Palmar abduction: reliability of 6 measurement methods in healthy adults

Results of Pyrocarbon Disc Interposition Compared to Trapeziectomy with Ligament Reconstruction and Tendon Interposition

BACKGROUND

To compare pyrocarbon disc interposition arthroplasty (PDI) with trapeziectomy plus ligament reconstruction tendon interposition (LRTI), the authors assessed whether PDI resulted in a higher pinch strength, and compared grip strength, range of motion (ROM), patient-reported outcomes, satisfaction, and complications between the approaches.

METHODS

Because of scarcity of preoperative hand measurements, the authors performed a descriptional cross-sectional cohort study of patients operated on between 2006 and 2014, with a minimum of 5 years of follow-up. Patients were treated with PDI or LRTI. The authors determined key pinch strength as the primary outcome, followed by tip and tripod pinch, grip strength, palmar abduction and opposition, Michigan Hand Outcomes Questionnaire (MHQ) and Patient-Reported Hand and Wrist Evaluation (PRWHE) scores, satisfaction level, and complications. Propensity score matching was used to match the study groups on demographic variables. A ratio of 2:1 was used, resulting in inclusion of 62 (of 154) PDI and 31 (of 31) LRTI thumbs.

RESULTS

Patients in the PDI group showed stronger key and tip pinch strength than did patients in the LRTI group ( P = 0.027 and P = 0.036, respectively). Tripod pinch, grip strength, and ROM were equal between the groups. MHQ and PRWHE were comparable, with higher satisfaction levels in the PDI group. Eight patients with PDI were converted to LRTI because of pain.

CONCLUSIONS

This study confirmed the hypothesis that key and tip pinch strength is stronger after PDI compared with LRTI for first carpometacarpal joint osteoarthritis. Both techniques have comparable outcomes considering patient-reported outcome (MHQ and PRWHE), ROM, and complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

The passive biomechanics of the thumb carpometacarpal joint: An in vitro study

The thumb carpometacarpal (CMC) joint facilitates multidirectional motion of the thumb and affords prehensile power and precision. Traditional methods of quantifying thumb CMC kinematics have been largely limited to range-of-motion (ROM) measurements in 4 orthogonal primary directions (flexion, extension, abduction, adduction) due to difficulties in capturing multidirectional thumb motion. However, important functional motions (e.g., opposition) consist of combinations of these primary directions, as well as coupled rotations (internal and external rotation) and translations. Our goal was to present a method of quantifying the multidirectional in vitro biomechanics of the thumb CMC joint in 6 degrees-of-freedom. A robotic musculoskeletal simulation system was used to manipulate CMC joints of 10 healthy specimens according to specimen-specific joint coordinate systems calculated from computed tomography bone models. To determine ROM and stiffness (K), the first metacarpal (MC1) was rotated with respect to the trapezium (TPM) to a terminal torque of 1 Nm in the four primary directions and in 20 combinations of these primary directions. ROM and K were also determined in internal and external rotation. We found multidirectional ROM was greatest and K least in directions oblique to the primary directions. We also found external rotation coupling with adduction-flexion and abduction-extension and internal rotation coupling with abduction-flexion and adduction-extension. Additionally, the translation of the proximal MC1 was predominantly radial during adduction and predominantly ulnar during abduction. The findings of this study aid in understanding thumb CMC joint mechanics and contextualize pathological changes for future treatment improvement.

Radial Collateral Ligament Laxity of Thumb Metacarpophalangeal Joint Following Trapeziometacarpal Arthrodesis

PURPOSE

Trapeziometacarpal (TM) arthrodesis may increase adduction motion of the thumb metacarpophalangeal (MCP) joint, causing radial collateral ligament laxity. Stability of the MCP joint is important to the long-term functional outcome after TM arthrodesis. This study assessed preoperative and postoperative radial collateral ligament laxity using dynamic radiographs to confirm whether laxity was exacerbated after surgery and examined whether there is a relationship between the fixation angle of arthrodesis and the degree of laxity.

METHODS

Forty-four thumbs in 33 patients who underwent TM arthrodesis and were followed for at least 5 years were studied. Dynamic radiographs in radial adduction-abduction and palmar adduction-abduction were obtained. We defined the midpoint of arc of motion as the fixation angle of arthrodesis in the radial and palmar planes. We measured the intersection angle between longitudinal axis of the first metacarpal (M1) and that of thumb proximal phalanx (P1). P1M1 angle in a palmar adduction view of dynamic radiographs reflected radial collateral ligament laxity in palmar adduction (adduction P1M1 angle). We subtracted a preoperative adduction P1M1 angle from a postoperative adduction P1M1 angle and defined its value as an exacerbated adduction P1M1 angle.

