Exploring Hand Therapy - · PDF filethat the best orthosis to use is a long opponens ......

Featured Article by Susan Weiss OTR/L, CHT

Nancy Falkenstein OTR, CHT

Susan Weiss OTR, CHT

The PURPLE BOOK is hot off the press!

•New illustrations•New questions•New chapters•NEW 3rd edition is

hereHand & Upper Extremity Rehabilitation: A Quick Reference Guide and

Review”. Studying for the CHT© exam See Purple Book (pages 8, 11) for details.As always EHT/Tx2go strives to bring you valuable education and products. Please visit our sponsors websites. If viewing online just click and go. Thank you to our sponsors for making this newsletter possible.This newsletter is for informational purposes only and is not intended to be a substitute for professional advise, diagnosis, or treatment. Opinions are that of the authors and not necessarily of EHT/Tx2go.

continued on page 3

In This Issue

1

Exploring Hand Therapy

Treatment2gowww.handtherapy.com

Featured Article Thumb OA .....................1

2014 Philly Hand Conference ..................7

Purple Book ......................................8, 11

New Releases G Codes ..........................8

Learn & Earn FREE CEU ........................8

Basics & Beyond CHT study ................12

Physical Agent Modalities ......................12

Volume 14, Issue 3 July - Sept. 2013

Thumb CMCJ OA

Thumb CMCJ OA affects up to 20% of men and women older than 40. If you review radiographs alone you will see that as much as 42% of males and 57% of females demonstrate radiographic evidence when age 75 or older. This is important to note as just because they have

OA on a radiograph does not mean they suffer from it. So don’t treat an x-ray but treat your patient’s symptoms!

It is important to know that this joint can be termed many things and one term is not more accurate than another but it is best to know all the terms. Terminology can range from:

•Thumb Carpometacarpal joint, (CMCJ)

•Thumb Trapeziometacarpal joint (TMCJ)

•Trapeziometacarpal joint (TM)

•Saddle joint•Basal joint

This uniquely mobile joint has the ability to have multidirectional

mobility due to the small ligaments however with its freedom of mobility we will sacrificestability.Asligamentsget lax the joint becomes damaged on the articular surface. Eventually the joint can’t compensate for the increased damage and the result is pain.

The most common complaints of the client with CMCJ OA are:

•pain•difficultyopeningjars•difficultyturningkeys•difficultypickingthingsup•difficultyholdingontoobjects

It is important as a clinician, while evaluating this patient, to rule out other potential diagnosis. Other diagnosis include the following:

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•Tenosynovitis•OA/RA•Septic Arthritis•Lupus•Psoriatic arthritis•Scleroderma•Gout•Gamekeeper’s thumb•CTS•De Quervains•Trigger thumb•Volar ganglion•Neuroma•SLAC/SNAC•FRC tendonitis

When you treat CMCJ pathology conservatively you may clinically implement any of the following:

•Activitymodifications•Rest•Nonsteroidal antiinflammatorydrugs(NSAIDs)

•Ibuprofen (Advil, Motrin IB) and naproxen (Aleve,

•Naprosyn•Exercises•Orthotics/Splinting•Modalities•Joint mob/distration

Orthotics have been used effectively and has been clinically shown to be effective via the current literature. Orthotics can effectively reduce pain by providing stability especially during loading activities.

The question that has been debated and studied is; what orthotic is to be used?

More recently it has been found that the best orthosis to use is a long opponens (top photo) if the patient has co-existing STT arthritis.

If there is not associated STT pathology then the most effective orthosis is a short opponens with wrist free (below photos).

The wear time will also need to be assessed and often times early on it is worn full time weaning to part time and then PRN as the pain improves.

Interestingly, the current literature has also suggested that strengthening the thumb extensors, abductors, and wrist extensors will help to counteract the deforming forces that act on the CMCJ joint and ultimately reduce pain.

Strengtheningthefirstdorsalinterossei is also helpful. For details on how to perform these exercises and how often check out Exploring Hand Therapy’s course “All About the Thumb CMCJ OA”. You will learn about orthotics for the CMCJ, conservative intervention and surgical options. All About the Thumb CMCJ Osteoarthritishttp://www.liveconferences.com/product.asp?cid=255

The literature also suggests that adaptive equipment use will help reduce pain and improve function in conservative treatment. Learning joint protection and activitymodificationwillenablethe patient to experience less pain as well. Additionally an array of other modalities including: ultrasound, electrical stimulation, heat,cold,coldlater,paraffin,iontophoresis and taping can also be attempted. Recently, mirror therapy has been used and shown in the literature to help reduce pain with arthritis.

If conservative treatment fails continued page 4




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than medical intervention will likely be next. This can include steroid injections, mild anti-inflammatorymedications,NSAIDS or surgical intervention. Soft tissue reconstruction for stage one only is considered and for the other stages an array of interventions will be entertained.

Nospecifictechniquehasshownto be best – the most common is based from the LRTI procedure. This is a ligment re-construction tendon interposition. The main goal with surgical intervention is for the surgeon to restore the normal tension of the volar beak ligament to reposition the thumb in its anatomic position to allow for improved thumb mechanics. The primary methods of surgical treatment will be either arthroplasty or arthodesis (this has fallen out of favor).Most of these surgical patients will require therapeutic intervention after surgery and most of them receive custom splints.

