orthoses, education and adaptations to items used in daily life, education in joint protection techniques, and suggestions for home-based treatment methods such as paraffin baths and ice packs (Hunter & Lo, 2008). The physician also should explain to the client the pathophysiology of the disease, the likely sequelae of the condition, and the potential for future invasive procedures such as joint replacement surgery. As with all forms of arthritis, the goals of treatment for those with CMC OA are typically reduction of pain, increased or maintenance of function, increased ROM and strength, and reduction of inflammation. Pain reduction can be accomplished in a number of ways, including use of the physical agent modalities (PAMs) in the form or heat or cold applications. When using any type of heat or cold modality, the therapy practitioner must remember that heat should not be applied if acute inflammation is present because the increase in local circulation could exacerbate swelling. As with ice treatments, heat should not be used with insensate hands. Immobilization of the CMC joint, allowing movement of the wrist and interphalangeal joint, can reduce and prevent pain. Rest during a painful exacerbation of symptoms reduces the duration of the painful event, reduces the possibility of further joint erosion, and maintains client function (Hochberg et al., 2012). Orthoses are available commercially, or the therapy practitioner can fabricate many styles. Factors such as severity of pain, demands of the task, severity of joint degeneration, and client preference affect the orthosis style decision. The orthoses described below are fabricated easily in the clinic and are comfortable for extended wear (Bielefeld & Neumann, 2011). The orthosis shown in Figure 20 is a hand-based thumb CMC support orthosis that was fabricated from thermoplastic. The orthosis leaves the MCP, interphalangeal joint, and wrist free, which allows for maximum hand and thumb function. In severe cases, such support might be inadequate; a longer gutter extending into the forearm might be helpful, or a typical thumb spica orthosis extending from the radial to ulnar side of the hand might be indicated (Figure 21). Several styles of synthetic rubber orthoses are available that offer more flexible support to the painful joint (Roberts, 2013). Although synthetic rubber or neoprene orthoses are not as rigid or supportive as thermoplastic , many clients appreciate their less restrictive 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 abduction to avoid adduction contracture (Figure 22). Figure 20: Thumb Carpometacarpal Support Orthosis
Figure 21: Forearm-Based Thumb Spica Orthosis
Source: Erin Peterson
Figure 22: Hand-Based Synthetic Rubber Orthosis
Source: Erin Peterson Targeted therapeutic exercises are also important in the conservative management of thumb CMC OA; however, it is imperative that therapists do not prescribe exercises that encourage positions of deformity or further joint damage. Gentle and nonresistive 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 increased pain, as this can lead to swelling and subsequent stiffness. 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 principles to decrease unneccessary stress on their painful and affected joints. In general, joint protection includes respecting pain, balancing rest and activity, reducing muscular effort, avoiding positions 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.
Source: Erin Peterson
EliteLearning.com/ Physical-Therapy
Book Code: PTNY1024
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