Therapy Following Thumb CMC Joint Therapy Following Thumb CMC Joint ArthroplastyArthroplasty

Louise Kelly, M.Sc., OT Reg. (Ont), CHT

Surgical ProceduresSurgical Procedures

• Distraction Arthroplasty. Kuhns, 2003

• Silicone Arthroplasty

• Ligamentous Reconstruction Tendon Interposition (LRTI)

• Trapeziectomy- hemi or complete

• Trapezio-metacarpal Arthrodesis

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

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

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

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.

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.

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.

ExerciseExercise

TWH:

Week 6- PROM wrist and thumb joints.

Variations:

Week 7-8, Poole and Pellegrini,

isometrics for thumb,

thumb setting

opposition

ExerciseExercise

Variations:

Brach, Week 5- AROM thumb opposition and composite flexion.

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.

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.

ModalitiesModalities

TWH:

Scar Management

massage

silicone gel inserts

desensitization, including immersion, contact and fluidotherapy

Edema Management

coban

isotoner glove

ComplicationsComplications

• Prolonged post-op pain

• CRPS

• Hypersensitivity of scar

• Palmar fasciitis

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.

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

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)

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

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

ResultsResults

– Satisfaction related to pain relief

– Self reported ADL better than observed performance on Jebsen

– Moberg, no difficulties

– Radiographic changes included subsidence, subluxation

ResultsResults

• Complications

– Radial sensory nerve numbness– Scar tenderness– RSD

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

RecommendationsRecommendations

• More prospective studies

• Use of standardized functional performance tests

• Use standardized protocol for measuring ROM and strength