Characterizing response to a dynamic stability modeled approach for thumb carpometacarpal joint pain: A retrospective study.

STUDY DESIGN: Retrospective case series. INTRODUCTION: Literature trends indicate that thumb dynamic stabilization may benefit clients with thumb carpometacarpal (CMC) joint pain and arthritis. There is minimal research investigating whether client characteristics predict responsiveness to hand therapy for thumb dynamic stabilization. PURPOSE OF THE STUDY: 1) To investigate how adults with thumb CMC joint pain responded to a hand therapy dynamic stabilization modeled intervention. 2) To determine if various client factors influenced responsiveness and to what extent. METHODS: An electronic medical record search identified adults treated from August 2009 through December 2015 for thumb CMC joint pain. Radiographs were retrospectively staged. Outcome measures were 1) Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) total disability score and 2) Numerical Pain Rating Scale (NPRS). Paired t-tests were performed to compare pre and post treatment measures. Multivariate analyses were used to investigate predictive factors. RESULTS: A total of 249 charts were analyzed. Large overall significant effects were noted for disability score (QuickDASH P <.001, X = 12.1, Cohen's d = 0.9). The average improvement of 2.1 (SD = 2.6) points exceeded the minimal clinically important difference (MCID) of 1.7 points on the NPRS pain scale. Significant predictors of QuickDASH Scores were radiographic staging, bilateral hand involvement and initial pain ratings. Significant predictors for change in pain scores (meeting or exceeding the minimal clinically important difference for the NPRS) were bilateral thumb involvement and initial "pain at worst" rating. CONCLUSION: After completing hand therapy with a dynamic stabilization approach, clients had less pain and disability. Those who had unilateral thumb pain, or those who started with higher pain levels were most likely to have clinically meaningful improvements in pain. Clients in early CMC osteoarthritis (OA) stages responded better than those in later stages, indicating that early referral to therapy is important.

Current uses of botulinum toxin A as an adjunct to hand therapy interventions of hand conditions.

STUDY DESIGN: Literature review. DISCUSSION: Botulinum toxin A, a neurotoxin causing temporary muscle paralysis at the neuromuscular junction, has been used to treat multiple acquired conditions of the hand and upper extremity. Initially approved for use in treating blepharospasm and strabismus in the 1980s, indications have expanded to include spasticity associated with cerebrovascular accidents, vasospastic disorders, focal dystonias, and pain conditions. This article reviews the current literature discussing the efficacy of botulinum toxin A in management of disorders of the hand and upper extremity relevant to hand therapists. LEVEL OF EVIDENCE: NA.

Current practice patterns in conservative thumb CMC joint care: survey results.

STUDY DESIGN: Cross-sectional descriptive survey INTRODUCTION: Best practice for conservative clinical care pathways is not well outlined in the literature for patients with thumb carpometacarpal joint (CMCJ) pain. This self-report survey investigated the current practice patterns of assessments and conservative interventions for the painful thumb CMCJ among hand therapists. METHODS: An online survey was distributed to members of the American Society of Hand Therapists (ASHT). Questions were included about evaluation measures and intervention techniques used for this population. A descriptive analysis was completed of the results. RESULTS: A total of 23.5% of the ASHT membership responded to the survey. Results were categorized using the International Classification of Functioning and Disability domains as a framework. The survey results report varying use of evaluation measures, therapeutic interventions, including orthotic fabrication, joint protection and patient education all therapeutic interventional techniques, and modalities. CONCLUSION: Therapists use a comprehensive array of evaluation measures and interventions for body functions and structures in the care of thumb CMC pain. In contrast, more consistent use is needed of psychometrically-sound functional outcome measures that show change in activities and participation. This survey highlights areas to employ current evidence, as well as, future research should address environmental factors and personal factors for this population LEVEL OF EVIDENCE: Not applicable.

The use of joint mobilization to improve clinical outcomes in hand therapy: a systematic review of the literature.

STUDY DESIGN: Systematic review. INTRODUCTION: Joint mobilizations are used as an intervention for improving range of motion, decreasing pain and ultimately improving function in patients with a wide variety of upper extremity diagnoses. However, there are only a limited number of studies describing this treatment for conditions affecting the elbow, wrist, and hand. Furthermore, it is unclear as to the most effective joint mobilization technique utilized and the most beneficial functional outcomes gained. PURPOSE: Examine the current evidence describing joint mobilizations for treatment of conditions of the elbow, wrist and hand, and offer informative practical clinical guidance. METHODS: Twenty-two studies dated between 1980 and 2011 were included in the systematic review for analysis. RESULTS: The current evidence provides moderate support for the inclusion of joint mobilizations in the treatment of lateral epicondylalgia (LE). In particular, mobilization with movement as described by Mulligan is supported with evidence from nine randomized clinical trials as an effective technique for the treatment of pain. Other described techniques include those known as Kaltenborn, Cyriax physical therapy, and Maitland, but the evidence for these techniques is limited. There is also limited evidence for the joint mobilizations in the treatment of wrist and hand conditions. CONCLUSIONS: The current literature offers limited support for joint mobilizations of the wrist and hand, and moderate support for joint mobilizations of the elbow for LE. There is moderate support for mobilization with movement. .

A simple distal radioulnar joint orthosis.

These authors describe an orthosis they have successfully used in their clinic to treat patients with distal radioulnar joint instability. In addition to describing how they fabricate the orthosis, these authors also describe how they determine if the patient needs volar or dorsal support, and how they then incorporate this support into the orthosis - Victoria Priganc, PhD, OTR, CHT, CLT, Practice Forum Editor.

Effects of a dynamic stability approach in conservative intervention of the carpometacarpal joint of the thumb: a retrospective study.

STUDY DESIGN: Retrospective cohort. INTRODUCTION: Conservative intervention of carpometacarpal joint (CMC) thumb pain, caused by osteoarthritis and ligament laxity, is frequently seen in hand therapy. Traditional intervention for pain and disability reduction includes orthoses, exercises, and joint protection education. The literature on conservative management is unclear which design or program of exercises create an effective result. Results of a conservative dynamic stability interventional model for thumb pain are presented as a design which positively effects pain and disability. PURPOSE OF THE STUDY: The purposes were to primarily investigate change in pain and disability in persons with CMC pain in a dynamic stability modeled approach to intervention, and secondarily, to assess the average number of visits and the duration of total visits in this model. METHODS: A retrospective chart review was completed on 35 charts of those seen at a multicenter hand therapy clinic. The pain and disability scores from the QuickDASH were used as outcome measures. RESULTS: The average group pain and disability scores improved by 17.9% (p < .01) and 19.3% (p < .01) respectively, with average individual disability improvement of 15.7%, which is greater than the accepted MCID. The average patient visits were 2.37 over an average range of 44.5 days. The group demographics match current literature: 31 females to 4 males, with average age of 58 years (range of 30-82 years). CONCLUSION: Significant reduction in pain and disability is noted with a conservative dynamic stability modeled approach to intervention, with information on average visits and duration in this model of care for individuals with thumb pain at the CMC joint. LEVEL OF EVIDENCE: 4.