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Thumb carpometacarpal osteoarthritis: A musculoskeletal physiotherapy perspective
Accepted Manuscript Thumb carpometacarpal osteoarthritis: a musculoskeletal physiotherapy perspective Jorge Hugo Villafañe, Kristin Valdes, Paolo Pedersini, Pedro Berjano PII:
S1360-8592(19)30089-0
DOI:
https://doi.org/10.1016/j.jbmt.2019.02.018
Reference:
YJBMT 1785
To appear in:
Journal of Bodywork & Movement Therapies
Received Date: 18 January 2019 Revised Date:
18 February 2019
Accepted Date: 19 February 2019
Please cite this article as: Villafañe, J.H., Valdes, K., Pedersini, P., Berjano, P., Thumb carpometacarpal osteoarthritis: a musculoskeletal physiotherapy perspectiveName of department(s) and institution(s) to which the work should be attributed, Journal of Bodywork & Movement Therapies, https:// doi.org/10.1016/j.jbmt.2019.02.018. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title: Thumb carpometacarpal osteoarthritis: a musculoskeletal physiotherapy perspective
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Correspondence for contact purposes only: Name Paolo Pedersini Department Clinical Research Institution Fondazione Don Carlo Gnocchi, Milan Country Italy Tel +39.3388782284 Email [email protected]
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1. Jorge Hugo Villafañe, IRCSS Fondazione Don Carlo Gnocchi, Milan, Italy, [email protected] 2. Kristin Valdes, Gannon University, Ruskin FL, USA, [email protected] 3. Paolo Pedersini, IRCSS Fondazione Don Carlo Gnocchi, Milan, Italy, [email protected] 4. Pedro Berjano, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy [email protected]
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Initial, surnames, appointments and highest academic degrees of all authors JH Villafañe, PhD; K Valdes, OTD, OT, CHT; P Pedersini, PT; P Berjano PhD, MD. Running Head: Narrative review for thumb osteoarthritis.
ACCEPTED MANUSCRIPT Title of your manuscript Thumb carpometacarpal osteoarthritis: a musculoskeletal physiotherapy perspective Authorship list Jorge Hugo Villafañea; Kristin Valdesb; Paolo Pedersinia#; Pedro Berjanoc
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Author affiliations IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy a; Gannon University, Ruskin FL, USA b ; IRCCS Istituto Ortopedico Galeazzi, Milan, Italy c
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Name of department(s) and institution(s) to which the work should be attributed None. Sources of support in the form of grants or industrial support None. Initial, surnames, appointments and highest academic degrees of all authors JH Villafañe, PhD; K Valdes, OTD, OT, CHT; P Pedersini, PT; P Berjano PhD, MD.
Corresponding author Dr. Pedersini Paolo, PT. Via Don A. Marini, 1 Travagliato (25039), BS. Italy Phone: +39-3388782284 Email: [email protected]
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e-mail: JHV: [email protected] ; KV: [email protected] ; PP: [email protected]; PB: [email protected]
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Running Head: Narrative review for thumb osteoarthritis.
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ACCEPTED MANUSCRIPT Thumb carpometacarpal osteoarthritis: a musculoskeletal physiotherapy perspective Abstract. Propose: To perform a literature review to provide the practitioner with a description of the information and techniques to enhance the provision of conservative interventions in
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clinical practice.
Methods: Studies were obtained from MEDLINE, CINAHL, Embase, PEDro and
CENTRAL databases from their inception to December 2017. Authors independently
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selected studies, conducted quality assessment, and extracted results.
Results: There is evidence to support a multimodal approach to the therapeutic
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management of the patient with CMC OA. This distinct approach includes: patient education, manual therapy, therapeutic exercise program, and orthotic provision. Conclusion: There is evidence to support some of the commonly performed conservative interventions to improve hand function and decrease hand pain.
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Keywords: Thumb, carpometacarpal joint, osteoarthritis, musculoskeletal pain.
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Thumb carpometacarpal osteoarthritis: a musculoskeletal physiotherapy perspective Introduction Thumb carpometacarpal (CMC) osteoarthritis (OA) is one of the most common form of hand OA affecting many individuals after the age of 50 and postmenopausal women
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(Haara et al., 2004). In thumb CMC OA, pain and functional limitations can lead to a high degree of disability (Luker et al., 2014) (Villafane et al., 2018b). The CMC joint is classified as having a concavo-convex saddle design (Matullo et al., 2007). The concavity of each
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articular surface is shallow, so the skeleton does not provide intrinsic stability of the joint. The ligaments and muscles surrounding the joint play varying roles in stability, laxity, and
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proprioception (Matullo et al., 2007).
