Advertisement

Beneficial Effects of Nonsurgical Treatment for Symptomatic Thumb Carpometacarpal Instability in Clinical Practice: A Cohort Study

Published:October 11, 2019DOI:https://doi.org/10.1016/j.apmr.2019.08.485

      Abstract

      Objective

      To describe outcomes of nonsurgical treatment for symptomatic thumb carpometacarpal joint (CMC-1) instability. Secondary, to evaluate the conversion rate to surgical treatment.

      Design

      Prospective cohort study.

      Setting

      A total of 20 outpatient clinics for hand surgery and hand therapy in the Netherlands.

      Participants

      A consecutive sample of patients with symptomatic CMC-1 instability (N=431).

      Intervention

      Nonsurgical treatment including exercise therapy and an orthosis.

      Main Outcome Measures

      Pain (visual analog scale [VAS], 0-100) and hand function (Michigan Hand Outcomes Questionnaire [MHQ], 0-100) at baseline, 6 weeks, and 3 months. Conversion to surgery was recorded for all patients with a median follow-up of 2.8 years (range, 0.8-6.7y).

      Results

      VAS scores for pain during the last week, at rest, and during physical load improved with a mean difference at 3 months of 17 (97.5% CI, 9-25), 13 (97.5% CI, 9-18), and 19 (97.5% CI, 12-27), respectively (P<.001). No difference was present at 3 months for MHQ total score, but the subscales activities of daily living, work, pain, and satisfaction improved by 7 (97.5% CI, 1-14), 10 (97.5% CI, 4-16), 5 (97.5% CI, 2-9), and 12 (97.5% CI, 2-22) points, respectively (P<.001-.007). After median follow-up of 2.8 years, only 59 participants (14%) were surgically treated. Both in the subgroups that did and did not convert to surgery, VAS pain scores decreased at 3 months compared with baseline (P<.001-.010), whereas MHQ total score did not improve in both subgroups. However, VAS and MHQ scores remained worse for patients who eventually converted to surgery (P<.001).

      Conclusions

      In this large sample of patients with symptomatic CMC-1 instability, nonsurgical treatment demonstrated clinically relevant improvements in pain and aspects of hand function. Furthermore, after 2.8 years, only 14% of all patients were surgically treated, indicating that nonsurgical treatment is a successful treatment of choice.

      Keywords

      List of abbreviations:

