The effectiveness of a manual therapy and exercise protocol in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial

Nonoperative Management of Trapeziometacarpal Joint Arthritis: A Systematic Review of the Clinical Trials

This systematic review evaluates nonoperative treatments for trapeziometacarpal joint osteoarthritis (TMJO), a common degenerative condition in postmenopausal females causing pain, reduced mobility, and diminished grip strength. Following PRISMA guidelines, a search was conducted across PubMed, Cochrane, Embase, and MEDLINE for randomized controlled trials (RCTs) assessing pain outcomes with nonoperative interventions over at least a six-month follow-up, using the visual analog scale (VAS) for pain measurement. Eleven RCTs yielded moderate-quality evidence for the following: (1) corticosteroid (CSI) and hyaluronic acid (HA) injections exhibit comparable mean delta pain scores after six months, with CSI offering early relief at two to three weeks. After 12 months, CSI led to a continued decrease in pain, with a mean delta pain score of 1.0 (p<0.05), contrasting with hyaluronic acid (HA) injections, which presented a modest though nonsignificant improvement, demonstrating a mean delta pain score of 0.5 (p=0.16). (2) Relatively novel therapies for TMJO, such as platelet-rich plasma (PRP) and dextrose, appear to surpass CSI in long-term effectiveness, with dextrose showing a mean delta pain score of 3.8 (p<0.001) at six months and PRP achieving a mean delta pain score of 5.5 (p=0.005) at 12 months. (3) Various hand therapies, notably standard hand exercises and extracorporeal shockwave therapy (ESWT), demonstrated significant pain reduction, with the former achieving a mean delta pain score of 1.5 (p=0.019) and the latter a score of 4.2 (p<0.001). (4) The use of orthoses substantially decreases pain levels, demonstrating a mean delta pain score reduction of 2.6 at a 180-day follow-up (p=0.023) and 2.2 at a 12-month follow-up (p=0.002). In conclusion, nonoperative treatments for TMJO, including intra-articular injections, hand therapy, and orthoses, provide significant pain relief at a minimum of six months follow-up. The synergistic effect of combined nonoperative management, as well as the effect size of each, is unknown.

The Effectiveness of Exercise-Based Rehabilitation in People With Hand Osteoarthritis: A Systematic Review With Meta-analysis

OBJECTIVE: To investigate the effectiveness of exercise-based rehabilitation programs compared with nonexercise intervention or no intervention for people with hand osteoarthritis (OA). DESIGN: Intervention systematic review with meta-analysis. LITERATURE SEARCH: We searched 5 databases on July 23, 2023. STUDY SELECTION CRITERIA: We included randomized controlled trials that compared the effectiveness of rehabilitation programs that included an exercise component, with nonexercise intervention or no intervention for people with hand OA. DATA SYNTHESIS: Standardized mean differences (SMDs) were pooled using a random-effects model. The risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool. The certainty of the evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. RESULTS: Fourteen trials were included in the meta-analysis (n = 1341 participants). In the immediate term (<24 weeks), there was low-certainty evidence of an effect of exercise-based rehabilitation on improving pain (13 trials; SMD = -0.65; 95% CI: -1.06, -0.25), function (11 trials; SMD = -0.35; 95% CI: -0.54, -0.15), and grip strength (14 trials; SMD = 0.21; 95% CI: 0.03, 0.38). There was moderate-certainty evidence of an effect on reducing stiffness (7 trials; SMD = -0.33; 95% CI: -0.51, -0.16). There was low-certainty evidence of no effect on improving pinch strength and quality of life. For the long term (≥24 weeks), there was low-certainty evidence that exercise-based rehabilitation had no additional effect on improving pain, function, and stiffness. CONCLUSION: Exercise-based rehabilitation improved pain, function, stiffness, and grip strength in people with hand OA in the immediate term; the benefits were not maintained in the long term. J Orthop Sports Phys Ther 2024;54(7):1-11. Epub 20 March 2024. doi:10.2519/jospt.2024.12241.

Adverse Events Reported in Trials Assessing Manual Therapy to the Extremities: A Systematic Review

Objective: This review aimed to describe the quality and comprehensiveness of adverse event (AE) reporting in clinical trials incorporating manual therapy (MT) as an intervention for extremity conditions using the Consolidated Standards of Reporting Trials (CONSORT)-Harms extension as the benchmark. The secondary aim was to determine whether the quality of AE reporting improved after the availability of the CONSORT reporting checklist. Design: Systematic review. Methods: A literature search was conducted using multiple databases to identify trials where MT was used to treat extremity conditions. Studies that reported AEs were identified and evaluated using the CONSORT-Harms extension. The frequency of trials reporting study AEs before and after the publication of the updated 2010 CONSORT statement was calculated, along with the categorization of how study AEs were reported. Results: Of the 55,539 studies initially identified, 220 trials met all inclusion criteria. Eighty trials (36.4%) reported AE occurrence. None of the studies that reported AEs adhered to all 10 criteria proposed by the 2010 CONSORT-Harms extension. The most commonly reported criterion was number four, which clarified how AE-related information was collected (30% of trials). The least reported criterion was number six, which describes the participant withdrawals for each arm due to AEs and the experience with the allocated treatment (1.3% of trials). The nomenclature used to describe AEs varied substantially. Fifty-nine of 76 trials (33.3%) were published after the updated CONSORT Harms-checklist was available, compared to 21 of 44 trials (46.7%) published before it was available. Conclusion: Reporting of AEs in trials investigating MT for extremity conditions is poor. Every included trial lacked adherence to all 10 criteria proposed by the CONSORT-Harms Extension. The quality and comprehensiveness of AE reporting did not improve after the most recent CONSORT update recommending AE reporting. Clinicians must obtain informed consent before performing any intervention, including MT, which requires disclosing potential risks, which could be better known with improved tracking, analyzing, and reporting of AEs. The authors recommend improved adherence to best practices for adequately tracking and reporting AEs in future MT trials.

Exercise-Based Interventions Are Effective in the Management of Patients with Thumb Carpometacarpal Osteoarthritis: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Exercise-based interventions are a common management strategy in patients with thumb carpometacarpal joint osteoarthritis (CMCJ OA); however, their exact effect on or the use of an optimal training programme for reducing pain and disability remains unclear. Our purpose was to evaluate the effectiveness of exercise-based interventions compared with other conservative interventions in patients with CMCJ OA. We performed a systematic review and meta-analysis based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Fourteen randomised clinical trials with 1280 patients were finally included. Exercise-based interventions present statistically and clinically better outcomes in reducing pain intensity (mean difference [MD]: -21.91; 95% confidence interval [CI]: -36.59, -7.24; p = 0.003) and wrist disability (MD: -8.1, 95% CI: -4.6, -11.5; p = 0.02) compared with no treatment at short-term follow-up. Proprioceptive exercises have statistically and clinically better outcomes compared with standard care only in pain intensity at very short-term (standardised mean difference [SMD]: -0.76; 95% CI: -1.30, -0.21; p = 0.007) and short-term (SMD: -0.93; 95% CI: -1.86, -0.01; p = 0.049) follow-up and statistically better results in wrist disability at very short-term (SMD: -0.94; 95% CI: -1.68, -0.21; p = 0.01) follow-up. No differences were found between the comparators at mid- and long-term follow-up. Low to moderate certainty of evidence suggests that exercise-based interventions can provide clinically better outcomes compared with no treatment in patients with thumb CMCJ OA, at least in the short term.

Effectiveness of proprioceptive neuromuscular facilitation therapy and strength training among post-menopausal women with thumb carpometacarpal osteoarthritis. A randomized trial

BACKGROUND

Thumb carpometacarpal osteoarthritis (CMC OA) greatly affects post-menopausal women. It is characterized by pain and functional deficits that limit the performance of activities of daily life and affect quality of life.

