CASE STUDY 1: NONSURGICAL
● Instruction in joint protection techniques and adapted techniques for ADL. ● Recommendation, due to pain associated with writing at her job, that Mrs. Hernandez complete work on a tablet computer using a stylus, which was adapted to increase circumference and thereby reduce pinching and force application to the CMC joint. ● Exploration of alternative methods for creating scarves, including crocheting while wearing orthoses; Mrs. Hernandez reported that she might take a break from crocheting and make machine-sewn blankets for a local homeless shelter. ● Instruction in the use of ice following activities that bring on pain or inflammation. ● Provision of a catalog of adapted equipment and instruction on how to select an adapted aid to decrease repetitive motion, pinching, and rotation forces on thumb; Mrs. Hernandez reported that she would immediately purchase an electric jar opener, since opening jars had become nearly impossible. Mrs. Hernandez was scheduled for a follow-up appointment in three weeks and was instructed to call in the meantime with questions or concerns. During her follow-up appointment, Mrs. Hernandez reported feeling much better. She had been wearing her orthosis during all activities, removing it for sleep and when at rest. She continued to crotchet but was using an adapted handle for the hook and taking frequent breaks. Mrs. Hernandez reported that work is much easier and less pain-producing because she is writing on a tablet computer rather than using pen and paper. The MAM-20 was re-administered. Scores were 68/80 for functional abilities and 3 for pain. Gross grasp strength had not changed, nor had AROM. Pinch strengths increased by 2 lb for each pinch. Mrs. Hernandez was encouraged to continue to use the orthosis and reduce its use as pain diminished. She was encouraged to use it when engaging in heavy activity. She would continue to follow joint protection techniques and seek adaptations as needed.
Mrs. Hernandez is a 62-year-old female with a diagnosis of left dominant hand thumb CMC osteoarthritis. Mrs. Hernandez is employed as an office manager of a busy orthopedist office and in her free time enjoys crocheting scarves; cooking; and playing with her grandchildren, ages two and four. Mrs. Hernandez was referred to rehabilitation for treatment of her left hand because she has reported increasing pain and decreasing functional abilities with work, leisure, and ADL activities. The therapist administered the Manual Ability Measure-20 (MAM-20) to determine the extent of Mrs. Hernandez’s functional deficits. She scored a 58/80 and reported pain as an 8 on a 0 to 10 visual analog scale (Chen & Bode, 2010). During visual examination, the therapist noted enlargement of the CMC joint with a squared appearance at the base of the thumb. AROM measurements of the MCP and IP joints indicated full ROM in flexion and extension, with no deformities of these joints. Thumb palmar abduction, however, was found to be 40 degrees in comparison to 60 degrees on the right hand, indicating early adduction contracture. Strength measurements using dynamometer and pinch meter were: Left Right Gross grasp 40 lb 79 lb Lateral pinch 5 lb 15 lb Three-jaw chuck 3 lb 13 lb Pincer grasp 3 lb 6 lb The therapist created a treatment plan to address the concerns of Mrs. Hernandez, which included pain; decreased ADL, work, and leisure functions; weakness (secondary to pain); and early adduction contracture. Treatment included: ● Fabrication and provision of a custom short-thumb spica orthosis with C-bar to prevent adduction contracture; an instruction sheet for care and use was provided.
CASE STUDY 2: SURGICAL
AROM of fingers and thumb were as follows: Right Hand (ext/flex) MCP PIP DIP
Mr. Chen, age 54, was seen by the therapist at an outpatient rehabilitation department one week after a right nondominant total wrist fusion. Fusion had been performed in response to a full carpal collapse due to OA from a crush injury that Mr. Chen sustained approximately 24 years ago. During the initial visit, the therapist interviewed Mr. Chen to learn about his presurgical activities, including work, ADL, and leisure. The therapist learned that Mr. Chen is attending classes at a local community college to be trained as a radiology technician. He was unable to continue work as an auto mechanic because of the pain and diminishing strength in his right hand. Mr. Chen reported that this is the best move he could have made, stating, “I don’t really want to work in a garage my whole life.” Mr. Chen scored a 73/80 on the MAM-20, with a pain score of 3. He is having no significant impairments in daily activities but states that he has a lot to get used to because of the new immobility of his wrist. Strength measurements were not taken due to recent surgery.
TAM*
Index Long
0/60 0/55 0/55 0/54
0/90 0/85 0/90 0/90 0/30
0/60 0/60 0/55 0/55
210 200 200 199
Ring
Small
Thumb
–10/30
— —
(n = 260) *TAM = total active motion
Mr. Chen was instructed in AROM exercise of the digits and thumb to prevent extensor tendon adhesions from forming, thus limiting movement of the digits and ultimately functional abilities. He was instructed to complete 10 repetitions of flexion and extension of MCPs, PIPs, and DIPs alone and 10 repetitions of all joints in a composite manner every waking hour. He was also instructed to maintain his hand in an elevated position when walking or resting to limit accumulation of edema. Since he lives alone, Mr. Chen was provided with a booklet of one- handed ADL techniques to assist him with ADL that are difficult due to immobility of his wrist and forearm. However, he was encouraged to use his hand whenever he could for light activities that do not cause pain or discomfort. Mr. Chen was scheduled to return to therapy in two weeks.
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Book Code: PTNY1024
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