Erosion and deterioration of the joint surfaces, ligamentous laxity, and osteophyte formation are hallmarks of CMC OA (Matullo et al., 2007). The three main theories of thumb CMC OA etiology are ligamentous laxity, joint compression, and lack of
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neuromuscular control of the joint. Proponents of ligamentous laxity theory (Bettinger et al., 2000) have found that thumbs with CMC OA exhibit degeneration of the palmar or beak ligament, and which may result in both higher than normal shear stress and
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deterioration of the joint. Some researchers (Koff et al., 2003; Kovler et al., 2004) have demonstrated the degeneration along the dorsoradial aspect of the trapezium that may be
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a result of the rotation of the thumb metacarpal on the trapezium during pinch and grip. Finally, the presence of mechanoreceptors in the dorsal CMC joint ligaments suggests that impaired proprioceptive function of these ligaments may lead to thumb instability (Hagert et al., 2012).
Thumb CMC OA is classified according to the Eaton system that classifies subluxation and extent of subluxation of the first metacarpal on the trapezium by a radiograph (Bijlsma et al., 2011). In early OA, the aim of conservative management should be reduced pain, improved function, and enhanced joint stability (Zhang et al., 2008). Early 3
ACCEPTED MANUSCRIPT management of CMC OA aims to improve the individuals of quality of life through pain reduction. There are both non-pharmacological and pharmacological conservative treatment interventions. These interventions can be modified to meet the individual’s needs as the disease process progresses (Bijlsma et al., 2011). Patient education may be
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provided to increase patient adherence, although this has not been studied through the scientific process yet (May, 2010). There have been two recent systematic reviews that evaluated the quality of the evidence for the conservative management of thumb CMC OA
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(Bertozzi et al., 2015; Spaans et al., 2015).
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ACCEPTED MANUSCRIPT Methods Authors performed a literature search to identify all the available studies that evaluated the effectiveness of conservative interventions that can be administered by a clinician in relieving pain and improving hand function in people with CMC OA. Studies
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were obtained from MEDLINE, CINAHL, Embase, PEDro and CENTRAL databases from their inception to December 2017. Authors independently selected studies, conducted quality assessments, and extracted the results.
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Results
There is recent evidence that supports multiple conservative interventions
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performed in therapy to improve hand function and decrease hand pain in patients with thumb CMC OA (Bertozzi et al., 2015). Manual therapy and therapeutic exercise have moderate evidence to improve pain in patients with thumb CMC OA at both the short- and intermediate-term follow-up (Bertozzi et al., 2015). The strongest evidence supports the
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combination of manual therapy and therapeutic exercises for CMC OA. That combination of interventions had a large effect size of -116.67 with a confidence interval (CI) of (137.55, -95.78) for the reduction of pain (Bertozzi et al., 2015). The effect size of orthoses
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(splints) on pain reduction was weak and not significant (g=0.46), with a range from -1.08 to 0.16 at a short-term follow-up, while it was very large but not significant (g=1.65), with a
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range from -4.04 to 0.74 at a long-term follow-up (Bertozzi et al., 2015). Manual therapy was effective in the reduction of pain at the short-term follow-up with an effect size of (g=1.86), with a range of -3.70 to -0.025 (Bertozzi et al., 2015). A multifaceted approach to the therapeutic management of the patient with CMC OA is recommended (Villafane et al., 2019). Best practice includes: patient education, manual therapy, therapeutic exercise program, and orthotic provision. Additional evidence is needed to determine at what stage of CMC OA conservative management beneficial and when the patient may require surgical intervention. The following information will 5
ACCEPTED MANUSCRIPT provide the practitioner with a description of the information and techniques to enhance the provision of the intervention in clinical practice. Patient education Pain relief and restoration of function are primary objectives of rehabilitation.
