A retrospective multicenter study of the Artelon? carpometacarpal joint implant

Background

This study aims to evaluate patient outcomes associated with use of the Artelon® Spacer for the treatment of arthritis of the carpometacarpal joint (CMCJ) of the thumb.

Methods

Patients with Eaton stage I, II, or III carpometacarpal (CMC) joint arthritis and disabling pain that had failed conservative treatment were evaluated at 12, 36, and 48 months postsurgery for changes in pinch, patient satisfaction, pain, range of motion, grip strength, grind test, operative time, and X-ray evidence of subsidence.

Results

Complete data was available for 46 subjects and 49 thumbs. A statistically significant improvement in pain when subjected to a first CMC joint grind test, CMCJ stability and patient perception of hand and wrist function following implant insertion was seen. Patient-oriented outcomes showed statistically significant improvement in the Disabilities of the Arm, Shoulder, and Hand; pain; pinch and grip strength; and range of motion. X-ray analysis revealed that none of the distributions of measures of osteophytes, subluxation, and joint space narrowing showed statistically significant change. Bone erosion/remodeling changes of the first metacarpal were statistically significant.

Conclusions

At a follow-up period of 4 years, patients had measured improvement as well as positive self-reported functional improvements following Artelon® implant insertion for the treatment of arthritis of the thumb CMCJ.     

Virtual health care & telehealth: Current therapy practice patterns

Study designSurvey Study.PurposeTo investigate recent practice changes with respect to the provision of virtual visits by hand therapists due to the COVID-19 pandemic by asking about changes in the frequency of virtual visits, the assessments and treatments currently provided virtually, and the opinions of therapists on the future on virtual visits in hand therapy practice.MethodsThe survey was distributed to the American Society of Hand Therapists (ASHT), the Australian Hand Therapy Association (AHTA), the Canadian Society of Hand Therapists (CSHT), and the European Federation for the Societies of Hand Therapy (EFSHT).ResultsOf the 819 responses, there were 573 therapists (70%) who reported that they currently use virtual visits in their practice. Only 38 therapists (4.6%) were providing virtual visits prior to COVID-19, representing a 15-fold increase in virtual visits since the beginning of the pandemic. Only 26% (n = 213) reported that they used patient-reported outcome measures (PROM) in conjunction with their virtual visits. Approximately 78% (n = 638) said that they thought there is a sustainable future for this method of care in hand therapy practice.DiscussionThis survey has helped identify the changing landscape in the provision of rehabilitation and established some of the common assessments and interventions currently utilized by hand therapists in the virtual environment. Next, steps for research are to investigate the reliability and validity of some of the assessments and interventions used, to establish whether virtual care will provide good outcomes for patients, and ultimately understand the optimal combination of conventional therapy and virtual care.     

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

Study designRetrospective cohort.IntroductionConservative 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 studyThe 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.MethodsA 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.ResultsThe 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).ConclusionSignificant 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 evidence4.     

Hand therapist use of patient report outcome (PRO) in practice: A survey study

PurposeThe purpose of this survey was to gain greater insight into hand therapists' use of Patient Report Outcome (PRO) measures.MethodsAn 11-question survey that evaluated therapists' perceptions, preferences, and patterns of use of patient report outcome measures was sent to members of ASHT.ResultsA total of 633 ASHT members participated in the survey study. A large majority of participants (92%) responded affirmatively to using a PRO measure in practice. The DASH was reported as the most frequently used measure (90%). The majority of therapists (84%) discuss the results of the outcome measurement score with their patients. Of the participants who use more than one outcome measure, 44% report that this allows them to better establish their patient's functional and physical limitations.ConclusionThe findings in this study suggest that a large percentage of hand therapists are currently including a PRO measure in their hand therapy practice.     

Injection of intra-articular sodium hyaluronidate (Sinovial) into the carpometacarpal joint of the thumb (CMC1) in osteoarthritis. A prospective evaluation of efficacy

