Exercises To Promote Dynamic Stability Of The Thumb

3/13/2017Conservative Managementof the Painful Thumb is a CHALLENGE!Teamwork is ImportantPerson –Therapist –Doctor – FamilyDynamic Stability of theThumbVirginia H. O’Brien OTD, OTR/L, CHTMinneapolis, 72Effects of Exercise, Orthoses &Joint Protection EducationWhy is the humanthumb at risk for pain?Evidence Reduction in Pain & Improvement in FunctionBased/Informed No consensus for which orthosis is bestPractice No consensus (YET) for which exercises are best Little is known about dosage of exercise for the small muscles of thehand (ACSM 2011) EULAR and ACR recommend Exercises, Orthoses & JPE 1st Dorsal Interosseous & the Opponens are emerging as keymuscles for thumb stabilityIs it because there isonly a 35 year warrantyon the 1st CMC joint ?What is the mystery ofdynamic stability for theCMC joint?Can something be doneabout it ?3/13/2017YES!Adams, O’Brien et al. 2017, Magnuson et al. 2016, McGee et al. 2015,Moubargha et al. 2015, Dziedzic et al.2011, Boudreau 2010, Stamm et al. 2002, Wajon 2000, Swigart 1999.3History of Dynamic Thumb Stability3/13/20175What is Dynamic Stability of the Thumb? Brand & Hollister: 1st DI as a lateral thenar, has a stabilizing effect onCMC (1993) Use of thumb muscles during function to stabilize and preventsuluxating forces at the CMC, with web space restoration andorthotic support (Taylor, 2000) Promote stability and functional strength about the CMC withresistive thumb exercises (Neuman & Bielefield, 2003) Dynamic Stability: known rehab strategies for other joints forinjuries and OA: i.e. Knee, Shoulder (Braun, Hurd, Meister, Wilks,Chmieleweski, Zeni, Elenbecker) Restore Functional ROM; at joint & soft tissues Re-education of specific muscles to improve thestrength of the hand and thumb Reduce pain and disability: May not change the courseof the disease (if present) Self-management of pain during function Stabilizing orthosis, as needed & a plan to wean out oforthosis or to wear only as needed for heavy tasks Lack of Neuromuscular coordination of motion seen often in thosewith CMC OA, thumb pain. (Van Heest & Kallemeier, 2008)3/13/201763/13/201771

3/13/2017“Effects of a Dynamic Stability Approach in ConservativeIntervention of the Carpometacarpal Joint of the Thumb: ARetrospective Study”3 Important Points for aStable Thumb .1. Widen Thumb Webspace: Keep it SUPPLE2. Use of ALL Thumb Motors to Stabilize and Centralize the1st metacarpal as it moves on the trapezium.3. Educate the Person to stabilize own thumbs for a lifetime.Primary Purpose: to investigate change of pain and disability from using a DYNAMICSTABILITY modeled approachSecondary Purpose:IncludingTherapists andSurgeons Ave.# visits Average “date-range” of visits3/13/20178“Effects of a Dynamic Stability Approach in ConservativeIntervention of the Carpometacarpal Joint of the Thumb: ARetrospective Study”These results align withprospective studies ofconservative care Study #1: increased loads in the FDI and OP will result in effects tothe joint kinematics and kinetics of the 1st CMC Study #2: that a more uniform distribution of loads and reducedsubluxation ratio will be realized across the surface of the thumbCMC joint.(O’Brien, Rosenstein, Magnusson, Nuckley, Adams, 2016)(O’Brien & Giveans, 2013)10Cadaveric Study #1 ResultsPositional OP alone changes metacarpal proximally & volarly,exacerbating subluxation FDI greatest effect is distaland dorsal pull. 3/13/20179Hypotheses:(Using QuickDASH as outcome measure)3/13/2017(O’Brien & Giveans, 2013)Effects of Selective Activation of the 1stDI & OP on ThumbCMC Kinematics: A Synopsis of 2 Cadaver StudiesPrimary Purpose Results: Reduction in Pain: 17.9% (p .01) Reduction in Disability: Group change : 19.3% improvement Individual change: 15.7% improvement Both exceeded MDC90 change of 15%Secondary Purpose Results: Average total visits: 2.37 ( 2-3 visits) Average number of days : 44.5 (6-7 wks)3/13/2017RotationalOP tends to over-rotate MC volarly &ulnarly.FDI pulls Trapezium dorsally,attenuates MC translationFDI & OP act to help center MC onTrapezium123/13/201711#2: Radiographic Analysis of Simulated FDI and OPActivation upon Thumb CMC Jt Subluxation: A CadaverStudyHypothesis & Purpose The FDI and OP work concomitantly to decrease subluxationin the CMC joint Investigation of effect of load application to the FDI, OP, andFDI OP on cadaver modelMethods: (Capsulotomy of CMC jt) Loading the FDI from 0 to 30N Loading the OP from 0 to 40N Simultaneously loading the FDI and OP from0 to 30 & 0 to 40N, respectively.3/13/2017132

