Hand Therapy
A Clinical Case
By Karen Fitt

What is Hand Therapy
Hand Therapy is the art and science of rehabilitation of the upper limb. It involves evaluation and testing to assess the injured limb from which a specific treatment program can be designed. A variety of specialised treatment techniques are used to achieve these goals, such as splinting.

What is a hand Therapist
Hand Therapists are registered Physiotherapists and Occupational Therapists who, through continuing education, clinical experience and independent study have become proficient in the treatment of upper limb conditions resulting from injury, disease or deformity.

What is the AHTA
The Australian Hand Therapy Association is Australia’s only professional association representing hand therapists. It provides support for it’s members through education, professional development, networking and representation at state and national levels. It also acts as a central referral point for doctors, allied health professionals and members of the public seeking the services of hand therapists in specific geographical locations.

Clinical report: Osteoarthritist(OA) thumb

Definition:
Osteoarthritis of the carpometacarpal(CMC) joint of the thumb is caused by a translatory instability of the trapeziometacarpal joint. This can be either inherent, degenerative or the sequelae of trauma, such as a Bennett’s fracture.

Degenerative OA is frequently seen in women over 50 years of age.

Presenting Clinical Signs & Symptoms:

• Aching, and occasional sharp pain; dorsal &/or volar base of thumb.
• Symptoms increase with activity level.
• Tender to palpate joint line.
• Dorsal subluxation of 1st metacarpal (visible bump on dorsal surface of joint). This causes a significant reduction of web space, and effective grasp, or space grip.
• Z deformity; Compensatory MCP hyperextension to place the thumb out of the palm for effective grasp.
• Positive grind test.
• Reduced range of movement and web space.
• X Ray findings can be inconsistent with the degree of symptoms.
• X Ray appearance is different to RA. RA appearance has bony erosion; OA appearance has spurs & lipping.

Aggravating Factors:

• Prolonged and forceful grip; writing, sewing, using a screwdriver.
• Pinch grip, especially lateral prehensile.
• Axial loading.
• Manual therapy / Localised high velocity techniques.

Easing Factors:

• Rest (splinting).
• Ergonomic appliances and advice.
• NSAIDS.
• Thenar release.

Differential Diagnosis:

• Rheumatoid Arthritis.
• DeQuervain’s Tenosynovitis.
• Radial nerve irritation.
• Scaphoid fracture.
• Scapho-lunate instability.
• Scapho-lunate ganglion.
• Bennett’s fracture.
• Forearm trigger points.

Treatment:

• Short opponens splint - This almost circumferential splint is designed to limit movement of the first metacarpal, while allowing the thumb to function with a weak pinch using the movement available at the IP joint of the thumb.
• Avoidance of aggravating activities, such as prolonged or forced pinching.
• Recommendation of energy saving devices; jar openers, tap turners.
• Thenar release of trigger points.
• NSAID - oral, topical.
• Surgery - There are several different operations available, the most common operation is the CMC joint suspension arthroplasty.

Research:
Hand therapy has been shown to be a very effective way of managing the pain and disability associated with OA of the thumb. In a recently published seven-year prospective study, Berggren et al (2001) demonstrated the effectiveness of hand therapy in reducing the need for surgery by up to 70%. Within the context of this study, hand therapy was defined as splinting, accessories and advice on how to accommodate activities of daily living. The researchers concluded with the recommendation that all patients with osteoarthritis of the carpometacarpal joint of the thumb be offered access to these modalities preoperatively.

Weiss et al (2000) also support the view that patients with osteoarthritis of the carpometacarpal joint can gain significant pain relief with splinting. This study demonstrated a preference for the short, or hand based opponens splint over the longer opponens type. Furthermore, although splinting appeared to reduce subluxation at the first CMC joint, it did not increase pinch grip strength.

In a retrospective study of 114 patients (130 thumbs) Swigart et al (1999) reported that over 70% of patients in the early stages, and 54% of patients in later stages of arthritis had a significant improvement in their symptoms with splinting. Overall splinting has been found to be a well-tolerated and effective conservative treatment to diminish, but not completely eliminate, the symptoms of CMC arthritis and inflammation.

More information about hand therapists and the AHTA is available on the website www.ahta.com.au

References:

1. Berggren M, Joost – Davidsson A, Lindstrand J, Nylander G, Povlsen. Reduction in the need for operation after conservative treatment of Osteoarthritis of the first carpometacarpal joint: a seven year prospective study. Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery Dec, 2001; 35(4):415-7.
2. Swigart CR, Eaton RG, Glickel SZ, Johnson C. Splinting in the treatment of arthritis of the first carpometacarpal joint. Journal of Hand Surgery (Am). Jan 1999; 24(1):86-91.
3. Weiss S, LaStayo P, Mills A, Bramlet D. Prospective analysis of splinting the first carpometacarpal joint; objective, subjective, and radiographic assessment. Journal of Hand Therapy. Jul-Sep 2000; 13(3):218-26.