RESULTS

Adduction P1M1 angle increased from 9° ± 5° to 18° ± 10°. The median exacerbated adduction P1M1 angle was 7°. Ten thumbs (23%) developed ulnar subluxation of MCP joint in the palmar adduction view of dynamic radiographs. Among them, two thumbs developed osteoarthritis of MCP joint (5%). Fixation angle of the arthrodesis was a mean of 35° ± 7° and 32° ± 9° in the radial arc and palmar arc planes, respectively. There was a positive correlation between increasing adduction P1M1 angle and TM arthrodesis in an increasingly palmarly abducted position.

CONCLUSIONS

Radial collateral ligament laxity of thumb MCP joint was exacerbated after TM arthrodesis. Greater fixation angle in palmar abduction resulted in more laxity of the joint.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Psychometric properties of body structures and functions measures in non-surgical thumb carpometacarpal osteoarthritis: A systematic review

BACKGROUND

Measurement of treatment outcomes and change in health status over time is a critical component of clinical practice and research for people with osteoarthritis. Numerous clinical tools are used to assess the structures and function of the thumb in persons with thumb carpometacarpal osteoarthritis however their psychometrics have not yet been systematically explored.

PURPOSE

The purpose of this study was to explore the psychometric properties of clinical tools used in persons with non-surgical thumb carpometacarpal osteoarthritis to objectively measure thumb structures and function, evaluate the quality of such studies, and subsequently make clinical and future research recommendations.

STUDY DESIGN

Systematic review.

METHODS

A systematic search and screening was conducted across nine databases. Original research published between 2002 and 2022 that involved the assessment of psychometric properties (validity, reliability, precision, responsiveness, sensitivity, specificity, and minimal clinically important difference) of clinical tools were included. Sample characteristics, methods, and psychometric findings from each study were compiled. The methodological quality of included studies was evaluated using the COnsensus-based Standards for the selection of health Measurement Instruments' checklist. Two independent researchers screened articles and assessed methodological quality and when not in agreement, a third party was consulted.

RESULTS

Eleven studies were included in the review. The mean age of all participants in the studies was 69 years of age. The study designs included prospective case-control, prospective cohort, and cross-sectional to determine the psychometric properties of the measurements and tools. The included studies examined techniques to assess range of motion, strength, and pain-pressure thresholds, and screen for arthritis (ie, provocative tests). The intermetacarpal distance method, Kapandji index, pain-pressure threshold test, and pain-free grip and pinch dynamometry demonstrate excellent reliability and acceptable precision. Metacarpal extension, adduction, and pressure-shear provocative tests have superior sensitivity and specificity and the extension and adduction tests have excellent reliability. Other assessments included in the review yielded less robust psychometric properties. Studies were of variable methodological quality spanning from inadequate to very good.

CONCLUSIONS

Based on the available literature on the psychometric properties of assessments of body structures and functions in persons with non-operative thumb carpometacarpal osteoarthritis, we offer a limited set of recommendations for use when screening for arthritis symptomology and measuring hand strength, thumb mobility, and pain thresholds. Additional psychometric research is needed in these domains as well as in dexterity, sensation, and objective measures of hand function. Future research should employ best practices in psychometric research.

Long-term follow-up of patients treated with pyrocarbon disc implant for thumb carpometacarpal osteoarthritis: the effect of disc position on outcomes measures

Pyrocarbon disc interposition arthroplasty is an effective treatment for thumb base osteoarthritis. However, as with all implant techniques, the disc can (sub)luxate over time. The relationship between disc position, the experienced pain, and the necessity for revision surgery is not known. This study evaluated the effect of radiographic pyrocarbon disc position on the Michigan Hand Questionnaire (MHQ) outcome measurement. In addition, the correlation between disc position and other factors, including pain intensity, thumb strength, and occupation, was assessed. In this retrospective study, we included 136 patients (161 thumbs) with a mean follow-up of 6.7 years (range 3.3-11). Radiographs were scored on disc position and classified as 'well aligned' (Grade 1) up to 'luxated' (Grade 4). A database used for outcome measures included MHQ scores, pain intensity, satisfaction, thumb strength, range of motion, occupation, and hand dominance. In bivariate analyses, we assessed any association between disc position and outcome measurements. Eighty of the 136 implants (59%) were well-positioned (not displaced), 41% were (slightly) displaced (grade 2-3). No relationship existed between the degree of disc displacement and MHQ scores. Manual labor occupation was the only factor that correlated with more severe disc displacement. We could not detect any association between disc position and other outcome variables including pain intensity, thumb strength, or hand dominance. In conclusion, our study suggests that radiographic disc displacement has little clinical consequences. Future studies must assess if there is a causality between heavy mechanical stress to the CMC1 joint and luxation of the pyrocarbon disc over time.Level of evidence: IV Therapeutic-Retrospective case series.

Thumb carpometacarpal palmar and radial abduction in adults with thumb carpometacarpal joint pain: Inter-rater reliability and precision of the inter-metacarpal distance method

STUDY DESIGN

Psychometric study of inter-rater reliability.