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Education of joint protection techniques can prevent further deterioration of the joint. Particular information that should be shared with the patient regarding the CMC joint is that the joint is most unstable during key pinch rather than jar grasping or twisting (Halilaj et al.,
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2015). Patients should be taught to perform pinching activities with a tip or tripod pinch rather than lateral or key pinch (Valdes and von der Heyde, 2012). Patient education can
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also be provided regarding the use of heat or cold for pain control. Adaptive device education can improve patient functioning for turning a key, opening a jar, or cutting food. Using video-based online content as a patient teaching tool, has a low level of evidence to support this method of patient education (Villafane et al., 2017a).
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Manual therapy
The manual therapy techniques used in the treatment of CMC OA include both neural mobilization and joint mobilization. Successful results have been reported with techniques
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that are described here (Bertozzi et al., 2015). a) Posterior-anterior gliding with distraction: Kaltenborn's posterior-anterior gliding with
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distraction can be applied to the thumb CMC joint to relieve pain and improve motor function (Villafane et al., 2014; Villafane et al., 2011). Kaltenborn classifies the movement patterns using the convex-concave rule. Gliding of the female portion of the CMC joint (the 1st metacarpal) occurs in the same direction as the bone movement (Exelby, 1996). The convex surface (the trapezium) glides in the opposite direction of the bone movement (Exelby, 1996; Kaltenborn and Evjenth, 1999). Traction is applied to distract the articular surfaces and while gliding one articular surface parallel to the other (Gokeler et al., 2003). Grade 3 traction is an 6
ACCEPTED MANUSCRIPT additional force that can be applied in the parallel axis resulting in soft tissue and joint stretching while separating the joint surfaces (Gokeler et al., 2003). The therapist stabilizes the patient’s right thumb metacarpal bone with his right thumb and index fingers while distracting the joint and gliding the patient’s first metacarpal
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in a posterior-anterior direction (See figure 1). The manual therapy sessions last three minutes, with a one-minute rest period. This mobilization sequence can be repeated 3 times (Villafane et al., 2014; Villafane et al., 2011).
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PLACE FIGURE 1 HERE.
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b) Passive joint mobilization (PJM): Passive joint mobilization translates the bone through the full mobility of the joint capsule (Maitland et al., 2001). Passive joint mobilization aims to improve joint nutrition and relieve pain (Glasgow et al., 2010). The technique can reduce pain by both mechanical and neurophysiological mechanisms (Green et al., 2001). Passive movements can also reduce pain by
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local and spinal mechanisms that inhibit muscle contractions (Hobbelen et al., 2007) and reduce joint ligament afferent transmission (Zusman, 1986.). To perform
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the technique, the therapist positions his right elbow on the scapular girdle of the patient and his forearm along the subject’s arm. The therapist then takes the right
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hand of the patient to stabilize the patient’s thumb and fingertips. The patient’s forearm is raised and the wrist and fingers are taken into neutral position and the shoulder turned laterally (75°-90°) while extending the elbow. The therapist moves the patient’s elbow, wrist and hand simultaneously into flexion and then the patient’s arm is brought back to the initial position (extension). To help reduce pain and improve function, some authors suggest combining PJM and conservative treatment of Myofascial Trigger Points (Villafane and Herrero, 2016).
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ACCEPTED MANUSCRIPT c) Passive accessory mobilization: Maitland’s techniques focus on oscillatory joint mobilization techniques to obtain passive arthrokinematic joint motion. The therapist varies both the frequency and amplitude of movements depending on the aim of the mobilization technique and the patient’s tolerance. The goal of accessory
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mobilization is to reduce joint stiffness and pain (Heiser et al., 2013).
The therapist moves the patient’s first metacarpal bone posteriorly and anteriorly using a gentle oscillatory technique as described by Maitland (Green et al., 2001)
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for three minutes, with a one minute rest, and the mobilization sequence can be repeated 3 times (Villafañe et al., 2013; Villafañe et al., 2012). These movements
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consist of 60 oscillations per minute; the force used for the mobilization is a smallamplitude oscillation. The oscillatory technique is performed as far as possible into range of the accessory-passive mobilization movement without producing pain. (See figure 2).
