Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Thumb Arthritis or “Just Thumb Pain”: Achieving a Pain Free Stable Thumb Virginia O'Brien, OTD, OTR/L, CHT Philadelphia 2017 Disclosures Virginia O’Brien, OTD, OTR/L, CHT • No relevant personal financial relationships • Editor, Caring for the Painful Thumb 2nd and 3rd ed. 2 Conservative Management of the Painful Thumb is a CHALLENGE! Teamwork is Important Person –Therapist –Doctor – Family 8 Finding the Source of Thumb Pain is like “Getting into the Weeds” Can You find the Deer? 9 Varieties of Thumb Pain • Trigger thumb • Sprained thumb • Ligament laxity of IP, MCP and CMC • Hypermobility Syndrome vs. Ehler-Danlos Syndrome • Fractures at each joint • Neurologic injuries which cause pain: localized or referred • Systemic Diseases which affect each joint: RA, OA, lupus, scleroderma 10 3 Important Points for a Stable Thumb…. 1. The thumb webspace: Keep it SUPPLE 2. Use of ALL thumb motors to Stabilize and Centralize the 1st metacarpal as it moves on the trapezium. 3. Educate the person to stabilize their own thumbs for a lifetime. Watch for these points throughout the presentation 11 Why is the human thumb at risk for pain? Is it because there is only a 35 year warranty on the 1st CMC joint ? What is the mystery of dynamic stability for the CMC joint? Can something be done about it ? YES! Keep in mind…… no two thumbs (painful or not) are alike. It is our job as therapists to partner with our patients and the referring physicians to understand causes of thumb pain, and to design and teach effective interventional programs. Carpometacarpal (CMC) joint Loose capsule Joint surfaces are not congruent Stability from soft tissues Ligamentous support Muscular support 23 • Controls the extent and direction of joint motion Helps maintain normal alignment of the joint Helps control and dissipate forces produced by activated muscles • • Extrinsic muscles Intrinsic muscles • • (Brand & Hollister, 1993) (Hagert, Lee, & Ladd, 2012) (Magnusson, Rosenstein, O’Brien, Nuckley, Adams, 2014) Volar CMC Stabilizing Ligaments Left Hand Intermetacarpal Ligament (not shown) Ulnar Collateral Anterior Oblique Ligament • Superficial • Deep (arrows) (Ladd, Lee and Hagert, 2012, Figure 3) 25 Volar CMC Stabilizing Ligaments (L) Intermetacarpal Ligament Anterior Oblique Ligament • Superficial • Deep Ulnar Collateral Courtesy of Anatomy Softwear Gloves™ by Pat McKee 26 Dorsal CMC Stabilizing Ligaments Right hand (Posterior/Dorsal) Intermetacarpal ligament First dorsal trapeziometarpal ligament Dorsal deltoid ligament complex: 1. Dorsal radial ligament 2. Dorsal central/collateral ligament 3. Posterior oblique ligament APL Ladd, Lee and Hagert, 2012, Figure 4 29 Stout deltoid-like CMC dorsoradial ligament structure -Joint instability ALONE may not be the primary etiological factor in development of OA of CMC. -Dynamic proprioceptive function of the joint is subject of continuing studies (Ladd et al. 2013) (Ladd et al. 2014) (Hagert et al. 2012) (Hallilaj et al. 2015) Green: DorRadLig; Orange: DColLig; Magenta: PostOblLig; APL: red 31 CMC Ligamentous Proprioception • Mechanoreceptors found in CMC ligaments (as in shoulder, wrist, knee and ankle) • Pacinian corpuscles: rapidly adapting, activated by joint compression and sudden perturbations* • Ruffini end organs: slowly adapting and constantly active, sensitive to axial stress and tensile strains RUFFINI END ORGANS IN CMC DRL (Hagert & Ladd, 2012) 32 Articular Cartilage • Avascular and aneural • Nutrition from synovial fluid and from subchondral bone • Movement necessary for joint nutrition • Joint motion increases synovial blood flow, circulates synovial fluid, increases penetration of solutes (Brandt et al. 2008) (Wang et al. 2012) The Thumb Column • Has 4 joints • 60-80 degree angle between 1st and 