ObjectiveTo compare the efficacy on pain relief and function of one, two or three injections of intra-articular hyaluronic acid in symptomatic osteoarthritis (OA) of the carpometacarpal joint of the thumb (CMCJ).MethodsAmong subjects with symptomatic OA of the CMCJ of the thumb referred to the Rheumatology Department of Nice, patients free of any joint injection in last 6 months with pain visual analogue score (VAS) >40 and with Kellgren and Lawrence score between 2 and 4 were included. Each subject was randomly allocated to receive, at weekly intervals, 1 (group 1) or 2 (group 2) or 3 injections (group 3) of 1 ml Sodium Hyaluronidate (Sinovial^®). Injections were given under imaging control. Sociodemographic characteristics, VAS and functionality (Dreiser Functional Index) were assessed at baseline, at one month and at three months. An intention to treat analysis was performed.ResultsForty two subjects were enrolled in the study. Their mean age was 64.8 (8.0) years, and 90.5% were women. Baseline pain VAS, and mean Dreiser functional index were respectively 57.7 (17.1) and 12.5 (5.8). A repeated measure analysis of variance (ANOVA) model was used to compare the time-course profile of the three treatment groups for VAS and Dreiser index. Due to statistically significant groups-time interaction the analyses were conducted at each evaluation time. No difference was found for VAS at 1 month (p = 0.075) and 3 months (p = 0.382). Intra group differences between baseline and three months was significant in groups 2 and 3 (p = 0.012 and p = 0.002).ConclusionNo significant differences were found between each group over the study period for pain relief and function. But the intra groups analysis results show that intra-articular sodium hyaluronidate injections into the carpometacarpal joint of the thumb in osteoarthritis can be efficacious on pain and fuctionality. What is now needed is a controlled placebo randomised study with larger samples and longer term follow up of the achieved effects.     

Dynamic stabilization of the painful thumb: A historical and evidence-informed synthesis

Study DesignExpert opinionIntroductionThumb carpometacarpal joint (CMC) osteoarthritis is a common condition seen in the hand therapy clinic. Prevalence is generally higher in females, and the percentage rises for post-menopausal females. Patients typically present with pain and functional difficulties. Conservative management is recommended before a surgical consult. Evidence is mounting that a dynamic stability modeled approach has a significant effect on pain and improving function.PurposeThe purpose of this paper is two-fold: first, to present the history and development of a dynamic stabilization model for treatment of the patient with thumb CMC osteoarthritis (OA), and second, to provide expert clinical commentary and recommendations for the treatment of thumb CMC OA in light of the best available evidence.MethodsExpert clinical commentary is based on an extensive review of relevant literature.ResultsThe current literature and expert opinion supports an evidence-informed multimodal intervention: modalities, pain relief techniques, manual release, joint mobilizations as deemed necessary, neuromuscular re-education through proprioceptive exercises, and education in joint protection principles.ConclusionA rationale for a dynamic stabilization approach is presented. The unique anatomy of the thumb deserves finely tuned care based on high quality research. To advance our knowledge and clinical skills we must not become stagnant, but continue to generate high level evidence. The standard for future thumb CMC OA studies should be well-defined intervention parameters, consistent documentation, and the use of appropriate patient-rated outcome measures.     

Dynamic stabilization home exercise program for treatment of thumb carpometacarpal osteoarthritis: A prospective randomized control trial

Study DesignRandomized control trial.IntroductionThumb carpometacarpal (CMC) osteoarthritis (OA) is a common cause of hand pain and disability. Standard conservative therapy (SCT) for thumb CMC OA includes an orthosis and instruction in joint protection, adaptive equipment, and pain relieving modalities. The dynamic stability home exercise (HE) program is complementary conservative therapy designed to strengthen the stabilizing muscles of the thumb CMC.Purpose of the StudyTo investigate whether the addition of HE to SCT (SCT+HE) was more effective at reducing pain and disability in thumb CMC OA compared to SCT alone.MethodsThe study compared 2 groups: SCT and SCT+HE. The SCT group received SCT with in-home pain management instructions, joint protection strategies with adaptive equipment, and a hand-based thumb-spica orthosis. The SCT+HE group received HE program instructions for adductor stretching and opponens and first dorsal interosseous strengthening in addition to SCT. Our primary outcome measure was the numerical rating scale (NRS) with secondary outcome measures of QuickDASH (shortened Disabilities of the Arm, Shoulder and Hand questionnaire), range of motion, grip strength, and pinch strength. Outcome measurements were assessed at first visit, 6 weeks, and 6 months.ResultsThere was no statistical difference between the 2 groups for NRS and QuickDASH at 6 weeks (P = .28 and P = .36, respectively) or 6 months (P = .52 and P = .97, respectively). However, there was a statistically significant decrease in NRS and QuickDASH scores at 6 weeks and 6 months within both groups.ConclusionsBoth SCT and SCT+HE are effective at reducing pain and disability in OA of the thumb CMC joint. Neither therapy program was superior to the other at improving NRS or QuickDASH scores at 6-week or 6-month follow-up.     