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Mobilization with movement (MWM) is a manual therapy technique that employs a sustained accessory glide at a joint at the same time as another movement that would normally be pain provoking is performed either actively or passively
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(Paungmali et al., 2004). The MWM and kinesiology tape can provide an effective treatment for individuals with thumb CMC OA. It has been reported that patients
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report decreased pain and improved function with MWM, (See Figure 3). The techniques can be added to the clinician’s repertoire of efficacious interventions (Adams et al., 2015; Villafane et al., 2013b). PLACE FIGURE 2 HERE. PLACE FIGURE 3 HERE.
d) Neural mobilization: Nerve mobilization removes nervous system tension by gliding a nerve by alternating movement of at least two joints (Coppieters and Alshami, 2007). In the initial movement, the elbow extends, which stretches the median 8
ACCEPTED MANUSCRIPT nerve, while the wrist flexes. In the final movement, the elbow flexes, shortening the median nerve, and the wrist extends (Coppieters and Alshami, 2007) (See Figure 4). The radial nerve mobilization technique alternates the combination of elbow flexion and wrist flexion and wrist ulnar deviation; and shoulder elevation
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simultaneously with elbow extension and wrist extension, (See Figure 5) (Villafane et al., 2013a; Villafane et al., 2012).
These movements consist of switching from one to the other constantly (1 second
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into extension and 1 second into flexion). The therapist can change the velocity of movements to ensure that no pain is produced. The techniques can be applied 3
PLACE FIGURE 4 HERE. PLACE FIGURE 5 HERE.
Therapeutic exercise program
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times for 3 minutes separated by 1-minute rest periods.
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Dynamic thumb stability exercises that strengthen the muscles that oppose the adductor pollicis and stabilize the thumb have been shown to improve thumb function and decrease pain (O'Brien and Giveans, 2013). A recent study demonstrated the importance
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of the opponens muscle and 1st dorsal interosessous muscle (Adams et al., 2015) A dynamic thumb stabilization exercise program has not been tested with a randomized
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controlled trial, but it is based on biomechanical and cadaver studies of the thumb (Valdes and von der Heyde, 2012). Another study showed the importance of a Neuromuscular Re-education (NMRE) with thumb opposition in closed kinetic chain exercises (Villafane et al., 2018a). All exercises should be performed pain free and progressed from isometric to light resistance as tolerated. Orthoses A variety of orthotic devices have been studied to determine patient preference and efficacy. The provision of the device should be discussed with the patient regarding their 9
ACCEPTED MANUSCRIPT lifestyle and preference to ensure compliance with the use of the device. The device helps to stabilize the CMC joint and rest the inflamed joint to reduce pain. Both custom and prefabricated devices have both been shown to be efficacious (Bertozzi et al., 2015). Outcome measures
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Pressure pain threshold (PPT) and the visual analogue scale (VAS), have been reported to be the most sensitive outcome measures of pain when tracking changes in thumb CMC OA (Pedersini et al., 2019). Clinicians should use either the PPT or VAS as of
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the outcome measures used in clinical practice (Villafañe et al., 2012). Grip and pinch strength can be measured reliably using the Jamar and Gauge Dynamometer, in patients
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with thumb CMC OA (Villafañe and Valdes, 2014; Villafane et al., 2017b; Villafañe et al., 2015). The use of a validated patient report outcome measure should also be incorporated into practice. Conclusions
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To improve hand function and decrease hand pain the conservative interventions commonly performed by clinician’s have a varied degree of evidence to support their use in clinical practice. Interventions that address thumb proprioception deficits and kinematic
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alterations required methodologically sound randomized controlled trials to determine their efficacy. Collaborative between rheumatologists, orthopedics, therapists, and patients is
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essential for a comprehensive management program. This collaboration will hopefully preserve thumb function in the future.
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ACCEPTED MANUSCRIPT Figure legends Figure 1. Kaltenborn posterior-anterior gliding with distraction. Figure 2. Maitland technique. Figure 3. Mobilization with movement technique.
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Figure 4. Nerve slider exercise used to target the median nerve. Figure 5. Nerve slider exercise used to target the radial nerve.
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Acknowledgements
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The authors would like to thank Barbara Piovanelli for her contributions to this study.
