Hand Therapy for Arthritis Mr Jonathan Kuan

In this podcast, Mr. Jonathan Kuhn, a physiotherapist and hand therapist at the Macquarie Hand Unit, provides a comprehensive overview of osteoarthritis in the hands and the role of hand therapy in managing this condition. He begins by outlining his qualifications and professional background, emphasizing his expertise in treating traumatic and complex upper limb conditions. Kuhn references an article by his colleague, Dr. Robert Crawley, which provides guidance on managing thumb injuries, particularly focusing on osteoarthritis.

Kuhn shares the common signs and symptoms associated with osteoarthritis, particularly in the hands. He describes the typical deformities seen in arthritis patients, such as the notable Z sign indicative of first CMC joint arthritis and the presence of Heberden's and Bouchard's nodes. As he explains, patients with osteoarthritis often experience joint instability, pain, and a progressive decrease in range of motion. In its initial stages, pain might present as dull after activity, but it intensifies into sharper pain that can persist even at rest. Additionally, he elaborates on the effects of the condition on muscle performance, specifically the tightening of the adductor pollicis muscle, which can lead to functional limitations in grip and pinch strength.

The lecture transitions into the role of hand therapy in managing osteoarthritis. Kuhn emphasizes that treatment is highly individualized, focusing on the patient's unique deformities, goals, and daily living requirements. He identifies the primary objectives of hand therapy: maintaining and improving upper limb function through personalized treatment plans that may include orthoses, joint protection strategies, exercises, and patient education. Kuhn highlights the importance of orthoses, which can significantly alleviate symptoms by reducing inflammation and providing structural support. He presents various types of orthoses used in therapy, including custom-made splints for specific conditions and functional braces that assist in joint positioning without restricting movement.

Exercise is another pivotal component of his exposition. Kuhn discusses the essential principles guiding exercise for patients with arthritis, stressing the need to avoid painful ranges of motion while promoting flexibility and strength. He illustrates several exercises aimed at specific muscle groups such as the first dorsal interosseous and opponent's pollicis, which are fundamental in restoring functional hand movements. These exercises not only target strength and mobility but also incorporate everyday activities, enhancing patient engagement and adherence to therapy.

In addition to exercise, Kuhn explores the use of thermal modalities, both heat and cold, in alleviating arthritic pain and stiffness. He provides practical examples of heat application methods, such as paraffin baths and arthritis gloves, as well as cold compresses for cases of acute inflammation. The efficacy and appropriateness of each treatment modality vary based on patient preference and specific symptoms.

Kuhn underscores the significance of patient education and joint protection principles in therapeutic practice. He discusses how educating patients about respecting pain, balancing activity with rest, and using adaptive equipment can significantly impact their overall well-being and enhance the management of their condition. By implementing strategies that promote joint protection early in the disease process, the goal is to mitigate further joint stress and facilitate better outcomes.

Throughout the lecture, Kuhn remains focused on practical application and the importance of collaboration in treatment approaches, inviting fellow therapists to reach out with questions or for further guidance. This thorough presentation not only enhances understanding of the challenges faced by those with osteoarthritis in the hand but also identifies effective therapeutic strategies to improve patient quality of life.

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It is my pleasure to introduce Mr. Jonathan Kuhn.

Jonathan is a physiotherapist and hand therapist at the Macquarie Hand Unit.

He completed both his Bachelor of Human Sciences and Doctor of Physiotherapy

at Macquarie University and holds accreditation with the Australian Hand Therapy

Association and certification with the American Society of Hand Therapists.

And he's worked both in Hobart and at the Macquarie Hand Unit.

Jonathan has experience in managing patients with traumatic and complex upper

limb conditions ranging from fractures, tendon repairs and burn-related injuries.

So please welcome Jonathan.

Cool. Awesome. So last speaker. So thank you.

So starting off, no financial disclosures today. However, I've spoken to a few

of you today and given out my business card so I just want to let that know.

I'd also like to thank my colleague no,

oh it's alright thanks Matt all good is that yeah cool sorry I also I also like

to thank my colleague Robert Crawley for giving us permission to reproduce her article, Dr.

Why Does My Thumb Hurt? But I believe this was published in the Australian Journal

of General Practitioners a few years ago.

It kind of gives a guide on the management, pre-op and post-op management of

thumb buff riders, u-cell injuries and dequivines.

Right, so common signs of patients with osteoarthritis in their hands generally

include joint deformities and their associated joint instabilities.

So starting off with the thumb, most commonly seen is the Z sign or shoulder

sign for first CMC joint arthritis.

