April – Hand

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    • #7468
      Laura Thornton

      A 39 year old female presents to the clinic with one year history of right radial wrist and basal thumb pain. Symptoms has gradually gotten worse over the last year with more responsibilities with her kids’ activities, including transportation, meal preparation, and helping out with school projects. Recent radiographic imaging showed moderate degeneration of the thumb CMC joint and the consulting orthopedic surgeon recommended CMC arthroplasty, but she doesn’t have time for surgery with her busy schedule.

      Please discuss prognostic factors and management strategies for this patient. Include any experiences with similar patients and successes/failures with multidisciplinary treatment.

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    • #7477
      Erik Kreil

      The article demonstrates both statistically and clinically significant improvements in outcomes when the interventions (patient education + splint + HEP regime) are patient-centered.

      With this in mind, I’ve jotted down a few considerations for our 39yo mom:
      – Pathology:
      POSITIVE – chronic but relatively short duration (~1yr),
      POSITIVE – sounds volume-dependent (gotten worse as activity has increased), so potentially an opportunity for modification
      NEUTRAL – moderate degeneration,
      NEGATIVE – it’s worsening

      – The person:
      She describes a very busy life (too busy for surgery), and one that is potentially ramping up in activity volume. Her stress appears high… both of which could potentially delay a simple, quick prognosis which is dependent on consistent adherence to a direct prescription from a clinical practitioner.

      My prescription:

      Exercises: The article highlights 58 participants who completed the HEP 1x/ day, compared to 2 others who completed the HEP 2-3x/day. The exercise prescription also considered their tolerance to the exercises, partially related to their pain levels and irritability. There’s no specific case information to base a decision on, but we know that she’s currently tolerating a high volume of daily activity without specifically mentioned need to stop or address it throughout the day. With these in mind, I’d feel more confident prescribing the exercises 1x/day.

      Management: I’d be really keen on providing a heavy dose of education day 1 and swing that into a discussion on potential compensatory strategies, such as using an assistive device to open jars when making meals or carrying bags on her shoulder when possible rather than gripping them with the affected hand.

      Splint: I might initially prescribe a hybrid brace (13 participants found success across the article) to accommodate her need to perform a variety of duties throughout the day. The mean time spent wearing the brace was ~9hrs, so a hybrid brace would make it more easy to adhere to as a prescription.
      Another reality here is that orthoses aren’t an intervention for me to weigh heavily, as the study demonstrated a poor relationship with a large enough orthoses-related VAS change for a DASH reduction meeting the MCID. If necessary, we could always transition to a more rigid brace.

      The study recorded changes across a 6-week timeline, which didn’t demonstrate adequate gains in pinch strength and the article suggests that more time may be required. (It should be noted that the average participant age is in their 60s, whereas our patient likely has a quicker prognosis for tissue growth since she’s still in her 30s). Even so, the study shows that pinch strength and pain levels are most highly associated with functional gains and patient satisfaction, so this is an important variable to see success with.

      For this patient, I’d expect a longer prognosis (potentially 2-3mos before considerable gains are observed). Some studies referenced in the study measured gains across a 1-year span, so I could see a motivated mother in her 30’s seeking an alternative to surgery meet gains quicker. Other things I might consider to help her along are the suggestion of a journal log (aiding to hold herself accountable) and a self-CMC distraction+mobilization technique we’ve learned to be clinically successful.

      I don’t have much anecdotal information to guide my thought process, so I’m really interested in what everyone else’s take on my prognosis compared to their own might be.

    • #7480
      Matt Fung

      Erik great breakdown of the patient presenting in front of us. She definitely has many factors working in her favor here as you mentioned, however her symptoms seem to be worsening leading her into our clinic.

      I also do not have much personal experience with treating patients with CMC OA. There was one patient who Kristin and I worked with the other day complaining of radial sided wrist pain and my initial primary Dx was CMC OA and of course after testing it was not.

      I too believe that this article has clinical value for promoting a patient centered approach that can be applied to our 39 y/o mother. Despite the study only recording changes over a 6-week period of time while attempting to address a chronic issue, their results did reflect short term positive change in pain and function. With continued adherence over a longer period of time as demonstrated by other studies cited in the article, I believe there is room for even more improvement depending on the patient.

      For this individual I believe educational interventions would be the biggest part of my treatment plan. It has already been recommended by a surgeon that she have a CMC arthroplasty. From my experience when patients are told they most likely need surgery from their surgeon, their first question is, “so what’s the point of doing therapy if this (insert joint/muscle) is damaged?” Setting realistic expectations and educating her on the benefits of conservative treatment centered around HEP + split use to manage her symptoms would be essential for patient buy-in day 1.

      For this patient I would begin with recommendations for activity modification or compensatory strategies to perform said activities to offload her affected thumb and decrease stresses that she is exposing her joint to on a day to day. As the article mentioned using necessary assistive devices when meal prepping or carrying her kids items over her shoulder and not gripping them with her hands would be a great place to start, as well as addressing other activities she is having difficulty with.

      In regards to a splint for this patient I would lean to a more rigid brace short thumb spica for increased protection of her CMC joint. I would prescribe the brace to be worn prn, recommending usage during provocative activities.

      I would have this patient performing exercises 1x/day centered around CMC distraction with mobilizations as well as incorporating some neural mobilizations presented during our course series.

      Prognosis: I too would expect a longer prognosis for the patient in order to see significant improvements in her symptoms. It does not sound like her life will be slowing down anytime soon, which appears to be a direct cause of her increased symptoms. Thus, my POC would encompass a multi-modal patient centered approach centered around education, compensatory strategies, splinting, and HEP.