PURPOSE

Analyze the effects of 4/weeks strength training, with and without proprioceptive neuromuscular facilitation (PNF) on the disability among post-menopausal women with thumb CMC OA. Secondly, analyze the effects on pain, mobility, and strength.

STUDY DESIGN

Superiority randomized clinical trial.

METHODS

42 women were randomly allocated to strength training program (SEG, n = 21) and to a strength training plus PNF therapy program (PNFG, n = 21). The Disability (disabilities of the arm, shoulder and hand questionnaire), pain (visual analogue scale), mobility (Kapandji Test), and hand strength were evaluated pre, post intervention (at 4 weeks) and follow-up (at 8 weeks).

RESULTS

Disability was significantly reduced in both groups after intervention, but reduction was statistically superior in PNFG (between-group mean difference [MD] = -16.69 points; CI = -21.56:-11.82; P<.001; d = 2.14). Similar results were observed for secondary outcomes: pain (MD = -2.03; CI = -2.83:-1.22; P<.001; d = 1.58), mobility (MD = 0.96; CI = 0.52:1.38; P<.001; d = 1.40) and strength (grip: MD = 3.47kg; CI = 1.25:5.69; P = .003; d = 0.97, palmar: MD = 0.97kg; CI = 0.14:1.80; P = .024; d = 0.72, tip: MD = 1.12kg; CI = 0.41:1.83; P = .003; d = 0.99 and key pinch: MD = 0.85kg; CI = 0.001:1.70; P = .049; d = 0.62). These improvements were maintained at follow-up.

CONCLUSIONS

The combination of PNF exercises and strength training is more effective for reducing disability pain and improve mobility and strength in post-menopausal women with CMC OA than a programme based solely on strength.

Effectiveness of Neural Mobilisation on Pain Intensity, Functional Status, and Physical Performance in Adults with Musculoskeletal Pain - A Systematic Review with Meta-Analysis

OBJECTIVE

To investigate up-to-date evidence of the effectiveness of neural mobilisation techniques compared with any type of comparator in improving pain, function, and physical performance in people with musculoskeletal pain.

DATA SOURCES

The following sources were consulted: PubMed, Web of Science, CENTRAL, CINAHL, Scopus, and PEDro databases; scientific repositories; and clinical trial registers. The last search was performed on 01/06/2023.

METHODS

Two reviewers independently assessed the studies for inclusion. We included randomised, quasi-randomised, and crossover trials on musculoskeletal pain in which at least one group received neural mobilisation (alone or as part of multimodal interventions). Meta-analyses were performed where possible. The RoB 2 and the Grading of Recommendations Assessment, Development and Evaluation tools were used to assess risk of bias and to rate the certainty of evidence, respectively.

RESULTS

Thirty-nine trials were identified. There was a significant effect favouring neural mobilisation for pain and function in people with low back pain, but not for flexibility. For neck pain, there was a significant effect favouring neural mobilisation as part of multimodal interventions for pain, but not for function and range of motion. Regarding other musculoskeletal conditions, it was not possible to conclude whether neural mobilisation is effective in improving pain and function. There was very low confidence for all effect estimates.

CONCLUSIONS

Neural mobilisation as part of multimodal interventions appears to have a positive effect on pain for patients with low back pain and neck pain and on function in people with low back pain. For the other musculoskeletal conditions, results are inconclusive.

Effectiveness of occupational therapy interventions on function and occupational performance among adults with conditions of the hand, wrist, and forearm: A systematic review and meta-analysis

INTRODUCTION

This systematic review and meta-analysis examines the effectiveness of occupational therapy interventions for adults with conservatively managed conditions of the hand, wrist, and forearm.

METHODS

Searches were carried out in CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, MEDLINE (OVID), EMBASE, and PubMed. Grey literature was searched for via Google Scholar. A systematic literature search was undertaken for randomised studies that examined occupational therapy interventions for treatment of hand, wrist, and forearm conditions. The primary outcome was function, with secondary outcomes of occupational performance, satisfaction with occupational performance, pain, and quality of life. Meta-analyses were completed, and GRADE was used to determine the certainty of evidence.

RESULTS

Twelve studies with 1429 participants were identified. Interventions included combinations of occupation-based intervention, assistive device provision, education, orthosis provision, and exercise programmes for arthritis, carpal tunnel syndrome, and fracture and tendon injuries of the hand, wrist, and forearm. Occupational therapy resulted in an improvement of function (REM, SMD -0.27, 95% CI -0.00 to -0.53, I2  = 69%, low certainty evidence) (p = 0.05), occupational performance (REM, SMD 0.83, 95% CI 1.61-0.06, I2  = 91%, low certainty evidence) (p = 0.04), satisfaction with occupational performance (REM, SMD 0.74, 95% CI 1.42-0.05, I2  = 89%, low certainty evidence) (p = 0.03), and pain reduction (FEM, MD -1.35, 95% CI -0.84 to -1.86, I2  = 0%, moderate certainty evidence) (p < 0.00001).

CONCLUSION

Further high-quality research is recommended to determine the effects of occupational therapy interventions on specific upper limb conditions, inclusive of a broader range of clinical and patient reported outcome measures.

Peripheral and central changes induced by neural mobilization in animal models of neuropathic pain: a systematic review

Introduction

Neural mobilization (NM) is a physiotherapy technique involving the passive mobilization of limb nerve structures with the aim to attempt to restore normal movement and structural properties. In recent years, human studies have shown pain relief in various neuropathic diseases and other pathologies as a result of this technique. Improvement in the range of motion (ROM), muscle strength and endurance, limb function, and postural control were considered beneficial effects of NM. To determine which systems generate these effects, it is necessary to conduct studies using animal models. The objective of this study was to gather information on the physiological effects of NM on the peripheral and central nervous systems (PNS and CNS) in animal models.

Methods

The search was performed in Medline, Pubmed and Web of Science and included 8 studies according to the inclusion criteria.

Results

The physiological effects found in the nervous system included the analgesic, particularly the endogenous opioid pathway, the inflammatory, by modulation of cytokines, and the immune system.

Conclusion

On the basis of these results, we can conclude that NM physiologically modifies the peripheral and central nervous systems in animal models.

Rhizarthrosis Part II: A New Approach of Manual Therapy and Therapeutic Exercise

Rhizarthrosis (RA), also known as trapezium-metacarpal osteoarthritis, is a degenerative condition affecting the thumb's first joint, leading to functional impairment and pain. Conservative treatment options are preferred for mild to moderate cases (Eaton-Littler grades I and II) and typically encompass a range of therapeutic modalities, including manual therapy. However, for the existing manual therapy techniques, there is a lack of comparative studies for efficacy, and therapeutic exercises are often generic and non-specific to RA. This study proposes a novel treatment protocol that combines manual therapy with specific therapeutic exercises grounded in the biomechanical analysis of the trapeziometacarpal joint. The focus is on enhancing joint stability, reducing pain, and improving function. The manual therapy component includes three phases. A passive phase, during which joint distractions are applied to alleviate discomfort and improve joint mobility. An active phase that addresses joint mobility on the adduction-abduction plane, the first plane of movement to suffer limitation: the therapist facilitates the isometric adduction of the thumb, followed by an assisted abduction. A second active phase is where Mulligan's Mobilization With Movement concept is applied. This technique involves passive pain-free joint mobilization with simultaneous active finger movements, to provide additional therapeutic benefits. The therapeutic exercises component focuses on strengthening the first dorsal interosseous muscle as an abductor to reduce thumb adductor muscle activation and joint stress. Patients are encouraged to perform finger spreading exercises using a rubber band between the first and fifth fingers, emphasizing first dorsal interosseous activation and stability of the thumb. This type of muscle strengthening does not involve movement of the trapeziometacarpal joint. It is recommended to start performing 5-10 repetitions or 5 seconds of isometric contraction, repeat throughout the day, and progressively increase the load by adding a turn to the rubber band or changing it, increasing the number of repetitions bringing it to 15 and/or increase the isometric contraction time to 10/15 seconds. The proposed therapeutic rationale, informed by biomechanical insights, lays a promising foundation for further investigation. Nevertheless, empirical validation through rigorous clinical trials remains essential to substantiate its clinical utility and advance the management of RA.

