Stabilization effectiveness and functionality of different thumb orthoses in female patients with first carpometacarpal joint osteoarthritis

Does thermoplastics' thickness influence joint stabilization and movement coordination? An inferential study of wrist orthoses

BACKGROUND

Given the existence of multiple low-temperature thermoplastics, clinicians fabricating can readily modify an orthoses' thickness, weight and flexibility, among other properties. However, there is limited evidence on the impact of such different materials on upper extremities' biomechanics.

OBJECTIVE

Our study aimed to investigate differences in joint stabilization and movement coordination provided by upper extremity orthotics fabricated with low-temperature thermoplastics of different thicknesses.

STUDY DESIGN

Inferential, cross-sectional study.

METHOD

We conducted a kinematic analysis of a standardized task through a three-dimensional motion capture system. Ten participants (5 female) performed the same task under three circumstances: 1) wearing a volar wrist immobilization orthosis, made with a 3.2-mm thick low-temperature thermoplastic; 2) using the same orthotic fabricated with a 1.6-mm thick material; and (3) without orthoses. We divided the standardized task into five logical phases for data analysis, obtaining the active range of motion of the shoulder, elbow, forearm, and wrist joints as the primary outcome. Secondary outcomes included movement smoothness and coordination, measured by the number of motor units, time, and distance travelled by the upper extremity.

RESULTS

Despite changes in thermoplastic thickness, both orthotics significantly restricted the wrist motion during task performance (F(2,16) = 14.32, P < .01, and η2p = 0.797), with no difference between the 2 devices and no significant changes to proximal joints' active range of motion. Although orthoses use increased the time required for task performance (F(2,16) = 23.05, P < .01, and η2p = 0.742), no significant differences in movement smoothness or coordination were noted.

CONCLUSION

Our results indicate that wrist orthoses fabricated with a 1.6-mm thick low-temperature thermoplastic can provide joint stabilization similar to a device made from a 3.2-mm thickness material, suggesting thinner thermoplastics' efficacy to stabilize joints in the absence of contractures or preexisting chronic conditions.

Trapeziectomy with suture-button suspensionplasty versus ligament reconstruction and tendon interposition: a randomized controlled trial

The purpose of the present study was to compare the results of patients operated with trapeziectomy and ligament reconstruction and tendon interposition (LRTI) using flexor carpi radialis tendon versus trapeziectomy followed by suspension of the first metacarpal to the second metacarpal using a Mini TightRope® suture button (suture button suspension: SBS). A single-center prospective randomized controlled trial was performed, comparing 37 patients with SBS and 39 with LRTI. All surgeries were performed by the same fellowship-trained hand surgeon. Patients were assessed by an independent observer at 40 months' follow-up. Pre- and postoperative strength, trapezial space ratio (TSR), range of motion, QuickDASH and visual analogue pain score were recorded. Both procedures improved functional parameters of pain, key strength, tip strength and grip strength while maintaining range of motion, without significant differences. In the SBS group, TSR decreased by 17%, compared to 28% in the LRTI group. The mean operative time was shorter in SBS (63 vs 91 minutes; p < 0.0001), as was immobilization time (2 vs 6 weeks; p < 0.0001), and patients resumed normal activity sooner (10 vs 12 week; p = 0.0138) and required less physical therapy (19.3 vs 13.1 weeks; p < 0.0001). We believe that our results are related to the hypothesis suggested by biomechanical studies that revealed better initial load bearing profile and maintenance of trapezial space following serial loading in cadaver models.

The effect of orthoses on the kinematics of the trapeziometacarpal, scaphotrapeziotrapezoidal, and radioscaphoid joints

