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Case Studies for the Master Clinician: The Osteoarthritic ThumbJeanine Beasley EdD, OTR, CHT, FAOTAVirginia O’Brien OTD, OTR, CHF

Jeanine Beasley EdD, OTR, CHT, FAOTA

Virginia O’Brien OTD, OTR, CHF

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Learning OutcomesAs a result of this course, participants will be able to:1) List three interventions from the dynamic stability

approach for treatment of the osteoarthritic thumb.

2) Select an orthosis for treatment of the osteoarthritic thumb that has support in the research.

3) Report a specific joint protection principle that applies to management of the osteoarthritic thumb.

AgendaPart 1:

Presenter Introduction

Part 2: Case Introduction

Part 3:

Assessment and Intervention

Part 4:

CMC Orthotics and Joint Protection

Part 5: Clinician Interview

Part 6:

References

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Part 2- Case Introduction

This case study will allow the participants to develop a problem-based approach to conservative treatment of the osteoarthritic thumb. Evidenced-based treatment will include orthoses, the dynamic stability approach, and joint protection interventions.

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“You Gave Me My Life Back”Case Study: “Betty M”

Conservative Care: Thumb Osteoarthritis with Pain at the Metacarpal Joint

HX: “Betty M” - MD reportRHDF 75 y.o., retired lab scientist (50 yrs.) c/o left thumb MCP pain. Shifting MCP joint, FPL nodule present-denies pain-no triggering, has UCL laxity

§ Pain for 10 years, w/ flare-up ~6 mo. ago. No reported accident/incidence of pain. Can't grip. Sharp pain with extension. Can't work in garden.

§ Surgical history: orthopedic: R middle finger trigger

§ Medical HX: arthritis x10 yrs. Previous cortisone injection-which joint?- “didn’t help”, drinking cherry juice- from cherries off her own tree, home exercises with catching tennis ball. Home Paraffin bath x few years; thyroid “issues”, sciatica (PT helped)

§ Medications: hormone replacement, thyroid medications

§ X-ray Report: Bone on bone 1st MCP joint w/ slight radial subluxation 1st MCP; Moderate osteoarthrosis 1st CMC w/ small osteophytes, subchondral sclerosis & early osseous fragmentation; Superimposed erosive osteoarthritis in multiple interphalangeal joints.

§ “Stoic patient, can tolerate a lot of pain.”

§ Previous (another facility) cortisone injection (unspecified joint) and splinting; “didn't work”

§ Wants non-pharm approach, agreed to conservative treatment with Hand Therapy

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Initial Visit Occupational Profile§ Pain x 8 months, unknown cause, focused at her thumb

MCP joint§ Enjoys gardening, sewing, knitting, painting and working

with tools; does all the household chores and repairs. Loves to be active and works out at the gym. Concerned about getting garden ready for spring, needs to start planting

§ Lives out of town, comes in to “Twin Cities” weekly; Does own driving, family assists with longer trips

§ Reports dropping items, difficulty holding tools, bathing, dressing, cutting & prepping food, household chores, doing her work outs, and any pushing, pulling, lifting and carrying

§ Upper Extremity Functional Index: 39/80

“Betty M” : PainPAIN 1/22/2018 3/5/18

LocationLeft Thumb MCP Joint

(NOT CMC)At DC: No MCP joint line pain

Description Aching, Nagging, Sharp and Stabbing Dull and not sharp, so much less

Exacerbated byUse and when the thumb is pushed

backwards

At rest 0-10/10 0/10 0/10

On use 0-10/10 3/10 Click is there, but less frequent, can move the thumb without

At worst.0-10/10 7/10 0-4/10 “if it is really pain”; No pain noted now

Progression Gradually getting worse. Much better

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“Betty M” ROMThumb 1/22/2018 1/22/2018 3/5/18

