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

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

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

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

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

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.

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.

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.

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

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

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.

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.

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

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

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.

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

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)

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) 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

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

Results Complications Radial sensory nerve numbness Scar tenderness RSD

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

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