      ADL (activities of daily living), CMC-1 (thumb carpometacarpal joint), MHQ (Michigan Hand Outcomes Questionnaire), OA (osteoarthritis), VAS (visual analog scale)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Lane L.B.
        • Henley D.H.
        Ligament reconstruction of the painful, unstable, nonarthritic thumb carpometacarpal joint.
        J Hand Surg Am. 2001; 26: 686-691
        • Spekreijse K.R.
        • Vermeulen G.M.
        • Moojen T.M.
        • et al.
        Surgical stabilization for symptomatic carpometacarpal hypermobility; a randomized comparison of a dorsal and a volar technique and a cohort of the volar technique.
        Eur J Plast Surg. 2016; 39: 345-352
        • Poole J.U.
        • Pellegrini Jr., V.D.
        Arthritis of the thumb basal joint complex.
        J Hand Ther. 2000; 13: 91-107
        • Chenoweth B.A.
        • O'Mahony G.D.
        • Fitzgerald C.
        • Stoner J.A.
        • O'Donoghue D.L.
        • Rayan G.M.
        Efficacy of dorsoradial capsulodesis for trapeziometacarpal joint instability: a cadaver study.
        J Hand Surg Am. 2017; 42: e25-e31
        • Hunter D.J.
        • Zhang Y.
        • Sokolove J.
        • Niu J.
        • Aliabadi P.
        • Felson D.T.
        Trapeziometacarpal subluxation predisposes to incident trapeziometacarpal osteoarthritis (OA): the Framingham Study.
        Osteoarthritis Cartilage. 2005; 13: 953-957
        • Neumann D.A.
        • Bielefeld T.
        The carpometacarpal joint of the thumb: stability, deformity, and therapeutic intervention.
        J Orthop Sports Phys Ther. 2003; 33: 386-399
        • Eaton R.G.
        • Glickel S.Z.
        • Littler J.W.
        Tendon interposition arthroplasty for degenerative arthritis of the trapeziometacarpal joint of the thumb.
        J Hand Surg Am. 1985; 10: 645-654
        • Edmunds J.O.
        Current concepts of the anatomy of the thumb trapeziometacarpal joint.
        J Hand Surg Am. 2011; 36: 170-182
        • Hagert E.
        • Lee J.
        • Ladd A.L.
        Innervation patterns of thumb trapeziometacarpal joint ligaments.
        J Hand Surg Am. 2012; 37: 706-714
        • Ladd A.L.
        • Lee J.
        • Hagert E.
        Macroscopic and microscopic analysis of the thumb carpometacarpal ligaments: a cadaveric study of ligament anatomy and histology.
        J Bone Joint Surg Am. 2012; 94: 1468-1477
        • Wouters R.M.
        • Tsehaie J.
        • Slijper H.P.
        • Hovius S.E.R.
        • Feitz R.
        • Selles R.W.
        Exercise therapy in addition to an orthosis reduces pain more than an orthosis alone in patients with thumb base osteoarthritis: a propensity score matching study.
        Arch Phys Med Rehabil. 2019; 100: 1050-1060
        • Kjeken I.
        • Smedslund G.
        • Moe R.H.
        • Slatkowsky-Christensen B.
        • Uhlig T.
        • Hagen K.B.
        Systematic review of design and effects of splints and exercise programs in hand osteoarthritis.
        Arthritis Care Res. 2011; 63: 834-848
        • Bertozzi L.
        • Valdes K.
        • Vanti C.
        • Negrini S.
        • Pillastrini P.
        • Villafane J.H.
        Investigation of the effect of conservative interventions in thumb carpometacarpal osteoarthritis: systematic review and meta-analysis.
        Disabil Rehabil. 2015; 37: 2025-2043
        • Tsehaie J.
        • Spekreijse K.R.
        • Wouters R.M.
        • et al.
        Predicting outcome after hand orthosis and hand therapy for thumb carpometacarpal osteoarthritis: a prospective study.
        Arch Phys Med Rehabil. 2019; 100: 844-850
        • Tsehaie J.
        • Spekreijse K.R.
        • Wouters R.M.
        • et al.
        Outcome of a hand orthosis and hand therapy for carpometacarpal osteoarthritis in daily practice: a prospective cohort study.
        J Hand Surg Am. 2018; 43: 1000-1009
        • Wajon A.
        • Ada L.
        No difference between two splint and exercise regimens for people with osteoarthritis of the thumb: a randomised controlled trial.
        Aust J Physiother. 2005; 51: 245-249
        • O'Brien V.H.
        • Giveans M.R.
        Effects of a dynamic stability approach in conservative intervention of the carpometacarpal joint of the thumb: a retrospective study.
        J Hand Ther. 2013; 26: 44-52
        • Valdes K.
        • Von Der Heyde R.
        An exercise program for carpometacarpal osteoarthritis based on biomechanical principles.
        J Hand Ther. 2012; 25: 251-262
        • Schoenaers M.
        • Degreef I.
        • De Smet L.