AROM(PROM) Right Left left

MP 55 35 (noted a clunk with flexion) 50

IP 35 50 60RABD 50 50+ 58PABD 48 48 60

Retropulsion (Kapandji method) 2 1.5+ 2

Kapandji Opposition Scale (0-10/10) 9 8 9

“Betty M”- Strength (1 pain-free trial)

Strength Right Left initially Right at DC Left at DC

Grip 55 45 60 503 pt Pinch 12 5 14 14

Lateral Pinch 15 4 15 11

1st DI MMT (0-5/5) 5/5 4/5 4+/5

Ulnar Dev at MCP 5° 15° 10°

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Betty M” Visit 1§ NO Orthosis§ Webspace Release: manually and

clip, followed with active abduction stretch

§ To address the MCP Deviation: Educ to keep thumb “in line”

§ Active “C”: PABD w/o Radial deviation

§ Progressed to “C” with RB for an isotonic and isometric hold at end range-avoiding Radial Deviation with the exercise

§ Heat: Home use of Paraffin Bath & warm water with Epsom Salts

9

“Betty M” Visit 2-3 wks. later§ Added Traction “In Line” for Pain Relief:

Grade 1 CMC and MCP Traction

§ Observed her PABD to check for true use of the opponens: watching the nail “rotate”, ensure slow reps in PAIN FREE range, and educ (NM pathways) to retrain her thumb to use thenar vs. extrinsic mm

§ Cont. with “C” PABD: AROM and w/ RB

§ FDI AROM 1st, then added RB resistance

§ Focus was on quality of motion, watching the thumb move, staying in the “C” position, activating the FDI with the Opponens, and keeping the thumb “in line” and not deviating

in front

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“Betty M” Visit 3: total 6 weeks§ ”Now my right hand is now worse

than my left…my left hand is so much better. I don't have the mental stop due to the pain that I had before. I am not dropping plates…I feel that I have the strength to grab the plates now. I can use all the tools for gardening, have been making the raised beds…used the tools to try them out…not had any problems…doing seeding now and it is just fine.”

§ Added “Chest Traction” for self mobilization: to improve retropulsion by widening the transverse arch

11

“Betty M” Joint Protection

§ Educated in Joint Protection techniques & Adaptive equipment

§ Have these in your clinic for hands-on trial, instruction

§ Upper Extremity Functional Index:§ Initial: 39/80§ Discharge: 79/80

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Part 3- Assessment and Treatment

PromotingDynamic Stability in OA of the ThumbVirginia H. O’Brien OTD, OTR/L, CHTMinneapolis, MinnesotaUSAvobrienotd@gmail.com

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Conservative Management of the Painful Thumb is a CHALLENGE!

Teamwork is Important Person-Therapist-Doctor-Family

What is Dynamic Stability?

For the wrist? Put a splint on it. Really?

For the elbow? Put a splint on it. Really?

For the thumb? Put a splint on it? Really?

We use orthoses when we are resting or restoring motion to a joint.

This may be necessary for a while, with the focus to create the environment for a thumb to be stable.

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Dynamic Thumb Stability: History § Lack of neuromuscular coordination seen often in

those with CMC OA, thumb pain. (Van Heest & Kallemeier, 2008)

§ Muscles may have either a stabilizing or a destabilizing effect on the thumb (Mobargha et al., 2016)

§ Web-space reduction and orthotic support to prevent subluxating forces at CMC for functional thumb use (Taylor, 2000)

§ Use of resistive thumb exercises which promote stability and functional strength at the CMC (Neuman & Bielefield, 2003)

§ Concepts align with dynamic stability rehab for other joints: i.e. knee, shoulder, ankle

Evidence for CMC OA Conservative Management§ EULAR and ACR recommend Exercises & Orthoses§ Moderate to good for CMC orthosis and general hand and

thumb exercises to promote less pain and strength§ Significance with specific style of orthosis combined with

exercise: Not conclusive§ Prospective studies have looked at the style of orthosis for

effectiveness: Not conclusive to style§ 1st Dorsal Interosseous is emerging as a key muscle for

thumb stability

(Zhang et al., 2007) (Valdes & Marik, 2010) (Ye, 2011) (Kjeken et al., 2011) (Hochberg et al., 2012) (Villafane et al., 2013) (Bertozzi et al., 2014) (Aebischer et al., 2016)

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Awaken the Stabilizing Muscles § Dynamic stability is re-creating the power of each muscle to do its job.

