Download joint - Hand Rehabilitation Foundation

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
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•
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]
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