Assessment and treatment of nonsurgical thumb carpometacarpal joint osteoarthritis: A modified Delphi-based consensus paper of the American Society of Hand Therapists

BACKGROUND

While the literature is abundant on hand therapy assessment and treatment of nonsurgical thumb carpometacarpal (CMC) osteoarthritis (OA), clarity and uniformity are meager, making it a desirable diagnosis to establish expert consensus.

PURPOSE

This study aimed to ascertain if consensus exists for the assessment and treatment of nonsurgical management of thumb CMC OA in the hand therapy clinical setting.

STUDY DESIGN

This was a consensus paper via the modified Delphi approach.

METHODS

A modified Delphi method was used to determine consensus among an expert panel, including hand therapists and hand surgeons, via two online surveys. A consensus paper steering committee (from the American Society of Hand Therapist's research division) designed the surveys and analyzed responses. Consensus was established as 75% agreement among the expert panel. Demographic information was collected from the expert panel.

RESULTS

The expert panel included 34 hand therapists and seven hand surgeons. The survey response rates were 93.6% for the first survey and 90.2% for the second survey. Consensus recommendations were classified according to the World Health Organization categorization. These included evaluating the body structures for clinical signs/clinical testing and body functions for pain, range of motion for palmar abduction, radial abduction, opposition, and thumb metacarpal phalangeal flexion/extension, and grip and tripod pinch strength. Further consensus recommendations were for the assessment of function using a region-specific, upper extremity patient-reported outcome measure (activity and participation), environmental factors, outcome expectation, and illness perception within the patient's unique environmental and social contexts. Treatment recommendations included the use of an orthosis during painful activities, a dynamic stability program (stable C posture, release of tight adductors, and strengthening of stabilizers), patient education, joint protection techniques, adaptive equipment, and functional-based intervention.

CONCLUSIONS

The findings describe the consensus of a group of experts and provide a clinical reference tool on the hand therapy assessment and treatment of nonsurgical thumb CMC joint OA.

Patient satisfaction with the CMC controller: A cohort study

STUDY DESIGN

Cohort study.

INTRODUCTION

The evidence specific to understanding patient satisfaction, preference and the effects on occupational performance using a CMC orthosis is sparse.

PURPOSE OF THE STUDY

The main purpose of this study was to determine patient satisfaction, aspects of the orthotic preference, and the effect on pain and function of the CMC Controller Plus neoprene orthotic device.

METHODS

This research was conducted at two outpatient clinics located in Pennsylvania and Florida during 2019. The subjects of this study included any individuals referred to one of two participating hand therapy facilities with either a primary or secondary diagnosis of thumb CMC joint arthritis or present with this diagnosis as a comorbidity. The CMC Controller Plus orthosis (Hely & Weber) was provided to each patient by the treating therapist at no cost to the patient after the patient agreed to take part in the study. None of the patients received hand therapy treatment for the CMC pain; the only intervention provided was the CMC Controller Plus.

RESULTS

The CMC Controller Plus orthosis improved the patients' functional status and reduced their pain. The effect size for the change in function was large (1.29) compared to the effect size for the reduction in pain which approached moderate at 0.49.

DISCUSSION

The CMC Controller Plus orthosis improved the patient's functional status by 52% and reduced their pain by 29%.

CONCLUSION

The results were both statistically and clinically significant.

Effectiveness of splinting for pain and function in people with thumb carpometacarpal osteoarthritis: a systematic review with meta-analysis

OBJECTIVE

To examine the effectiveness of splinting for reducing pain and improving function and health-related quality of life (HR-QoL) in people with thumb carpometacarpal osteoarthritis (CMC OA).

DESIGN

The Cochrane Library, MEDLINE, Embase, CINAHL, ISI Web of Science, Scopus and Google Scholar, 3 trial registries and 4 conference proceedings were systematically searched for randomised and non-randomised controlled trials up to March 17th, 2018. Two reviewers independently applied the inclusion criteria to select potential studies and assess risk of methodologic bias using the Cochrane Collaboration's Risk of Bias Tool. Studies were pooled using the inverse variance method to calculate standardised mean difference (SMD). Sensitivity analyses were conducted and the quality of evidence for each outcome was judged following the Grades of Recommendation Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Twelve studies were retrieved (n = 1353), 4 comparing a splint to control and 8 to another splint. In the medium-term (3-12 months), low quality evidence showed that splints cause a moderate to large reduction in pain (SMD 0.7 [95% confidence interval (CI) 1.04, 0.35], P < 0.0001) and small to moderate improvement in function (SMD 0.42 [95% CI 0.77, 0.08], P = 0.02). No significant effect was found at short-term or for different types of splints. No studies reported HR-QoL.