2nd MCs • wide arc of CMC motion Interphalangeal Metacarpophalangeal IP MP 60-80⁰ Carpometacarpal Scaphotrapezial (Kapandji, 1982) CMC ST Two theories to explain the “apparent” rotation of the thumb producing pronation and supination The trapezium is like the saddle on a scoliotic horse. The CMC joint is like a Universal Joint Movement in 2 planes at right angles (Brand & Hollister, 1993) (Kapandji, 1982) Know Your Thumb Muscles: Extrinsics • Extensor Pollicis Longus • Extensor Pollicis Brevis • Abductor Pollicis Longus • Flexor Pollicis Longus 40 Know your Thumb Muscles: Intrinsics • Abductor Pollicis Brevis • Flexor Pollicis Brevis – deep and superficial heads • Opponens Pollicis (Deep) • AFO-acronym to remember the Thenars • Adductor Pollicis •First Dorsal Interosseous! 48 Muscles that influence the Thumb 9 muscles influence the thumb We have a big job to help our patients with their thumbs!!!! Thumb is 70% of the dominant hand, 60% of the non-dominant hand (Disability ratings) Accessed at: militarydisabilitymadeeasy.com 49 SO, Is the Position of Habit… … A cause of more than just Osteoarthritis? • Could poor muscle motor patterns, tight web space structures, ligamentous hypo- or hypermobility be a cause of: • Trigger thumb? • Cascading OA from CMC to MP and IP? • Ulnar Collateral Ligament strain/overstretching? 67 Hypermobility Lax ligaments (and maybe weak intrinsics) allow dorsal translation of metacarpal on trapezium, further stretching the already lax ligaments Chronic ligamentous instability alters proprioceptive input, decreasing awareness of thumb posture (Van Heest & Kallemeier, 2008) Moulton’s research Moulton showed MP flexion of 30° 30º moves contact area on the trapezium more dorsally, unloading the volar articular surface Achieving this position during functional activity is important May require an orthosis with MCP ext. block temporarily (Moulton et al., 2001) (Mobargha et al. 2015) The multidirectional pull of these muscles: Opponens Sesamoids First Dorsal Interosseous Adductor Abductor Brevis Flexor Brevis Abductor Pollicis Longus Opponens Abductor Longus Extensor Pollicis Brevis 3/13/2017 79 3/13/2017 Potential De-Stabilizers Dynamic Stabilizers 80 First Dorsal Interosseous Adductor Pollicis Opponens (Deep) Abductor Pollicis Brevis (Superficial) 81 Effects of Exercise, Orthoses & Joint Protection Education Evidence Based/Informed Practice • Reduction in Pain & Improvement in Function • No consensus for which orthosis is best • No consensus (YET) for which exercises are best • Little is known about dosage of exercise for the small muscles of the hand (ACSM 2011) • EULAR and ACR recommend Exercises & Orthoses • 1st Dorsal Interosseous is emerging as a key muscle for thumb stability Magnuson et al. 2016, McGee et al. 2015, Dziedzic et al. 2011, Boudreau 2010, Stamm et al. 2002, Wajon 2000, Swigart 1999. 83 Evidence for 1st DI in Thumb Stability • Radiological subluxation reduction in 2 cadaver studies, with 1st DI and OP together (O’Brien et al.2016) • Radiological subluxation reduction with 1st DI maximal voluntary contraction in young subjects without CMC OA (McGee et al. 2015) • 1stDI counteracts CMC dorsoradial imbalance and malalignment (Mobargha et al. 2015) • In a population study, in persons > 50 yrs, the 1st DI strength was a strong predictor of thumb pain (Swan et al. 2015) Insert new CMC picture of 1st DI 95 Conclusions: 2 cadaver studies • Concomitant activation of 1st DI and OP and OP alone reduce radiographic subluxation. • OP as predominant reducing force • OP and 1st DI+OP activation reduce subluxation in a dose dependent manner. • Hand therapy may improve pain and function by reducing subluxation with activation of 1st DI and OP. (O’Brien et al. 2016) 96 Doesn’t the thumb deserve the same amount of attention therapists have given to shoulder problems? T H I N K It is time to Fine Tune Conservative Management to treat functional impairment caused by Thumb Pain 99 Dynamic Stability for the Painful Thumb Conservative Management Program 100 3 Important Points for a Stable Thumb…. 