Date Presented 03/26/20
In adults with first carpometacarpal degenerative joint disease, does a dynamic stabilization home exercise program (HEP) decrease pain and increase function more than a traditional HEP? Research is needed to assess if this approach will lead to greater function and less pain than the currently accepted approach. It is important for OTs to have a holistic approach that includes traditional joint protection, orthosis use, and self-management of HEPs.
Primary Author and Speaker: Cindy Ivy
Additional Authors and Speakers: Kaylee Martino, Sara Murphy, Celine De Jesus, Stephanie Kannas, Kimberly McVeigh, Allison Nickolaou
PURPOSE: Research Question: In adults with 1st carpometacarpal (CMC) degenerative joint disease (DJD) does a dynamic stabilization home exercise program (HEP) decrease pain and increase function more than a traditional HEP? The thumb CMC is the most functional joint in the hand with movement in all planes, stabilization of objects, and sustaining large forces. CMC DJD is exacerbated from activities like handwriting, holding books, turning doors, crafts, or using scissors. Occupational therapy (OT) intervention includes joint protection principles, exercise, use of assistive devices, and orthotics. There are few high-level studies that focus on OT management of CMC DJD, showing some effectiveness of orthoses (Spaans et al., 2015). Studies of DJD in the shoulders and knees have incorporated dynamic stabilization (DS). DS describes the body’s ability to contract muscles and adjust muscle tension in response to fine movements in order to steady joints so that they are not experiencing unwanted movement or load. This theory was applied to the thumb with focus on targeting the opponens pollicis and 1st dorsal interosseous muscles to stabilize the CMC (McGee et al., 2015). One retrospective study found the dynamic stability approach to significantly reduce pain and disability for the 35 participants (O’Brien & Gieveans,2013). There are no published prospective studies to determine the efficacy of dynamic stability of the 1st CMC for DJD. Research is needed to assess if this approach will give greater function and less pain than the currently accepted approach. It is important for OTs to have a holistic approach that includes traditional joint protection, orthosis use, and HEPs.
DESIGN: The study is an RCT design comparing pre and post outcomes of traditional HEP (TEP) based on published programs versus dynamic stabilization therapy (DST) HEPs. Participants were recruited through fliers. Selection criteria included having 1st CMC DJD as established through prior diagnosis from a physician and/or positive “lever test” (Model et. al, 2016) which has excellent sensitivity and specificity. Inclusion criteria was 18-85 years of age and not seeing OT or physical therapy for the thumb. Exclusion criteria included inability to participate in a follow-up as well as comorbidities of the upper extremity.
METHOD: 61 individuals with thumb CMC DJD were seen over 2.5 years. Participants received either the TEP or the DST HEP based on coin-flip randomization. Visual analogue pain scores (VAPS), QuickDASH, pinch & grip were measured at baseline, 6 weeks and 6 months. They were instructed on exercises and given a home log to track completion. Data was analyzed using multiple one-way repeated measure ANOVAs. Between group differences were measured using between group MANOVAs (p< .01).
RESULTS: Outcomes from baseline to 6-week and 6-month post were statistically significant (P=.0003) in VAPS for both groups. In the QuickDASH, there was not a statistical significance in the DST group. The QuickDASH scores decreased for the TEP, but not for the DST group.
CONCLUSIONS: The study does not show that a DST HEP improves function and pain more than a TEP, however, it does show that a home exercise program may improve pain for persons with 1st CMC DJD. Both groups had statistically significant improvements in pain scores over time. By decreasing pain levels during activities that people enjoy, individuals with CMC DJD can participate in meaningful activities. This research is important in order to inform practice for HEP planning with persons with DJD. No prospective studies on CMC dynamic stabilization exercise have been published to date on this population. The results invite reflection on qualitative exploration of clients’ routines and habits in regard to a HEP.
References
McGee, C., O’Brien, V., Van Nortwick, S., Adams, J., & Van Heest, A. (2015). First dorsal interosseous muscle contraction results in radiographic reduction of healthy thumb carpometacarpal joint. Journal of Hand Therapy, 28(4), 375-381. doi: 10.1016/j.jht.2015.06.002
Model, Z., Liu, A. Y., Kang, L., Wolfe, S. W., Burket, J. C., & Lee, S. K. (2016). Evaluation of physical examination tests for thumb basal joint osteoarthritis. American Association for Hand Surgery, 11(1), 108-112. doi:10.1177/1558944715616951
O’Brien, V. H., & Giveans, M. R. (2013). Effects of a dynamic stability approach in conservative intervention of the carpometacarpal joint of the thumb: a retrospective study. Journal of Hand Therapy, 26(1), 44-52. doi: 10.1016/j.jht.2012.10.005
Spaans, A. J., van Minnen, P. I., Kon, M., Schuurman, A. H., Shreuders, A. R., & Vermeulen, G. M. (2015). Conservative treatment of thumb base osteoarthritis: A systematic review. The American Society for Surgery of the Hand, 40(1), 16-21. doi: 10.1016/j.jhsa.2014.08.047