INTRODUCTION

Functional use of the thumb can be limited in individuals with thumb carpometacarpal (CMC) osteoarthritis(OA), especially in the presence of a thumb adduction contracture. Goniometry is a common method of assessing palmar and radial abduction of the thumb base and can be used as a method of determining effectiveness of an intervention for adduction contracture. However, goniometry for the assessment of these motions has been shown to have low to moderate reliability. The intermetacarpal distance (IMD) measurement method has been shown to be the most reliable for measuring CMC palmar abduction in individuals with healthy hands but has not been studied in persons with thumb CMC OA.

PURPOSES

The purpose of this study was to determine the inter-rater reliability and precision of the inter-metacarpal distance method for measuring palmar and radial abduction in persons with symptoms of thumb CMC OA.

METHODS

Two trained hand therapists utilized the IMD method to measure palmar and radial abduction in the affected hands of 22 subjects (28 thumbs) with a physician-confirmed diagnosis or positive provocative test consistent with a diagnosis of thumb CMC OA. The intraclass correlation coefficient (ICC_2,2) was used to assess inter-rater reliability of the IMD method. To determine the precision of the measurements, the standard error of measurement (SEM), minimal detectable change (MDC), and MDC percent were calculated. Findings were supplemented with descriptive data on the IMD values as well as descriptive data on the sample.

RESULTS

Intraclass correlation coefficients for both radial and palmar abduction were found to be >.75, indicating excellent reliability. The precision of the IMD measurements were acceptable-to-excellent as evidenced by MDC% values of <30% and <10% for radial and palmar abduction respectively.

CONCLUSIONS

We present a new method for measuring thumb radial abduction. The inter-metacarpal distance method has excellent inter-rater reliability and acceptable-to-excellent precision when measuring palmar and radial abduction in individuals with or suspected to have thumb CMC OA. Currently, it is the most reliable tool for measuring thumb abduction.

Dynamic stabilization of the painful thumb: A historical and evidence-informed synthesis

STUDY DESIGN

Expert opinion INTRODUCTION: Thumb carpometacarpal joint (CMC) osteoarthritis is a common condition seen in the hand therapy clinic. Prevalence is generally higher in females, and the percentage rises for post-menopausal females. Patients typically present with pain and functional difficulties. Conservative management is recommended before a surgical consult. Evidence is mounting that a dynamic stability modeled approach has a significant effect on pain and improving function.

PURPOSE

The purpose of this paper is two-fold: first, to present the history and development of a dynamic stabilization model for treatment of the patient with thumb CMC osteoarthritis (OA), and second, to provide expert clinical commentary and recommendations for the treatment of thumb CMC OA in light of the best available evidence.

METHODS

Expert clinical commentary is based on an extensive review of relevant literature.

RESULTS

The current literature and expert opinion supports an evidence-informed multimodal intervention: modalities, pain relief techniques, manual release, joint mobilizations as deemed necessary, neuromuscular re-education through proprioceptive exercises, and education in joint protection principles.

CONCLUSION

A rationale for a dynamic stabilization approach is presented. The unique anatomy of the thumb deserves finely tuned care based on high quality research. To advance our knowledge and clinical skills we must not become stagnant, but continue to generate high level evidence. The standard for future thumb CMC OA studies should be well-defined intervention parameters, consistent documentation, and the use of appropriate patient-rated outcome measures.

Towards an Extensive Thumb Assist: A Comparison between Whole-Finger and Modular Types of Soft Pneumatic Actuators

Soft pneumatic actuators used in robotic rehabilitation gloves are classified into two types: whole-finger actuators with air chambers that cover the entire finger and modular actuators with chambers only above the finger joints. Most existing prototypes provide enough finger flexion support, but insufficient independent thumb abduction or opposition support. Even the latest modular soft actuator realized thumb abduction with a sacrifice of range of motion (RoM). Moreover, the advantages and disadvantages of using the two types of soft actuators for thumb assistance have not been made clear. Without an efficient thumb assist, patients’ options for hand function rehabilitation are very limited. Therefore, the objective of this study was to design a modular actuator (M-ACT) that could support multiple degrees of freedom, compare it with a whole-finger type of thumb actuator with three inner chambers (3C-ACT) in terms of the RoM, force output of thumb flexion, and abduction, and use an enhanced Kapandji test to measure both the kinematic aspect of the thumb (Kapandji score) and thumb-tip pinch force. Our results indicated superior single-DoF support capability of the M-ACT and superior multi-DoF support capability of the 3C-ACT. The use of the 3C-ACT as the thumb actuator and the M-ACT as the four-finger actuator may be the optimal solution for the soft robotic glove. This study will aid in the progression of soft robotic gloves for hand rehabilitation towards real rehabilitation practice.