The in vivo effect of four different types of thumb and thumb-wrist orthoses on the three-dimensional kinematics of the trapeziometacarpal (TMC), scaphotrapeziotrapezoidal (STT) and radioscaphoid joints was quantified using computed tomography (CT). Eighteen healthy female volunteers were recruited. The dominant hand of each subject was scanned in four thumb and wrist positions, each in three conditions: without orthosis, with a thumb orthosis (Push Ortho and immediate fitting, IMF) and with a thumb-wrist orthosis (Ligaflex Manu and IMF). CT images were analyzed and rotations relative to the more proximal bone were expressed in a joint-specific coordinate system. Without orthosis, the largest STT rotations were observed during radioulnar deviation of the wrist and the STT range of motion (ROM) was significantly lower during wrist flexion-extension. All tested orthoses caused a significant reduction of the ROM at each joint compared to free motion. Significant differences in movement reduction were observed between prefabricated and IMF orthoses.The IMF thumb-wrist outperformed the Ligaflex Manu in terms of immobilization of the radioscaphoid joint. In addition, the IMF thumb orthosis immobilized the TMC joint significantly better during thumb abduction and adduction than the Push Ortho. We found that different types of thumb and thumb-wrist orthotics are effective in reducing joint mobility. While this reduction tends to be higher using IMF compared to prefabricated orthoses, this effect is only significant for the radioscaphoid and TMC joint. The finding that thumb movements do not induce large STT rotations suggests that the thumb does not need to be immobilized in case of isolated STT osteoarthritis.

The immediate effect of thumb orthoses on upper extremity's movement: A kinematic analysis of five unique devices

BACKGROUND

Thumb orthoses are a standard treatment modality, with substantial evidence to support its usage for multiple conditions affecting the upper extremity. Despite commonly prescribed, little is known about the immediate impact of such devices on the upper extremity, including potential modifications on motor patterns.

RESEARCH QUESTION

We aimed to determine the changes in the upper limb kinematics during the usage of thumb orthotics, comparing differences in orthotic design, length, and fabrication materials.

METHODS

In this cross-sectional study, subjects performed a standardized reaching task and the placing subtest of the Minnesota Manual Dexterity Test (MMDT) while wearing five unique thumb orthoses. Besides the active range of motion of the shoulder, elbow, wrist and hand joints, movement smoothness (Number of Movement Units-NMU), speed, and motion control strategies were analyzed through eight Qualisys Oqus 300 cameras (Qualisys AB, Göteborg, Sweden).

FINDINGS

Ten non-disabled, university students participated in this study. Despite differences in fabrication materials, all orthotics reduced thumb's abduction (13.3° to 4.3°), and metacarpophalangeal flexion (11.5° to 4.2°). Although orthotics impacted movement smoothness and hand function during its usage, forearm-based devices further increased the NMUs and the time required for the MMDT performance (Control: NMU = 4.8, MMDT = 58.1; Long Orthotics: NMU = 6.6, MMDT = 78.2), while short, flexible orthoses provided thumb stabilization without significant impact on upper extremity movement strategies.

SIGNIFICANCE

Although joint stabilization was similar among orthotics fabricated with rigid and flexible materials, the improved hand dexterity observed during the use of flexible devices suggests an advantage of flexible orthotics for enhanced stability and hand function. These results can assist healthcare professionals during the selection and prescription of thumb orthotics, providing information not only on the range of motion but other sensorimotor aspects involved in upper extremity movement patterns that may be affected by orthotics usage.

Comparative Effectiveness of Orthoses for Thumb Osteoarthritis: A Systematic Review and Network Meta-analysis

OBJECTIVE

To evaluate the best option among orthoses for carpometacarpal (CMC) osteoarthritis (OA) of the thumb, using a network meta-analysis.

DATA SOURCES

Medline, Embase, Cochrane, and ClinicalTrials.gov registry databases were used. PubMed, Embase, Cochrane Controlled Trials Register, Cochrane, and other databases were used without language restrictions.

STUDY SELECTION

We searched randomized controlled trials (RCTs) on adults with OA of the thumb by studying any orthosis from the beginning to March 10, 2020.

DATA EXTRACTION

Data were extracted and checked for accuracy and completeness by pairs of reviewers. Outcomes were pain and function. Comparative treatment effects were analyzed by random-effects model for direct pairwise comparisons and Bayesian network meta-analyses to integrate direct and indirect evidence.

DATA SYNTHESIS

Eleven RCTs involving 619 patients were included. We evaluated 5 groups, for 4 different orthoses: short thermoplastic CMC splint (rigid CMC) (n=5), long thermoplastic carpometacarpal-metacarpophalangeal splint (rigid CMC-MCP) (n=7), short neoprene CMC splint (soft CMC) (n=1), long neoprene CMC-MCP splint (soft CMC-MCP) (n=5), and one as a control group (n=5). Our results show that all splints were superior to placebo to reduce pain intensity and the top-ranked intervention was the rigid CMC-MCP (surface under the cumulative ranking curve analysis [SUCRA], score: 65.4). In function evaluation, we report a 71.6 SUCRA for rigid CMC.

