effective at preventing this accommodation, especially in chronic conditions like OA where the stimulation may be used for months or years. TENS can be applied using high-rate or low-rate stimulation (Bellew et al., 2016). High- rate TENS utilizes the Gate theory to essentially “close the gate” to pain by flooding the sensory receptors with the electrical stimulation from the unit instead (Bellew et al., 2016). Low-rate TENS utilizes the endorphin and enkephalin theory, which suggests the body’s own pain mediators, like serotonin, are activated by the stimulation and therefore reduce pain (Bellew et al., 2016). While high-rate TENS immediately reduces pain, the relief will end once the unit is removed. Conversely, low-rate TENS takes at least 45 minutes to begin alleviating pain but will continue with pain relief for several hours after discontinuation of the treatment. Due to this, most medical-grade units offer waveforms with combined high and low rates to capitalize on both theories of pain reduction. Clients can be taught how and when to use their TENS unit by therapists and can then use it independently at home. When electrodes are placed around the painful area, TENS has been shown to reduce pain associated with OA (Wu et al., 2021). et al., 2011). The following section discusses postsurgical protocols. The reader is advised that the values mentioned in the protocols are guidelines. Postsurgical protocols vary considerably across clinical settings. It is important that therapists work closely with surgeons; the number of weeks might vary depending on the individual surgeon’s protocol, the experience of the therapist working with a surgeon, the client’s joint condition at the time of surgery, and other factors.
build, as opposed to melting off each time the hands are placed in the paraffin unit. Once the dipping is complete, the hands should be wrapped in plastic and placed in a towel wrap or commercially available mitt to hold the heat for approximately 15 minutes. In addition to the warming qualities of the wax, the oil component moisturizes the skin to prevent cracking and itching. Moist heat can also be used to reduce stiffness, but it is not as effective as paraffin at reaching small hand joints; liquid paraffin wax encircles the fingers and thumb completely, whereas moist heat leaves air spaces between the semirigid and flat hot packs resting on the top and bottom of the uneven and three-dimensional surfaces of the hand (Bellew et al., 2016). Transcutaneous electrical stimulation (TENS) can also be utilized to reduce musculoskeletal pain. While commercial units are available for purchase over the counter from a variety of places (e.g., drugstores or online retailers), medical-grade units issued to a client under a physician’s order tend to be better in terms of offering more waveforms and longer battery life. Due to normal effects in which a person’s sensory system becomes accommodated to a specific stimulation, a unit with multiple waveforms is more Surgery Surgery is an alternative only if conservative measures have failed and there are major mechanical symptoms (Hochberg, 2012). Surgical options include total joint replacement (arthroplasty), joint fusion (arthrodesis), cartilage transplantation, or arthroscopy to clean the joint by removing pieces of cartilage or bone that have broken off. These procedures are typically performed by orthopedists or plastic surgeons who have been specially trained in surgery of the hand and wrist. Hand surgeons work closely with OTs and PTs who specialize in hand rehabilitation (Taylor
OSTEOARTHRITIS OF THE PROXIMAL AND DISTAL FINGER JOINTS
2017). Clients experiencing OA of the hand often report that it starts with morning soreness and stiffness of the affected joints. They describe increasing difficulty with pinching and grasping, and note pain and crackling when moving the joint (Harvard Health Publications, 2017). OA of the PIP and DIP joints eventually causes enlargement of the joints and might create deformities with possible spontaneous fusion. People with OA of the hand might eventually find it impossible to open jars, turn a key, write, or type. Many people with OA of the hand find that with age, their hands thicken and become stiff. The DIP joint can also be immobilized in isolation of the PIP joint. This orthosis can be fabricated as volar based with a tip cover, or as seen in Figure 14, as a clamshell design. This orthosis protects and immobilizes painful DIP joints, and it can also be used to help a client understand the outcome of an elective joint fusion (Cooper, 2020). In addition to use of orthoses, a client with painful interphalangeal joints can benefit from education concerning joint protection techniques and from adaptive equipment that makes use of the hands for functional tasks easier; less painful; and in some cases, possible. Physical agent modalities, including ice packs applied for 20 minutes, can be used to reduce pain in an acutely inflamed PIP joint. Chronic pain that is noninflammatory can also be reduced with heat modalities such as hot packs applied for 20 minutes or paraffin wax dips. Both hot packs and paraffin baths can be purchased commercially.
Several conditions associate commonly with OA of the wrist and hand, including OA of the proximal and distal finger joints. A brief overview of each of these conditions is presented below, followed by a discussion of conservative medical management, surgical management, and appropriate therapeutic interventions. The distal interphalangeal (DIP) joint is the most common site for OA of the hands. These joints are the site for the fibrous and bony nodules known as Heberden’s nodes . Bouchard’s nodes can develop on the proximal interphalangeal (PIP) joints, and OA of these joints can cause the fingers to stiffen and swell (Harvard Health Publications, Conservative management Conservative therapeutic management of PIP and DIP joints focuses on pain control, prevention of deformity, and prevention of occupational dysfunction. Pain control and deformity prevention are most commonly achieved with an orthosis that holds the affected joint in a pain-free extended and laterally aligned position. For a painful DIP joint, this positioning is best accomplished with a thin thermoplastic custom orthosis held in place with hook and loop straps such as Velcro (Cooper, 2020). The orthosis can be either volar or dorsally based. A circumferential plaster cast can also be used, but might not be appropriate in the case of enlarged joints or those with nodes. Since plaster is not a water-resistant material, this will need to be replaced and refabricated often. For the PIP joint, a gutter orthosis extends from the proximal end of the proximal phalanx to just before the DIP joint. This preserves DIP joint function if the joint is not also involved. The DIP joint can be included in the orthosis if it is painful or becoming deformed (Figure 13).
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