3/13/2017Results #2: In a Dose Dependent Manner OP improved SubluxationRatio (SR) FDI minimal effect on SR OP FDI improved SR in allloading states In 75% greater, significantlyimproved SR (p .014) FDI in combination with OPmay reduce subluxation,reduce pain and symptomsFDIOP3/13/2017FDI OP14Activation of the First Dorsal Interosseous Muscle Results inRadiographic Reduction of the Thumb CMC Joint (Fluoroscopic Study) Hypothesis: Activation of the 1stDirectly reduces subluxation of the1st metacarpal to trapezium Methods: 17 healthy subjects (5M, 12F)AP of thumb CMC joint:At restManual radialtranslation stressManual stress w/ 1st DIAt rest with 1st DIConclusions for Both CadavericStudies: These biomechanical data support use ofFDI and OP in conservative exerciseprograms. thumb CMC joint pain3/13/201715Results6%Subluxation with Stress,Reduction with FDIActivation (27)9%No subluxation (3)ICC 0.74 Mean age: 26, no CMC OA Measured Max. VoluntaryContraction 1st DI strength3/13/2017RotterdamIntrinsic HandMyometer(RIHM)84%(McGee, O’Brien, Van Nortwick, Adams,Van Heest, 2015)(McGee, O’Brien, Van Nortwick, Adams, Van Heest, 2014)16Stout deltoid-like CMC dorsoradial ligament structure Joint instability ALONE maynot be the primary etiologicalfactor in development of OA ofCMC. Dynamic proprioceptivefunction of the joint is subjectof continuing studies(Hallilaj et al. 2015) (Ladd et al. 2013) (Ladd et al. 2014)(Hagert et al. 2012)3/13/2017Subluxation at Rest, NoFurther Subluxation withStress (2)3/13/201717Carpometacarpal (CMC) joint Loose capsule Joint surfaces are notcongruent Stability from softtissues Ligamentous support Muscular supportGreen: DorRadLig; Orange: DColLig;Magenta: PostOblLig; APL: red18193

3/13/2017The anatomy and biomechanics of the thumb CMCis similar (in many ways) to that of the shoulderMuscles that influence the Thumb9 muscles influenceThumb is 70% of thethe thumbdominant hand, 60% ofthe non-dominantWe have a big job hand (Disability ratings)2/18/17Doesn’t the thumb deserve the same amount ofattention we have given to shoulder problems?to help ourpatients withtheir thumbs!!!!Accessed at: militarydisabilitymadeeasy.com21Know and USE Your ExtrinsicThumb Muscles:22Know and USE your Thumb Intrinsics Muscles Extensor Pollicis Longus Extensor Pollicis Brevis Abductor Pollicis Longus Flexor Pollicis Longus Abductor Pollicis Brevis Flexor Pollicis Brevis – deep andsuperficial heads Opponens Pollicis (Deep) AFO-acronym to remember theThenars Adductor Pollicis First DorsalInterosseous!23The multidirectional pull of these muscles:Range of Motion of the ThumbOpponensFLEXION @ MP & IPPALMAR ABDRADIAL ABD24SesamoidsFirst ONFlexor BrevisAbductorPollicisLongusOpponensAbductor LongusExtensor PollicisBrevisOPPOSITION3/13/2017263/13/2017274

