Figure 20: Thumb Carpometacarpal Support Orthosis
Figure 22: Hand-Based Synthetic Rubber Orthosis
Source: Erin Peterson
Figure 21: Forearm-Based Thumb Spica Orthosis
Source: Erin Peterson Targeted therapeutic exercises are also important in the conser- vative management of thumb CMC OA; however, it is imperative that therapists do not prescribe exercises that encourage posi- tions of deformity or further joint damage. Gentle and nonresis- tive AROM exercises to the thumb performed with low repetitions at moderate frequency (e.g., five repetitions each, three to four times a day) are appropriate when the client is not experiencing a flare. Exercises should not be painful and should not cause in- creased pain, as this can lead to swelling and subsequent stiff- ness. If tolerated, pain-free isometric strengthening exercises for the opponens pollicis and the abductor pollicis brevis may also be appropriate to help improve thumb CMC stability (Bielefeld & Neumann, 2011). O’Brien and Giveans (2013) outlined a dynamic stability program for the thumb CMC to reduce pain and improve function. Included in the program are exercises and client self- mobilizations to reduce subluxation of the CMC, decrease muscle tightness of the adductor pollicis, and strengthen the first dorsal interosseous muscle (O’Brien & Giveans, 2013). Additionally, clients should be educated on joint protection prin- ciples to decrease unneccessary stress on their painful and af - fected joints. In general, joint protection includes respecting pain, balancing rest and activity, reducing muscular effort, avoiding po- sitions of deformity, and using larger and stronger joints (Beasley, 2011). Therapists are able to analyze the activities of the client and provide education and adaptive devices to help the client integrate these principles into their daily routines. still exist, however, and surgeons continue to find new options to restore the thumb CMC (Lubahn et al., 2011). The most widely used excision and arthroplasty technique for the thumb CMC is the ligament reconstruction tendon interpo- sition (LRTI) procedure. In general, the trapezium is completely removed, and a tendon or partial tendon is harvested from the client and used as a soft tissue interpositional athroplasty, tak- ing the place of the trapezium (Cannon, 2020). Donor tendons in- clude all or part of the flexor carpi radialis (FCR), abductor pollicis longus (APL), or (rarely) the extensor carpi radialis brevis (ECRB; Badia, 2011). Depending on the donor tendons used, clients may have decreased wrist flexion strength or other complications (Du- erinckx & Verstreken, 2022). Outcomes are generally good follow- ing LRTI procedures, but rehabilitation can be long and painful (Badia, 2011). Due to this, surgeons are continually researching other methods of restoring the thumb CMC joint, including use of prosthetics. Various brands and types of prosthetics can be used for the thumb CMC joint depending on the surgeon’s preference and the needs
Source: Erin Peterson Several styles of synthetic rubber orthoses are available that of- fer more flexible support to the painful joint (Roberts, 2013). Al- though synthetic rubber or neoprene orthoses are not as rigid or supportive as thermoplastic , many clients appreciate their less re - strictive nature. These clients might be required to maintain more flexibility of their hand due to the demands of their work or home activities. The neoprene orthosis shown below has a hand-sewn webspace component that assists in maintaining the thumb in ab- duction to avoid adduction contracture (Figure 22).
Surgical management and postsurgical therapeutic intervention Over the years, many surgical approaches to treatment of arthritis of the CMC joint and other hand joints have been tried and dis- carded, or improved on. Current approaches to OA of the CMC joint include arthroplasty and arthrodesis. Arthroplasty is the re- construction of a diseased or destroyed joint, and arthrodesis re- fers to joint fusion in which two (or more) bones that articulate to form the diseased area are connected through either a bone graft or fixation device such as interosseous wiring. Carpometacarpal joint arthroplasty
While silicone implants are commonly used for PIP joint arthro- plasty procedures, they are not recommended for CMC arthro - plasty (Lubahn et al., 2011). Due to repeated stress demands placed on the thumb CMC during daily use and the wide range of mobility of the joint, silicone implants often fragment after sev- eral years of use, leading to silicone synovitis, which necessitates removal of the implant. Instead, surgeons have utilized multiple excisional techniques for the damaged CMC joint with varying anatomical nuances. In general, excision of the affected bone re- gardless of the technique has been shown to improve function in most clients (Lubahn et al., 2011). Complications for some clients
EliteLearning.com/ Physical-Therapy
Book Code: PTCA2624
Page 81
Powered by FlippingBook