Splinting the degenerative basal joint: custom-made or prefabricated neoprene?

The purpose of this study was to compare the objective, subjective, and radiographic responses of patients with carpometacarpal joint osteoarthritis (CMCJ-OA) wearing a prefabricated neoprene splint (PFN), which crosses the CMCJ and metacarpophalangeal joint, with those of patients wearing a custom-made thermoplastic short opponens splint (CMT), which crosses only the CMCJ. Patients ( N = 25) with first CMCJ stage I and II osteoarthritis were assigned randomly to wear either the PFN splint or the CMT splint for one week. After one week, the subjects rated their function in the splint and their satisfaction and pain levels on visual analogue scales. Pinch measurements were performed and x-rays were taken to assess carpometacarpal subluxation. The second splint was then applied for one week and all measures were repeated. The subjects rated the PFN splint significantly higher, and most reported that they would choose the PFN splint over the CMT splint for daily and long-term use. Both pain and function were improved with splinting, but the effect was amplified with the PFN splint compared with the CMT splint. Both splints reduced subluxation at the first carpometacarpal joint, but the CMT effect was greater. This study further supports current evidence that subjects with stage I and II first CMCJ-OA will have pain relief with thumb splinting. In addition, the PFN splint will provide greater relief when compared with the CMT splint. Furthermore, this study reveals that patients prefer the PFN splint to the CMT splint.     

Clinical effects of proprioceptive thumb exercise for individuals with carpometacarpal joint osteoarthritis: A randomized controlled trial

Study DesignRandomized Control Trial.IntroductionThumb CMC joint OA is a common diagnosis. Currently there is no evidence available to under if proprioceptive neuromuscular training is an effective intervention for this population.Purpose of the studyTo establish the effectiveness of a proprioceptive training program as a complementary therapy for patients with thumb CMC joint OA.MethodsStandard conservative thumb CMC joint OA treatments were received by both the control (n = 26) and experimental groups (n = 26) for a period of 12 weeks. The experimental group received a proprioceptive training program during the same intervention period. Outcome measures included severity of pain with activity according to the numerical rating scale (NRS), QuickDASH, Canadian Occupational Performance Measure (COPM), and proprioception via joint position sense (JPS).ResultsFifty-two females participated in the study. Both the experimental and control group made both clinically and statistically significant changes in the mean VAS and COPM scores over time. Only the experimental group achieved a statistically and clinically significant change in JPS error score over time.DiscussionExperimental group achieved a statistically significant change in JPS over time in concordance with previous investigations. Changes in pain scores differed from prior investigations and the between-group comparison was not statistically significant. Changes in the Quick DASH was similar to previous findings.ConclusionProprioceptive training in addition to a traditional rehabilitation program decreased error scores on the joint position sense test.     

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

Study DesignRetrospective case series.IntroductionLiterature 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 Study1) 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.MethodsAn 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.ResultsA 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.ConclusionAfter 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.     

Carpometacarpal and metacarpophalangeal joint collapse is associated with increased pain but not functional impairment in persons with thumb carpometacarpal osteoarthritis

IntroductionDue to the complex shape of the carpometacarpal (CMC) joint, a fixed joint collapse deformity of the thumb CMC (CMC1) and metacarpophalangeal (MCP1) joint can present in advanced stages of CMC1 osteoarthritis (OA), resulting in adduction of the first metacarpal (MC1) and hyperextension of the MCP1.Purpose of the StudyTo determine whether joint collapse deformity is associated with worse pain and/or functional impairment.Study DesignCross-sectional.MethodsThis study used the baseline data from 140 patients enrolled in a longitudinal study of treatment for CMC1 OA. (efficacy of combined conservative therapies on clinical outcomes in patients with CMC1 OA). Joint collapse was determined at baseline using a pinch gauge. Pain was assessed on a visual analog scale (0-100) and function was assessed using the Functional Index for Hand Osteoarthritis questionnaire (0-30). Pain and function and the presence of joint collapse were entered in a univariate logistic regression. The final adjusted model for pain and joint collapse included age and sex. The final adjusted model for function and joint collapse included Kellgren Lawrence grade and grip strength.ResultsAbout 20% of participants demonstrated joint collapse on the tip-pinch test. The presence of joint collapse was associated with increased pain in the unadjusted [P = .047, OR = 2.45, 95% CI (1.01, 5.910)] and adjusted model [P = .049, OR = 2.45, 95% CI (1.00, 5.98)].ConclusionCMC1 patients with joint collapse reported increased pain compared with those without joint collapse. Future studies should determine the relationship between thumb hypermobility and joint collapse and how to manage these conditions effectively.     