Joint Distraction for Thumb Carpometacarpal Osteoarthritis: 2-Year Follow-up Results of 20 Patients

Background  Joint distraction is a fairly new treatment for patients with symptomatic thumb carpometacarpal osteoarthritis (CMC1 OA). A previous pilot study of five patients showed that CMC1 joint distraction is technically feasible. The current study presents the results of CMC1 joint distraction in 20 patients with a 2-year follow-up period. Purposes  The primary study aim was to assess if patients with CMC1 OA have better physical function and less pain 2 years after CMC1 joint distraction. Second, we assessed the number of patients who achieved a minimal clinically important difference (MCID) in patient-reported outcome measures at each follow-up time point. Furthermore, this study sought differences on magnetic resonance imaging (MRI) of the CMC1 joint before and after distraction. Adverse events were noted and reported. Methods  Twenty patients (median age of 54 years) with symptomatic CMC1 OA and an established indication for a trapeziectomy were enrolled. An external distractor device was placed over the CMC1 joint and left in situ for 8 weeks. Disabilities of the Arm, Shoulder, and Hand (DASH) score, Michigan Hand Outcome Questionnaire (MHQ), visual analogue scale (VAS), and grip strength were recorded preoperatively and at 3, 6, 12, and 24 months postoperatively. Results  Two years after joint distraction, physical function and pain scores had improved significantly compared with baseline: DASH from 48 to 17, MHQ from 56 to 83, and VAS for pain from 50 to 18 mm. Fourteen of 19 patients (74%) reached an MCID in DASH and MHQ scores. One patient was not satisfied with treatment outcome and chose to proceed with a trapeziectomy 14 months after initial distraction therapy. Conclusions  This study demonstrates that CMC1 joint distraction can postpone more invasive surgical interventions (e.g., trapeziectomy) for at least 2 years. Larger comparative studies are needed to assess the value of CMC1 joint distraction in the treatment of CMC1 OA. Level of Evidence  This is a Level IV, prospective case series study.

Medium to Long-Term Follow-Up After Pyrocarbon Disc Interposition Arthroplasty for Treatment of CMC Thumb Joint Arthritis

PURPOSE

Pyrocarbon disc interposition arthroplasty has been designed for the surgical treatment of Eaton-Glickel grade II/III carpometacarpal thumb joint arthritis. This study presents the results of this technique with a minimum 5-year follow up.

METHODS

We assessed 4 questionnaires for patient-reported outcome measurements in a cross-sectional study: the Patient-Rated Wrist and Hand Evaluation, Disabilities of Arm, Shoulder, and Hand questionnaire, Michigan Hand Questionnaire, and questions about satisfaction at the 5-year follow up. We evaluated grip and pinch strength, range of motion, and the radiological position of the disc. Finally, a Kaplan-Meier survival analysis was performed.

RESULTS

A total of 164 thumbs (in 137 patients) were available for follow-up varying from 5 to 12 years. Median Patient-Rated Wrist and Hand Evaluation, Disabilities of Arm, Shoulder, and Hand, and Michigan Hand Questionnaire scores were 17, 18, and 76, respectively. The satisfaction score was 9 (Likert scale of 1-10). Grip and pinch strength reached nearly 100% compared with the contralateral hand. Range of motion resulted in a Kapandji score of 10. Thumb height showed a marginal loss and the Kaplan-Meier survival curve showed a survival rate of 91%.

CONCLUSIONS

Our study suggests that pyrocarbon disc interposition arthroplasty is a reliable and feasible treatment for carpometacarpal thumb joint arthritis at medium-term follow-up. It was associated with a high level of patient satisfaction; it maintained thumb height and the implant survived in 91% of patients. Strength and range of motion were comparable to the contralateral hand after a minimum follow-up of 5 years.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Short-term effects of occupational therapy on hand function and pain in patients with carpometacarpal osteoarthritis: secondary analyses from a randomized controlled trial

OBJECTIVE

To assess the short-term effects of multimodal occupational therapy on pain and hand function in patients referred for surgical consultation due to carpometacarpal joint (CMC1) osteoarthritis (OA).

METHODS

In this randomized controlled trial, CMC1 OA patients referred for surgical consultation at three rheumatology departments were randomized to 3 months multimodal occupational therapy (including patient education, hand exercises, orthoses, and assistive devices) or usual treatment (OA information). Pain was measured on a numeric rating scale from 0-10 (0, no pain). Function included grip and pinch strength (Newtons), range-of-motion [palmar and CMC1 abduction (°); flexion deficit in digits 2-5 (mm)], and self-reported Measure of Activity Performance of the Hand (MAP-Hand; range: 1-4; 1, no activity limitation) and QuickDASH (range: 0-100; 0, no disability). Between-group difference was assessed with follow-up values as dependent variables and group as an independent variable, adjusted for baseline values and time to follow-up.