Complex motions embedded in a hand exercise regimen - effects on thumb function in participants with carpometacarpal osteoarthritis: A pilot study

Objective

The goal of this pilot study was to identify changes associated with completion of a unique six-week hand exercise program in persons with carpometacarpal osteoarthritis.

Methods

Twenty-four individuals, aged 55-80, with doctor-diagnosed carpometacarpal osteoarthritis participated in the study. Movement data from standard clinical motions and complex multi-planar motions were obtained using a motion capture system at three-time points: an initial visit, after two weeks of hand exercises, and after completion of the six-week exercise program.

Results

This exercise program produced trends of improvement in complex multi-planar motions. Specifically, joint angle changes were seen during opposition and the formation of an "okay sign" that was included as part of the exercise program.

Conclusion

Through the use of motion capture, changes were identified in thumb joint function after exercise. Specifically, motions associated with the more complex multi-planar tasks showed changes in individual joint contributions following the six-week exercise intervention. The results suggest that further exploration of this exercise program, particularly the inclusion of complex multi-planar tasks during osteoarthritis treatment and associated evaluations, should be considered in future clinical studies.

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.

Is Hand Therapy Associated With a Delay in Surgical Treatment in Thumb Carpometacarpal Arthritis?

PURPOSE

Thumb carpometacarpal (CMC) osteoarthritis (OA) causes functional disability and an increased health care burden in the aging population. The role of therapy in thumb CMC OA has been minimally analyzed in the literature. We hypothesized that patients treated with therapy for thumb CMC OA would demonstrate reduced rates of surgery for this diagnosis.

METHODS

We queried a national insurance dataset for all patients with an International Classification of Diseases, Ninth Revision, or International Statistical Classification of Diseases, Tenth Revision, code for thumb CMC OA, with a minimum of 2 years of follow-up. A 2:1 propensity-matched cohort of patients with CMC OA who did not receive therapy versus a therapy cohort was created, with a minimum of two sessions of hand therapy for inclusion. The primary outcome was the rate of thumb CMC OA surgery occurring within 2 years of diagnosis; time to surgery and use of thumb CMC injections were secondary outcomes. Multivariable logistic regression analysis was used to identify the risk factors for undergoing surgical treatment.

RESULTS

After matching, the therapy cohort comprised 14,548 patients, with a matched group of 28,930 patients who did not undergo therapy. In the overall sample, the rate of surgery within 2 years was 22.5%. Two-year surgical treatment rates were significantly higher for those who did not undergo therapy when compared with those who did (29.3% vs 13.1%). Patients treated with therapy had a significantly longer time to surgery, with no difference in the rate of surgery after one year. In multivariable regression of all included variables, lack of therapy intervention had the highest odds of surgery for thumb CMC OA (odds ratio 4.3).

CONCLUSIONS

We present the findings of a large insurance database evaluating the association of therapy with rates of surgical treatment for thumb CMC arthritis. On average, those treated with therapy had longer times to surgery, and the 2-year surgery rates for patients diagnosed with thumb CMC arthritis were significantly higher in those who did not undergo therapy treatment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Effect of a stabilization exercise program versus standard treatment for thumb carpometacarpal osteoarthritis: A randomized trial

STUDY DESIGN

Randomized, interventional trial with 1 year follow-up.

INTRODUCTION

Though recommended, evidence is lacking to support specific exercises to stabilize and strengthen the first carpometacarpal (CMC) joint for cases of osteoarthritis (OA).

PURPOSE OF THE STUDY

To determine in a naturalistic setting, whether standard treatment plus a home exercise program (ST+HEP) is more effective than standard treatment (ST) alone in improving Quick Disabilities of Arm, Shoulder and Hand (qDASH) scores, and secondarily, in other patient-centered (pain, function) and clinical outcomes (range of motion, strength).

METHODS

A total of 190 patients from a hand therapy practice in northwestern PA were enrolled by informed consent and randomized into ST or ST+HEP groups. Average age was 60 years, most were female (78%) with sedentary occupations most common (36%). ST group received orthotic interventions, modalities, joint protection education and adaptive equipment recommendations, while the ST+HEP group received a home exercise program in addition to ST for 6-12 months. Follow-up occurred at 3, 6, and 12 months. Outcomes included grip strength, pinch strength, range of motion (ROM), qDASH, Patient Specific Functional Scale (PSFS) and pain ratings. At the 6 month mark, all subjects could change groups if desired. Efficacy data analysis included both parametric and non-parametric tests. The threshold for statistical significance was 0.05 and adjusted for multiple comparisons.

RESULTS

Repeated measures ANOVA failed to show a statistically significant difference in strength and ROM assessments between treatment groups over the 12 month follow-up (P ≥ .398). Differences between groups did not exceed 13%. Both the ST and ST+HEP groups evidenced improvement over time in most patient-focused assessments (P ≤ .011), including improvements exceeding reported clinically important differences in pain with activity and PSFS scores. Scores for these measures were similar at each follow-up period (P ≥ .080) in each group. The presence of CTS exerted no effect on outcomes; longer treatment time was weakly related to poorer qDASH and PSFS scores initially. Of those enrolled, 48% of subjects completed the study.

CONCLUSIONS

The addition of a high-frequency home exercise program did not improve clinical or patient-centered outcomes more so than standard care in our sample however, study limitations are numerous. Both groups had decreased pain with activity and improved PSFS scores, meeting the established minimally clinically important difference (MCID) of each at 6 and 12 months. Adherence with the home program was poor and/or unknown.

Autologous Fat and Platelet-Rich Plasma Injections in Trapeziometacarpal Osteoarthritis: A Systematic Review and Meta-Analysis

BACKGROUND

For the treatment of carpometacarpal arthritis of the thumb, various therapies are used. Infiltration therapy with autologous substances such as platelet-rich plasma and autologous fat have recently gained increasing attention because of beneficial pain-reducing effects in arthritis and the associated regenerative potential. However, the extent of clinical evidence in this area and how well autologous substances work in terms of pain reduction and improvements in hand function remain unclear.

METHODS

A systematic review and meta-analysis were conducted to evaluate the current evidence and to provide more insight into pain reduction and improvement in hand function after infiltration of autologous substances. The authors identified 11 clinical trials, of which we included eight in the meta-analysis.

RESULTS

Autologous substances achieved a good and long-lasting pain reduction, which may also be accompanied by corresponding improvement in hand function. Autologous substances appear to be more effective than corticoid infiltrations. The infiltration of autologous fat seems to be particularly promising in more advanced stages of carpometacarpal arthritis of the thumb. Our meta-analysis showed a mean pain reduction of 2.4 to 3 in visual analogue scale score and a reduction of 18 to 19 points in the Disabilities of the Arm, Shoulder, and Hand questionnaire after infiltration with autologous substances.

CONCLUSION

Both platelet-rich plasma and autologous fat infiltration offer an efficient and long-lasting, minimally invasive therapy option in the treatment of carpometacarpal arthritis of the thumb.

Training-induced hypoalgesia and its potential underlying mechanisms

It is well-established that a single bout of exercise can reduce pain sensitivity (i.e., exercise-induced hypoalgesia) in healthy individuals. However, exercise-induced hypoalgesia is often impaired in individuals with chronic pain. This might suggest that repeated bouts of exercise (i.e., exercise training) are needed in order to induce a reduction in pain sensitivity (i.e., training-induced hypoalgesia) among individuals with chronic pain, given that a single bout of exercise seems to be insufficient to alter pain. However, the effect of repeated bouts of exercise on pain sensitivity and its underlying mechanisms remain poorly understood. Therefore, the purpose of this review was to provide an overview of the existing literature on training-induced hypoalgesia, as well as discuss potential mechanisms of training-induced hypoalgesia and offer considerations for future research. Existing literature suggests that training interventions may induce hypoalgesic adaptations potentially driven by central nervous system and immune system factors. However, the limited number of randomized controlled trials available, along with the lack of understanding of underlying mechanisms, provides a rationale for future research.