        Eaton and Littler ligament reconstruction for the painful first carpometacarpal joint : patient satisfaction.
        Acta Orthop Belg. 2017; 83: 30-34
        • Lane L.B.
        • Eaton R.G.
        Ligament reconstruction for the painful "prearthritic" thumb carpometacarpal joint.
        Clin Orthop Relat Res. 1987; : 52-57
        • Wouters R.M.
        • Tsehaie J.
        • Hovius S.E.R.
        • Dilek B.
        • Selles R.W.
        Postoperative rehabilitation following thumb base surgery: a systematic review of the literature.
        Arch Phys Med Rehabil. 2018; 99: 1177-1212
        • Vermeulen G.M.
        • Slijper H.
        • Feitz R.
        • Hovius S.E.
        • Moojen T.M.
        • Selles R.W.
        Surgical management of primary thumb carpometacarpal osteoarthritis: a systematic review.
        J Hand Surg Am. 2011; 36: 157-169
        • NVPC, NVvH
        Dutch Plastic (NVPC) and Hand (NVvH) Surgery Societies: guideline for conservative and surgical treatment for primary osteoarthritis of the thumb base joint (Richtlijn Conservatieve en Chirurgische Behandeling van Primaire Artrose van de Duimbasis).
        2014
        • von Elm E.
        • Altman D.G.
        • Egger M.
        • Pocock S.J.
        • Gotzsche P.C.
        • Vandenbroucke J.P.
        The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.
        Lancet. 2007; 370: 1453-1457
        • Zhou C.
        • Selles R.W.
        • Slijper H.P.
        • Feitz R.
        • van Kooij Y.
        • Moojen T.M.
        • et al.
        Comparative effectiveness of percutaneous needle aponeurotomy and limited fasciectomy for Dupuytren's contracture: a multicenter observational study.
        Plast Reconstr Surg. 2016; 138: 837-846
        • Handtherapie Nederland
        Guideline thumb training program (richtlijn duimprogramma).
        Handtherapie Nederland, 2018
        • Valdes K.M.T.
        A systematic review of conservative interventions for osteoarthritis of the hand.
        J Hand Ther. 2010; 23: 334-350
        • Hawker G.A.
        • Mian S.
        • Kendzerska T.
        • French M.
        Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP).
        Arthritis Care Res (Hoboken). 2011; 63: 240-252
        • Poole J.
        Measures of hand function: Arthritis Hand Function Test (AHFT), Australian Canadian Osteoarthritis Hand Index (AUSCAN), Cochin Hand Function Scale, Functional Index for Hand Osteoarthritis (FIHOA), Grip Ability Test (GAT), Jebsen Hand Function Test (JHFT), and Michigan Hand Outcomes Questionnaire (MHQ).
        Arthritis Care Res (Hoboken). 2011; 63: 189-199
        • London D.A.
        • Stepan J.G.
        • Calfee R.P.
        Determining the Michigan Hand Outcomes Questionnaire minimal clinically important difference by means of three methods.
        Plast Reconstr Surg. 2014; 133: 616-625
        • Shauver M.J.
        • Chung K.C.
        The minimal clinically important difference of the Michigan hand outcomes questionnaire.
        J Hand Surg Am. 2009; 34: 509-514
        • Cohen J.
        Statistical power analysis for the behavioral sciences.
        2nd ed. Lawrence Erlbaum Asscociates, Mahwah, NJ1988
        • de Groot J.A.
        • Janssen K.J.
        • Zwinderman A.H.
        • Bossuyt P.M.
        • Reitsma J.B.
        • Moons K.G.
        Correcting for partial verification bias: a comparison of methods.
        Ann Epidemiol. 2011; 21: 139-148
        • Little R.J.
        A test of missing completely at random for multivariate data with missing values.
        J Am Stat Assoc. 1988; 83: 1198-1202
        • Little R.J.
        • D'Agostino R.
        • Cohen M.L.
        • Dickersin K.
        • Emerson S.S.
        • Farrar J.T.
        • et al.
        The prevention and treatment of missing data in clinical trials.
        N Engl J Med. 2012; 367: 1355-1360
        • Zeger S.L.
        • Liang K.Y.
        Longitudinal data analysis for discrete and continuous outcomes.
        Biometrics. 1986; 42: 121-130
        • Preisser J.S.
        • Lohman K.K.
        • Rathouz P.J.
        Performance of weighted estimating equations for longitudinal binary data with drop-outs missing at random.
        Stat Med. 2002; 21: 3035-3054
        • Tsehaie J.
        • Porsius J.T.
        • Rizopoulos D.
        • Slijper H.P.
        • Feitz R.
        • Hovius S.E.R.
        Response to conservative treatment for thumb carpometacarpal osteoarthritis is associated with conversion to surgery: a prospective cohort study.
        Phys Ther. 2019; 99: 570-576