Conservative therapeutic interventions for osteoarthritic finger joints: A systematic review

Study DesignSystematic review.IntroductionHand osteoarthritis (OA) is a chronic and disabling disease causing pain and functional limitations in approximately 54%-67% of the adult population aged 55 years and older.Purpose of the StudyThe objective of the study is to evaluate the evidence supporting conservative therapeutic interventions for the treatment of OA finger joints.MethodsEighteen studies dated between 1979 and 2016 were identified meeting the inclusion criteria. They were analyzed based on Structured Effectiveness for Quality Evaluation of a Study, level of evidence, and effect size.Results and ConclusionsThe current evidence varies in quality and effect sizes but generally supports the use of active range of motion and resistive exercises, joint protection, electromagnetic therapy, paraffin wax, and balneotherapy (combined and/or not combined with mud packs and magnetotherapy), and distal interphalangeal orthoses as effective treatment interventions for individuals with OA finger joints.     

Certified hand therapists membership in the American Society of Hand Therapists: A survey study

Study DesignSurvey research.MethodsA pilot tested survey was administered through an electronic mailing system to 5777 CHTs with email addresses on file at Hand Therapy Certification Commission. The survey was electronically distributed on two separate occasions to maximize the response rate.ResultsThe response rate was 53% (n = 1271). The majority of the respondents who were not members of ASHT, 49% (441), indicated that member fees are too expensive, and 35% (311) respondents selected other as the reason. They specified that they were members in another country, the expenses were too high, or that they were retired. Ten percent (93) of respondents answered that they did not know what member benefits were offered, and 4% (40) responded that they do not value the member benefits offered. Finally, 2% (14) of participants answered that they do not value membership in any other professional organization.DiscussionWhile ASHT membership cost is lower than the benefits the member receives, some do not believe that the costs outweighs the benefits. The combination of these factors accounts for approximately half of all CHTs choosing not to join ASHT.ConclusionMany established members value their membership and find it beneficial not only for themselves but also for furthering the profession as well. Many CHTs identified cost as the most apparent factor for not joining ASHT.     

Convergent validity and responsiveness of the Canadian Occupational Performance Measure for the evaluation of therapeutic outcomes for patients with carpometacarpal osteoarthritis

Study DesignThis is a longitudinal, observational, multicenter, cohort study.IntroductionThumb carpometacarpal (CMC) osteoarthritis (OA) is associated with more pain and restrictions than other hand OA. The use of patient-identified occupational performance goals to guide hand therapy treatment and to measure clinical outcomes is fundamental for a patient-centered intervention. The COPM enables subjects to identify goals for hand therapy and engage in a subject-specific therapeutic process.Purpose of the StudyThe purpose of this study is to evaluate the convergent validity and responsiveness of the COPM to evaluate the relationship between the patient’s self-perception and satisfaction of performance in everyday living and pain intensity, upper limb function, and manual ability.MethodsEligible participants to multiple hand therapy centers were recruited. Outcomes measures (VAS scale, QuickDASH, MAM-36, and the COPM questionnaire) were measured at the baseline and 3 months after.ResultsOne hundred forty-five (n = 145) consecutive patients for five different hand rehabilitation centers with symptomatic thumb CMC OA were screened for eligibility criteria. COPM-P and COPM-S were the most responsive instruments, with an area under the curve of 0.88 (95% CI 0.79-0.96) and 0.88 (95% CI 0.80-0.96), respectively.ConclusionsAlthough more investigation in this area is necessary to conclude that the COPM is the best option to evaluate the effectiveness of hand therapy interventions for thumb OA. The COPM focuses on function and occupation and, in comparison with others upper limb scales, does not require the use of another complementary scale for addressing both satisfaction and ADL status. COPM is an instrument with a good convergent validity and responsiveness to evaluate the relationship between the patient’s self-perception and satisfaction in thumb CMC OA.     

The range of movement of the thumb

Purpose

The movements at each thumb joint are flexion and extension (called radial abduction in the CMCJ) and additional movements of anteposition, retroposition and opposition at the CMCJ, due to the saddle shape of the articulation. Our study was designed to provide a means of thumb movement measurement and provide a range for each.

