1. Therapy Following Thumb CMC Joint Arthroplasty
Louise Kelly, M.Sc., OT Reg. (Ont), CHT

2. Surgical Procedures Distraction Arthroplasty. Kuhns, 2003
Silicone Arthroplasty
Ligamentous Reconstruction Tendon Interposition (LRTI)
Trapeziectomy- hemi or complete
Trapezio-metacarpal Arthrodesis

3. Therapy 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

4. Literature 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

5. Post-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

6. Splint
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.

7. Exercise 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.

9. Exercise
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.

10. Exercise TWH: Week 6- PROM wrist and thumb joints. Variations:
Week 7-8, Poole and Pellegrini,
isometrics for thumb,
thumb setting
opposition

11. Exercise
Variations:
Brach, Week 5- AROM thumb opposition and composite flexion.

12. Strengthening 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.

13. Activity 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.

14. Modalities TWH: Scar Management massage silicone gel inserts
desensitization, including immersion, contact and fluidotherapy
Edema Management
coban
isotoner glove

15. Complications Prolonged post-op pain CRPS Hypersensitivity of scar
Palmar fasciitis

16. Outcomes
Aggregate grip and pinch strength 20% improvement at 2 years post surgery with continued improvement to 6 years.
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.

17. Summary 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

18. Literature Review for CMC Joint Arthroplasty
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)

19. 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

20. Literature Review (Cont’d)
Follow up 12 months to 9 years
Results
Complete pain relief %
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

21. Results Satisfaction related to pain relief
Self reported ADL better than observed performance on Jebsen
Moberg, no difficulties
Radiographic changes included subsidence, subluxation

22. Results Complications Radial sensory nerve numbness Scar tenderness
RSD

23. Results 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

24. Recommendations More prospective studies
Use of standardized functional performance tests
Use standardized protocol for measuring ROM and strength