.For the calculation of the sample, which estimated that 68 individuals were required, a standard deviation of 5 and difference to be detected of 3Kg / f measurements dynamometer between groups with and without JA, level of significance of 5%, a power of study of 80%, using the laboratory calculator of epidemiology and statistics of USP (available in: www.lee.dante.br/cgi-bin/uncgi/calculo_amostral 20 . Data were descriptively evaluated through mean, deviation, median, minimum and maximum, in continuous variables, and through of frequencies and percentages for categorical variables.To verify the homogeneity of the groups in relation to variables such as age, time of diagnosis of the disease, occupation, dominance, Student's t-tests were performed for comparison of mean between groups; Mann Whitney test was used for nonparametric comparison of selected numerical variables: Palmar grip strength, ulnar deviation, finger deviation, proximal interphalangeal (IFP) and distal interphalangeal (IFD).Each group was trend check in diagnosis time for comparison, according to the normality in the data.
This study is part of a doctoral project entitled: Effect of an exercise protocol on hands function in patients with Jaccoud's Arthropathy associated with Systemic Lupus Erythematosus: pre and post pilot study, submitted and approved by the CEP Participated 67 women with SLE, of which 32 had JA.Sociodemographic and clinical characteristics are presented in Table 1.Groups were considered homogeneous for the analyzed variables.

RESULTS
Table 1.Sample characterization of patients with systemic lupus erythematosus from a reference outpatient clinic in Salvador, Bahia, Brazil, 2014.
T test for comparison between groups; Fisher's exact test for proportions between groups.
When comparing groups in relation to numerical variables analyzed, a significant difference was observed between groups in all parameters, with exception of degree of extension of distal right first IF (p= 0,073), left fourth distal IF (p= 0,083) and degree of extension of distal left first IF (p= 0,435), according Table 2. Palmar grip is an essential movement for the manual functions, indispensable for the accomplishment of Daily Life Activities (ADL's) and labor.Decreased performance for ADL's has been observed in people with JA 14 .There remain gaps in extent to which this health condition reduces functional capacity for work.No differences were observed between groups for occupation and time of disease in this study.Likewise, the time of diagnosis seems not to be decisive in the evolution of the functional.Several factors can influence palmar grip strength such as: body posture, shoulder position, elbow, wrist, hand and fingers 21 .identified in the JA group.Probably due to reduction of palmar grip strength and, as compensation, grip muscles participating 10,16 in adduction, flexion and ulnar deviation of the wrist and fingers 5,10 .Another justification may be for people with JA have distended joint capsules and extensor tendons shortened to metacarpals ulnar side, with consequent ulnar deviation 5 .The deformity begins to settle in the second and third fingers and other fingers are being pushed towards the same direction 14 .Functional impacts are observed between 0º and 15º of ulnar deviations 22 .

An ulnar deviation of wrists and fingers was
People with JA have hypermobile joints 5 , as confirmed in present study.Literature has not been elucidated whether hypermobility is a result of soft tissue laxity or is a primary process of this health condition 5 .May be fibrin and fibrous thickening of joint capsules of a person with JA 23 .It has been found that there is deviation in joints left fourth distal IF and distal first IF bilaterally in patients with SLE, even in the absence of JA.Patients diagnosed with SLE have hypermobile joints when compared to healthy individuals 24 .Believed that genesis of this kinetic-functional pattern is residual fibrosis with consequent alteration in joint capsule 5 .
Thumb is considered important in hand performance.
Accounting for about 60% of palmar grasping and grip movements 3 .Because it presents looser ligaments and tends to a previous wear 25 .Patients with JA are favorable for ulnar deviation of wrist, thumb's movements are functionally compromised, which may be related to the frequent subluxation 3,5 .IF joint of the thumb is identical to that of other fingers in relation to structure and function, and may present the same degree of joint complexity 17 .
Fourth finger has a smaller role in hand functionality, compared to other fingers.Its loss would imply in only 10% in function 16 .Noteworthy that left fourth distal IF was the only joint that did not present a significant difference between people with and without JA.A probability for this finding that chance has outcome influenced.
This study has advantages of being innovative, besides being able to contribute to early treatment, before functional changes installation, in order to delay their appearance.It was inexpensive, quick and easy to perform.However, the absence of a segment does not allow establishing causal relationships between the variables.

CONCLUSION
People with AJ associated with SLE had higher articular amplitude and lower palmar grip strength compared to those with SLE.These results suggest that there is still a need for complementary studies to observe functionality of these people's hands.Randomized clinical trials should be performed in order to establish protocols and treatments for these disorders.

Table 2 .
Characteristics of grip strength and hand angulation in patients with Systemic Lupus Erythematosus with and without Jaccoud Arthropathy in an outpatient clinic in Salvador, Bahia, Brazil, 2014.of the Catholic University of Salvador, CAAE: 63008116.6.0000.5628, in accordance with 466/12 resolution.Participant's cultural, social, moral, religious and ethical values have always been preserved and the procedure provided will ensure reliability and privacy.Materials and data collected in research had sole purpose foreseen and informed in Informed Consent Form (ICF).This study only started after the participant signed ICF, allowing their research participation.

Table 2 .
Characteristics of grip strength and hand angulation in patients with Systemic Lupus Erythematosus with and without Jaccoud Arthropathy in an outpatient clinic in Salvador, Bahia, Brazil, 2014.