RESULTS

Among 180 patients (mean age 63 (SD 8) years; 81% women), 170 completed the short-term follow-up assessment (3-4 months after baseline). Compared to usual treatment, occupational therapy yielded significantly improved pain at rest (-1.4 [-0.7, -2.0], P < 0.001), pain following grip strength (-1.1 [-0.5, -1.7], P = 0.001), grip strength (23.4 [7.5, 39.3], P = 0.004), MAP-Hand (-0.18 [-0.09, -0.28], P = 0.001), and QuickDASH (-8.1 [-4.6, -11.5], P < 0.001).

CONCLUSION

The multimodal occupational therapy intervention had significant short-term effects on pain, grip strength, and hand function in patients with CMC1 OA.

Radial and palmar active range of motion measurement: reliability of six methods in healthy adults

The current study aims to assess the reliability of 6 range-of-motion measurement methods for the thumb carpometacarpal joint: Pollexograph-thumb, Pollexograph-metacarpal, radius-metacarpal goniometry, intermetacarpal goniometry, intermetacarpal distance, and thumb-distal-interphalangeal distance. A senior hand surgeon, an experienced resident, and a less experienced research fellow evaluated the dominant hands of 29 healthy subjects. All 6 methods were performed for radial adduction, radial abduction, and palmar abduction, but only distance methods were measured for palmar adduction. Intrarater and interrater reliability were computed using intraclass correlation coefficient, standard error of measurement, and smallest detectable difference. Pollexograph-thumb method showed the highest active range of movement for radial adduction (12°) and abduction (71°), while all the other angular methods resulted in approximately 20° for radial adduction and 50° for radial abduction. Distance methods showed comparable mean results for radial and palmar range of motion (adduction/abduction): intermetacarpal distance (50 mm/60 mm) and thumb-distal-interphalangeal distance (50 mm/120 mm). Interrater reliability using the results of the intraclass correlation coefficient demonstrates that Pollexograph-thumb and Pollexograph-metacarpal showed excellent reliability for radial adduction and abduction, whereas Pollexograph-thumb method revealed the best reliability for palmar abduction. Moreover, thumb-distal-interphalangeal distance also showed excellent reliability for radial and palmar abduction. Conventional goniometry showed a large variety of reliability results, ranging from poor to excellent. No clinical benefit can be derived from assessing the palmar adduction. We found that the Pollexograph-thumb showed excellent reliability results throughout all measurements. Thumb-distal-interphalangeal-joint distance is especially valuable for assessing radial and palmar abduction.

Complex thumb motions and their potential clinical value in identifying early changes in function

BACKGROUND

Early diagnosis and treatment of osteoarthritis of the thumb allows for early interventions that may mitigate osteoarthritis progression and decrease severity later in life. Early identification of motion changes is limited by the clinical reliance on single planar measurements using goniometry. Multi-planar measurements using motion capture can provide insights into joint function and pathophysiology that cannot be obtained from single-plane goniometry measurements. Thus, the goals of this research were 1) to determine differences in thumb motions across three groups of participants (young healthy (n = 23), older healthy (n = 11), and those with carpometacarpal osteoarthritis (n = 24)) and 2) to determine if multi-planar motions provided additional movement information in comparison to standard planar measures.

METHODS

In this study, a motion capture system was used to collect standard clinical ranges of motion and complex multi-planar tasks. Differences in motion patterns due to aging and osteoarthritis were identified. Motions tested included palmar adduction-abduction, radial adduction-abduction, metacarpophalangeal flexion-extension, interphalangeal flexion-extension, functional adduction-abduction, opposition, and circumduction.

FINDINGS

Results indicated that motion capture was capable of detecting changes in carpometacarpal mobility that were not detected using standard approaches. Our results suggested that use of multi-planar measurements have the potential to identify changes that are indicators of early stages of osteoarthritis.

INTERPRETATION

Early indicators are clinically useful as they will enhance patient treatment by permitting the application of treatment approaches sooner, potentially leading to reduced overall functional deficits.

Outcomes of Endoscopic Carpal Tunnel Release With Ring Finger Flexor Digitorum Superficialis Opponensplasty in Severe Carpal Tunnel Syndrome

PURPOSE

To evaluate the outcomes of endoscopic CTR with ring finger flexor digitorum superficialis (FDS) opponensplasty for the treatment of patients with severe carpal tunnel syndrome (CTS).

METHODS

We prospectively studied 52 patients who were graded as having severe CTS by physical examination and electrodiagnostic studies and who underwent endoscopic CTR-ring finger FDS opponensplasty. Preoperative and postoperative data were collected for active perpendicular thumb abduction; Kapandji score for thumb opposition; grip, key, and tip pinch strength; Medical Research Council score on sensory and motor recovery; Semmes-Weinstein monofilament testing; thenar muscle bulk recovery; and work status.