1. The thumb webspace: Keep it SUPPLE 2. Use of ALL thumb motors to Stabilize and Centralize the 1st metacarpal as it moves on the trapezium. 3. Educate the person to stabilize their own thumbs for a lifetime. Watch for these points throughout the presentation 101 What is Different about Dynamic Thumb Stability Intervention? Innovative techniques that go beyond Pinch strengthening Orthotics - Joint Protection - Adaptive Equipment Exercises that first mobilize and then stabilize the thumb – which do not involve painful pinching Re-education of specific muscles which assist in thumb stabilization is a key element Pain modification techniques Strategy to wean from an orthosis, if able 102 How does Pain affect Learning in Musculoskeletal Rehab? Pain can hinder learning of new motor skills at the cortical level Novel motor skill training should be presented at the first sign of pain to prevent poor motor patterns Can protect “pain associated cortical changes” Strength training does not achieve the same effect as motor-skill training Encourage a cognitive/conscious effort This is the first step to skill level performance Quality vs. quantity when beginning skill development (Boudreau, Farina, & Falla, 2010) NeuroMuscular Science 104 OBSERVE: WHAT DO YOU SEE? 114 What if the thumb appears NORMAL? 115 Compare Hands Palmar Abduction Radial Abduction And in every area of the evaluation - Manual release of the adductor and any over-active, dominant muscle - Joint mobilization to reduce / realign the CMC - Muscle re-education / strengthening - Use of adaptive tools and joint protection techniques - Orthosis/Orthoses as needed - Strategy to wean from orthosis With respect for pain at each step Manual Release Adductor: One of the strongest muscle per square measure in the body. Manual release of this muscle increases the potential ROM of the thumb lost due to web space contracture. Helps to “set the stage” to gain congruency of joint surfaces for the next portions of the exercise program. Manual Release Adductor Muscle Release is the KEY ContractRelax release Myo-Fascial or “Tender Point” release VIDEO Release of soft tissues in the web space VIDEO 157 Joint Mobilization Initiated after Manual Release (adductor release) and soft tissue elongation ....... AND before muscle re-education* Approximates the joint surfaces (centralizes MC on Trapezium), helps improve motion and the production of nutritional substances in the joint. Joint mobilization of the thumb column restores stable thumb biomechanics, and reduces pain. * Must be done pain free!!! (Villafane, Silva, Diaz-Perreno & Fernandez-Carnero, 2011) Distraction is the first level (grade I) of joint mobilization Opens joint spaces, relieves pain & increases nutrition Grasp the base of involved thumb, hold arms behind back The weight of the arms provides distraction If this position causes pain in shoulders, bring arms in front of body, relax, and bring elbows back to distract the CMC joint In both photos, the subject’s RIGHT CMC is being distracted Hands behind body... ..or in front Self-Joint Mobilization Retropulsion VIDEO Must be PAIN-FREE: restores Retropulsion, improves CMC/STT glide (Villafañe, Silva, Diaz-Perreno & Fernandez-Carnero, 2011) Joint Mobilization With a “Skull Rock” Place opposite thumb in webspace Roll hand back and forth Grasp thumb Then move arm forward and back METHOD ONE METHOD TWO Feels a little uncomfortable, but feels better later. VIDEO (Villafañe, Silva, Diaz-Perreno & Fernandez-Carnero, 2011) 165 Check Retropulsion: Better? 