CONCLUSIONS

Although the current evidence is unclear on the use of the splint in OA of the thumb, it is not known which orthosis is more effective and whether the orthosis is more effective than other interventions. The network meta-analysis shows that a long thermoplastic splint it is the best choice for pain relief and the short thermoplastic CMC splint is the best treatment to increase function. These results may suggest initial treatment with a long rigid orthosis and then a short rigid orthosis.

User perspectives on orthoses for thumb carpometacarpal osteoarthritis

STUDY DESIGN

Qualitative and interpretive description.

INTRODUCTION

Orthoses are often the first-choice treatment for thumb carpometacarpal osteoarthritis (CMCOA). It is unknown to what extent the orthoses are used in the way intended by health professionals and why patients continue using the orthoses despite minimal pain reduction.

PURPOSE OF THE STUDY

The purpose of this study is to investigate user perspectives and experiences with 2 types of CMCOA orthoses.

METHODS

Semistructured interviews were conducted with 16 individuals with CMCOA who used the Push-Ortho-Thumb-Brace-CMC (Nea International BV, Netherlands) and a custom-made orthosis. The data were analyzed using the phenomenological and the framework approach.

RESULTS

Four men and 12 women participated (mean age, 57 years; half of whom were employed). Five central phenomena were identified, explaining the essence of the relation between user and orthosis: the orthosis as stabilizer, tool, healer, preventer, and nuisance. Users mentioned better appearance and the ability to do a variety of activities as advantages of the Push-Ortho-Thumb-Brace-CMC and better support and the ability to do strenuous activities as advantages of the custom-made orthosis. The central phenomena were related to the users' understanding of the disease process and the working mechanism of the orthoses and affected the patterns of usage and orthosis preference.

DISCUSSION

It is recommended that the provider recognizes user perspectives and discusses the disease process of CMCOA along with the working mechanism of the orthosis to support therapy adherence.

CONCLUSIONS

There is a wide variety in usage patterns of the CMCOA orthoses, which are influenced by different user perspectives.

The Osteoarthritis Thumb Therapy (OTTER) II Trial: a study protocol for a three-arm multi-centre randomised placebo controlled trial of the clinical effectiveness and efficacy and cost-effectiveness of splints for symptomatic thumb base osteoarthritis

INTRODUCTION

The economic cost of osteoarthritis (OA) is high. At least 4.4 million people have hand OA in the UK. Symptomatic thumb base OA affects 20% of people over 55 years, causing more pain, work and functional disability than OA elsewhere in the hand. Most evidence-based guidelines recommend splinting for hand OA. Splints that support or immobilise the thumb base are routinely used despite there being limited evidence on their effectiveness. The potential effects of placebo interventions in OA are acknowledged, but few studies investigate the clinical efficacy of rehabilitation interventions nor the impact of any placebo effects associated with splints.

METHODS AND ANALYSIS

Participants aged 30 years and over with symptomatic thumb base OA will be recruited into the trial from secondary care occupational therapy and physiotherapy centres. Following informed consent, participants will complete a baseline questionnaire and then be randomised into one of three treatment arms: a self-management programme, a self-management programme plus a verum thumb splint or a self-management programme plus a placebo thumb splint. The primary outcome is the Australian Canadian Osteoarthritis Hand Index (AUSCAN) hand pain scale. The study endpoint is 8 weeks after baseline. Baseline assessments will be carried out prior to randomisation and outcomes collected at 4, 8 and 12 weeks. Cost-effectiveness analysis will be conducted and individual qualitative interviews conducted with up to 40 participants after 8 weeks to explore perceptions and outcome expectations of verum and placebo splints and exercise.

ETHICS AND DISSEMINATION

South Central-Oxford C Research Ethics Committee approved this study (16/SC/0188). The findings will be disseminated to health professional conferences, journals and lay publications for patient organisations. The research will contribute to improving the management of thumb base OA and help clinicians and patients make informed decisions about the value of different interventions.

TRIAL REGISTRATION NUMBER

ISRCTN54744256.

