2018 TRIA Hand Therapy Conference

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2018 TRIA Hand Therapy Conference Virginia O Brien OTD, OTR/L, CHT Practical Intervention for Hand Osteoarthritis: Applying Evidence-Informed Intervention Virginia O Brien OTD, OTR/L, CHT TRIA Hand

have no relevant personal financial relationships Editor, Caring for the Painful Thumb 2 nd and 3 rd ed.

In all occupations of life (OT FW-III) Client factors: Full medical hx & co-morbidities Smoking/diabetes/HBP/medications Hx of hand accidents, incidents, pain onset Activity Demands: home, work, play

1 2018 TRIA Hand Therapy Conference Virginia O Brien OTD, OTR/L, CHT Practical Intervention for Hand Osteoarthritis: Applying Evidence-Informed Intervention Virginia O Brien OTD, OTR/L, CHT TRIA Hand Therapy Conference Meeting Bloomington, MN November 9, 2018 Disclosure Virginia O Brien OTD, OTR, CHT Hand Therapy Fellowship Coordinator University of Minnesota Medical Center Minneapolis, MN USA I have no relevant personal financial relationships Editor, Caring for the Painful Thumb 2 nd and 3 rd ed. All Purchases are Donations to AHTF Jan Albrecht Memorial Scholarship Fund How does thumb pain affect function? In all occupations of life (OT FW-III) Client factors: Full medical hx & co-morbidities Smoking/diabetes/HBP/medications Hx of hand accidents, incidents, pain onset Activity Demands: home, work, play Performance Skills: ROM, sensation, cognitive Performance Patterns: roles, habits, routines Contexts: Where does this happen? (AOTA, 2014) Evaluation Specifics Observation of the thumb, all joints, UE ROM of both thumbs (compare) Strength of grip and pinch Pain assessment during evaluation/tasks Provocative Tests for differentiation Outcome Measures > Outcome measures need to be: Reliable is the extent to which a measurement is consistent, free from error Valid Validity (truth) assures a test is measuring what it is intended to measure. Responsive - Responsiveness assesses the effectiveness of intervention over time > V/R/R vs. Standardization: not the same > Convention for use of a tool: once it is published, it is in the public domain > Rule: contact the researcher that you are using the tool and how you are using the tool. (Portney & Watkins, 2009, p. 77, 112) TRIA Hand Therapy Conference 1

2 Observation of the thumb typical deformity Observation of the thumb deformities Adduction contracture Hyperextension or deviation of MPJ Shoulder Appearance ZIG ZAG REVERSE ZIGZAG The Reverse Zig Zag Deformity Rather than hyper-extending at the MP, hyper-extension occurs at the IP and the MP joint compensates by going into hyper-flexion. It can be present for a lifetime without a problem. Thumb pain can develop due to ligament stretching and dynamic instability can contribute to joint changes over time. What if the thumb appears NORMAL? Range of Motion of the Thumb MP & IP RADIAL ABD PALMAR ABD RETROPULSION OPPOSITION Compare hands Measuring Abduction ROM Palmar Abduction Radial Abduction And in every area of the evaluation Goniometric (least reliable) Calipers: Inter-metacarpal distance (normal 80 mm) (most reliable) (Murugkar et al. 2009) (de Krakar et al.2009) PollexoBox (2 nd most reliable) TRIA Hand Therapy Conference 2

Wu, & Wood, 2009) (Kapandji, 1986) CMC and finger MCPs Flat on table (Kapandji, 1992) Progress noted on opposite

Measurement of each motion plane Beighton Test for Hypermobility Strength of pain-free grip/pinch (Jonsson, 1996)

, 2010) Radial Wrist exam: Part of Differential Diagnostics Radial Aspect of 3 zones of wrist evaluation Radial

(not osseous, but remember its contribution) STT Arthritis Patient has pain proximal to CMCJ Patient has