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Subjects. Rehabilitation nursing : the official journal of the Association of Rehabilitation Nurses 42, 139-145. Villafane, J.H., Valdes, K., O'Brien, V., Seves, M., Cantero-Tellez, R., Berjano, P., 2018a. Conservative management of thumb carpometacarpal osteoarthritis: An Italian survey of current clinical practice. Journal of bodywork and movement therapies 22, 37-39. Villafane, J.H., Valdes, K., Pedersini, P., Berjano, P., 2018b. Osteoarthritis: a call for research on central pain mechanism and personalized prevention strategies. Clinical rheumatology. 38(2):583-4. Villafañe, J.H., Valdes, K., Vanti, C., Pillastrini, P., Borboni, A., 2015. Reliability of handgrip strength test in elderly subjects with unilateral thumb carpometacarpal osteoarthritis. Hand 10, 205-209. Zhang, W., Moskowitz, R.W., Nuki, G., Abramson, S., Altman, R.D., Arden, N., Bierma-Zeinstra, S., Brandt, K.D., Croft, P., Doherty, M., Dougados, M., Hochberg, M., Hunter, D.J., Kwoh, K., Lohmander, L.S., Tugwell, P., 2008. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis and cartilage / OARS, Osteoarthritis Research Society 16, 137-162. Zusman, M., 1986. Spinal manipulative therapy: review of some proposed mechanisms, and a new hypothesis. Austr J Physiother. 32 (2): 89-99.
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S1360-8592(19)30089-0
DOI:
https://doi.org/10.1016/j.jbmt.2019.02.018
Reference:
YJBMT 1785
To appear in:
Journal of Bodywork & Movement Therapies
Received Date: 18 January 2019 Revised Date:
18 February 2019
Accepted Date: 19 February 2019
Please cite this article as: Villafañe, J.H., Valdes, K., Pedersini, P., Berjano, P., Thumb carpometacarpal osteoarthritis: a musculoskeletal physiotherapy perspectiveName of department(s) and institution(s) to which the work should be attributed, Journal of Bodywork & Movement Therapies, https:// doi.org/10.1016/j.jbmt.2019.02.018. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title: Thumb carpometacarpal osteoarthritis: a musculoskeletal physiotherapy perspective
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Correspondence for contact purposes only: Name Paolo Pedersini Department Clinical Research Institution Fondazione Don Carlo Gnocchi, Milan Country Italy Tel +39.3388782284 Email [email protected]
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1. Jorge Hugo Villafañe, IRCSS Fondazione Don Carlo Gnocchi, Milan, Italy, [email protected] 2. Kristin Valdes, Gannon University, Ruskin FL, USA, [email protected] 3. Paolo Pedersini, IRCSS Fondazione Don Carlo Gnocchi, Milan, Italy, [email protected] 4. Pedro Berjano, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy [email protected]
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Initial, surnames, appointments and highest academic degrees of all authors JH Villafañe, PhD; K Valdes, OTD, OT, CHT; P Pedersini, PT; P Berjano PhD, MD. Running Head: Narrative review for thumb osteoarthritis.
ACCEPTED MANUSCRIPT Title of your manuscript Thumb carpometacarpal osteoarthritis: a musculoskeletal physiotherapy perspective Authorship list Jorge Hugo Villafañea; Kristin Valdesb; Paolo Pedersinia#; Pedro Berjanoc
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Author affiliations IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy a; Gannon University, Ruskin FL, USA b ; IRCCS Istituto Ortopedico Galeazzi, Milan, Italy c
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Name of department(s) and institution(s) to which the work should be attributed None. Sources of support in the form of grants or industrial support None. Initial, surnames, appointments and highest academic degrees of all authors JH Villafañe, PhD; K Valdes, OTD, OT, CHT; P Pedersini, PT; P Berjano PhD, MD.
Corresponding author Dr. Pedersini Paolo, PT. Via Don A. Marini, 1 Travagliato (25039), BS. Italy Phone: +39-3388782284 Email: [email protected]
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e-mail: JHV: [email protected] ; KV: [email protected] ; PP: [email protected]; PB: [email protected]
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Running Head: Narrative review for thumb osteoarthritis.
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ACCEPTED MANUSCRIPT Thumb carpometacarpal osteoarthritis: a musculoskeletal physiotherapy perspective Abstract. Propose: To perform a literature review to provide the practitioner with a description of the information and techniques to enhance the provision of conservative interventions in
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clinical practice.
Methods: Studies were obtained from MEDLINE, CINAHL, Embase, PEDro and
CENTRAL databases from their inception to December 2017. Authors independently
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selected studies, conducted quality assessment, and extracted results.
Results: There is evidence to support a multimodal approach to the therapeutic
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management of the patient with CMC OA. This distinct approach includes: patient education, manual therapy, therapeutic exercise program, and orthotic provision. Conclusion: There is evidence to support some of the commonly performed conservative interventions to improve hand function and decrease hand pain.