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.

Mobilisation or immobilisation-based treatments for first carpometacarpal joint osteoarthritis: A systematic review and meta-analysis with subgroup analyses

Introduction

Both joint mobilisation and immobilisation are thought to be effective in the treatment of first carpometacarpal joint (CMCJ) osteoarthritis (OA). The objective of this review was to establish whether either intervention reduced pain and improved pinch strength in people with first CMCJ OA in the short term and assess whether one intervention is superior to the other.

Method

This was a systematic review and meta-analysis. Seven databases were searched until May 2021. Only RCTs were included. The Cochrane Risk of Bias Tool and the Grade of Recommendations Assessment, Development and Evaluation system were utilised to rate the evidence. Random-effects meta-analysis with subgroup analyses were used.

Results

Eight studies were included with a total of 417 participants. Mobilisation treatments included manual therapy with or without exercise while immobilisation interventions utilised thumb splinting with several different designs. Very low-quality and low-quality evidence showed that mobilisation led to statistically but not clinically significant improvements in pain (standardised mean difference (SMD) = 0.53; 95% confidence interval (CI) = 0.03 to 1; I2 = 60%; p = 0.06) and pinch strength (SMD = 0.35; 95% CI = 0.03 to 0.7; I2 = 12%; p = 0.3) compared to placebo. Very low-quality and low-quality evidence showed no effect on pain and pinch strength compared to a control or no intervention. Subgroup analyses revealed no difference between interventions.

Discussion

Neither mobilisation nor immobilisation alone led to clinically important improvements in pain or pinch strength in the short term in people with symptomatic first CMCJ OA. Neither therapeutic strategy appeared to be superior.

Arthroscopic Management of Thumb Carpometacarpal Joint Arthritis and Pathology

Basilar thumb arthritis is a debilitating condition characterized by pain, reduced joint stability, and reduced capacity for daily activities. Various arthroscopic approaches have been described based on patient factors, as well as radiographic and arthroscopic staging criteria. Here we provide an overview of arthroscopic management of basilar thumb arthritis, including patient evaluation, surgical techniques, outcomes, and new developments. We describe our preferred approach for Eaton stage I-III disease, consisting of arthroscopic hemitrapeziectomy with suture button suspensionplasty. This technique is safe, reliable, and allows for early range of motion and quicker recovery while minimizing scarring and reducing the risk of nerve injury.

Intervention reporting and dissemination of information for the management of hand osteoarthritis

INTRODUCTION

A variety of exercise programs are recognized to be effective for the management of hand osteoarthritis (HOA). It is important to report the essential elements of these exercise programs for clinicians to replicate properly and facilitate their implementation with individuals who suffers from HOA, especially if they are found to be effective programs.

PURPOSE OF THE STUDY

The objective of this article was to assess content reporting using three exercise reporting standardized assessment tools among exercise interventions randomized controlled trials (RCTs) involving individuals with HOA.

STUDY DESIGN

A descriptive study was used.

METHODS

Two pairs of trained assessors independently identified, selected, and scored the reporting quality of the exercise programs of RCTs on the management of HOA using three standardized assessment tools: the Consensus on Exercise Reporting Template (CERT) checklist, Consensus on Therapeutic Exercise Training (CONTENT) scale, and Template for Intervention Description and Replication (TIDieR) checklist to review the quality of reporting of 11 RCTs included in a recent Ottawa Panel guideline.

RESULTS

Based on consensus reached by two different pairs of reviewers and an arbitrator, the mean total scores for the 11 included exercise programs were reported as follows: the mean total score for the CERT, CONTENT, and TIDieR was 10.58/19 ± 4.34, 3.27/9 ± 1.90, and 5.92/12 ± 2.54, respectively. The overall Pearson's Correlation (r) between the methodological quality and intervention reporting was 0.86, 0.71, and 0.54 for moderate-to-high RCTs and 0.47, 0.79, and 0.42 for fair-to-poor methodological quality for the CERT checklist, CONTENT scale, and TIDieR checklist, respectively.

CONCLUSIONS

The intervention reporting in the management of HOA is poor among low-, moderate-, and high-quality clinical trials. The least reported information was intervention parameters related to behavior change. Improving reporting is recommended to ensure replication of effective exercise programs to enhance quality of life of individuals with HOA.

Update on Thumb Basal Joint Arthritis Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Comprehend anatomy and biomechanics of the normal and arthritic trapeziometacarpal joint. 2. Evaluate best evidence for diagnosis and for operative and nonoperative treatment of thumb osteoarthritis. 3. Understand treatment pitfalls of basilar joint arthritis and complication avoidance.

SUMMARY

Articular and ligamentous anatomy of the trapeziometacarpal joint enables complex motions. Disability from arthritis, common at the trapeziometacarpal joint, is debilitating. Furthering the understanding of how trapeziometacarpal arthritis develops can improve treatment. The authors provide current best evidence for diagnosis and treatment of basilar joint arthritis. Pitfalls in treatment are discussed.

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.

A probiotic intervention on pain hypersensitivity and microbiota composition in patients with osteoarthritis pain: Study protocol for a randomized controlled trial

OBJECTIVES

This study aims to examine the effects of probiotics on pain hypersensitivity at the end of a six-week intervention program in patients with osteoarthritis (OA)-related pain.

PATIENTS AND METHODS

This double-blind randomized controlled clinical trial with two parallel arms will be conducted between January 2021 and July 2022. At least 30 participants (age range, 50 to 90 years) of both sexes with a diagnosis of symptomatic hip or knee (Kellgren-Lawrence scale ≥3) will be recruited in each arm (total n=60) to achieve adequate statistical power in the analyses. The intervention will be administered for six weeks followed by a four-week follow-up period. The experimental group will receive a probiotic product plus the usual medical care. The control group will receive a probiotical sham plus the usual medical care. Assessment points will be measured at baseline, end of intervention, and one-month post-intervention. The outcomes of this intervention will be a change in visual analog scale pain and the gut microbiota composition. Group by time effects will be compared using mixed-model analysis of variance.

CONCLUSION

A reduction in pain hypersensitivity in patients with knee OA-related pain could suggest an involvement of microbiota, or part of it, in chronic pain state mechanisms.

Effectiveness of manual therapy in patients with thumb carpometacarpal osteoarthritis: a systematic review and meta-analysis

Background: The effectiveness of Manual Therapy (MT) in thumb carpometacarpal osteoarthritis (OA) is unclear.Objective: This study aimed to determine the effectiveness of MT for functional outcomes in patients with thumb carpometacarpal OA. Design: Systematic review and meta-analysis of randomized clinical trials. Methods: An electronic search was performed in the Medline, Central, Embase, PEDro, Lilacs, Cinahl, SPORTDiscus, and Web of Science databases. The eligibility criteria for selecting studies included randomized clinical trials that compared MT versus other interventions in functional outcomes, such as thumb and/or hand function questionnaires, pinch and/or grip strength, thumb and/or hand range of motion, and pain intensity or pressure pain threshold in patients with thumb carpometacarpal OA. Results: Five clinical trials met the eligibility criteria; for the quantitative synthesis, four studies were included. The mean difference (MD) for grip strength was 0.87kg (95% CI = 0.29-1.44, p = .003), for pinch strength was 0.10kg (95% CI = -0.01-0.20, p = .06), and for the pressure pain threshold was 0.64kg/cm² (95% CI = 0.07-1.20, p = .03). All differences were in favor of the MT group. Conclusions: In the short-term, there was moderate to high evidence, with statistically significant differences in the functional outcomes, in favor of MT versus sham interventions in patients with thumb carpometacarpal OA. However, these differences are not clinically important.