CONCLUSIONS

Splinting demonstrated a moderate to large effect for pain and small to moderate effect for function in the medium-term but not in the short term. Quality of the evidence is low. Major challenges are the lack of diagnostic criteria and of a gold-standard outcome measure for thumb CMC OA.

An occupational perspective in hand therapy: A scoping review

Introduction

There have been calls for the occupational therapy profession to realign with its values around occupation. However, the profession faces challenges in practice areas that have historically been underpinned by a biomechanical approach, such as hand therapy. The aim of this scoping review was to describe what is known about an occupational perspective in the hand therapy literature.

Method

This scoping review utilised a recognised five-step approach. A search was conducted in four databases for papers published between 2005 and 2016. Numerical and thematic analyses were employed, using the Canadian Practice Process Framework as a theoretical framework.

Results

Fifty papers were included in the scoping review. Six themes were identified: the centrality of occupation; inconsistencies in terminology; where in the occupational therapy process?; informal discussion as a key occupational strategy; occupational therapists’ expectations of patients; and a bottom-up approach focusing on biomechanical strategies to implementing the plan.

Conclusion

Whilst there has been some integration of an occupational perspective into hand therapy literature, there are still challenges. Inconsistent terminology, the lack of an occupational perspective throughout the occupational therapy process and a bottom-up approach to interventions all demonstrate the continuing tensions between the biomechanical approach and an occupational perspective.

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.

Therapy management of thumb carpometacarpal osteoarthritis: Exploring UK therapists’ perceptions of joint instability

Introduction

Carpometacarpal joint osteoarthritis is a common and painful condition associated with ligament laxity, subluxation and joint instability. Therapy management includes several interventions targeting the symptoms associated with instability and subluxation. This study aimed to explore the perceptions of experienced therapists, about their understanding of joint instability in carpometacarpal joint osteoarthritis and its relationship with laxity, subluxation and strength, and the perceived effectiveness of exercise interventions.

Methods

A qualitative research design, consisting of individual semi-structured interviews was conducted with nine therapists. Interviews were transcribed and analysed using a thematic analysis.

Results

Three themes were identified: (a) relationships between instability and laxity – the terms laxity and instability were often used interchangeably. Instability was associated with laxity, subluxation and disease progression, and was perceived to be a problem that includes the whole thumb column; (b) clinical reasoning by stage of disease – conflicting opinions were expressed regarding instability being present in pre-arthritic lax joints, early disease or all stages of disease; (c) the role of exercise in management – there was disagreement as to whether instability could be modified by developing muscle strength, or whether treatment should be focussed on compensating for instability.

Conclusion

Different perceptions of instability were reflected in wide-ranging opinions regarding the need to manage instability, and regarding the potential for altering instability. The impact of instability on function, and the concept of instability were not easily identified. A clearer definition of instability would facilitate the development and assessment of interventions for instability.

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.

Rehabilitation protocol after suspension arthroplasty of thumb carpometacarpal joint osteoarthritis

STUDY DESIGN

Retrospective case series.

INTRODUCTION

When conservative modalities and therapies fail to control symptoms of thumb carpometacarpal (CMC) joint osteoarthritis, surgery may be indicated.

PURPOSE OF THE STUDY

To present a rehabilitation protocol used in a series of patient cases after suspension arthroplasty and to evaluate outcomes.

METHODS

Twenty-seven patients with CMC osteoarthritis were treated by the same arthroplasty technique and the same rehabilitation program. Patients were evaluated before and 12th week after surgery, and at the last follow-up using a visual analog scale; the Disability of the Arm, Shoulder, and Hand questionnaire; strength measurements; range of motion evaluations; and radiographic assessment.