It's normally characterized by the increased prominence of the first metacarpal base.

As Matt said, it's the radial subluxation of that joint.

Moving towards the fingers,

commonly seen are the Hebertins and Bouchard's NURCH which are osteophyte formations

at the DIP joint and PIP joint respectively and patients normally complain that

these joints are generally quite sore to knocks and bumps.

Other common signs seen are deviated DIP joints and PIP joints with the most

common actually being the index fingers at the DIP joint adopting an ulnarly

deviated position and this is generally due to the attenuation of the ligaments

from the inflammatory condition but also from the repetitive stress of lateral pinching.

Next up, pain is also a very common symptom expressed by patients in this population.

In its infancy, generally patients complain of a dull, achy pain normally after

activity, However, it generally settles down with rest.

However, as the condition progresses, the pain generally becomes sharper and

much more constant even occurring at rest.

Range of motion in the arthritic can also be affected, it generally varies throughout the day.

Commonly patients find increased stiffness or effort in initiating their movement

first thing in the morning or after a period of inactivity or rest.

However, as the condition progresses with the worsening erosion of the articular

surface or osteophyte formation or the narrowing of their joint spaces,

this can generally result in the overall decrease in their range of motion,

tightening of their soft tissue can also lead to,

can also impact on their movement most of the common muscle effect is the adductive

polysis it generally tightens causing the patient to adopt sort of a palmally

adducted or palmally contracted thumb so kind of like that.

It's also worthwhile to mention that a patient's ROM can be affected from an

attrition of their attrition rupture of a tendon which is called a Von Jackson

syndrome which I'm not going to talk today about today sorry.

Reduced grip and pin strength is also seen in patients in this population.

This is a result from cell fractures most commonly being

pain limiting however a reduction in motion and joint stability can also affect

their strength so this picture over here shows the patient adopting so that

swan neck deformity characterized by the hyperextension of the thumb which reduces

the effectiveness of FPL as their pinching muscle.

I might also like to add that in that posture it puts additional stress on the

first CMC joint worsening their symptoms.

So how can hand therapy help? Well hand therapy's management for arthritis is

highly individualized and specific to the patient's condition or the face of

their condition, deformity and ADL requirements.

The patient's personal goals should be considered in determining the treatment plan,

and the overall arching goals of hand therapy is to maintain and hopefully improve

the upper limb function through the use of orthosis, joint protection strategies,

hand exercises, physical modalities and patient education.

So orthoses are generally the hallmarks of a hand therapist and its use is generally

supported in the management of arthritic conditions.

So custom-made orthoses or prefabricated orthoses can be used to help reduce

inflammation, pain, improve function, minimize deforming forces,

correct or prevent worsening contractures and also rest or protect structures following surgery.

So, I'm just going to quickly run through some of the orthosis here.

So, these are thermoplastic spins that we customate for our patients.

The top one is called long opponents. It's generally used after trapeziectomies or post-op.

The shorter variant is the short opponents. It's commonly used to manage first CMC joint arthritis.

It's generally a very functional splint as it places patients in a seagrass

posture, helping stretch out the web space and allowing them free use of the fingers.

The center picture is a leather wrist brace which is commonly used for radiocarpal

joint arthritis and my personal favorite is the CMC push brace over here.

It's a very functional brace as it does not limit range of motion but it places

the, it helps push the MP joints into slight MP flexion distributing the force

across all joints evenly.

And yes, that is my thumb actually. So I'll be seeing you Matt in a few years. Hopefully not.

Moving over to digital support.

Digital supports the humble co-band or uh

silicon digi tubes can be

a good starting point for patients with the deep j arthritis

uh how uh as it provides compression

and some thermal relief however as

hand therapies we can make something fancier like the neoprene store here or

if they require much more um more support a thermal option such as a mallet

splints can be fabricated so that it can be used at night for resting or during

functional activities.

And similarly these malarothoses are generally used for about 6-8 weeks post

a DIP joint arthrodesis.

Moving on to exercises. The general principles of upper limb exercise include

avoiding painful range of motion and the importance of working within the patient's

comfort levels as to not stir up their symptoms.

So generally exercise has been found to be effective in decreasing arthritis

related pain, increasing blood flow and improving overall cartilage health.

Additionally hand function can also be maintained and improved when exercise

is combined with good joint protection strategies.

So simple exercise like tendon gliding, moving the fingers through all different ranges of motion,

gentle intrinsic stretches and most importantly working on regaining proper

prehension grasping techniques so working on their thumb opposition as most

patients with thumb uphrase as I said have a tight adductive policies tend to posture.