Above: LRTI excision of the trapezium and reconstruction of the ligament. Below: Post LRTI.

Above: red circle depicts radiographically the excision of the trapezium after the LRTI procedure.

Frequently Asked Questions about CMCJ OA

Q: What are the 8 muscles that surround the thumb?A: 1. First Dorsal Interosseous, 2. APL, 3. EPL, 4. Opponens Pollicis, 5. Adductor Pollicis, 6. Abductor Pollicus, 7. Flexor Pollicis Brevis, 8. Flexor Pollicis Longus

Q: Does a shoulder sign mean the patient will have more pain?

A: No not at all. The shoulder sign means the thumb is more dislocated and less subluxed. It may have less pain in actuality as it becomes moreofafixeddeformityandtheless motion yields less pain.

Q: Would I change my implementation or goals if a patient arrives for conservative therapy and he/she has a shoulder sign?

A: If they have a shoulder sign it is likely that a neoprene or soft orthosis/splint will be more helpful than a custom molded orthosis. The hard orthosis often creates increased pain on the dislocated joint.

Q: Would the web-space be something I would expect to be “normal” post surgical intervention?

A: After surgical intervention the web space is often improved dramatically.

Q: In your opinion what would you say is the most important activity modification I can teach my patient if they have:1. Subluxed CMCJ and 2. Dorsal Dislocation?

A: Avoidance of lateral pinch is KEY in both subluxation and dislocation.

Q: For conservative treatment why do we avoid strengthening the Adductor Pollicis muscle?

A: The adductor pollicis muscle (photo below) pulls the thumb into the deforming posture and assists with dorsal dislocation ofthefirstmetacarpal.Q: Can I stretch the Adductor Pollicis muscle?

Continued on page 6



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Objectives: Identify the OT PQRS program measures

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Identify key components of incorporating function into documentation for G codes reporting

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Identify several different methods of completing daily documentation

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Determine functional limitation G code reporting to CMS and how often to report



Quiz Corner

1.ListatleasttwointerchangeabletermsforthefirstCMCJ OA.

2. List at least three differential diagnosis for CMCJ OA.

3. What orthosis is typically prescribed when STT is involved with thumb CMCJ OA?

4. If the STT is not involved what orthotic is typically prescribed?

5. Therapists can recommend non steroidal anti-inflammatorydrugstohelpdecreasepainaboutthethumb CMCJ. True or False

6. What is a common surgical intervention technique discussed in this article?

7. In regards to question #6, what bone is excised?

8. List at least 2 common complaints a patient presents with when diagnosed with thumb CMCJ OA.

9.GoutmaybeadifferentialdiagnosisoffirstCMCJOA. True or False.

10. Mirror therapy has been found to decrease OA pain. True or False

Answers on page 10

6

Featured article continued from page 4

A: Yes you can do contract – relax exercises and fascia stretches to help decrease the tight adductor pollicis muscle. This can potentially improve web space contractures.

Q: What are signs of overuse? And how do I modify my clinical and home program?A: If the patient is fatigued after the treatments or has extended periods of pain your treatment is overzealous and should be toned down. To learn more about “All About the Thumb CMCJ Osteoarthritis” visit:


All About the Thumb CMCJ Course Description:

This .250 AOTA APP CEU interactive, dynamic web-based or DVD course is designed to teach conservative and surgical management techniquesforthepainfulfirstCMCJ. Learn and view LRTI surgery, various custom CMCJ orthosis fabrication, evaluation and various treatment options. Instruction methods include: PowerPoint, lecture, exercise demonstration, orthotic fabrication, surgical video and lecture. This course is an

intermediate level for learning. Upon Successful completion of the examination (80%) your certificatewillbesentviaemail.

Course Objectives:•Review evaluation techniquesforfirstCMCJ

•Describe conservative therapeutic management for firstCMCJpain

•View fabrication of various orthoticdesignsforthefirstCMCJ splint

•Identify exercise regime for firstCMCJpain

•Review modalities used to managefirstCMCJ

•Observe LRTI surgery on

Continued page 9




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Featured Article Continued from page 6

o

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video•Determine post operative

care after thumb CMCJ surgery

Bibliography

•Armstrong AL, Hunter JB, Davis TR. The prevalence of degenerative arthritis of the base of the thumb in postmenopausal women. J Hand Surg Br 1994;19(3):340–1.

•Day CS, Gelberman R, Patel AA, Vogt MT, Ditsios K, Boyer MI. Basal joint osteoarthritis of the thumb: a prospective trial of steroid injection and splinting. J Hand Surg Am2004;29(2):247–51.

•Eaton RG, Glickel SZ. Trapeziometacarpal osteoarthritis:staging as a rationale for treatment. Hand Clin

•1987;3(4):455–71.•Egan M, Brousseau L. Splinting

for osteoarthritis of the carpometacarpal joint: review of the evidence. Am J Occup Ther 2007;61(1):70-78.

