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). 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.
Figure 21: Forearm-Based Thumb Spica Orthosis
Source: Erin Peterson
Figure 22: Hand-Based Synthetic Rubber Orthosis
Source: Erin Peterson
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 discarded, or improved on. Current approaches to OA of the CMC joint include arthroplasty and arthrodesis. Arthroplasty is the reconstruction of a diseased or destroyed joint, and arthrodesis refers 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
The most widely used excision and arthroplasty technique for the thumb CMC is the ligament reconstruction tendon interposition (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, taking the place of the trapezium (Cannon, 2020). Donor tendons include 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 (Duerinckx & Verstreken, 2022). Outcomes are generally good following 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 of the client (Holme et al., 2021). In a systematic review, overall outcomes were good regardless of the type of implant, but researchers discovered failure rates ranged from 2.6% to 19.9% (Holme et al., 2021). Failures included loosening or dislocation of the implant, which necessitated revision, often by performing an LRTI (Badia, 2011; Holme et al., 2021).
While silicone implants are commonly used for PIP joint arthroplasty procedures, they are not recommended for CMC arthroplasty (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 several 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 regardless of the technique has been shown to improve function in most clients (Lubahn et al., 2011). Complications for some clients still exist, however, and surgeons continue to find new options to restore the thumb CMC (Lubahn et al., 2011).
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