Pressure algometry and palpation of the upper limb peripheral nervous system in subjects with hand osteoarthritis are repeatable and suggest central changes

STUDY DESIGN

Case-control study.

INTRODUCTION

A subset of patients with hand osteoarthritis (OA) shows evidence of central pain phenotypes.

PURPOSE OF THE STUDY

To examine whether differences exist in experimental pain responses in the affected and nonaffected sides of patients with unilateral hand OA. To investigate the test-retest reliability of pressure algometry and manual digital palpation in patients with unilateral hand OA.

METHODS

The hand OA group consisted of 20 patients, and the control group consisted of 20 healthy subjects. Pressure pain threshold (PPT) measurements were made 2 times, consisting of 3 repeat trials, each using computerized algometry and manual digital palpation. Grip and key strength (dynamometer), pain (visual analog scale), and function (Disabilities of the Arm, Shoulder and Hand [short version]) were also measured. The 2-way analysis of variance was conducted to determine the differences between sides and groups. Intraclass correlation coefficient (ICC) and standard error of measurement were calculated.

RESULTS

Patients with hand OA had decreased PPTs over the thumb carpometacarpal joint as well as radial and median nerves compared with controls (all P < .01). No significant group effect by side interaction was detected for any measure. The minimal detectable change values needed to detect change in subjects with hand OA were C5-C6 joint (0.3-0.5 kg/cm²), carpometacarpal joint (0.3-0.5 kg/cm²), hamate bone (0.2-0.4 kg/cm²), radial nerve (0.2-0.8 kg/cm²), median nerve (0.3-0.6 kg/cm²), and ulnar nerve (0.2-0.4 kg/cm²) for PPT. Test-retest reliability was calculated for both hands of participants with OA (ICC, 0.98-0.99) and healthy participants (ICC, 0.74-0.99).

DISCUSSION

Although pressure algometry and manual digital palpation are techniques already used in previous studies and have been shown to be reproducible and moderately reliable for joint palpation, this current study suggests that pressure algometry and manual digital palpation could also be reliable methods of determining nerve sensitivity of the radial, ulnar and median nerves in subjects with hand OA.

CONCLUSIONS

Hyperalgesia in patients with hand OA might be associated with clinical measures, and bilateral signs in unilateral OA could suggest central changes.

The effects of an 8-week knitting program on osteoarthritis symptoms in elderly women: A pilot randomized controlled trial

BACKGROUND

Exercise therapy is effective in reducing symptoms and disability associated with hand osteoarthritis (HOA) but often has low adherence. An intervention consisting in a meaningful occupation, such as knitting, may improve adherence to treatment. This pilot randomized controlled trial (RCT) studied the adherence and clinical effectiveness of a knitting program in older females suffering from HOA to evaluate the acceptability of this intervention and assess the feasibility of a larger-scale RCT.

METHODS

Single-blind, two-arm pilot RCT with a parallel group design with 37 participants (18 control, 19 intervention). Control participants were given an educational pamphlet and assigned to a waiting list. The knitting program (8-week duration) had two components: bi-weekly 20-min group knitting sessions and daily 20-min home knitting session on the 5 remaining weekdays. Measures included knitting adherence (implementation outcomes) as well as stiffness, pain, functional status, hand physical activity level, patient's global impression of change, health-related quality of life, self-efficacy, and grip strength (clinical outcomes measured throughout the 8-week program and 4 weeks after the intervention).

RESULTS

Our protocol is feasible and the intervention was acceptable and enjoyable for participants, who showed high adherence. No difference was observed between the two groups for any of the clinical outcome measures (all p > .05).

CONCLUSION

Knitting is a safe and accessible activity for older women with HOA. However, our 8-week knitting program did not result in improvements in any of our outcome measures. Knitting for a longer period and/or with higher frequency may yield better outcomes.

Choice of control group treatments in hand osteoarthritis trials: A systematic review and meta-analysis

OBJECTIVES

To assess how patient characteristics and study design influence the effectiveness of control interventions in hand OA trials.

METHODS

The study protocol was registered in PROSPERO (CRD42020163473). Two authors independently searched four electronic databases from their inception to December 31, 2019. Randomized and non-randomized controlled hand OA trials were included if pain intensity was assessed using a validated scale. We allocated control groups into one of the following: placebo, add-on treatment, no treatment, or active treatment. The standardized mean differences (d) of pain, as well as subjective function and hand strength, were pooled with 95% confidence intervals (CI) and 90% prediction intervals using random-effects models. Meta-regression and post-hoc subgroup analyses were performed to investigate which factors potentially impacted placebo analgesia and between-study heterogeneity.

RESULTS

Thirty-one placebo, 11 add-on, 12 no-treatment, and 10 active-treatment controls were included in meta-analyses. Effective pain relief was observed in placebo (d = -0.50, 95% CI -0.63 to -0.37), add-on (d = -0.35, 95% CI -0.59 to -0.12), and active-treatment (d = -0.92, 95% CI -1.35 to -0.48) groups. In subjective function, these treatments had smaller but beneficial effects; hand strength, contrastingly, was not improved. Placebo effects were larger when flare designs were used (d = -0.96) and more homogeneous when minimum pain thresholds were set (d = -0.46, 90% prediction intervals -0.79 to -0.14).

CONCLUSION

Placebo, add-on, and active control treatments were more effective than the no treatment control in relieving hand pain and improving subjective function. By choosing minimum pain thresholds and flare requirements at patient enrollment, moderate pain relief may be replicated among control participants in future randomized placebo-controlled trials.

Efficacy of a Combination of Conservative Therapies vs an Education Comparator on Clinical Outcomes in Thumb Base Osteoarthritis: A Randomized Clinical Trial

IMPORTANCE

A combination of conservative treatments is commonly used in clinical practice for thumb base osteoarthritis despite limited evidence for this approach.

OBJECTIVE

To determine the efficacy of a 6-week combination of conservative treatments compared with an education comparator.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, parallel trial with 1:1 allocation ratio among people aged 40 years and older with symptomatic and radiographic thumb base osteoarthritis in a community setting in Australia.

INTERVENTIONS

The intervention group (n = 102) received education on self-management and ergonomic principles, a base-of-thumb splint, hand exercises, and diclofenac sodium, 1%, gel. The comparator group (n = 102) received education on self-management and ergonomic principles alone. Intervention use was at participants' discretion from 6 to 12 weeks.

MAIN OUTCOMES AND MEASURES

Hand function (Functional Index for Hand Osteoarthritis; 0-30) and pain (visual analog scale; 0-100 mm) were measured at week 6 (primary time point) and week 12. An α of .027 was used at week 6 to account for co-primary outcomes.

RESULTS

Of the 204 participants randomized, 195 (96%) and 194 (95%) completed follow-ups at 6 and 12 weeks, respectively; the mean (SD) age of the population was 65.6 (8.1) years, and 155 (76.0%) were female. At week 6, hand function improved significantly more in the intervention group than the comparator (between-group difference, -1.7 units; 97.3% CI, -2.9 to -0.5; P = .002). This trend was sustained at 12 weeks (-2.4 units; 95% CI, -3.5 to -1.3; P < .001). Pain scores improved similarly at week 6 (between-group difference, -4.2 mm; 97.3% CI, -11.3 to 3.0; P = .19). At week 12, pain reduction was significantly greater in the intervention group (-8.6 mm; 95% CI, -15.2 to -2.0; P = .01). There were 34 nonserious adverse events, all in the intervention group-mostly skin reactions and exercise-related pain exacerbations.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial of people with thumb base osteoarthritis, combined treatments provided small to medium and potentially clinically beneficial effects on hand function but not pain.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry Identifier: ACTRN12616000353493.

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.

The effects of hand splinting in patients with early-stage thumb carpometacarpal joint osteoarthritis: a randomized, controlled study

Background/aim

Evidence for the effectiveness of splinting in thumb carpometacarpal osteoarthritis is limited. We aimed to evaluate the effects of a prefabricated carpometacarpal metacarpophalangeal immobilization splint on pain, hand function, and hand strength in patients with early-stage thumb carpometacarpal osteoarthritis.