    • #7482

      I agree with Erik and Matt’s prognostic factors for this patient. I think her young age is a positive prognostic factor. I also think that she not wanting to have surgery is a positive prognostic factor, as she will likely be adherent with her exercises and splint usage knowing that a surgeon has recommended surgery, which she is trying to avoid. I think overall the patient has a good prognosis – yes she is busy and likely many things she is doing has been aggravating her symptoms, but that also means there is a big opportunity to make an impact with activity modifications.

      I shadowed our hand OT for a similar patient who we determined had CMC OA. This patient was a 50 yo female who was a chicken farmer who’s job was to collect up to about one-thousand eggs a day. She also did not want to get surgery and could not afford to be injured or else she couldn’t get paid. I only saw her for the eval, but the hand OT was great about going through activity modifications with the patient, and used specific examples with both collecting eggs as well as other household activities such as opening jars and cooking. I don’t remember what kind of splint the OT gave this patient. The hand OT’s initial HEP for the patient was to write down all other activities that aggravate her thumb so they could continue to troubleshoot activity modifications.

      Similar to Erik and Matt, as well as the hand OT, education would be at the top of my priority list for the patient. What I thought was awesome about the article was that the subjects were only seen three times, and they improved a decent amount. The specific brace type and activity modifications were tailored to the patient, but the exercises were not, indicating that perhaps a general strengthening protocol for HEP would be an okay choice for this patient. Matt I agree that after our course series, I would additionally add neural mobs to be performed as well. I would have the patient perform her exercises 1x/day and self-thumb distraction as much as she can throughout her day (when waking up, when stopped at a red light while driving, during commercials if watching tv).

    • #7500
      Cameron Holshouser

      I do not have any current experience with 1st CMC OA. Reading everyone’s detailed responses have been very helpful.

      Prognostic Factors
      – no trauma
      – gradual worsening
      – absence of sensation or motor changes
      – age (39)
      – able to continue ADL’s
      – sleep not disturbed
      – stress
      – job (being a mom with young kids)
      – duration of symptoms > 1 year
      – moderate degenerative changes at 39 y/o

      Management Strategies
      – Due to my lack of experience with this joint, I would try to relate to other joints that I treat frequently while keeping in mind the anatomy and function of the 1st CMC joint.

      – 1st thing would be to decrease load of the 1st CMC joint as often as possible for 3-6 weeks
      o Education: activity modification (Assistive devices, potentially decrease school project assistance and changing meal prep for 1-2 weeks), NSAIDS
      o Manual: joint distraction/glides, pain free ROM (A/PROM, AAROM)
      o Splinting: I would recommend using a splint to meet the needs of the patient’s lifestyle and comfort. Based on this study, as long as the splint was client-centered, there were benefits in pain and functional outcomes after 6 weeks. Because of this, I would offer a variety of splints and let the patient choose which splint works best for them to improve adherence. If the patient did not care, I would recommend a thermoplastic short thumb splica with the MCP immobilized in 30 degrees of flexion. I think immobilizing the CMC joint would be best for someone who might have problems with stability in the CMC joint during her ADL’s.

      -While working on offloading the joint, I would want to focus on intrinsic/extrinsic hand muscle ROM and strength to help support the stability of the CMC complex. I like Matt’s Idea of also incorporating nerve glides with this population. I also think working on overall upper body strength focusing on functional exercises with hand modifications would be appropriate and helpful for the patient.

    • #7514
      Laura Thornton

      Great input guys! I appreciate the priority on activity modification and education, which is key.

      Let’s talk exercise specifics – there’s a lot of great approaches here (neurodynamic, self-mobilization, general strengthening, stabilization of the CMC complex).

      What do you guys think about these two articles from JHT? They might shed some light on ideas for what to do with these patients.

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    • #7517
      Erik Kreil

      I love relating the CMC joint to the shoulder joint, since they both lack osseus stability and are highly mobile for it.

      The theory of CMC OA occurring from degenerative ligamentous laxity (requiring inc active stabilizers) reminds me of secondary shoulder impingement pathology’s “Silent Subluxation Cycle” process… am I way off on this?

    • #7519
      Cameron Holshouser

      I like these articles because they highlight a rehabilitative approach for CMC OA. Again going with the theme of relating to other joints, we don’t always brace everyone with stability problems. Going off Erik’s point of shoulder instability, there is decent evidence to support a conservative rehab approach with non-traumatic cases. These articles highlight how conservative management with a dynamic stability program can result in significant reductions in pain and disability. I did not look, but I would be interested in an RCT of dynamic stability rehab vs splinting + rehab to see if there was a difference. I do think the hand/thumb is different than other joints because we use our hands for everything and it is a highly sensitive area (homunculus model), so maybe unloading with bracing may help better with short term pain reductions vs just rehab.

    • #7524

      Erik I think you’re onto something comparing this to the subluxation cycle.

      Cam, I never would have thought of the homunculus model as a reason why the hand may be different than other joints, but I think its a great point.

      I really liked the second article posted and how it uses ACSM exercise guidelines in its prescription for its own CMC OA exercise guidelines. It reinforces the idea that the hand/thumb is not completely different than any other joint in the body, although I keep on thinking that it is (most likely due to lack of treating it). I also liked that it was biomechanical in nature, but then provided some really key concepts to help with exercise prescription. It would be interesting to see if they implemented this exercise prescription in a RCT similar to what Cam referred to.

      My last thought is that as I’m reading these article about CMC OA, I’m surprised by the low number of visits the articles are reporting. Is this because education is such a big component of this pathology? I would think even if this is the case, that these educational concepts would need to be reinforced several times for them to really stick.

    • #7526
      Erik Kreil

      That’s a good point, Jeff.. I wonder if it’s in part because the thumb is a joint that can easily be self-manipulated by the other patient hand? That gives the patient access to the manual tx… and they can already do the exercises.. so I think you’re right to wonder about the education component.

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