Hand osteoarthritis: clinical phenotypes, molecular mechanisms and disease management

Osteoarthritis (OA) is a highly prevalent condition, and the hand is the most commonly affected site. Patients with hand OA frequently report symptoms of pain, functional limitations and frustration in undertaking everyday activities. The condition presents clinically with changes to the bone, ligaments, cartilage and synovial tissue, which can be observed using radiography, ultrasonography or MRI. Hand OA is a heterogeneous disorder and is considered to be multifactorial in aetiology. This Review provides an overview of the epidemiology, presentation and burden of hand OA, including an update on hand OA imaging (including the development of novel techniques), disease mechanisms and management. In particular, areas for which new evidence has substantially changed the way we understand, consider and treat hand OA are highlighted. For example, genetic studies, clinical trials and careful prospective imaging studies from the past 5 years are beginning to provide insights into the pathogenesis of hand OA that might uncover new therapeutic targets in the disease.

Necessity of Immobilizing the Metacarpophalangeal Joint in Carpometacarpal Osteoarthritis: Short-term Effect

BACKGROUND

Conservative treatment for carpometacarpal (CMC) joint osteoarthritis (OA) may include orthotic fabrication to decrease pain. Different types of orthoses have been used as conservative interventions to improve symptoms, but there are no guidelines specifying if inclusion of the thumb metacarpophalangeal (MCP) in an orthosis is required in the treatment of thumb CMC joint OA. The main objective of this study is to determine the effectiveness of 2 different thumb CMC joint orthotic designs on pain reduction and improved hand function: one design immobilizes both the MCP joint and the CMC joint and the other design immobilizes only the CMC joint.

METHODS

A total of 66 patients were included in the study. One group of 33 patients received a short thumb orthosis with the MCP joint excluded, and the other group of 33 patients received a short thumb orthosis with the MCP joint included. Outcomes measures included the visual analog scale for pain and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH; Spanish version) for function.

RESULTS

In both patient groups, the orthoses contributed to decreased pain levels and improved functional abilities ( F_1.0 = 315.467 and F_1.0 = 72.419; both, P < .001). There was no significant difference between the 2 groups regarding pain or improvement in daily activities ( F_1.0 = 0.553 and F_1.0 = 2.539; both, P > .05).

CONCLUSION

There are benefits of either thumb orthotic design on pain reduction and functional improvement even after 1 week of using the orthoses as the sole conservative treatment.

Orthotic use for CMC osteoarthritis: Variations among different health professionals in Brazil

STUDY DESIGN

Cross-sectional descriptive study.

INTRODUCTION

Osteoarthritis (OA) is the most prevalent musculoskeletal disease in the adult and older adult populations. The use of orthoses to stabilize the thumb's articular complex is one of the most common conservative management strategies. Despite substantial research about this topic, there is insufficient evidence about the optimal use of orthoses to inform clinical practice, contributing to practice variations within and across health professionals.

PURPOSE OF THE STUDY

To identify the prescription patterns, design preferences, and barriers for the use of orthotic devices among Brazilian health care professionals involved in the treatment of patients with OA of the basal thumb joint.

METHODS

An electronic questionnaire was sent to occupational therapists, physiotherapists, and rheumatologists across Brazil through professional association mailing lists. Survey included questions about orthosis design, materials, and barriers to the use of orthotic interventions. Respondents indicated their use based on photographs of 25 orthoses models that were selected through bibliographic review and expert consultation. Descriptive statistics, the chi-square test for independence, and the Fisher exact test were used to compare differences among orthotic prescription preferences, barriers, and challenges observed amidst the 3 participants' professional classes.

RESULTS

There was no consensus about orthotic prescription among 275 professionals who answered the survey. About 69% of participants reported the use of multiple orthosis during treatment of patients with thumb OA. Results suggest significant variations in the number of joints included and stabilization strategies adopted, with a preference for orthotics made in rigid materials and involving the wrist, carpometacarpal, and metacarpophalangeal joints (P < .001). The lack of knowledge about orthotic options, institutional regulations, and policies were the major barriers reported by respondents (P < .01).

CONCLUSION

A plentiful variety of different orthoses designs were observed in this study, and the prescriptions made by 3 professional classes showed differences regarding types of stabilization, joint involvement, and positioning. Despite the existence of clinical trials suggesting benefits for specific custom-made design models, our results indicated widespread clinical variation in practices and preferences.

LEVEL OF EVIDENCE

Not applicable.

Linking ICF components to outcome measures for orthotic intervention for CMC OA: A systematic review

STUDY DESIGN

Systematic review.