3 Opposition Measure RETROPULSION? Or RE-POSITION Or SUPINATION Or COUNTER OPPOSITION Kapandji scale of opposition: 0-10 scale (Edgar, Finlay, Wu, & Wood, 2009) (Kapandji, 1986) CMC and finger MCPs Flat on table (Kapandji, 1992) Progress noted on opposite palmar MCP joints How do YOU measure IT? Measurement of each motion plane Beighton Test for Hypermobility Strength of pain-free grip/pinch (Jonsson, 1996) (Kennedy et al., 2010) Radial Wrist exam: Part of Differential Diagnostics Radial Aspect of 3 zones of wrist evaluation Radial zone Central zone Ulnar zone CMC Joint STT Joints DeQuervain s Assessment Dorsal Radial Sensory Nerve assessment (not osseous, but remember its contribution) STT Arthritis Patient has pain proximal to CMCJ Patient has generalized wrist pain, more with activity, esp. with radial wrist motion Patient may have NO pain with CMC grind test Test: Place in forearm neutral position Apply pressure at volar aspect of STT joint with ulnar to radial deviation movement (like Scaphoid Shift Test) POSITIVE if painful, don t expect a CLUNK No statistics on this test (Kozin & Michlovitz, 2000) TRIA Hand Therapy Conference 3

tasks: tying, zipping, button, Pain with holding coffee cup, book, lifting laptop Adduction stress test: Hold the ulnar wrist to keep wrist in neutral.

4 1 st CMC Joint pain 2⁰ to OA Positive pain w/ palpation over CMC joint line Positive CMC EXTension and ADDuction test [change!!! not Grind] Positive Crank test (instability shear test) Positive pinch test (pain with 3-point and Lateral pinches) Functional Presentation: Pain with pinch and grip Pain with functional pinching tasks: tying, zipping, button, Pain with holding coffee cup, book, lifting laptop Adduction stress test: Hold the ulnar wrist to keep wrist in neutral. Firmly direct adduction force on MC head ulnarly to mid-axis of Index metacarpal or to firm end point. Pain at CMC=Positive Test (Gelberman et al Figure 1) Extension Stress Test: Hold the ulnar wrist to keep wrist in neutral. From 5-10 mm proximal to MCP joint, extend thumb until MC is in parallel plane to the palm or firm end point reached. Pain at CMC=Positive Test (Gelberman et al Figure 2) Ligament Laxity: Test Anterior-Posterior assessment for CMC joint play (holding thumb in Palmar abduction) Stabilize Metacarpal, traction the CMC Hold Trapezium (concave on convex=same direction) Glide Trapezium in anterior-posterior planes Compare to opposite hand for hypo/hypermobility & pain Case: pt presented with thumb pain; dx as CMC OA, with medical hx of skier s thumb Intervention: jt mobs to the CMC and STT, and carpal arch self mobilization; with the thumb dynamic stability program DeQuervain s Tests Finkelstein s Eichoff s Test Palpate the DRSN, check for +Tinel s Resisted thumb extension and radial abduction (EPB, APL) Eichhoff s maneuver: thumb in full composite flexion, then HAND is ulnarly deviated passively to end range, then quick stretch Positive + if pain is produced, but differentiate 1 st Dorsal Compartment pain from CMC pain. Have person specifically POINT to the painful spot. WHAT Test for DeQuervain s Let s be Evidence Informed, willing to change!!!!!!!!!!! (Elliot, 1992) (Goubau et al.2015) TRIA Hand Therapy Conference 4

Testing for DeQuervain Tenosynovitis Finkelstein s is not = to what we are doing Eichhoff s test is = what we are doing Both were described as passive tests by the examiner to the person The More