Materials and methods

Sixty-three hands with stage 1 or 2 thumb carpometacarpal osteoarthritis were enrolled in the study. The nonsplint group received oral information about how to accommodate daily activities. The splint group was given a prefabricated carpometacarpal metacarpophalangeal immobilization splint for 6 weeks. Pain was evaluated using the Australian/Canadian Osteoarthritis Hand Index (AUSCAN). Hand functions were evaluated using the AUSCAN and the Quick Disabilities of Arm, Shoulder and Hand (Q-DASH) questionnaire. Grip and pinch strengths were measured using a hydraulic dynamometer and a hydraulic pinch gauge.

Results

The AUSCAN pain, stiffness, function, total scores, and Q-DASH scores were significantly decreased in the splint group compared to the nonsplint group. Significant increments in grip and pinch strengths were detected in the splint group compared to the nonsplint group.

Conclusion

The prefabricated carpometacarpal metacarpophalangeal immobilization splint is effective in improving pain, hand function, and hand strength in patients with thumb carpometacarpal osteoarthritis.

Study of Medical Ultrasound for Rhizarthrosis (SUR): study protocol for a randomized controlled single-center pilot-trial

BACKGROUND

Rhizarthrosis (trapeziometacarpal osteoarthritis) is the second most common site of osteoarthritis in the hand affecting 10-30% of adults over the age of 50. Up to four times as many women as men have rhizarthrosis. Clinical symptoms include functional disability of the thumb, pain, joint swelling, and reduced strength. The first carpometacarpal joint is pivotal in the opposition of the thumb and allows a high degree in flexibility to humans. Current therapies focus mainly on surgical strategies, which should be considered in advanced, therapy-resistant stages to relieve pain and improve function. However, conservative treatment methods are urgently required in presurgical stages. The efficacy of conservative treatment options for rhizarthrosis, which are intended to preserve function, joint integrity and to relieve pain, has not been adequately studied. In the clinical study protocol presented here, we investigate the efficacy of multimodal hand therapy versus therapeutic ultrasound versus combination therapy with both hand therapy and therapeutic ultrasound.

METHODS

This study is a single-center, randomized, controlled, parallel-group pilot trial. One hundred fifty patients with rhizarthrosis and current disease activity will be randomized to one of three conservative interventions over 6 months. Interventions are (1) multimodal hand therapy (2) therapeutic ultrasound, and (3) combination therapy with both hand therapy and ultrasound therapy. The primary outcome measure is the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score after 6 months. Secondary endpoints are changes in pain, quality of life, disability progression, and changes of hand function. Safety will also be assessed.

DISCUSSION

Clinical data suggest that multimodal hand therapy may improve functionality and reduce pain in rhizarthrosis. Clinical data regarding therapeutic ultrasound are not available. Clinical evidence is lacking. This study is the first clinical study investigating the effects of multimodal hand therapy in direct comparison to therapeutic ultrasound and to a combination therapy with both hand therapy and ultrasound therapy for rhizarthrosis.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT04115085; Registered on September 30, 2019.

Conservative management of De Quervain's tendinopathy with an orthopedic manual physical therapy approach emphasizing first CMC manipulation: a retrospective case series

De Quervain's tendinopathy (DQT) is a musculoskeletal disorder that limits hand function of affected individuals. Management of DQT can include splinting, activity modification, medications, corticosteroid injections, physical therapist management, and surgery. There is limited evidence to support the combination of manual therapy and exercise interventions within an Orthopedic Manual Physical Therapy (OMPT) approach when managing patients with DQT. Three patients identified with DQT underwent a multi-modal treatment regimen including carpometacarpal (CMC) thrust and non-thrust manipulation, end range radiocarpal mobilization, mobilization with movement (MWM), strengthening exercises, and grip proprioception training. Outcomes were assessed using the numeric pain rating scale (NPRS), Jamar hand dynamometer grip strength, and the Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) questionnaire. These measures were administered at baseline and discharge. Each patient demonstrated improvements in all outcome measures and required ten visits or less to reach a satisfactory outcome. The NPRS improved by a mean of 7.1 points on a 0-10 scale, Quick DASH improved by an average of 37.1%, and grip strength improved by a mean of 27.6 pounds. Each patient was able to return to daily tasks without pain and all improvements were maintained at six month follow-up. An impairment based OMPT management approach was effective in managing three patients with DQT. The inclusion of first CMC manipulation within this multi-modal approach may enhance conservative management of patients with DQT. Because a cause and effect relationship cannot be inferred from a case series, further research is recommended to investigate the efficacy of this management approach.

Effect of immobilization of metacarpophalangeal joint in thumb carpometacarpal osteoarthritis on pain and function. A quasi-experimental trial

STUDY DESIGN

A quasi-experimental trial.

INTRODUCTION

Orthoses are effective to decrease pain and improve function in patients with carpometacarpal osteoarthritis (CMC OA). However, current research does not support one design of an orthosis as more effective and/or more favorable than another.

PURPOSE OF THE STUDY

The aim of this study was to compare the effectiveness of 2 different static orthosis on pain and functional abilities on CMC OA.

METHODS

Eighty-four patients, 91.7% females (mean ± standard deviation age, 60.1 ± 9.6 years), with thumb CMC OA were randomized into 1 of 2 groups. For group A, a Ballena orthotic was constructed, and for group B, a Colditz orthotic was constructed. Both static orthoses were worn for 3 months. The outcome measures included pain with activity measured with the visual analog scale and functional abilities assessed with the Disabilities of the Arm, Shoulder and Hand.

RESULTS

Both orthoses improved pain level and functional abilities (F_[1.0] = 413.327 and F_[1.0] = 211.742; both P < .001). There was no statistically significant difference between 2 groups regarding to pain recovery and functional improvement (F_[1.0] = 0.075 and F_[1.0] = 7.248; both P > .05).

DISCUSSION

The main purpose was to compare the effect of 2 different thermoplastic thumb orthoses. Previous studies support the use of CMC orthoses to decrease hand pain and improve hand function, but different orthoses have been described and in most cases, orthotic interventions were accompanied by other medical treatments.

CONCLUSIONS

A clinically significant reduction in pain intensity and improvement in functional abilities was achieved with both orthoses in patients with thumb CMC OA.

LEVEL OF EVIDENCE

2.

TRIAL REGISTRATION

ClinicalTrials.gov registration number: NCT02780999.

Effects of Neurodynamic Mobilizations on Pain Hypersensitivity in Patients With Hand Osteoarthritis Compared to Robotic Assisted Mobilization: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effectiveness of the neurodynamic mobilization techniques compared with passive robotic physiologic movement in patients with hand osteoarthritis (OA).

METHODS

We conducted a randomized controlled trial. A total of 72 patients (mean ± SD age 71 ± 11 years) with dominant symptomatic hand OA were randomized in 2 groups, and both received 12 treatment sessions over 4 weeks. The experimental group received neurodynamic mobilization of the median, radial, and ulnar nerves, and the control group received robotic-assisted passive movement treatment. Both groups also participated in a program of hand stability exercises. Outcome measures included pain intensity, pressure pain thresholds (PPTs), and strength measurements. Group-by-time effects were compared using mixed-model analyses of variance.

RESULTS

After the intervention, the experimental group had statistically significant, higher PPTs than the control group at the thumb carpometacarpal joint by 0.7 kg/cm² (95% confidence interval [95% CI] 0.6, 0.8), the median nerve by 0.7 kg/cm² (95% CI 0.6, 0.7), and the radial nerve by 0.5 kg/cm² (95% CI 0.3, 0.6); however, the difference was not statistically significant at 3 months postintervention. Although mean values in the experimental group were higher than in the control group at all PPT sites at both assessments, these differences were not statistically significant. The experimental group experienced a statistically significant reduction in pain immediately postintervention, but this was not present at the 3-month follow-up. There were no statistically significant differences in pinch or grip strength between groups.