INTRODUCTION/PURPOSE

The purpose of this study was to systematically review outcome measures used for assessment of orthotic intervention in the conservative management of thumb carpometacarpal osteoarthritis to determine if they characterize International Classification of Functioning, Disability, and Health (ICF) components. The determinants of patient satisfaction regarding the orthotic intervention were also extracted from the studies.

METHODS

A comprehensive literature search was conducted. Outcome measures in the included studies were linked to the ICF. Determinants of patient satisfaction regarding the orthotic intervention were also extracted.

RESULTS

Nine studies met inclusion criteria. Eight (47.1%) outcomes were linked to body structures and functions, 8 (47.1%) to activity limitations and participation restrictions, and 1 (5.9%) outcome fell into the nondefinable quality of life category. Four studies assessed patient satisfaction.

DISCUSSION/CONCLUSIONS

This systematic review on orthotic intervention for thumb carpometacarpal osteoarthritis found opportunities related to assessment and outcome measures when present studies are linked to the ICF.

LEVEL OF EVIDENCE

2a.

The effect of thumb splinting on thenar muscles atrophy, pain, and function in subjects with thumb carpometacarpal joint osteoarthritis

BACKGROUND

When the first carpometacarpal joint of the wrist is immobilized using an orthosis to combat the effects of osteoarthritis, atrophy of the thenar muscles may occur.

OBJECTIVES

The aim of this study was to evaluate the thenar muscle diameter and cross-sectional area, joint function, and pain, before and after being supplied with an orthosis in patients with grades 1 and 2 carpometacarpal osteoarthritis compared to a control group.

STUDY DESIGN

Randomized clinical trial.

METHODS

A total of 25 volunteer patients were randomized into two groups (an orthosis group and a control group) using a randomization table. A visual analog scale, the Michigan Hand Questionnaire, and ultrasound were used to measure pain, function, and specific muscle cross-sectional areas at baseline and after 4 weeks in both groups.

RESULTS

Mean visual analog scale pain scores decreased by 20% after 4 weeks of splinting, while those in the control group decreased by 3%. Changes in scores were significantly different between both groups ( p = 0.001). There was no significant difference between the groups in either the Michigan Hand Questionnaire score or the muscle cross-sectional area.

CONCLUSION

A large and significant effect on perceived pain in patients with first carpometacarpal joint osteoarthritis was observed after 4 weeks of splint use. Differences in treatment effects were found with regard to muscle cross-sectional areas, but these were not significant. Clinical relevance Custom-made splints may be recommended for the treatment of first carpometacarpal joint osteoarthritis. Moderate to large but non-significant treatment effects were found with regard to muscle cross-sectional areas.

Effectiveness of physical and occupational therapy on pain, function and quality of life in patients with trapeziometacarpal osteoarthritis - A systematic review and meta-analysis

Introduction

Trapeziometacarpal osteoarthritis is associated with more pain and restrictions than other hand osteoarthritis due to the functional importance of the thumb. While the effectiveness of surgical and pharmacological interventions has been widely examined, there is a lack of specific evidence about conservative non-pharmacological trapeziometacarpal osteoarthritis therapies. The objective of this systematic review was to provide evidence-based knowledge on the effectiveness of physiotherapy and occupational therapy on pain, function and quality of life.

Methods

A literature search of Medline, CINAHL, PEDro, OTseeker, EMB Dare Cochrane Database of Systematic Reviews and Cochrane CENTRAL was performed. Randomized and quasi-randomized controlled trials and corresponding systematic reviews, observational studies, pragmatic studies and case–control studies were included. The risk of bias was assessed.

Results

Out of 218 studies, 27 were retained. A narrative summary and a series of meta-analyses were performed. Concerning pain reduction, the meta-analysis showed parity of pre-fabricated neoprene and custom-made thermoplastic splints: standardized mean difference (SMD) –0.01 (95%CI −0.43, 0.40) (p=0.95). Multimodal interventions are more effective on pain compared to single interventions: standardized mean difference −3.16 (95%CI −5.56, −0.75) (p = 0.01).

Discussion

Physical and occupational therapy-related interventions, especially multimodal interventions, seem to be effective to treat pain in patients with trapeziometacarpal osteoarthritis. Pre-fabricated neoprene splints and custom-made thermoplastic splints may reduce pain equally. Single interventions seem not to be effective. Significant evidence for effectiveness on function and quality of life could not be found.