§ Thumb – First Dorsal Interosseous appears to work proprioceptively with Opponens Pollicis

§ ACTION ITEM:TRY THIS. Position your thumb in PABD…

§ First Dorsal Interosseous (FDI) activation reduces the MP on the Trapezium

§ -works with OP to reduce the CMC, best in PABD vs. RABD

§ -ONLY muscle that has a distraction and ulnar-ward force at the CMC

§ Evidence is yet to come for why the FDI seems to shut down in the presence of thumb pain…however…what we know is…

(Boutan 2000) (O’Brien, Rosenstein, Magnusson, Nuckley, & Adams, 2016) (Mobargba et al. 2015)

FDI Weaker in Thumb Pain§ FDI tempers the OP; counteracts CMC

dorsoradial imbalance and malalignment§ In a population study, persons > 50 yrs.,

FDI strength was a strong predictor of thumb pain§ 8 of 173 reported thumb pain & 8 had

weaker FDI strength compared to the norm of the group. (RIHM used to measure)

§ A simple MMT of the FDI can be done in your clinic

(Swan et al., 2015)

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Evidence for CMC Proprioception§ Well established evidence: Muscles and ligaments

have proprioceptive end organs§ How the ligaments and muscles communicate

proprioceptively is current focus of study.§ CMC DRL stimulation does affect the FDI, APB,

APL and EPL (ones studied)§ Proprioception of CMC ligaments of OA

population are different than non-OA population; more disorganized ( altered information)

§ What we don’t know- How the exercise of mm around the thumb helps to restore this proprioception?

§ FDI has a stabilizing affect, the APL has a destabilizing effect

(Mobargba et al. 2015)

3 Important Points for a Stable Thumb….

1. Widen Thumb Webspace: Keep it SUPPLE

2. Stabilize and Centralize the 1st CMC with 1st DI and all other Thumb muscles

3. Educate the Person to stabilize own thumbs for a lifetime.

Overarching Principle: Pain Free

Environment

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RADIAL ABD PALMAR ABD

RETROPULSION

FLEXION @ MP & IP

Wide Range of Motion of the Thumb

OPPOSITION

Left Thumb

Volar view

Opponens

First Dorsal Interosseous

Adductor

Abductor Brevis

Flexor Brevis

Abductor Longus

1st Dor

sal In

t.

Adductor

Opponens

Abd.

Lon

gus

Sesamoids

Adductor

Opponens

The Multidirectional Pull of Thumb Muscles

Flexor Brevis

Abd. BrevisExte

nsor

Pol

licis

Bre

vis

Abductor Pollicis Longus

Ext Pollicis Brevis

Not Drawn: Flex Poll Longus/Ext Poll Longus

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Potential De-Stabilizers Dynamic StabilizersEx

tens

or P

ollci

sBr

evis

1stD

I

APL

Add. Pol

APL

APB

OP

The trapezium is like the saddle on a scoliotic horse.

The CMC joint is like a Universal Joint

(Brand & Hollister, 1993)

(Kapandji, 1982)

Movement in 2 planes at right angles

Two theories to explain the “apparent” rotation of the thumb producing pronation and supination

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Check out your own Left Thumb "Rotation"

MC Extension + Thumb Adduction = “Supination” (retropulsion)

MC Flexion+ Thumb Abduction = “Pronation” (opposition)

( Edmunds, 2006)

With respect for pain at each step

Dynamic Thumb Stability Intervention§ Manual release of the adductor and any over-

active, dominant muscle§ Joint mobilization to reduce/realign the CMC § Muscle re-education /strengthening§ Adaptive tools and joint protection techniques§ Orthosis/Orthoses as needed§ Strategy to wean from orthosis

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§ Adductor: One of the strongest muscle per square measure in the body.

