Effectiveness of Conservative Exercises for Trapeziometacarpal Osteoarthritis with and Without a Mobile App: An Observational Study

Ludovico Caruso; Daniela Vigliarolo; Adriano Cannella; Giuseppe Taccardo; Marco Passiatore; Vitale Cilli; Loredana Maggi; Gaia Nigro; Diego Farinella; Francesco Frontani; Matteo Guzzini; Luciana Marzella; Rocco De Vitis

doi:10.20944/preprints202503.2001.v1

Submitted:

25 March 2025

Posted:

26 March 2025

You are already at the latest version

Abstract

Background: Thumb carpo-metacarpal arthritis, a form of arthritis at the base of the thumb, causes pain, swelling, and limited mobility, significantly affecting patients' quality of life. This study aimed to evaluate the efficacy of an exercise protocol, comparing standard treatment with an app-assisted approach. Methods: Two groups of 10 patients each were randomly assigned standard treatment or standard treatment plus a Hand Rehab App. Both groups received physiotherapy sessions over three phases spanning three months. Results: Both groups showed improvement, with Group 0 showing more significant improvements in several variables. However, the clinical significance of these improvements differed between groups. Discussion: Group 0 had significant improvements in FLEX IF, FLEX MF TT, and VAS AT NIGHT, while Group 1 had significant improvements in FLEX MF and TT. Group 1 showed greater improvement in JAMAR and TT, while both groups showed similar improvements in other variables. Overall, Group 1 showed more improvement in key measurements. Conclusion: This study suggests that adding a specific app to exercise therapy may enhance outcomes for trapeziometacarpal osteoarthritis patients, particularly in terms of pain relief and functionality.

Keywords:

metacarpophalangeal joint

;

arthroplasty

;

thumb

;

osteoarthritis

;

conservative treatment

;

trapeziometacarpal osteoarthritis

Subject:

Medicine and Pharmacology - Orthopedics and Sports Medicine

Introduction

Trapeziometacarpal osteoarthritis, a degenerative condition affecting the thumb’s carpometacarpal joint, is a common source of pain and functional impairment in the hand. This condition significantly impacts patients' daily activities, often necessitating targeted therapeutic interventions to alleviate symptoms and improve hand function [1,2,3].

Diagnosis relies on a comprehensive clinical history, physical examination, and radiographic assessment, often utilizing Eaton's classification to categorize disease severity [4]. Management decisions are based on both radiographic staging and symptomatology [3,4,5,6,7,8,9,10].

Hand rehabilitation is essential in managing trapeziometacarpal osteoarthritis Stage 1 and stage 2, as it can reduce pain, enhance mobility and functionality, and prevent further joint degeneration [3,11,12].

Optimizing recovery in TMC OA requires adherence to specific behavioral guidelines that minimize joint strain [13,14]. These include avoiding activities that require a strong grip or excessive wrist flexion, such as lifting heavy objects or using hand tools, as well as steering clear of twisting or rotating motions, like wringing a cloth. Utilizing assistive devices, such as a circular blade knife or grip support, can help reduce stress on the thumb joint. Additionally, maintaining the hand in a neutral position and avoiding repetitive movements that provoke discomfort are crucial for managing symptoms effectively.

To develop evidence-based recommendations for the management of TMC OA, a modified Delphi method was employed to achieve consensus among a panel of experts, including hand therapists and hand surgeons. This process was overseen by a steering committee from the American Society of Hand Therapists. The resulting consensus recommendations were categorized according to the World Health Organization's framework, covering assessments of anatomical structures, physiological functions (such as pain and range of motion), and functional capacity. Specific focus areas included thumb mobility (palmar and radial abduction, opposition, metacarpophalangeal joint flexion/extension), grip strength, and tripod pinch strength. Additionally, recommendations emphasized the use of patient-reported outcome measures tailored to the upper extremity.

The consensus also produced detailed treatment recommendations. These included the use of orthotic devices during activities that provoke pain, implementation of dynamic stability programs to maintain joint posture and strengthen stabilizers, and patient education on joint protection strategies. Adaptive equipment and function-based interventions were also advocated to enhance daily living activities. [13].

Various evidence-based techniques and strategies are employed in the rehabilitation of trapeziometacarpal osteoarthritis [13,14,15,16,17], each targeting different aspects of the condition:

Heat Therapy: Applying heat through methods such as hot compresses, paraffin therapy, or infrared lamps helps to reduce pain and alleviate muscle stiffness by promoting relaxation of soft tissues.