RESULTS

Follow-up was 17.5 months on average (range, 7-34 months). Thumb abduction improved significantly from 13.2° (±4.6°) before surgery to 61.7° (±6.4°) afterward. Mean thumb opposition (as measured by Kapandji score) improved significantly from grade 1.5 to 8.7. Tip pinch strength significantly improved from 38.9% to 72.9% of the contralateral side. Medical Research Council scores improved to S3+ and S4 in 85% of patients and to M4 and M5 in 96% of patients. Sensory threshold recovery to 3.61 and 4.31 monofilament occurred in 85% of patients. We observed thenar muscle bulk recovery in 51.9% of patients. Time to return to work was 5 weeks after surgery, on average. Two patients reported scar pain, 2 reported pillar pain, and we found ring finger proximal interphalangeal joint contracture in 3.

CONCLUSIONS

Endoscopic CTR with FDS opponensplasty provides satisfactory outcomes of improved thumb abduction and opposition, sensory and motor recovery, and early return to work in patients with severe CTS.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Exercise Therapy in Addition to an Orthosis Reduces Pain More Than an Orthosis Alone in Patients With Thumb Base Osteoarthritis: A Propensity Score Matching Study

OBJECTIVE

To compare the effect of exercises and orthotics with orthotics alone on pain and hand function in patients with first carpometacarpal joint (CMC-1) osteoarthritis (OA) and to predict outcomes on pain and hand function of exercises and orthotics.

DESIGN

Prospective cohort study with propensity score matching.

SETTING

Data collection took place in 13 outpatient clinics for hand surgery and hand therapy in The Netherlands.

PARTICIPANTS

A consecutive, population-based sample of patients with CMC-1 OA (N=173) was included in this study, of which 84 were matched on baseline demographics and baseline primary outcomes.

INTERVENTIONS

Exercises and orthotics versus orthotics alone.

MAIN OUTCOME MEASURES

Primary outcomes included pain and hand function at 3 months, measured using visual analog scale (VAS, 0-100) and the Michigan Hand Outcomes Questionnaire (MHQ, 0-100).

RESULTS

A larger decrease in VAS pain at rest (11.1 points difference; 95% confidence interval, 1.9-20.3; P=.002) and during physical load (22.7 points difference; 95% confidence interval, 13.6-31.0; P<.001) was found in the exercise + orthotic group compared to the orthotic group. In addition, larger improvement was found for the MHQ subscales pain, work performance, aesthetics, and satisfaction in the exercise + orthotic group. No differences were found on other outcomes. Baseline scores of metacarpophalangeal flexion, presence of scaphotrapeziotrapezoid OA, VAS pain at rest, heavy physical labor, and MHQ total predicted primary outcomes for the total exercise + orthotic group (N=131).

CONCLUSIONS

Non-surgical treatment of patients with CMC-1 OA should include exercises, since there is a relatively large treatment effect compared to using an orthosis alone. Future research should study exercises and predictors in a more standardized setting to confirm this finding.

Reconstruction of extensive pulp defects of the thumb with a radial-based pedicled flap from the index finger

This article defines a sensate, pedicled heterodigital flap from the proximal radial side of the index finger for reconstructing large soft tissue defects of the thumb. The pedicle consists of the radial digital artery of the index finger. Dorsal sensory branch of proper digital nerve and one of the terminal sensory branches of radial nerve are included in the flap for sensation. The results of 17 consecutive patients at 24 months revealed mean static two-point discrimination of 7 mm at the reconstruction site and 10 patients were able to feel 4 mm at the reconstructed thumb. The mean range of motion of metacarpophalangeal and interphalangeal joints of operated thumbs reached 94% and 66%, the mean grip span reached 96% compared with the uninjured side. The presented flap provided a simple yet favourable alternative for reconstruction of the thumb tip, with thick and durable tissue requiring minimum dissection and donor side morbidity. Level of evidence: IV.

Growth of the New Thumb Metacarpal After Pollicization for Thumb Hypoplasia

PURPOSE

To investigate the radiographic length and width of the new thumb metacarpal in relation to the middle finger proximal phalanx; to assess the incidence of premature physeal closure of the new metacarpal; and to consider whether there is a relationship between growth characteristics and the presence of union or nonunion of the new trapezium to the retained index finger metacarpal base.

METHODS

Forty pollicizations were assessed with preoperative or immediate postoperative radiographs and follow-up radiographs to establish the growth characteristics of the new thumb metacarpal. Functional outcomes comprising grip strength, pinch strength, and range of motion were correlated with radiological findings of presence or absence of open physes and presence or absence of union of the new trapezium to the metacarpal base.

RESULTS

The new thumb metacarpal physis was open in 28 pollicizations and closed in 12. In the latter group, all physes of the hand had closed indicating skeletal maturity. The length and width indices of the new thumb metacarpal in relation to the middle finger proximal phalanx were equivalent to or greater than the perioperative growth indices. There was a reduced postoperative length ratio in those patients with nonunion of the new trapezium to the base of the metacarpal. There was no change in strength and range of motion parameters with growth other than that related to normal improvement with age.