5 Testing for DeQuervain Tenosynovitis Finkelstein s is not = to what we are doing Eichhoff s test is = what we are doing Both were described as passive tests by the examiner to the person The More Accurate Test- the WHAT test: Active testing by shearing tendons of 1 st Dorsal Compartment against the palmar distal edge of that pulley (Goubau et al. 2015) Name of test Explanation of statistic Eichhoff test: Test result Accuracy Closer to one is better Sensitivity Specificity Eichhoff s vs. WHAT Test: Statistical Results Closer to one is better Closer to one is better Positive likelihood ratio Larger is better Negative likelihood ratio Smaller is better WHAT test: Test result How to administer WHAT Test: Designed to test solely the tendons of the 1 st DC Pt fully flexes the wrist w/in pain tolerance and extends and fully abducts the thumb Examiner applies resistance to the abducted thumb, and pt keeps the thumb in abduction against the resistance and is allowed to give in when unable to maintain the resistance; the test is complete Positive test =Pain on resisted pressure by the examiner This aligns with other resistive tests for tenosynovitis/tendonitis: APL, EPB, ECU, EDC, FPL, flexor tenosynovitis, Lateral and Medial Epicondylitis, etc. Practical Intervention for Hand Osteoarthritis: Applying Evidence-Informed Intervention for Thumbs and Fingers Virginia O Brien, OTD, OTR/L, CHT TRIA Hand Therapy Conference Bloomington, MN November 9, 2018 This Conservative Dynamic Stability for the Painful Thumb Management Program includes the following: Manual release of the adductor and any overactive, dominant muscle Joint mobilization to reduce / realign the CMC Muscle re-education / strengthening Orthosis/Orthoses as needed Use of adaptive tools and joint protection techniques Strategy to wean from orthosis With respect for pain at each step TRIA Hand Therapy Conference 5

3 Important Points for a Stable Thumb. 1. The thumb webspace: Keep it SUPPLE 2.

Educate the person to stabilize their own thumbs for a lifetime.

Manual release of this muscle increases the potential ROM of the thumb lost due to web space contracture.

Watch for these points throughout the presentation Manual Release Adductor Muscle Release is the KEY Release of soft tissues in the web

nutritional substances in the joint. Joint mobilization of the thumb column restores stable thumb biomechanics, and reduces pain.

6 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 1 st metacarpal as it moves on the trapezium. 3. Educate the person to stabilize their own thumbs for a lifetime. 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. Watch for these points throughout the presentation Manual Release Adductor Muscle Release is the KEY Release of soft tissues in the web space Myo-Fascial or Tender Point release Contract- Relax release 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 being distracted is Hands behind body.....or in front TRIA Hand Therapy Conference 6

Joint Mobilization: Chest Joint Mobilization With a Skull Rock Place

(Villafañe, Silva, Diaz-Perreno TRIA Hand Therapy & Conference-2018

back DO THIS DAILY, 1-2x! Do this for about a minute.

Interestingly, you will know when the joint goes back into place.

muscles to restore stable balance Focus: Abductor Pollicis Brevis Opponens

Pollicis Longus Flexor Pollicis Brevis Isolate the Abductor and Opponens

position Close the chain by touching thumb to the index Place Hold Relax

Re-education of palmar abduction The CMC joint is most stable in the C

7 Joint Mobilization: Chest Joint Mobilization With a Skull Rock Place opposite thumb in webspace Roll hand back and forth Grasp thumb (Villafañe, Silva, Diaz-Perreno TRIA Hand Therapy & Conference-2018 Fernandez-Carnero, 2011) METHOD ONE Then move arm forward and METHOD TWO back DO THIS DAILY, 1-2x! Do this for about a minute. At first, it feels a little uncomfortable, but feels better quickly. Interestingly, you will know when the joint goes back into place. Muscle Re-education first, before Strengthening Re-education of the thumb muscles to restore stable balance Focus: Abductor Pollicis Brevis Opponens Pollicis 1 st Dorsal Interosseous Extensor Pollicis Brevis Abductor Pollicis Longus Flexor Pollicis Brevis Isolate the Abductor and Opponens Make the thumb puppet sing Closed Chain Exercise Re-education Make the C position Close the chain by touching thumb to the index Place Hold Relax and Repeat Don t let the MP joint collapse 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 TRIA Hand exercise Therapy Conference-2018 is done pain free TRIA Hand Therapy Conference 7