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Keywords: Thumb, carpometacarpal joint, osteoarthritis, musculoskeletal pain.
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Thumb carpometacarpal osteoarthritis: a musculoskeletal physiotherapy perspective Introduction Thumb carpometacarpal (CMC) osteoarthritis (OA) is one of the most common form of hand OA affecting many individuals after the age of 50 and postmenopausal women
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(Haara et al., 2004). In thumb CMC OA, pain and functional limitations can lead to a high degree of disability (Luker et al., 2014) (Villafane et al., 2018b). The CMC joint is classified as having a concavo-convex saddle design (Matullo et al., 2007). The concavity of each
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articular surface is shallow, so the skeleton does not provide intrinsic stability of the joint. The ligaments and muscles surrounding the joint play varying roles in stability, laxity, and
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proprioception (Matullo et al., 2007).
Erosion and deterioration of the joint surfaces, ligamentous laxity, and osteophyte formation are hallmarks of CMC OA (Matullo et al., 2007). The three main theories of thumb CMC OA etiology are ligamentous laxity, joint compression, and lack of
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neuromuscular control of the joint. Proponents of ligamentous laxity theory (Bettinger et al., 2000) have found that thumbs with CMC OA exhibit degeneration of the palmar or beak ligament, and which may result in both higher than normal shear stress and
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deterioration of the joint. Some researchers (Koff et al., 2003; Kovler et al., 2004) have demonstrated the degeneration along the dorsoradial aspect of the trapezium that may be
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a result of the rotation of the thumb metacarpal on the trapezium during pinch and grip. Finally, the presence of mechanoreceptors in the dorsal CMC joint ligaments suggests that impaired proprioceptive function of these ligaments may lead to thumb instability (Hagert et al., 2012).
Thumb CMC OA is classified according to the Eaton system that classifies subluxation and extent of subluxation of the first metacarpal on the trapezium by a radiograph (Bijlsma et al., 2011). In early OA, the aim of conservative management should be reduced pain, improved function, and enhanced joint stability (Zhang et al., 2008). Early 3
ACCEPTED MANUSCRIPT management of CMC OA aims to improve the individuals of quality of life through pain reduction. There are both non-pharmacological and pharmacological conservative treatment interventions. These interventions can be modified to meet the individual’s needs as the disease process progresses (Bijlsma et al., 2011). Patient education may be
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provided to increase patient adherence, although this has not been studied through the scientific process yet (May, 2010). There have been two recent systematic reviews that evaluated the quality of the evidence for the conservative management of thumb CMC OA
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(Bertozzi et al., 2015; Spaans et al., 2015).
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ACCEPTED MANUSCRIPT Methods Authors performed a literature search to identify all the available studies that evaluated the effectiveness of conservative interventions that can be administered by a clinician in relieving pain and improving hand function in people with CMC OA. Studies
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were obtained from MEDLINE, CINAHL, Embase, PEDro and CENTRAL databases from their inception to December 2017. Authors independently selected studies, conducted quality assessments, and extracted the results.
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Results
There is recent evidence that supports multiple conservative interventions
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performed in therapy to improve hand function and decrease hand pain in patients with thumb CMC OA (Bertozzi et al., 2015). Manual therapy and therapeutic exercise have moderate evidence to improve pain in patients with thumb CMC OA at both the short- and intermediate-term follow-up (Bertozzi et al., 2015). The strongest evidence supports the
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combination of manual therapy and therapeutic exercises for CMC OA. That combination of interventions had a large effect size of -116.67 with a confidence interval (CI) of (137.55, -95.78) for the reduction of pain (Bertozzi et al., 2015). The effect size of orthoses
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(splints) on pain reduction was weak and not significant (g=0.46), with a range from -1.08 to 0.16 at a short-term follow-up, while it was very large but not significant (g=1.65), with a
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range from -4.04 to 0.74 at a long-term follow-up (Bertozzi et al., 2015). Manual therapy was effective in the reduction of pain at the short-term follow-up with an effect size of (g=1.86), with a range of -3.70 to -0.025 (Bertozzi et al., 2015). A multifaceted approach to the therapeutic management of the patient with CMC OA is recommended (Villafane et al., 2019). Best practice includes: patient education, manual therapy, therapeutic exercise program, and orthotic provision. Additional evidence is needed to determine at what stage of CMC OA conservative management beneficial and when the patient may require surgical intervention. The following information will 5
ACCEPTED MANUSCRIPT provide the practitioner with a description of the information and techniques to enhance the provision of the intervention in clinical practice. Patient education Pain relief and restoration of function are primary objectives of rehabilitation.