CONCLUSIONS

We are unable to demonstrate premature physeal closure following routine pollicization. The growth of the metacarpal continues in a normal manner to skeletal maturity. A failure of union of the new trapezium to the metacarpal base may compromise growth.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Inter-rater and inter-instrument reliability of goniometric thumb active and passive flexion range of motion measurements in healthy hands

Introduction

Goniometry is a common measure of range of motion and may be assessed by different therapists and goniometers. To date, there is limited psychometric data on active and passive range of motion measurements of individual thumb joints. The purpose of this study was to analyze inter-rater and inter-instrument reliability of passive and active flexion goniometric measures of thumb joints in healthy adults.

Methods

A within-subjects psychometric design was utilized. Two raters each used two goniometers (Baseline™ Flexion-Hyper Extension and Baseline™ 180 Degree Digit) to measure each participant’s (n = 48) thumb carpometacarpal, metacarpophalangeal, and interphalangeal flexion range of motion. Inter-rater and inter-instrument reliability and stability were evaluated through use of intraclass correlation coefficient, standard error of the measurement, and minimal detectable change test statistics.

Results

Inter-rater reliability was poor for carpometacarpal flexion and good-to-excellent for metacarpophalangeal and IP flexion. Between-rater error ranged between 3.9 and 6.3 degrees for active measurements and between 3.9 and 7.9 degrees for passive. Error was generally less when using the Baseline™ 180 Degree Digit goniometer. Inter-instrument reliability was excellent for all joints.

Discussion

These findings validate the concerns that thumb goniometry inter-rater reliability may differ in clinical and non-clinical populations, support further study in clinical populations, and support a common assumption that the same rater should test the same client with the same goniometer to minimize measurement error. When compared to the Baseline™ Flexion-Hyper Extension Goniometer, the Baseline™ 180 Degree Digit had higher repeatability across raters. Further research on within-rater reliability is required as is study on clinical populations.

Examination of the torque required to passively palmar abduct the thumb CMC joint in a pediatric population with hemiplegia and stroke

Many activities of daily living involve precision grasping and bimanual manipulation, such as putting toothpaste on a toothbrush or feeding oneself. However, children afflicted by stroke, cerebral palsy, or traumatic brain injury may have lost or never had the ability to actively and accurately control the thumb. To translate insights from adult rehabilitation robotics to innovative therapies for hand rehabilitation in pediatric care, specifically for thumb deformities, an understanding of the torque needed to abduct the thumb to assist grasping tasks is required. Participants (n=16, 10 female, 13.2±3.1 years) had an upper extremity evaluation and measures were made of their passive range of motion, anthropometrics, and torques to abduct the thumb for both their affected and non-affected sides. Torque measures were made using a custom wrist orthosis that was adjusted for each participant. The torque to achieve maximum abduction was 1.47±0.61inlb for the non-affected side and 1.51±0.68inlb for the affected side, with a maximum recorded value of 4.87inlb. The overall maximum applied torque was observed during adduction and was 5.10inlb. We saw variation in the applied torque, which could have been due to the applied torques by the Occupational Therapist or the participant actively assisting or resisting the motion rather than remaining passive. We expect similar muscle and participant variation to exist with an assistive device. Thus, the data presented here can be used to inform the specifications for the development of an assistive thumb orthosis for children with "thumb-in-palm" deformity.

Measuring thumb range of motion in first carpometacarpal joint arthritis: The inter-rater reliability of the Kapandji Index versus goniometry

Introduction

Goniometric measurement of thumb range of motion is often used as an outcome measure in assessing patients with first carpometacarpal osteoarthritis. Despite common use and demonstrated construct validity, the reliability of this technique has not been well established. The Kapandji Index is an alternate functional measure of thumb motion suitable for use with this client group. The purpose of this study was to examine the inter-rater reliability of the goniometric measures for thumb joint range of motion compared to the Kapandji Index in patients with first carpometacarpal joint osteoarthritis.

Methods

Two independent assessors, who were blind to each other’s measurements, measured thumb range of motion in 33 patients (54 thumbs). All participants were undergoing treatment for carpometacarpal joint osteoarthritis. Active range of motion was measured with a goniometer for all the thumb joints using a standardised measurement protocol. The Kapandji Index score was recorded. Relative reliability was assessed by using the intraclass correlation coefficient. Absolute reliability was also calculated by determining the standard error of measurement (SEM68) and the minimal detectable difference (MDD90).

Results

Inter-rater reliability for the goniometer was highly variable ranging from poor to excellent (intraclass correlation coefficient 0.128–0.860). The SEM68 ranged from 9° to 13°, and the resulting MDD90 varied from 21° to 31° for the different thumb joints. The Kapandji Index had excellent inter-rater reliability among the different raters (intraclass correlation coefficient 0.772–0.917).

