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Therapy Following Thumb CMC Joint Therapy Following Thumb CMC Joint ArthroplastyArthroplasty
Louise Kelly, M.Sc., OT Reg. (Ont), CHT
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Surgical ProceduresSurgical Procedures
• Distraction Arthroplasty. Kuhns, 2003
• Silicone Arthroplasty
• Ligamentous Reconstruction Tendon Interposition (LRTI)
• Trapeziectomy- hemi or complete
• Trapezio-metacarpal Arthrodesis
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Therapy Post CMC Joint ArthroplastyTherapy Post CMC Joint Arthroplasty
• Goals of treatment– Maintain thumb webspace– Maximize thumb ROM– Decrease pain and sensitivity– Strengthen the thumb– Return to usual daily functioning
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Literature on Therapy ManagementLiterature on Therapy Management
1. Poole and Pellegrini
Journal of Hand Therapy, 2000
2. Roberts, Jabaley and Nick
Journal of Hand Therapy, 2001
3. Brach
Hand Surgery Quarterly, 2003
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Post-op ImmobilizationPost-op Immobilization
TWH protocol:Forearm based POP, thumb IP joint free, 3-4 weeks.
Variations:Poole and Pellegrini, thumb IP included, 4 weeks.Roberts et. al., bivalve, thumb IP free. Ulnar portion discontinued at 10 days, radial gutter to 3 weeks
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SplintSplint
TWH:
Forearm based thumb spica with IP free. Start weaning off at 6 weeks.
Variations:
Poole and Pellegrini, splint as above for 3 months.
Brach, as above, thumb in maximum abduction. Wean off 8-10 weeks.
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ExerciseExercise
TWH:
Week 3-4, AROM wrist and thumb within pain limits.
Variations:
Poole and Pellegrini, Week 5-AROM wrist and thumb MCP and IP. Block basal joint.
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ExerciseExercise
Variations:
Roberts et. al., Week 3- AROM wrist and thumb, 3-4 times daily.
Brach, Week 4- wrist and thumb MCP and IP AROM. Home program includes isometrics for thumb abduction and extension performed in the splint.
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ExerciseExercise
TWH:
Week 6- PROM wrist and thumb joints.
Variations:
Week 7-8, Poole and Pellegrini,
isometrics for thumb,
thumb setting
opposition
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ExerciseExercise
Variations:
Brach, Week 5- AROM thumb opposition and composite flexion.
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StrengtheningStrengthening
TWH:
Week 6- grip and pinch strengthening, therapyputty.
Variations:
Poole and Pellegrini, not till week 9.
Roberts et. al., isometrics and active resisted.
Brach, gripping at week 8.
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Activity LevelActivity Level
TWH:
Light activity started at week 6. Increase within patient’s tolerance.
Variations:
Roberts et. al., Week 3- light activity initiated.
All:
Unrestricted work and activity permitted 4 to 6 months.
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ModalitiesModalities
TWH:
Scar Management
massage
silicone gel inserts
desensitization, including immersion, contact and fluidotherapy
Edema Management
coban
isotoner glove
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ComplicationsComplications
• Prolonged post-op pain
• CRPS
• Hypersensitivity of scar
• Palmar fasciitis
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OutcomesOutcomes
1. Aggregate grip and pinch strength 20% improvement at 2 years post surgery with continued improvement to 6 years.
2. Grip, pinch, self reported ADL and pain all improved significantly at mean follow up of 1 year, 11 months. Patients did not reach maximum improvement until second year.
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Summary of Key Points for TherapySummary of Key Points for Therapy
• Splint should position the thumb in maximum abduction
• Avoid CMC joint motion in initial weeks of treatment
• Avoid lateral pinch in first month of therapy, modify pinch activities later
• Desensitize scar if necessary• Educate patient regarding time frame for
outcomes
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Literature Review for CMC Joint Literature Review for CMC Joint ArthroplastyArthroplasty
• 14 articles reviewed, 1986 to 2003, numerous procedures described
• 12 retrospective; 2 prospective ( Hematoma and Distraction Arthroplasty, Kuhns, 2003; Swanson vs APL arthroplasty, Tagil & Kopylov, 2002)
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Literature Review (Cont’d)Literature Review (Cont’d)
• Outcomes evaluated– Pain– ROM– Satisfaction– Grip strength– Tip pinch strength– Key/lateral pinch strength– Radiographic changes– Jebsen– Moberg pick up test– Purdue Peg Board– ADL- self report– AIMS
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Literature Review (Cont’d)Literature Review (Cont’d)
• Follow up 12 months to 9 years
• Results– Complete pain relief 73-97%– Significant post op pain up to 26%– Heavy work painful 50% – ROM similar to non-operated hand– Grip improved more than pinch, equal to non-
operated hand
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ResultsResults
– Satisfaction related to pain relief
– Self reported ADL better than observed performance on Jebsen
– Moberg, no difficulties
– Radiographic changes included subsidence, subluxation
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ResultsResults
• Complications
– Radial sensory nerve numbness– Scar tenderness– RSD
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ResultsResults
• Better in age 60 and over
• Gains in ROM first
• Continued improvement in pain relief and strength from 2 to 6 years
• Loss of key pinch after 6 years
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RecommendationsRecommendations
• More prospective studies
• Use of standardized functional performance tests
• Use standardized protocol for measuring ROM and strength