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Education of joint protection techniques can prevent further deterioration of the joint. Particular information that should be shared with the patient regarding the CMC joint is that the joint is most unstable during key pinch rather than jar grasping or twisting (Halilaj et al.,
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2015). Patients should be taught to perform pinching activities with a tip or tripod pinch rather than lateral or key pinch (Valdes and von der Heyde, 2012). Patient education can
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also be provided regarding the use of heat or cold for pain control. Adaptive device education can improve patient functioning for turning a key, opening a jar, or cutting food. Using video-based online content as a patient teaching tool, has a low level of evidence to support this method of patient education (Villafane et al., 2017a).
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Manual therapy
The manual therapy techniques used in the treatment of CMC OA include both neural mobilization and joint mobilization. Successful results have been reported with techniques
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that are described here (Bertozzi et al., 2015). a) Posterior-anterior gliding with distraction: Kaltenborn's posterior-anterior gliding with
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distraction can be applied to the thumb CMC joint to relieve pain and improve motor function (Villafane et al., 2014; Villafane et al., 2011). Kaltenborn classifies the movement patterns using the convex-concave rule. Gliding of the female portion of the CMC joint (the 1st metacarpal) occurs in the same direction as the bone movement (Exelby, 1996). The convex surface (the trapezium) glides in the opposite direction of the bone movement (Exelby, 1996; Kaltenborn and Evjenth, 1999). Traction is applied to distract the articular surfaces and while gliding one articular surface parallel to the other (Gokeler et al., 2003). Grade 3 traction is an 6
ACCEPTED MANUSCRIPT additional force that can be applied in the parallel axis resulting in soft tissue and joint stretching while separating the joint surfaces (Gokeler et al., 2003). The therapist stabilizes the patient’s right thumb metacarpal bone with his right thumb and index fingers while distracting the joint and gliding the patient’s first metacarpal
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in a posterior-anterior direction (See figure 1). The manual therapy sessions last three minutes, with a one-minute rest period. This mobilization sequence can be repeated 3 times (Villafane et al., 2014; Villafane et al., 2011).
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PLACE FIGURE 1 HERE.
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b) Passive joint mobilization (PJM): Passive joint mobilization translates the bone through the full mobility of the joint capsule (Maitland et al., 2001). Passive joint mobilization aims to improve joint nutrition and relieve pain (Glasgow et al., 2010). The technique can reduce pain by both mechanical and neurophysiological mechanisms (Green et al., 2001). Passive movements can also reduce pain by
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local and spinal mechanisms that inhibit muscle contractions (Hobbelen et al., 2007) and reduce joint ligament afferent transmission (Zusman, 1986.). To perform
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the technique, the therapist positions his right elbow on the scapular girdle of the patient and his forearm along the subject’s arm. The therapist then takes the right
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hand of the patient to stabilize the patient’s thumb and fingertips. The patient’s forearm is raised and the wrist and fingers are taken into neutral position and the shoulder turned laterally (75°-90°) while extending the elbow. The therapist moves the patient’s elbow, wrist and hand simultaneously into flexion and then the patient’s arm is brought back to the initial position (extension). To help reduce pain and improve function, some authors suggest combining PJM and conservative treatment of Myofascial Trigger Points (Villafane and Herrero, 2016).
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ACCEPTED MANUSCRIPT c) Passive accessory mobilization: Maitland’s techniques focus on oscillatory joint mobilization techniques to obtain passive arthrokinematic joint motion. The therapist varies both the frequency and amplitude of movements depending on the aim of the mobilization technique and the patient’s tolerance. The goal of accessory
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mobilization is to reduce joint stiffness and pain (Heiser et al., 2013).
The therapist moves the patient’s first metacarpal bone posteriorly and anteriorly using a gentle oscillatory technique as described by Maitland (Green et al., 2001)
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for three minutes, with a one minute rest, and the mobilization sequence can be repeated 3 times (Villafañe et al., 2013; Villafañe et al., 2012). These movements
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consist of 60 oscillations per minute; the force used for the mobilization is a smallamplitude oscillation. The oscillatory technique is performed as far as possible into range of the accessory-passive mobilization movement without producing pain. (See figure 2).