Conclusions

Measurement of goniometric active range of motion of the thumb may have limited utility as a measure of clinical effectiveness for patients with carpometacarpal joint osteoarthritis. However, the Kapandji Index is a reliable measure of functional range of motion.

Stability of the Basal Joints of the New Thumb After Pollicization for Thumb Hypoplasia

PURPOSE

To investigate the presence or absence of union of the new trapezium to the retained metacarpal base after pollicization and to relate this to stability of the new trapezium and the new carpometacarpal joint.

METHODS

Thirty-six patients (46 pollicizations) were assessed at clinical review. Mean time from surgery to review was 96 months (range, 9-260 mo). Clinical assessment measured range of motion (ROM) at the carpometacarpal joint, stability of the carpometacarpal joint, and extrinsic and intrinsic strength of both hands. Radiological review evaluated 3 parameters: bony union between the new trapezium and retained metacarpal base, stability of the new trapezium in relationship to the metacarpal base, and carpometacarpal joint stability.

RESULTS

There was radiographic nonunion between the new trapezium and the retained metacarpal base in 8 (1 treated) of 46 pollicizations. Relative risk of instability of the new trapezium was 39 times more likely if nonunion was present. Nine pollicizations were unstable at the carpometacarpal joint, 8 in those with union and 1 with nonunion. Relative risk of instability was 1.4 times more likely for those with union. For patients with nonunion, ROM and grip strength variables were reduced but only grip strength reached statistical significance. In patients with carpometacarpal joint instability, ROM and grip strength variables were reduced but none of the variables reached statistical significance.

CONCLUSIONS

This study suggests that when the surgeon is attempting to obtain union of the new trapezium to the retained metacarpal base, failure to do so results in a poorer thumb with a significantly increased risk of trapezial instability and decreased grip strength. There is a mildly increased risk of carpometacarpal joint instability with union, but significantly poorer function as a consequence of this has not been demonstrated.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Inter-rater reliability for measurement of passive physiological range of motion of upper extremity joints is better if instruments are used: a systematic review

QUESTION

What is the inter-rater reliability for measurements of passive physiological or accessory movements in upper extremity joints?

DESIGN

Systematic review of studies of inter-rater reliability.

PARTICIPANTS

Individuals with and without upper extremity disorders.

OUTCOME MEASURES

Range of motion and end-feel using methods feasible in clinical practice.

RESULTS

Twenty-one studies were included of which 11 demonstrated acceptable inter-rater reliability. Two studies satisfied all criteria for internal validity while reporting almost perfect reliability. Overall, the methodological quality of studies was poor. ICC ranged from 0.26 (95% CI -0.01 to 0.69) for measuring the physiological range of shoulder internal rotation using vision to 0.99 (95% CI 0.98 to 1.0) for the physiological range of finger and thumb flexion/extension using a goniometer. Measurements of physiological range of motion using instruments were more reliable than using vision. Measurements of physiological range of motion were also more reliable than measurements of end-feel or of accessory range of motion.

CONCLUSIONS

Inter-rater reliability for the measurement of passive movements of upper extremity joints varies with the method of measurement. In order to make reliable decisions about joint restrictions in clinical practice, we recommend that clinicians measure passive physiological range of motion using goniometers or inclinometers.

Palmar abduction measurements: reliability and introduction of normative data in healthy children

PURPOSE

Previously, we studied normative and reliability data of palmar thumb abduction measurements (conventional goniometry, the Pollexograph thumb, the Pollexograph metacarpal, the Inter Metacarpal Distance, the American Society of Hand Therapists method, and the American Medical Association method) in healthy adults. Because many interventions aiming to improve palmar abduction are performed at an early age, the goal of this study was to assess normative and reliability data of these measurement methods in children.

METHODS

We performed measurements with the Pollexograph thumb, the Pollexograph metacarpal and Inter Metacarpal Distance in 100 healthy children to acquire normative data. A retest was performed in 63 children to assess intraobserver reliability.

RESULTS

Mean active and passive palmar abduction measured with the Pollexograph thumb was 62 degrees (range, 40 degrees to 76 degrees). The range of motion of the Pollexograph metacarpal was smaller (mean 49 degrees, range, 32 degrees to 64 degrees). The mean Inter Metacarpal Distance was 50 mm (range, 36-70 mm). Intraclass correlation coefficients of the Pollexograph thumb, Pollexograph metacarpal, and Inter Metacarpal Distance indicated excellent reliability (intraclass correlation coefficients between 0.85 and 0.92).

CONCLUSIONS

Normative Pollexograph thumb and Pollexograph metacarpal data showed that means measured in children are comparable to values found in healthy adults. Reliability data indicated that the Pollexograph thumb, the Pollexograph metacarpal, and Inter Metacarpal Distance are also reliable measurement methods in children.