Methods

A prospective cohort study was performed looking at 100 consecutive individuals without thumb pathology to determine thumb joint range of movements and evaluate the reliability of such measurements.

Results

The mean age was 26 (range of 18–37) with 62 female individuals. The mean range of movement of the IPJ was flexion of 88 ° (80–90 °) and extension of 12 ° (0–45 °). That of the MCPJ was flexion of 60 ° (43–70 °) and extension of 8.1 ° (0–15 °). That of the CMCJ was anteposition of 61.2 ° (50–71 °), retroposition of 31.1 mm (25–38 mm), radial abduction of 62.9 ° (53–71 °), opposition Kapandji grade 9 (grades 9–10) and adduction of 10.2?±?4 ° (5–20 °). CMC adduction was difficult to measure with a poor intra- and inter-observer correlation (inter-reliability correlation coefficient of 0.02 and intra-reliability coefficient of 0.04). For the remaining measurements, the mean inter-reliability correlation coefficient was 0.82 (p?<?0.01) while the mean intra-reliability correlation coefficient was 0.93 (p?<?0.01). There was negative correlation identified between IPJ extension and MCPJ extension (?0.50) and between CMCJ radial abduction and MCPJ extension (?0.60).

Conclusions

Having established the normal ranges of movements for the thumb joints and shown that our measurement methods are reliable and reproducible, we have identified that a reduction in certain thumb joint movements appears to be compensated for by an increased movement range in the other joints.     

In Vivo Measurement of Thumb Joint Reaction Forces During Smartphone Manipulation: A Biomechanical Analysis

The relationship between arthritis or repetitive stress injuries (RSIs) in thumbs and rapidly increasing hours of smartphone usage is not fully elucidated. We evaluated axial joint reaction forces (AJRFs) and thumb torques in 19 healthy subjects performing typical smartphone tasks, which included tapping, tap game, and swiping. We measured force and torque when a subject tapped or swiped the panel of the smartphone and analyzed the motions of each joint using surface markers and motion capture systems. We calculated AJRFs and torques on each thumb joint using inverse dynamics. The results were then compared with representative activities such as computer keyboard typing and handwriting. The mean AJRFs/torques at the thumb carpometacarpal joint (CMCJ) while tapping the smartphone and tap gaming were 12.5 N/95.5 N mm and 21.1 N/187.21 N mm, respectively. AJRFs and torques were significantly higher during tap gaming activities than during simple tapping subtasks (p = 0.003 and p < 0.001, respectively). Compared with those during computer keyboard typing, the mean AJRFs and torques at the CMCJ during smartphone tapping was 3 (p = 0.075) and 1.4 times (p = 0.680) larger, respectively. Considering the rapidly increasing dependency on smartphones in our daily lives, long‐term exposure of the thumb to repetitive AJRFs and torques may lead to an acceleration of arthritis or aggravation of RSIs in thumbs. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2437–2444, 2019     

The use of occupation-based interventions and assessments in hand therapy: A cross-sectional survey

IntroductionThe purpose of this study was to gather information on how hand therapists incorporate occupation-based interventions in their clinical practice and what outcome measures hand therapists use to measure the occupational performance of their clientsStudy DesignCross-Sectional Survey Design.MethodsThe 16-item Survey was distributed to members of the American Society of Hand Therapists on two occasions.ResultsThree hundred eleven hand therapists responded to the survey. Hand therapists use a variety of occupation-based interventions (OBI) in clinical practice and most believe they are important. Findings from this study reveal that incorporating an occupation-based assessment along with or in place of an assessment of body functions and structures is not performed routinely. One hundred twenty-six (41%) respondents indicated that they use occupation-based activities 26-50% of the time with their clients.DiscussionThe top three OBI interventions used by hand therapists included dressing tasks, cooking and meal preparation, and in hand manipulation of coins and medication. The lack of understanding of the theoretical models regarding occupation-based interventions may be a barrier toward implementation of occupation-based interventions and assessments as many hand therapists may have trained under a medical model.ConclusionMost respondents to this survey indicated that they believe OBI should be performed by hand therapists and use them routinely in practice. The most frequently used type of assessment was the DASH (Disabilities of the Shoulder Arm & Hand). The least frequently used assessment was the Short Form 36 and patient specific occupation-based assessment.