§ Manual release of this muscle increases the potential ROM of the thumb lost due to web space contracture.

§ Helps to “set the stage” to gain congruency of joint surfaces for the next portions of the exercise program.

Manual Release

Manual ReleaseAdductor Muscle Release is the KEY

Followed by Abduction stretch

Manual “Trigger Point”

Release

Contract-Relax

Release

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Elongate Soft Tissues in the Web Space

BEFORE

1) Web-to-web: press in to relax tissues 2) Extend Thumb and Index to stretch tissues 3) Hold each 15-30 sec. Repeat 3-5 times

AFTER

Initiated after Manual Release: adductor release, soft tissue elongation ...

AND before Muscle Re-education*

§ To Reduce Pain

§ To Approximate Joint Surfaces: centralize the MC on Trapezium to improve motion and production of nutritional substances in the joint.

§ To Restore Stable Thumb Biomechanics

* Must be done pain free!

Joint Mobilization

(Villafane et al., 2011 and 2013)

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§ Distraction is the first level (Grade I) of joint mobilization

§ Opens joint spaces, relieves pain & increases nutrition

§ Grasp the base of involved thumb, hold arms behind back The weight of the arms provides distraction

Hands behind body...

..or in front

v If this position causes pain in shoulders, bring arms in front of body, relax, and bring elbows back to distract the CMC joint

In both photos, the subject’s RIGHT CMC is being distracted.

Joint Mobilization: Chest

(Villafañe, Silva, Diaz-Perreno & Fernandez-Carnero, 2011)HELPS RESTORE RETROPULSION

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Joint MobilizationWith a “Skull Rock”

(Villafañe, Silva, Diaz-Perreno & Fernandez-Carnero, 2011)

METHOD ONE METHOD TWO

Place opposite thumb in webspace

Roll hand back and forth

Then move arm forward and back

Grasp thumb

Can feel a little uncomfortable, but feels better later.

VIDEO

Re-education of the thumb muscles to restore stable balance IN PAIN FREE CONTEXTFocus: Stability

Abductor Pollicis Brevis Opponens Pollicis1st Dorsal InterosseousExtensor Pollicis BrevisAbductor Pollicis LongusFlexor Pollicis Brevis

Muscle Re-education first, before Strengthening

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Isolate the Abductor and Opponens

Make the thumb puppet sing

Closed Chain Exercise: Watch thumb nail “roll”

Use “Hand Tricks” to enable patients to find their muscles

La-La-La-La-La-La

Touch thumb to index. Use other hand to position MC into an ARCH; add pinch, holding the arch.

If COLLAPSE noted; STOP, RELAX and start again

VIDEO

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The CMC joint is most stable in the “C” position

This exercise is done pain free.

Note the rubber band placement on the metacarpal

Isometric and Isotonic Muscle Re-education of palmar abduction

Isolate the Extensor Pollicis Brevis

EPB Extends and Abducts the METACARPAL With The APL

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Put Thumb into Function -Combined Action

(isometric to isotonic)

Extensor Pollicis BrevisAbductor Pollicis LongusAbductor Pollicis BrevisOpponens PollicisAND the 1st Dorsal Interosseous

Abduct without losing the MP flexion posture

1st DI has a distal and ulnar-ward pull on 1st Metacarpal: ***NOT A COMPRESSIVE FORCE***

(O’Brien & Giveans, 2013) (Mobargha, 2016) (OBrien et al. 2016) (Adams et al. 2018)

Active Motion

Closed Chain Exercises

Resistance: Eccentric & Concentric

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1st Dorsal Interosseous Exercise

Rubber Band Exercise: Abduct the Index away from theMiddle Finger

GOAL: 100 repetitions per day???