CONCLUSION

We found that neurodynamic mobilizations decreased hypersensitivity in patients with hand OA immediately after the intervention; however, differences were no longer present at 3 months. The results suggest that these techniques may have some limited value in the short term but do not have lasting effects.

Outcome of a Hand Orthosis and Hand Therapy for Carpometacarpal Osteoarthritis in Daily Practice: A Prospective Cohort Study

PURPOSE

Initial treatment for symptomatic carpometacarpal (CMC) osteoarthritis (OA) of the thumb is usually nonsurgical. However, evidence on the effect of a hand orthosis and hand therapy for mid- and long-term results is limited, and it is unknown how many patients undergo additional surgical treatment. Therefore, the aim of this study is to describe the outcome of a hand orthosis and hand therapy for CMC OA in a large cohort study, and to evaluate the conversion rate to surgical treatment.

METHODS

In this multicenter, prospective cohort study, patients treated with a hand orthosis and hand therapy for primary CMC OA between 2011 and 2014 were included. Pain (visual analog scale) and function (Michigan Hand Questionnaire) were measured at baseline, 6 weeks, 3 months, and at 12 months after the start of treatment. All patients converted to surgery were recorded between 2012 and 2016. Outcome was compared with baseline, and post hoc comparisons were made between patients who were not converted to surgery and patients who were converted to surgery after initially receiving a hand orthosis and hand therapy. Lastly, subgroup analysis was performed based on baseline pain levels.

RESULTS

After a mean follow-up of 2.2 ± 0.9 years, 15% of all patients were surgically treated. In the group that was not converted to surgery, pain (visual analog scale) significantly improved from 49 ± 20 at baseline to 36 ± 24 at 12 months. The Michigan Hand Questionnaire score was essentially unchanged from 65 ± 15 at baseline to 69 ± 10 at 12 months. Post hoc testing showed that improvement in pain was only significant between baseline and 6 weeks, and thereafter stabilized until 1 year after the start of treatment. The group that converted to surgery did not show any improvement in pain and function at follow-up.

CONCLUSIONS

In this cohort of patients with thumb CMC OA who underwent hand therapy including an orthosis, 15% of the patients underwent additional surgical treatment. The patients (85%) who did not undergo surgery improved in pain and function, although only improvements in pain were significant and clinically relevant. Most improvement was seen in the first 6 weeks and stabilized till 1 year after the start of treatment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Efficacy and safety of non-pharmacological, pharmacological and surgical treatment for hand osteoarthritis: a systematic literature review informing the 2018 update of the EULAR recommendations for the management of hand osteoarthritis

To update the evidence on efficacy and safety of non-pharmacological, pharmacological and surgical interventions for hand osteoarthritis (OA), a systematic literature review was performed up to June 2017, including (randomised) controlled trials or Cochrane systematic reviews. Main efficacy outcomes were pain, function and hand strength. Risk of bias was assessed. Meta-analysis was performed when advisable. Of 7036 records, 127 references were included, of which 50 studies concerned non-pharmacological, 64 pharmacological and 12 surgical interventions. Many studies had high risk of bias, mainly due to inadequate randomisation or blinding. Beneficial non-pharmacological treatments included hand exercise and prolonged thumb base splinting, while single trials showed positive results for joint protection and using assistive devices. Topical and oral non-steroidal anti-inflammatory drugs (NSAIDs) proved equally effective, while topical NSAIDs led to less adverse events. Single trials demonstrated positive results for chondroitin sulfate and intra-articular glucocorticoid injections in interphalangeal joints. Pharmacological treatments for which no clear beneficial effect was shown include paracetamol, intra-articular thumb base injections of glucocorticoids or hyaluronic acid, low-dose oral glucocorticoids, hydroxychloroquine and anti-tumour necrosis factor. No trials compared surgery to sham or non-operative treatment. No surgical intervention for thumb base OA appeared more effective than another, although in general more complex procedures led to more complications. No interventions slowed radiographic progression. In conclusion, an overview of the evidence on efficacy and safety of treatment options for hand OA was presented and informed the task force for the updated European League Against Rheumatism management recommendations for hand OA.

Is a joint-specific home exercise program effective for patients with first carpometacarpal joint osteoarthritis? A critical review

Introduction

First carpometacarpal joint osteoarthritis is a common degenerative condition. The thumb has been reported to account for up to 50% of hand function and is functionally and biomechanically unique in the hand. To this end, it would seem appropriate that exercise programs for first carpometacarpal joint osteoarthritis would be specifically tailored to the thumb. However, this is not widely reflected in the literature. This review aimed to critically evaluate studies presenting primary evidence to determine whether a joint-specific exercise program is effective for patients with osteoarthritis in the first carpometacarpal joint.

Methods

Six electronic databases were searched for papers presenting primary data relating to home exercise programs that were specific to osteoarthritis in the first carpometacarpal joint. Methodological quality of included papers was evaluated using the Structured Effectiveness for Evaluation of Studies tool and levels of evidence were established based on National Health and Medical Research Council (NHMRC) guidelines. Qualitative analysis of the combined body of literature was performed and a recommendation generated and then graded according to NHMRC guidelines.

Results

Searching identified three relevant papers. Overall, methodological quality was moderate, with limitations primarily related to lack of power. Findings from the body of literature demonstrated considerable variation, but evidence to support specific thumb strengthening exercises was found. This provided an NHMRC Grade D level of recommendation.

Conclusions

It is recommended that future studies consider optimal frequency of strengthening exercises and the potential role of adductor pollicis release and passive carpometacarpal joint mobilization in home exercise programs for first carpometacarpal osteoarthritis.

The Ottawa Panel guidelines on programmes involving therapeutic exercise for the management of hand osteoarthritis

OBJECTIVE:

To identify programmes involving therapeutic exercise that are effective for the management of hand osteoarthritis and to provide stakeholders with updated, moderate to high-quality recommendations supporting exercises for hand osteoarthritis.

METHODS:

A systematic search and adapted selection criteria included comparable trials with exercise programmes for managing hand osteoarthritis. Based on the evaluated evidence, a panel of experts reached consensus through a Delphi approach endorsing the recommendations. A hierarchical alphabetical grading system (A, B, C+, C, C-, D-, D, D+, E, F) was based on clinical importance (≥15%) and statistical significance ( P < 0.05).

RESULTS:

Ten moderate- to high-quality studies were included. Eight studies with programmes involving therapeutic exercise (e.g. range of motion (ROM) + isotonic + isometric + functional exercise) seemed to be effective. Forty-six positive grade recommendations (i.e. A, B, C+) were obtained during short-term (<12 weeks) trials for pain, stiffness, physical function, grip strength, pinch strength, range of motion, global assessment, pressure pain threshold, fatigue and abductor pollicis longus moment and during long-term (>12 weeks) trials for physical function and pinch strength.

CONCLUSION:

Despite that many programmes involving exercise with positive recommendations for clinical outcomes are available to healthcare professionals and hand osteoarthritis patients that aid in the management of hand osteoarthritis, there is a need for further research to isolate the specific effect of exercise components.

The effectiveness of physical therapies for patients with base of thumb osteoarthritis: Systematic review and meta-analysis

BACKGROUND

Trapeziometacarpal osteoarthritis (known as base of thumb OA) is a common condition causing pain and disability worldwide.

OBJECTIVE

The purpose of this review was to evaluate the effectiveness of multimodal and unimodal physical therapies for base of thumb osteoarthritis (OA) compared with usual care, placebo or sham interventions.

DESIGN

Systematic review and meta-analysis.

METHOD

We searched MEDLINE (PubMed), CINAHL, Embase, AMED, PEDro, Cochrane Database of Systematic Review, Cochrane Register of Controlled Trials (CENTRAL) from inception to May 2017. Randomized controlled trials involving adults comparing physical therapy treatment for base of thumb OA with an inactive control (placebo or sham treatment) and reported pain, strength or functional outcomes were included. Meta-analyses were performed where possible. Methodological risk of bias was assessed with the Cochrane Risk of Bias tool.