3/13/2017- Manual release of the adductor and any over-active,dominant muscle- Joint mobilization to reduce / realign the CMC- Muscle re-education / strengthening- Use of adaptive tools and joint protection techniques- Orthosis/Orthoses as needed- Strategy to wean from orthosisWith respect for pain at each stepPotential De-Stabilizers3/13/2017Dynamic Stabilizers283/13/2017Manual Release32Manual ReleaseAdductor Muscle Release is the KEY Adductor: One of the strongest muscle per square measurein the body. Manual release of this muscle increases the potential ROMof the thumb lost due to web space contracture. Helps to “set the stage” to gain congruency of jointsurfaces for the next portions of the exercise program.3/13/2017Myo-Fascial or“Trigger Point”release333/13/2017Elongate Soft Tissues in the Web SpaceFollowed by Abduction stretch34Joint MobilizationInitiated after Manual Release: adductor releaseand soft tissue elongation .AND before Muscle Re-education* To Reduce Pain To Approximate Joint Surfaces: centralize the MC on Trapezium toimprove motion and production of nutritional substances in the joint. To Restore Stable Thumb Biomechanics1) Web to web: press in to relax tissues, 2) Extend Thumband Index to stretch tissues, 3) Hold each 15-30 seconds.Repeat 3-5 times* Must be done pain afane et al., 2011)363/13/2017( Villafane et al. 2013)375

3/13/2017Self-Joint MobilizationRetropulsion Distraction is the first level (grade I) of jointmobilization Opens joint spaces, relieves pain &increases nutrition Grasp the base of involved thumb, holdarms behind back The weight of the armsprovides distraction If this position causes pain in shoulders,bring arms in front of body, relax, and bringelbows back to distract the CMC jointHands behind body.or in frontIn both photos, the subject’s RIGHTCMC is being distractedVIDEOMust be PAIN-FREE: restores Retropulsion,improves CMC/STT glide3/13/201738Joint MobilizationWith a “Skull Rock”Place oppositethumb in webspaceRoll handback andforthVIDEOMETHOD ONE3/13/2017(Villafañe, Silva, Diaz-Perreno & Fernandez-Carnero, 2011)39Muscle Re-education first: Before StrengtheningRe-education of the thumb muscles to restore stable balanceIN PAIN FREE CONTEXTFocus: Retrain in Kinetic ChainGrasp thumbAbductor Pollicis BrevisOpponens Pollicis1st Dorsal InterosseousExtensor Pollicis BrevisAbductor Pollicis LongusFlexor Pollicis BrevisThen move armforward and backMETHOD TWOFeels a little uncomfortable initially; feels better later.3/13/2017(Villafañe, Silva, Diaz-Perreno & Fernandez-Carnero, 2011)423/13/201743Isometric and Isotonic Muscle Re-educationof palmar abductionIsolate the Abductor and OpponensThe CMC joint is moststable in the “C”positionVIDEOMake the thumbpuppet sing3/13/2017Closed Chain ExerciseNote the rubber band placement on the metacarpal443/13/2017This exercise is done pain free476

3/13/20171st Dorsal Interosseous Exercise21Rubber BandExercise:Abduct theIndex awayfrom theMiddle Finger1st DI has a distal and ulnar-ward pull on 1st Metacarpal:***NOT A COMPRESSIVE FORCE***3/13/2017(Mobargha, 2016) (Obrien et al. 2016)48NEW GOAL:100repetitionsper day?33/13/201751Thumb Stability Exercises: Using a Rubber BandIn PalmarAbductionis best!“Piano playing” or Other Functionaltasks(Active to isometric to isotonic)Start with a thinner rubber band at P 1 IF. Lift IF up and down slowly and smoothly.ISOKINETIC: Concentric/eccentric Extensor Pollicis Brevis Abductor Pollicis Longus Abductor Pollicis Brevis Opponens Pollicis AND the 1st Dorsal InterosseousTo progress, advance RB distally on IFtoward P2 and P3: PAIN-FREE ONLY.DOSE: 10 reps 2-3 sets/session3/13/2017Advance to thicker RB, and repeat the sameprogression.GOAL: 100 x / day !!?!!?!!523/13/2017Train to Abduct and Extend without losing theMP flexion posture533 Important Points for a Stable Thumb . For the patient who has a very1. The thumb webspace: Keep it SUPPLE2. Use of ALL thumb motors to Stabilize and Centralize the 1stmetacarpal as it moves on the trapezium.3. Educate the person to stabilize their own thumbs for a lifetime.unstable CMC, performing 1st DIstrengthening may be painfulinitially. External support may be needed with co-contraction of the “C”position manual support of themetacarpal OR performing exercise withorthotic support at the CMC.Are Your ThumbsStable?If the program is unsuccessful in stabilizing the CMC and relieving pain,reconstruction may be a consideration.3/13/2017543/13/2017567