1 2

Rubber-band Variations to Re-educate and Strengthen Stabilizing Muscles

Be Inventive to Create Ways For Resistive Exercises/Activities

1st DorsalInterosseous

OpponensPollicis

&

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• For a very unstable CMC, 1st

DI strengthening may be painful initially.

• External support may be needed.

• Co-contraction in “C” position, manual support at the CMC or with orthotic support at the CMC

If the program is unsuccessful in stabilizing the CMC and relieving pain, ligament reconstruction may be a consideration.

More Research…For Thumb Stability§ Which are the key exercises?§ What is the optimal number of exercises?§ What is the dosage of exercises which effect

change?§ For which OA grades is dynamic stability

optimal? Effective?§ How will you contribute to Evidence for Thumb

Stability?

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“No two thumbs are alike.” -Jan Albrecht

It’s NOT about an Orthosis! It is about Dynamic Stability!

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Part 4-CMC Orthotics and Joint Protection

70-88% of therapists working with this diagnosis recommend an orthosis

O’Brien VH, McGaha JL. Current practicePatterns in conservative thumb CMC joint Arthritis. Journal of Hand Therapy, 27 (1): 14-22/

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Why do we use an orthosis?

Decrease Pain (Bani et al., 2013a, 2013b; Becker et al., 2013; Berggren et al., 2001; Boustedt et al., 2009; Egan and Brousseau, 2007; Gomes Carreira et al., 2010; Hermann et al., 2014; Kjeken et al. 2011; Rannou et al. 2009;Valdes and Marik, 2010; Wajon and Ada, 2005; Weiss et al., 2004;Weiss et al. 2000, Bongi et al. 1991; Melvin & Carlson-Rioux, 1989; Swigart 1999)

Increase Function (Bani et al., 2013a, 2013b, 2014; Becker et al., 2013; Boustedt et al. 2009; Hermann et al. 2014; Rannou et al. 2009, Sillem et al. 2011, Wajon & Ada, 2005; Gomes Carreira et al. 2010)

Decrease inflammation (Zhang et al., 2007; Swigart et al., 1999 )

Pinch Strength (Rannou et al., 2009; Wajon & Ada, 2009)

Stability (Hamann et al., 2014, Barron et al. 2013)

Individuals with CMC OA have 2-3 times the functional limitations in dressing, eating, and carrying a 10# load. (Dillon et al., 2007)

Decrease Pain- 6 Systematic Reviews Aebischer et al., 2016 (SR)

Bani et al., 2012, 2014

Becker et al., 2013

Berggren et al., 2001

Bongi et al., 1991

Boustedt et al., 2009

Egan & Brousseau, 2007 (SR)

Gomes Carreira et al., 2010

Hermann et al., 2014

Kjeken et al., 2011 (SR)

McKee & Rivard, 2005 (SR)

Melvin & Carlson-Rioux, 1989

Sillem et al., 2011

Swigart, 1999

Rannou et al., 2009

Valdes & Marik, 2010 (SR)

Wajon & Ada, 2005 (both improved)

Weiss et al., 2004, 2000

Ye et al. 2011 (SR)

çSOFT----------HYBRID--------MORE RIGIDè

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When should an orthosis be worn?§ No standard instructions in many of the

studies. (Henrique TQ de Ameda et al., 2016)

§ During heavy or painful activities and at night (Berggren et al., 2001; Bongi et al., 1991; Buurke et al., 1999; Melvin & Carlson-Rioux, 1989; Swigart et al., 1999; Weiss et al., 2000).

Increased Function

DASHBani et al., 2012 (improved over time)

Becker et al., 2013 Boustedt et al., 2009

Gomes Carreira et al., 2010

AUSCANHermann et al., 2014

Sillem et al., 2011 (Hybrid Orthosis)

Cochin Hand Function Scale

Rannou et al., 2009 (12 months night wear)

Sollerman TestWajon & Ada, 2005

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Decreased InflammationSwigart et al.,

1999

Zhang et al., 2007 (SR)

“The focus of splinting the thumb CMC is to decrease inflammation by providing rest and immobilization.”