RESULTS

Five papers with low risk of bias were included. Meta-analyses of mean differences (MD) with 95% confidence intervals (95% CI), were calculated for between-group differences in point estimates at 4 weeks post-intervention. Multimodal and unimodal physical therapies resulted in clinically worthwhile improvements in pain intensity (MD 2.9 [95% CI 2.8 to 3.0]; MD 3.1 [95% CI 2.5 to 3.8] on a 0-10 scale, respectively). Hand function improved following unimodal treatments (MD 6.8 points [95% CI 1.7 to 11.9)] on a 0-100 scale) and after a multimodal treatment (MD 20.5 (95%CI -0.7 to 41.7).

CONCLUSIONS

High quality evidence shows unimodal and multimodal physical therapy treatments can result in clinically worthwhile improvements in pain and function for patients with base of thumb OA.

The knitting community-based trial for older women with osteoarthritis of the hands: design and rationale of a randomized controlled trial

BACKGROUND

The prevalence of hand osteoarthritis (HOA) has been reported to be higher amongst women over 50 years old (66%) compared to men of the same age (34%). Although exercise therapy has been shown effective in reducing symptoms and disability associated with HOA, adherence to treatment programs remains low. The primary objective of this RCT is to examine the effectiveness of a 12-week knitting program for morning stiffness (primary outcome) and pain relief (secondary outcome) 2 h post-wakening in females (aged 50 to 85 years old) with mild to moderate hand osteoarthritis (HOA).

METHODS/DESIGN

A single-blind, two-arm randomized controlled trial (RCT) with a parallel group design will be used to reach this objective and compare results to a control group receiving an educational pamphlet on osteoarththritis (OA) designed by the Arthritis Society. The premise behind the knitting program is to use a meaningful occupation as the main component of an exercise program. The knitting program will include two components: 1) bi-weekly 20-min knitting sessions at a senior's club and 2) 20-min home daily knitting sessions for the five remaining weekdays. Participants assigned to the control group will be encouraged to read the educational pamphlet and continue with usual routine. Pain, morning stiffness, hand function, self-efficacy and quality of life will be measured at baseline, six weeks, 12 weeks (end of program) with standardized tools. We hypothesize that participants in the knitting program will have significant improvements in all clinical outcomes compared to the control group. A published case study as well as the preliminary results of a feasibility study as examined through a 6-week pre-post study (n = 5 women with HOA) involving 20-min daily knitting morning sessions led to this proposed randomized controlled trial research protocol. This article describes the intervention, the empirical evidence to support it.

DISCUSSION

This knitting RCT has the potential to enhance our understanding of the daily HOA symptoms control and exercise adherence, refine functional exercise recommendations in this prevalent disease, and reduce the burden of disability in older women.

TRIAL REGISTRATION

(ACTRN12617000843358) registered on 7/06/2017.

The Effectiveness of Neural Mobilization for Neuromusculoskeletal Conditions: A Systematic Review and Meta-analysis

Study Design Systematic review with meta-analysis. Objectives To determine the efficacy of neural mobilization (NM) for musculoskeletal conditions with a neuropathic component. Background Neural mobilization, or neurodynamics, is a movement-based intervention aimed at restoring the homeostasis in and around the nervous system. The current level of evidence for NM is largely unknown. Methods A database search for randomized trials investigating the effect of NM on neuromusculoskeletal conditions was conducted, using standard methods for article identification, selection, and quality appraisal. Where possible, studies were pooled for meta-analysis, with pain, disability, and function as the primary outcomes. Results Forty studies were included in this review, of which 17 had a low risk of bias. Meta-analyses could only be performed on self-reported outcomes. For chronic low back pain, disability (Oswestry Disability Questionnaire [0-50]: mean difference, -9.26; 95% confidence interval [CI]: -14.50, -4.01; P<.001) and pain (intensity [0-10]: mean difference, -1.78; 95% CI: -2.55, -1.01; P<.001) improved following NM. For chronic neck-arm pain, pain improved (intensity: mean difference, -1.89; 95% CI: -3.14, -0.64; P<.001) following NM. For most of the clinical outcomes in individuals with carpal tunnel syndrome, NM was not effective (P>.11) but showed some positive neurophysiological effects (eg, reduced intraneural edema). Due to a scarcity of studies or conflicting results, the effect of NM remains uncertain for various conditions, such as postoperative low back pain, cubital tunnel syndrome, and lateral epicondylalgia. Conclusion This review reveals benefits of NM for back and neck pain, but the effect of NM on other conditions remains unclear. Due to the limited evidence and varying methodological quality, conclusions may change over time. Level of Evidence Therapy, level 1a. J Orthop Sports Phys Ther 2017;47(9):593-615. Epub 13 Jul 2017. doi:10.2519/jospt.2017.7117.

Systematic review of non-surgical therapies for osteoarthritis of the hand: an update

OBJECTIVE

To update our earlier systematic reviews which evaluated all published randomized controlled trials (RCTs) evaluating pharmacological and non-pharmacological therapies in patients with hand osteoarthritis (OA). Surgical therapies were not evaluated.

DESIGN

RCTs published between March 2008 and December 2015 were added to the previous systematic reviews.

RESULTS

A total of 95 RCTs evaluating various pharmacological and non-pharmacological therapies in hand OA were analyzed in this update. Generally, the methodological quality of these RCTs has improved since the last update, with more studies describing their methods for randomization, blinding, and allocation concealment. However, RCTs continue to be weakened by a lack of consistent case definition and a lack of standardized outcome assessments specific to hand OA. The number and location of evaluated hand joints continues to be underreported, and only 25% of RCTs adequately described the method used to ensure allocation concealment. These remain major weaknesses of published RCTs. A meta-analysis could not be performed because of marked study heterogeneity, insufficient statistical data available in the published RCTs, and a small number of identical comparators.

CONCLUSION

Hand OA is a complex area in which to study the efficacy of therapies. There has been an improvement in the overall design and conduct of RCTs, however, additional large RCTs with a more robust methodological approach specific to hand OA are needed in order to make clinically relevant conclusions about the efficacy of the diverse treatment options available.

Neural manual vs. robotic assisted mobilization to improve motion and reduce pain hypersensitivity in hand osteoarthritis: study protocol for a randomized controlled trial

[Purpose] The aim of the present study is to detail the protocol for a randomised controlled trial (RCT) of neural manual vs. robotic assisted on pain in sensitivity as well as analyse the quantitative and qualitative movement of hand in subjects with hand osteoarthritis. [Subjects and Methods] Seventy-two patients, aged 50 to 90 years old of both genders, with a diagnosis of hand Osteoarthritis (OA), will be recruited. Two groups of 36 participants will receive an experimental intervention (neurodynamic mobilization intervention plus exercise) or a control intervention (robotic assisted passive mobilization plus exercise) for 12 sessions over 4 weeks. Assessment points will be at baseline, end of therapy, and 1 and 3 months after end of therapy. The outcomes of this intervention will be pain and determine the central pain processing mechanisms. [Result] Not applicable. [Conclusion] If there is a reduction in pain hypersensitivity in hand OA patients it can suggest that supraspinal pain-inhibitory areas, including the periaqueductal gray matter, can be stimulated by joint mobilization.

Evidence-Based Medicine: Thumb Basal Joint Arthritis

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Assess the patient's history, clinical examination, and radiographic findings to diagnose and stage basilar joint arthritis. 2. Recall the cause and epidemiology of the condition. 3. Formulate a management plan including nonoperative management, and evaluate the candidacy for surgical treatment. 4. Understand the rationale for the various surgical options available (including rehabilitation), their potential complications, and the evidence related to outcomes.

SUMMARY

This article has been prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is designed for clinicians to analyze and structure their care of a patient with arthritis of the trapeziometacarpal joint.