•Weiss S, LaStayo P, Mills A, Bramlet D. Prospective

analysisofsplintingthefirstcarpometacarpal joint: an objective, subjective and radiographic assessment. J Hand Ther 2000;13(3):218-227.

•Wajon A, Ada L. No difference between two splint and exercise regimens for people with osteo-arthritis of the thumb: A randomised controlled trial. Aust J Physio 2005;51:245-249.

•Colditz JC. The biomechanics of a thumb CMC immobilization splint:designandfitting.JourHand Ther 2000;13:228-235.

•Boustedt C, Nordenskiöld U, Lundgren Nilsson A.Effects of a hand-joint protection programme with an addition of splinting and exercise. Clin Rheumatol 2009;28:793-799.

•Valdes, K, vonder Heyde, Rebecca. An Exercise Program for Carpometacarpal Osteoarthritis Based on Biomechanical Principles . Journal of Hand Therapy Volume 25, Issue 3 , Pages 251-263, July 2012

•Yaprak Ataker, Eftal Gudemez, Sibel Comert Ece, Nazan Canbulat, Ayan Gulgonen Rehabilitation Protocol after Suspension Arthroplasty of Thumb Carpometacarpal Joint Osteoarthritis, Oct. 2012 Journal of Hand Therapy Vol. 25, Issue 4, Pages 374-383

•O’Brien, V, Giveans, R, Effects of a dynamic stability approach in conservative intervention of the carpometacarpal joint of the thumb: A retrospective study. Journal of Hand Therapy Volume 26, Issue 1 , Pages 44-52, January 2013

Listed below are two additional excellent thumb and arthritis Ebook courses available through Exploring Hand Therapy/Treatment2go:

Arthritis Unloaded: OsteoArthritis

Objectives:• Identify the anatomy of a joint•Distinquishes the stages of OA•Recognize evaluation techniques specifictoOA

•Recognize conservative treatment measures for OA

• Identify an understanding of surgical interventions associated with arthritis


Arthritis Unloaded: Rheumatoid

Objectives:• Identify the anatomy of the joint•Understand the stages of RA•Apply evaluation techniques specifictoRA

•Recognize conservative treatment•Understand surgical interventions

associated with arthritis•Differentiate appropriate

documentation for RA and modalities

• Identifysplintoptionsforspecificdeformities associated with RA






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Quiz answers from page 6

In Memory ofLori Ann KursayApril 17, 1961 -

September 13, 2013Obituary

Kursay(Griffith),LoriAnn, of Clearwater, FL passed away on September 13th, 2013 at the Suncoast Hospice Care Center, Palm Harbor after a courageous battle with

cancer. Lori was predeceased by her parents, Grethe and Joseph Kursay and brother Mark Kursay. She is survived by her husband: Allen L. GriffithII,histhreechildren;SarahE.Griffith,AllenL.GriffithIIIandKyleM.Griffith;byherin-laws,BettyandAllenGriffithofBelleair,FL;hersisterandhusband, Doris Kursay and Mike Flanagan; nephew Kyle Gartman; sister-in-law Elizabeth Kursay all

from St. Petersburg, FL. She had additional Family throughout the United States and Denmark. Lori was born and raised in New Jersey and made her way to Florida in 1979. She is a graduate of the University of Florida and spent over twenty years servingasanOccupationalTherapist/CertifiedHandTherapist at both Largo Medical Center and Morton Plant Hospital. Beloved by her family, patients and colleagues, Lori touched many with her charismatic personality. Her love of life and travel took her worldwide with recent visits with family and friends in the United States, Australia and New Zealand. She was unconditionally loved and will be forever missed by family, friends and all who knew her. A Celebration of Lori’s Life will be held at 10 am on Saturday, September 28, 2013 at the Belleair Country Club, 1 Country Club Lane, Belleair, FL. In lieuofflowers,donationsmaybemadetoSuncoastHospice, 5771 Roosevelt Road, Clearwater, FL 33760. Please visit www.mossfeasterclearwater.com

Tribute to a colleague and friend

1. Terms associated with Thumb CMCJ OA•Thumb Carpometacarpal joint, (CMCJ)•Thumb Trapeziometacarpal joint (TMCJ)•Trapeziometacarpal joint (TM)•Saddle joint•Basal joint

2. Differential diagnosis•Tenosynovitis•OA/RA•Septic Arthritis•Lupus•Psoriatic arthritis•Scleroderma•Gout•Gamekeeper’s thumb•CTS•De Quervains•Trigger thumb•Volar ganglion•Neuroma•SLAC/SNAC•FRC tendonitis

3. Long opponens thumb orthosis

4. Short opponens thumb orthosis

5.False. According to most state practice acts OTs and PTs cannot prescribe any medication. Check with your state to determine if you are permitted to recommend drugs to patients/clients.

6. LRTI

7. Trapezium

8. Most common complaints associated with thumb CMCJ OA are:

•pain;difficultyopeningjars;turningkeys•picking things up; holding onto objects

9. True

10. True

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Exploring Hand Therapy - · PDF filethat the best orthosis to use is a long opponens ......

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