“Overall, splinting was found to be a well-tolerated and effective conservative treatment to diminish, but not completely eliminate, the symptoms of carpometacarpal joint arthritis and inflammation.”

Increased Pinch Strength

Rannou et al. 2009Wajon & Ada, 2009

Bani et al., 2014Grenier et al. 2016

Other studies do not show an increase

2.47# 3.25# 2.64 #

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Hamann N. et al., 2014: CMC and MCP joint motion restriction is at the expense of hand functionality.

• Motion analysis with orthoses in place for AROM

• Sollerman Test for functionality

STABILITY

Rhizo Forte V/2013 BSN

Rhizo Hit SPOR

Rhizomed MEDI High Stabilization (êAROM –Low functionality)

Push® MetaGrip®Largest Functionality

To include the MP or not to include the MP that is the question……

Vegt, A. E., Grond, R., Grüschke, J. S., Boomsma, M. F., Emmelot, C. H., Dijkstra, P. U., & Sluis, C. K. (2017). The effect of two different orthoses on pain, hand function, patient satisfaction and preference in patients with thumb carpometacarpal osteoarthritis. Bone Joint J, 99-B(2), 237-244. Accessed March 09, 2017. https://doi.org/10.1302/0301-620X.99B2.37684.

§ Both decreased pain § PUSH® MetaGrip® with the MP free§ allowed more function

Professional clinical judgment is required

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Cantero-Tellez, R., Hugo Villfane, J., Valdez, K., Berjano, P. (2018) Effect of immobilization of metacarpophalangeal joint in thumb carpometacarpalOsteoarthritis on pain and function. A quasi-experimental trial, 31, 68-73.

Clinically significant reduction in pain and improved DASH scores

STABILITY

§ Weiss et al., 2000, 2004

§ Reported decreased CMC joint subluxation using radiographic assessment and observed joint position.

§ Both hard and soft orthoses decreased pain and subluxation

§ Better alignment with custom orthosis.

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Reducing the Need for Surgery

§ Berggren et al. (2001). A seven year prospective study.

§ Joint Protection, adaptive equipment, soft orthoses (leather or textile)

§ After 7 months 23 out of 33 (70%) did not want an operation. During the next 7 additional years only 2 more had surgery.

What about joint protection and OA?

Osborne, et. al (2007) Does self- management lead to sustainable health benefits in people with arthritis? A 2 year transition study of 452 Australians. The Journal of Rheumatology, 34(5), 1112-1117

Study found that such programs decreased pain, fatigue, and health distress.

The European League Against Rheumatism (EULAR) in their systematic review stated education concerning joint protection with an exercise regimen is recommended for all patients with hand OA evidence level of IV.

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Respect Pain

Swigart et al. (1999) Splinting in the treatment of arthritis of the first carpometacarpal joint. The Journal of Hand Surgery, 24A (1), 86-91. (splints decreased pain and inflammation)

è

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Balance RestAnd Activity

There is a moderate evidence to support jointprotection education and adaptive equipment forincreased hand function and pain reduction in patientswith OA. (Valdes K, Marik T., 2010)

Exercise in aPain Free Range

Combining joint protection andpain-free hand home exercises were found to be an effective means to increase hand function (Boustedt C. 2009, Stamm TA, et al. 2002)

Low-impact general conditioning increased the aerobic capacity and decreased depression and anxiety in patients with arthritis. (Minor MA, et al. 1989)

Manual therapy and Therapeutic Exercise strongestEvidence. (Bertozzi et al., 2015)

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Avoid Positions ofDeformityThe European League AgainstRheumatism in their systematic review state that education concerning joint protection with an exercise regimen is recommended for all patients with hand OA.(Zhang W, et al. 2006)

Lateral pinch can cause subluxation of the thumb CMC joint (Zancolli 1987, Brunelli & Brunelli, 1991). Protect the thumb ray with a “C” Shaped tripod pinch.