Strengthening, so a strengthening program for arthritic joints should be used

with caution to avoid aggravation or worsen their deformities.

It is important to note that stability must not be compromised for the possibility

of increasing strength with a large focus placed on improving their neuromuscular control.

So I just want to echo on what Matt has said earlier is to strengthen the friendly

muscles. So I've just got a few pictures, a few videos over here.

Few videos over here that Hope will play. So, some of the friendly muscles for

thumb arthritis include the first dorsal interosseous and the opponent's polycysts.

So, as Matt has said, the first dorsal interosseous originates from the base

of first metacarpal and based on these actions help pull the radially subluxed

MP joint back into the joint.

So, if we all want to do some exercises, it generally involves with your thumb

resting on your middle finger with the index finger being placed in slight MP

flexion and abducting that joint.

And the best way to know that if you're doing it correctly is if you put your

index finger in your first web space, you should feel a bulging muscle there.

If it is correctly, if you go sort of window wiper, you should not feel anything moving there.

So if you feel that bulge there, you're activating the right muscle.

Other commonly prescribed exercise is paper tearing, it's a very functional exercise,

kind of mimics like opening a bag of chips, peeling a mandarin skin and it works

on the two friendly muscles, first dorsal interosseous and opponent's policies

in a very functional way.

And last but not least, the tennis ball tracing exercise,

once again functional way of activating first dorsal interosseous and opponent's

policies but also regains the C-shaped prehension grass and that's the grass

that we tend to try to get our patients to work on as it places the first CMC

joint in a much more advantageous position.

And moving on to thermal vandalities. So thermal dyes such as heat and cold

are commonly used as adjunct treatments for arthritic conditions.

Heat is generally preferred by the patients as superficial heat can help with

decreasing their pain and perceived stiffness.

A few ways of doing this is through paraffin heat, paraffin wax bath,

we pack, warm water soak.

Other ways can include sort of wearing arthritis gloves, the gentle compression

and the neoprene like material. It helps keep the warmth in.

We generally advise patients wearing it full-time but can just wear it whenever

it's sore or preferably at night, especially in winter.

And my personal favourite is to get the patients to warm their hand up by wrapping

their hands around a cup of coffee is usually a really good start for the morning

if they get morning joint pain and stiffness. Question.

Once I've done the paraproflex back, what's...

Over the... Yeah. Well, we generally use paraffin wax bath in the hand therapy

because wax has lots of moisturizing factors in it.

So with their scars, there's no difference between them.

It's just that that machine costs a few hundred dollars to get.

So warm water soak is good enough.

Yes, it does. It lasts longer in the warm. They can take it out of the wax bath,

forms a glove on their hand, and they can walk around doing exercise with it.

And they can throw that wax back into the pot and reuse it.

But not everyone has a wax bath at home. So warm water soak does the job.

Then there are some subset of patients who prefer cold.

Prefer cold mobilities as the lower joint temperature can help with a bit of their inflammation.

This is probably potentially more applicable to patients with acute flare-ups

of their inflammatory conditions.

So just a cold water pack or wrapping their hands around a glass of cold water. Thank you.

Cool. Last but not least, patient education and joint protection principles

form a crucial part of the patient's treatment plan.

So joint protection strategies are ideally initiated early in the disease process

and throughout their management program in an effort to decrease and prevent

further stress on their joints.

Current research indicates strong evidence for the efficacy of patients,

for patient education, drone protection principles and exercise in promoting

ADLs, ADL performance and overall mental well-being of the patients with arthritic conditions.

So I believe on one of the QR codes on the general list,

you guys can scan that, has the article that I talked about earlier and extend

the breakdown on six of these principles but essentially they involve sort of respecting pain.

So in terms of getting the patients to still perform all their day-to-day tasks

but taking regular rest breaks and not pushing themselves too hard in their

activities before causing their symptoms to worsen.

Balance and rest activities, exercising the pain-free range or intensity,

avoiding positions of deformity whether that will be through neuromuscular control

or through the use of orthosis,

reducing the effort and force can include using anti-slip mats or getting adaptive

equipment which a physio or hand therapist can help prescribe and the use of

larger and stronger joints.

So instead of holding their grocery bags with just tips of their fingers,

using their elbows or using a trolley can sort of reduce the amount of stress onto their joints.

And that's it from me. So myself and my colleagues are more than happy to take

any calls or emails if you guys have any questions.