Nicola Goldsmith MSc SROT ExCo IFSHT

Transcription

1 Nicola Goldsmith MSc SROT ExCo IFSHT

2 OA Anatomy and deformity Rationale for therapy Common therapeutic techniques

3 Most common form of arthritis The thumb is the most important digit OA is clinical and pathological outcome of a variety of processes that lead to structural failure of one or more synovial joints (Swanson 1995) > 4% 85% Age Age 75-79

4 What is affected? Predominantly articular cartilage (Swanson 1995) Along with (Nuki 1999) Subchondral bone Ligaments Capsule Synovial membrane Periarticular muscles (Arthritis Research Campaign 2005)

5 Pain Weakness Pinch and grasp Instability Deformity Osteophyte formation Crepitus Swelling Subluxation Reduced movement

6 Dorsal Volar Primary dynamic stabilisers 50% people with CMCJ OA also have STT OA The 1st CMCJ complex is made up of 4 articulations with the trapezium: 1st metacarpal Scaphoid Trapezoid Radial facet of the 2nd MCP

7 Evolution the opposable thumb The shape of the articular surfaces Concave / convex Dependence on ligaments and muscles for stability and limitation of movement Trauma -Acute trauma -Cumulative trauma Forces used in function

8 Common influences: Genetics Ligamentous Laxity Ligaments are there to absorb and resist force Joint Impingement The female factor APL insertion

9 Degeneration of the dorsal oblique ligament at the MC insertion Metacarpal translates on trapezium Initial damage on palmar surface of the metacarpal Mechanical instability increases Dorsal surface damage Pellegrini (1991)

10 Incongruence (Xu L et al 1998). Rotation of the CMCJ Increased incongruence in joint on dorsoradial and volar-ulnar aspects Focal lesions Progression to OA.

11 Less congruent than men s with smaller contact area (Ateshian et al 1995) Male trapezium bones = less concave (flatter) (Kovler et al 2004) Greater articular stresses 20% thinner cartilage layers (Xu 1998) Hormonal factor (Lubhan et al 2006)

12 Accessory slips of APL insert into Dorso-radial corner of the base of metacarpal Dorso-radial and oblique ligaments Volar trapezium APB APL therefore acts as dynamic ligament restraining and influencing relative position of trapezium and first metacarpal (Zancoli and Cozzi 1992). Muscles also stabilise and are more efficient in particular positions

13 Adduction Subluxation CMCJ Hyper-extension MCPJ Flexion IPJ First MC: Migrates dorsally Pronates Adducts

14 Unstable joint Painful joint from stiffness, inflammation and/or instability Minimise pain Maintain movement Maximise function and independence Prevention of deformity Desire to delay surgery Decrease forces on joint Evidence from Berggren et al 2001 HT protects from surgery

15 Analgesics Non-steroidal anti-inflammatories Intra-articular joint injections Joint protection Exercise Splinting Heat Electrotherapy Acupuncture Review paper Valdes 2010 HT works!!

16 Reduce load on the thumb Remember that forces increase 12 13x from tip to base This increases if MCPJ is hyper-extended Maintain functional level It is not about stopping use of the hand Cumulative effects Every little counts

17 Principles Reduce adduction (lateral pinch) Reduce forces Torque, frequency and intensity Spreading the load Using devices Splints Assistive tools for ADL Identifying risk Requires behavioural and cognitive change

18 Much research has been for RA Stamm et al (2002) Three month trial Two groups Info re OA, JP and exercise advice Info re OA only Results grip strength and global hand function increased in JP / exercise group Valdes (2010) review paper Supports use of JP

19 Boustedt et al (2009) Joint protection training improved status of the patient When add exercise and splinting (1 year FU) Improved night pain Improved pain on movement Decreased stiffness Increased grip strength Improved ADL

20 Thumb base is inherently unstable Improving core stability will maintain position, strength and function Exercise training is all about being SPECIFIC What sort of exercises? How to maintain soft tissue length? Which ones for CMCJ stability? Those which flex, supinate and abduct What needs to be added when MCPJ is hyperextended? How to grade the exercise programme?

21 Training muscles Studies have shown that pain-free muscle strengthening, carried out in a graded manner can accelerate tendon metabolism and healing of tissue Initial strengthening Isometric exercises in mid-range, Graded into inner and outer range. Eccentric strengthening Specific strengthening of involved muscles against resistance, increasing range, speed and strength Ligament afferent input provides information for dynamic stabilisation Combination of cognitive and physical including proprioception, isometric, eccentric and concentric muscle control and cognitive training Bilateral movements may help (Haggert)

22 Early intervention will bring the most benefits Stabilisation Minimise pain before strengthening APL is a key muscle to strengthen Consider the 1 st dorsal interosseous Intrinsic and extrinsic Start active and small movements Avoid EPL by flexing tip IPJ or blocking it Use a cone

23 Aims to Avoid Reduce pain Improve stability Support subluxation Encourage function Consider adjoining joints To protect from damage Decrease inflammation Reduce torque Causing stiffness Preventing function Pressure points Bulky splints Blocking joints that should move Think about the materials available for splinting

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25 Thank you See you in Argentina IFSHT 2016