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Mobilization with movement (MWM) is a manual therapy technique that employs a sustained accessory glide at a joint at the same time as another movement that would normally be pain provoking is performed either actively or passively
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(Paungmali et al., 2004). The MWM and kinesiology tape can provide an effective treatment for individuals with thumb CMC OA. It has been reported that patients
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report decreased pain and improved function with MWM, (See Figure 3). The techniques can be added to the clinician’s repertoire of efficacious interventions (Adams et al., 2015; Villafane et al., 2013b). PLACE FIGURE 2 HERE. PLACE FIGURE 3 HERE.
d) Neural mobilization: Nerve mobilization removes nervous system tension by gliding a nerve by alternating movement of at least two joints (Coppieters and Alshami, 2007). In the initial movement, the elbow extends, which stretches the median 8
ACCEPTED MANUSCRIPT nerve, while the wrist flexes. In the final movement, the elbow flexes, shortening the median nerve, and the wrist extends (Coppieters and Alshami, 2007) (See Figure 4). The radial nerve mobilization technique alternates the combination of elbow flexion and wrist flexion and wrist ulnar deviation; and shoulder elevation
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simultaneously with elbow extension and wrist extension, (See Figure 5) (Villafane et al., 2013a; Villafane et al., 2012).
These movements consist of switching from one to the other constantly (1 second
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into extension and 1 second into flexion). The therapist can change the velocity of movements to ensure that no pain is produced. The techniques can be applied 3
PLACE FIGURE 4 HERE. PLACE FIGURE 5 HERE.
Therapeutic exercise program
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times for 3 minutes separated by 1-minute rest periods.
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Dynamic thumb stability exercises that strengthen the muscles that oppose the adductor pollicis and stabilize the thumb have been shown to improve thumb function and decrease pain (O'Brien and Giveans, 2013). A recent study demonstrated the importance
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of the opponens muscle and 1st dorsal interosessous muscle (Adams et al., 2015) A dynamic thumb stabilization exercise program has not been tested with a randomized
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controlled trial, but it is based on biomechanical and cadaver studies of the thumb (Valdes and von der Heyde, 2012). Another study showed the importance of a Neuromuscular Re-education (NMRE) with thumb opposition in closed kinetic chain exercises (Villafane et al., 2018a). All exercises should be performed pain free and progressed from isometric to light resistance as tolerated. Orthoses A variety of orthotic devices have been studied to determine patient preference and efficacy. The provision of the device should be discussed with the patient regarding their 9
ACCEPTED MANUSCRIPT lifestyle and preference to ensure compliance with the use of the device. The device helps to stabilize the CMC joint and rest the inflamed joint to reduce pain. Both custom and prefabricated devices have both been shown to be efficacious (Bertozzi et al., 2015). Outcome measures
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Pressure pain threshold (PPT) and the visual analogue scale (VAS), have been reported to be the most sensitive outcome measures of pain when tracking changes in thumb CMC OA (Pedersini et al., 2019). Clinicians should use either the PPT or VAS as of
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the outcome measures used in clinical practice (Villafañe et al., 2012). Grip and pinch strength can be measured reliably using the Jamar and Gauge Dynamometer, in patients
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with thumb CMC OA (Villafañe and Valdes, 2014; Villafane et al., 2017b; Villafañe et al., 2015). The use of a validated patient report outcome measure should also be incorporated into practice. Conclusions
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To improve hand function and decrease hand pain the conservative interventions commonly performed by clinician’s have a varied degree of evidence to support their use in clinical practice. Interventions that address thumb proprioception deficits and kinematic
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alterations required methodologically sound randomized controlled trials to determine their efficacy. Collaborative between rheumatologists, orthopedics, therapists, and patients is
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essential for a comprehensive management program. This collaboration will hopefully preserve thumb function in the future.
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ACCEPTED MANUSCRIPT Figure legends Figure 1. Kaltenborn posterior-anterior gliding with distraction. Figure 2. Maitland technique. Figure 3. Mobilization with movement technique.
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Figure 4. Nerve slider exercise used to target the median nerve. Figure 5. Nerve slider exercise used to target the radial nerve.
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Acknowledgements
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The authors would like to thank Barbara Piovanelli for her contributions to this study.
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