4 3 2 1 Progress noted on opposite palmar MCP joints (Kapandji, 1992) 167 Muscle Re-education first before Strengthening Re-education of the thumb muscles to restore stable balance Focus: Abductor Pollicis Brevis Opponens Pollicis 1st Dorsal Interosseous Extensor Pollicis Brevis Abductor Pollicis Longus Flexor Pollicis Brevis Isolate the Abductor and Opponens Closed Chain Exercise Make the thumb puppet sing VIDEO Isometric and Isotonic Muscle Re-education of palmar abduction The CMC joint is most stable in the “C” position Note the rubber band placement on the metacarpal This exercise is done pain free Isolate the Extensor Pollicis Brevis VIDEO 2/18/17 173 EPB: Home Program Keep the middle thumb knuckle lifted, making an arch! 176 VIDEO 1st Dorsal Interosseous Exercise 2 1 Rubber Band Exercise: Abduct the Index away from the Middle Finger NEW GOAL: 100 repetitions per day??? 3 182 Start with a thinner rubber band: First at P1 IF. Lift finger up and down slowly and smoothly. ISOKINETIC: Concentric/eccentric Thumb Stability Exercises: Using a Rubber Band To progress, advance RB distally Advance to thicker RB, and repeat the on IF, toward P2 and P3: PAINsame progression. FREE ONLY. DOSE: 10 reps 2-3 sets/session GOAL: 100 x / day !!???!!??!! 183 184 Rubber-band Variations to re-educate and strengthen stabilizing muscles VIDEO 184 “Piano playing” to strengthen (isometric to isotonic) Extensor Pollicis Brevis Abductor Pollicis Longus Abductor Pollicis Brevis Opponens Pollicis AND the 1st Dorsal Interosseous Abduct without losing the MP flexion posture The thumb CMC joint is at risk! Once you have been strengthening this most important muscle, the 1st dorsal interosseous, then it is important you learn to “fire” it when you are using your hand to stabilize your thumb in daily tasks. For the patient who has a very unstable CMC, performing 1st DI strengthening may be painful initially. External support with cocontraction of the “C” position, manual support of the metacarpal, or performing exercise with orthotic support at the CMC may be needed. If the program is unsuccessful in stabilizing the CMC and relieving pain, surgical options may be a consideration. Practice Dynamic Thumb Stability Intervention • Web Space release & Stretch: Palmar & Radial Abduction • Achieve a C position, Isometric and Isotonic • Perturbate that C position • 1st Dorsal Interosseous: Feel the Stability of thumb when it is activated • 1st DI: AROM, Isometric, Isotonic, and then during FUNCTION • Feel the Opponens work with the 1st DI • How will you begin using this for ALL your thumb patients? 189 Equipment to “unload” thumbs What about an Orthosis? • Design or select according to need • For activity or rest (may need both) • Immobilize? Stabilize? • Reduce deformity • An uncomfortable orthosis is useless! Plan to wean from an orthosis Manual release of the adductor and any overactive, dominant muscle Joint mobilization to reduce / realign the CMC Muscle re-education / strengthening Use of adaptive tools and joint protection techniques Orthosis/Orthoses as needed Did you Learn 3 Important Points for Stable Thumb…. 1. The thumb webspace: Keep it SUPPLE 2. Use of ALL thumb motors to Stabilize and Centralize the 1st metacarpal as it moves on the trapezium. 3. Educate the person to stabilize their own thumbs for a lifetime. Keep up the Good Work for your thumbs and those of your patients. 221 “No two thumbs are alike.” -Jan Albrecht It’s NOT about an Orthosis (Splint)! It is about Dynamic Stability! 222 In Remembrance: Jan Albrecht (1935-2016) OT & Hand Therapist Extraordinaire • Jan Albrecht, OTR, CHT (1991-2011) • She discovered the power of dynamic thumb stability for her own painful thumb • Used her passion and commitment to teach others: patients, therapists, and physicians 223 Questions ? Virginia O’Brien [email protected] 224