the joint is stable, and the surgeon approves. Optional dynamic orthoses can be continued or discontinued according to the client’s progress. Light strengthening exercises can be initiated at this time. Increases in resistance should be introduced gradually and according to pain tolerance. During this time, therapy can be discontinued, but prior to the final visit, the client should be instructed in joint protection techniques to ensure the pain- free status of the CMC and prevent disruption of the joint. (See Appendix A.)
deformities and enhancing function. Care should be taken not to apply these forces to newly reconstructed CMC joints (Bielefeld & Neumann, 2011). Clients will discover renewed interest in some daily activities that were avoided due to pain, and should be encouraged to participate in desired activities within pain limitations. Scar control, edema control, and ice should be continued as needed. During the ninth and tenth postoperative weeks, the thumb orthosis can be discontinued if the client is reporting less pain,
WRIST OSTEOARTHRITIS
Kienbock’s disease involves breakdown of the lunate resulting from trauma of that bone. Active adults age 20 to 40 years are most likely to report the disease. Kienbock’s disease might involve both wrists, but is primarily a unilateral joint condition. Although an exact etiology for the condition has not been determined, repetitive trauma of the wrist is the suspected cause (Dewing et al., 2012). Individuals such as carpenters and roofers, who spend a great deal of time bearing weight on extended wrists when using heavy tools, tend to have higher incidences of Kienbock’s disease (Dewing et al., 2012). Individuals also might have a mechanical inclination toward developing the condition, as when there is a positive ulnar variance (Rubin et al., 2012). SLAC wrist, SNAC wrist, and Kienbock’s disease have similar presentations regarding client symptoms and dysfunction. Each results in pain both with movement and at rest, and they limit movement and overall function of the wrist. TENS used intermittently throughout the day reduces pain and decreases the need for pain medications (Bellew et al., 2016). A wrist immobilization orthosis should be provided to a client to reduce movement of the wrist and the painful impact of force. Orthoses can be fabricated from thermoplastic such as those in Figure 23, or can be purchased from a vendor. Either method is acceptable as long as it performs appropriately and does not cause harm to the client. Regardless of whether the device is custom-made or prefabricated, it should be rigid and able to hold up against the demands of a client’s daily occupations. A circumferential or clamshell orthosis offers the most stability of the wrist. These volar- and dorsal-based devices can be purchased or fabricated by a practitioner. Leather orthoses are available commercially and resist dirt, grime, and wear experienced in jobs in industries such as construction, auto mechanics, and farming. Figure 23: Volar-Based Thermoplastic Wrist Immobilization Orthosis
Several conditions are commonly associated with OA of the wrist and hand. An overview is provided here, followed by discussions of conservative medical management, surgical management, and occupational therapy interventions. Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) are the two most common patterns of posttraumatic wrist arthritis. Both conditions lead to abnormal joint kinematics because of changes in the orientation of the lunate due to changes to the scaphoid. Change can occur as a result of rheumatoid arthritis, calcium pyrophosphate dehydrate deposition disease, neurogenic disease, or nonunion of the scaphoid (Shah & Stern, 2013). Over time, the lunate assumes an extended posture that can result in a dorsal intercalated segment instability deformity. Both conditions lead to OA of the radioscaphoid articulation and eventual midcarpal collapse (Shah & Stern, 2013). Conservative management Prior to surgical intervention, nonsurgical treatments of symptomatic OA of the wrist in any of the forms described might include wrist immobilization, anti-inflammatory medication, and corticosteroid injection (Shah & Stern, 2013). When symptoms can no longer be managed with conservative methods or at the point when functional decline is no longer acceptable, the client might opt for surgical intervention. Pain leading to disuse is the primary problem in those with severe OA of the wrist, regardless of the diagnosis (e.g., Kienbock’s, SLAC wrist). Since the primary role of therapy is to preserve function and occupational engagement, preventing or reducing pain within the hand and wrist during activities is the target of intervention. Pain reduction and enhanced functional use of the hand are accomplished through multiple methods, including physical agent modalities, orthosis wear, joint protection, work simplification techniques, and adaptive equipment. Some individuals choose a conservative approach as a permanent method of dealing with pain of the wrist; others eventually opt for surgical intervention to reduce pain permanently. Therapists first determine the extent of pain in the wrist and then gain an understanding of how it affects daily occupations for a client. Several assessment tools, described previously, can be used for this occupational profile (AOTA, 2020). When a therapist understands how a client needs to use their hand and analyzes the motions required, they can offer suggestions regarding work simplification aids or tools that will do work and decrease the amount of force on the wrist. For example, a client can be instructed to use a rolling trivet when cooking to move heavy pots along a kitchen counter, rather than place undue force on the wrist by carrying the pot (Cooper, 2020). Work simplification techniques can also be suggested, such as using a cart when cleaning to avoid carrying cleaning items or items needing to be relocated. (See Appendix A.) A client should also be instructed to use ice packs to dull pain when possible. Ice packs can be applied for a maximum of 20 minutes at a time, with the skin covered by a layer of toweling to prevent damage to the skin. Other physical agent modalities such as transcutaneous electrical stimulation (TENS) can also be suggested and should be applied and provided to the client for home use by a PT/OT familiar with their indications and use.
Note: Photograph provided courtesy of Dr. Lucinda Dale.
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