RESULTS

Average follow-up period was 31.5 months. There was a decreasing trend in both subjective scores during follow-ups (p=0.0001). Thirty-three percent and 30% improvements on radial and palmar abductions, respectively, and 29% improvement on pinch strengths were recorded at the final follow-up. Postoperative grip improvement was not preserved at the last follow-up.

CONCLUSIONS

The results demonstrate a high degree of patient satisfaction suggesting the efficacy of this surgical technique and postoperative rehabilitation protocol.

LEVEL OF EVIDENCE

Level 4.

Functional patterns of thumb key pinch and their influence on thumb strength and stability

Introduction

Trapeziometacarpal osteoarthritis (TMC OA) is a common condition frequently related to instability and hypermobility. Many factors are involved in the development of this degenerative process. Recent research suggests that the position of the metacarpophalangeal (MCP) joint may influence TMC joint contact wear patterns and subsequent development of OA. The aim of this study is to explore the alignment of the MCP joint of the thumb during lateral pinch in order to describe the naturally occurring alignment in a group of healthy volunteers without symptoms.

Methods

One hundred and nine participants were asked to apply a lateral pinch manoeuvre to a pinchmeter, while their thumbs were assessed. Passive hypermobility of the thumb MCP (MCP) joint was assessed, key pinch strength was measured, key pinch position was photographed and the angle of the joints during the assessment was measured.

Results

Four different functional pinch patterns were identified. The most frequent pattern seems to be MCP hyperextension described by Moulton as harmful for the TMC joint. The level of strength obtained did not correspond to the pinch pattern used, and hypermobility of the thumb MCP joint did not determine the position of the thumb during key pinch.

Conclusion

Four different thumb postures were identified during lateral pinch; however, these postures were not associated with any difference in pinch strength. We conclude that the more unstable and mechanically inefficient postures are compensated by functional capacity.

Pilot randomized controlled trial comparing specific dynamic stability exercises with general exercises for thumb carpometacarpal joint osteoarthritis

Introduction

Exercises are widely used and recommended for peripheral joint and hand osteoarthritis (OA); however, the evidence on which specific exercise regimen is most effective is unclear.

Methods

A pilot randomized controlled trial was conducted to compare the effect of specific first carpometacarpal (CMC) joint stabilizing exercises and general exercise on function, pain and strength. Thirty-nine participants with OA of the first CMC joint were recruited and randomly assigned into one of two exercise groups. Exercises were taught as a home programme then reviewed and only progressed as tolerated. The participant and assessing physiotherapist were blinded. Primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire at three and six months. Pinch and grip strength, pain scores at rest and during pinch and abductor pollicis longus (APL) moment were secondary measures.

Results

Twenty-two patients completed follow-up at six months. At baseline the general exercise group had significantly stronger pinch and APL moments but was not different in any other measures. The improvement (reduction) of DASH scores at three and six months was not significantly different between the two groups; however, the general exercise group had a greater reduction in DASH score from baseline to three months (13 points P = 0.001). The outcomes were not affected ( P > 0.05) by any variables except APL moment at baseline. Increased APL moment at baseline was associated with an improved outcome in both groups ( P = 0.01).

Conclusions

While this pilot study was inadequately powered the results can be used to plan a future large-scale trial.

Occupational therapy-based and evidence-supported recommendations for assessment and exercises in hand osteoarthritis

AIMS

The aims of this study were to develop recommendations for occupational therapy assessment and design of hand exercise programmes in patients with hand osteoarthritis.

METHODS

An expert group followed a Delphi procedure to reach consensus for up to 10 recommendations for assessment and exercises, respectively. Thereafter, an evidence-based approach was used to identify and appraise research evidence supporting each recommendation, before the recommendations were validated by the expert group.

RESULTS

The process resulted in 10 recommendations for assessment and eight for design of exercise programmes. The literature search revealed that there is a paucity of clinical trials to guide recommendations for hand osteoarthritis, and the evidence for the majority of the recommendations was based on expert opinions. Also, even if a systematic review demonstrates some evidence for the efficacy of strength training exercises in hand OA, the evidence for any specific exercise is limited to expert opinions.

CONCLUSIONS

A first set of recommendations for assessment and exercise in hand osteoarthritis has been developed. For many of the recommendations there is a paucity of research evidence. High-quality studies are therefore needed to establish a high level of evidence concerning functional assessment and the effect of hand exercises in hand osteoarthritis.