Isolate the Extensor Pollicis Brevis Piano playing to strengthen (isometric to

Brevis Opponens Pollicis Abduct without losing the MP flexion posture 1 st Dorsal

form Progress to co-contraction/ isometric Progress to Isotonic ALWAYS PAIN FREE

the patient who has a very unstable CMC, performing 1 st DI strengthening may be

> External support with co-contraction of the C position, manual support of the

8 Isolate the Extensor Pollicis Brevis Piano playing to strengthen (isometric to isotonic) Extensor Pollicis Brevis Abductor Pollicis Longus Abductor Pollicis Brevis Opponens Pollicis Abduct without losing the MP flexion posture 1 st Dorsal Interosseous Exercise VIDE O Guided Active ROM AROM with observation for proper form Progress to co-contraction/ isometric Progress to Isotonic ALWAYS PAIN FREE Rubber Band Exercise: Abduct the Index away from the Middle Finger NEW GOAL: 100 repetitions per day??? 76 Rubber-band Variations to re-educate and strengthen stabilizing muscles > For the patient who has a very unstable CMC, performing 1 st DI strengthening may be painful initially. > External support with co-contraction 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, ligament reconstruction may be a consideration. TRIA Hand Therapy Conference 8

9 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 Practice Lab: Thumb Evaluation OBSERVE for differences, deformities Are there ROM differences? Measure Opposition and Retropulsion: Normal? Pain? Provocative Tests: Ext & ADD stress tests; STT pain; CMC joint Laxity; Crank Test; WHAT test Test for UCL sprain Pain with pinch/grip? Hyperextension at the MCP? At the IP? Sensory & Motor Nerves normal? Dorsal radial sensory Nerve Froment s/jeanne s sign See Grid in your handout booklet Practice Dynamic Thumb Stability Intervention Web Space release & Stretch: PAIN FREE 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 1 st DI: AROM, Isometric, Isotonic (how much force w/o pain?) Feel the Opponens work with the 1 st DI How will you begin using this for ALL your thumb patients? Thumb Ext/Flex AROM(PROM) RANGE OF MOTION & SENSATION MP IP RABD PABD Kapandji Retropulsion(1-4) Kapandji Opposition (0-10) Motor Nerves: Radial: thumb Abd Median: thumb to LF tip Ulnar: IF/RF adduction under LF Sensory Nerves: Tinel s: MN/UN/DRSN Paresthesia: MN/UN/RN Right Left THUMB PROVOCATIVE TESTS: with new Evidence Informed Tests Present: + /-Pain (0-10) Right Left CMC shoulder appearance CMC joint line pain Extension Stress Test Adduction Stress Test WHAT Test Froment s Sign/Jeanne s Sign (UN Or Laxity?) Crank Test (AP glide trpzm) [Hypomobile/hypermobile] UCL stress test Zig-Zag Deformity Reverse Zig-Zag Deformity STT Test (OA of the carpus) Beighton Hypermobility (SF only) 1 st DI Strength (MMT: 0-5/5) PAIN FREE GRIP/PINCH TEST Pain Free Grip/Pinch Right Test Grip test: 1: AVE: 3 point pinch: AVE: Lateral pinch: AVE: Left TRIA Hand Therapy Conference 9

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 1 st metacarpal as it moves on the trapezium. 3.

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

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 1 st metacarpal as it moves on the trapezium. 3. Educate the person to stabilize their own thumbs for a lifetime. Did you Learn these points throughout the presentation? 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 Thank You! No two thumbs are alike. -Jan Albrecht Questions? It s NOT about an Orthosis (Splint)! It is about Dynamic Stability! Virginia O Brien vobrienotd@gmail.com Thank you References available upon request TRIA Hand Therapy Conference 10

Dynamic Stability of the Thumb

Dynamic Stability of the Thumb Conservative Management of the Painful Thumb is a CHALLENGE! Teamwork is Important Person Therapist Doctor Family Virginia H. O Brien OTD, OTR/L, CHT Minneapolis, Minnesota