Joint protection for OA should also take into account the specific deformity or potential deformity which may include instability of the CMC joint and the deformities of the involved interphalangeal joints. Because excessive pinching during ADLs impart large forces to the thumb CMC joint, educating patients in decreasing pressure to the thumb CMC joint is important.

1 kg of pressure at the tip is 12 kg at the CNC joint(Cooney & Chao, 1974)

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Adaptive equipment used in onestudy included enlarged writing grips, “Dycem,” anangled knife, a book holder, and other equipmentbased on individual daily activities. (Stamm TA, et al.2002)

Reduce the Effort and Force

There is a moderate evidence to support jointprotection education and adaptive equipment forincreased hand function and pain reduction in patientswith OA. (Valdes K, Marik T. 2010)

Use Larger/Stronger Joints

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Joint Protection§ Several studies support the effectiveness of joint

protection programs in decreasing pain and increasing ADL.

(Brosseau L, et al, 2003, Hurkmans E, et al. 2003, Beardmore TD, 2008, Ettinger WH, et al. 1997, Valdes K, Marik T. A 2010, Dziedzic et al., 2011, Stamm et al., 2002)

§ We are poised as therapists to demonstrate our Distinct Value in this area

Orthotic Preferences§ Weiss el al. (2000): Found both long and short

splints decreased pain and 73% preferred a short splint.

§ Valdes & Marik (2010): Patients preferred exclusion of the wrist and a flexible orthosis

§ de Almeida et al. (2016): widespread clinical variation in practices and preferences

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Combinations§ Boustedt et al., 2009: Pain and stiffness

decreased with orthotics, exercise, and joint protection vs. joint protection alone.

§ Aebicher et al., 2016: Single interventions not effective and should be combined with orthotics.

§ O’Brien VH and Giveans MR. Effects of a dynamic stability approach in conservative intervention of the carpometacarpal joint of the thumb: a retrospective study. J Hand Ther 2012; 26: 44–51.

Conclusion

§ CMC Orthoses can decrease pain, increase function, decrease inflammation, increase pinch strength, improve thumb stability, and may reduce the need for surgery.

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Part 6: References

Aebischer B, Elsig S, Taeymans J. Effectiveness of physical an occupational therapy on pain, function and quality of life in patients with tarpeziometacarpal osteoarthrtitis- A systematic review and meta-analysis. Hand Therapy 2016;21 (1);5-15.

Banks LN, Lindau TR. Epidemiology of osteoarthritis of the hand and wrist. OA Musculoskeletal Medicine 2013;1(3):23.

Bani AA. A custom-made neoprene thumb carpometacarpal orthosis with thermoplastic stabilization: An orthosis that promotes function and improvement in patients with the first carpometacarpal joint osteoarthritis. Prosthet Orthot Int 2014; 38(1): 79–82.

Bani MA, Arazpour M, Kashani RV, et al. Comparison of custom-made and prefabricated neoprene splinting inpatients with the first carpometacarpal joint osteoarthritis. Disabil Rehabil Assist Technol 2012; 8(3): 232–237.

Bani MA, Arazpour M, Kashani RV, et al. The effect of custom-made splints in patients with the first carpometacarpal joint osteoarthritis. Prosthet Orthot Int 2012; 37(2): 139–144.

Barron, O.A., Glickel, S.Z., Eaton, R.G. Basal joint arthritis of the thumb. J Am Acad Orthop Surg. 2000;8:314–323.

Beasley, J. Therapist’s examination and conservative management of the arthritis of the upper extremity. In Skirven TM, Osterman AL, Fedorcsyk JM, Amadio PC, Eds. Rehabilitation of the Hand and Upper Extremity, 6th ed. Philadelphia, PA: Elsevier: 2011:1330-1344.

Becker SJ, Bot AG, Curley SE, et al. A prospective randomized comparison of neoprene vs thermoplast handbased thumb spica splinting for trapeziometacarpal arthrosis. Osteoarthr Cartil 2013; 21(5): 668–75.

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