Passive Range-of-Motion Exercises: These exercises are crucial for enhancing joint mobility, reducing stiffness, and preventing adhesions.
Manual Therapy: Techniques like massage, joint mobilization, and manipulation can reduce pain, improve blood circulation, and support the healing process.
Braces and Aids: Dynamic daytime braces and static nighttime braces provide support and stability to the hand, helping to reduce pain during both activity and rest.
Muscle Strengthening Exercises: These exercises are designed to enhance the strength of hand muscles and improve joint balance, often using light weights, elastic bands, or specialized equipment.
Thumb-Specific Exercises: Targeted exercises focus on promoting joint stability and preventing further cartilage deterioration.
Correcting Postural Habits: Identifying and modifying behaviors or movements that exacerbate trapeziometacarpal osteoarthritis is crucial for long-term management.
Thumb Grip Strengthening Exercises: These exercises are important for improving grip strength, enabling patients to perform daily tasks more effectively.

Several studies [11,12,13,14,15,16,17] have demonstrated the efficacy of these techniques in reducing symptoms and improving joint function in patients with trapeziometacarpal osteoarthritis.

Despite the availability of various therapeutic interventions, there remains a lack of consensus on the most effective rehabilitation techniques, underscoring the need for further research in this area [18,19,20,21].

The customization of rehabilitation programs based on the individual needs and the specific pathology of each patient is vital for achieving optimal outcomes.

Conservative management through rehabilitation is often effective but surgical intervention may be necessary in cases where hand function cannot be restored [3,22]. However rehabilitation remains essential in managing post-operative conditions [22,23,24,25,26,27].

Several rating scales found in the literature are used to evaluate hand osteoarthritis: Numeric Rating Scale (NRS), Visual Analogue Scale (VAS), Disability of the Arm, Shoulder and Hand (QUICK DASH), Functional Index for Hand OsteoArthritis (FIHOA), Activities of Daily Living (ADL), Instrumental ADL (IADL), Joint position sense (JPS), Canadian Occupational Performance Measure (COPM), Patient global assessment (PGA), Arthritis Hand Function Test (AHFT), Patient Specific Function Scale (PSFS), Sollerman Hand Function Test (SHFT), Michigan hand questionnaire (MHQ), and Measure of activity performance of the hand (MAP-Hand), Australian Canadian Osteoarthritis Hand Index (AUSCAN), Cochin Hand Function Scale (CHFS), Grip Ability Test (GAT), Jebsen Hand Function Test (JHFT), and Michigan Hand Outcomes Questionnaire (MHQ), ABILHAND score, Upper Extremity Functional Index (UEFI) [28,29,30,31,32,33,34,35,36,37].

Given the varied approaches to rehabilitation in TMC OA, this study aims to evaluate the effectiveness of specific interventions to establish a more standardized treatment protocol.

Material and methods

Study Objectives

The primary objective of this study was to develop and evaluate personalized exercises for patients with trapeziometacarpal osteoarthritis, focusing on joint economy and ergonomic principles to enhance quality of life. The secondary objective was to assess whether an app-assisted approach could improve the outcomes of standard treatment in comparison to traditional methods.

Joint Economy and Ergonomics

Joint economy and ergonomics are essential components in managing trapeziometacarpal osteoarthritis, aimed at minimizing joint stress and enhancing patient well-being. The following principles were emphasized:

Controlled Movements: Patients were instructed on coordinated movements to reduce joint wear and tear.

Avoidance of Forced Movements: Avoidance of forced or repetitive movements that could exacerbate joint stress was encouraged.
Load Distribution: Techniques to ensure equal load distribution during daily activities were taught to prevent joint overload.
Ergonomic Tools and Environment: Recommendations included the use of ergonomic tools and adjustments to the workspace to reduce strain on the thumb and other hand joints.
Safe Lifting and Posture: Patients were educated on safe lifting techniques and proper posture during activities to minimize tension and stress on the joints.
Activity Management: Patients were advised to take regular breaks, vary activities to prevent muscle fatigue, and use support devices like ergonomic mice and keyboards.

These principles were tailored to individual patients based on their lifestyle and environment, and were reinforced through professional guidance and patient education.

Current Treatment Practices

This study was motivated by the limited recent advancements in conservative treatment for trapeziometacarpal osteoarthritis. Current treatment practices include education on pain-preventive functional gestures, improving active range of motion (ROM), proprioceptive exercises, manual therapy, and the use of tailor-made splints and joint strengthening exercises. These practices were integrated into the treatment protocol for both study groups.

Study Design and Participants

This was a randomized, controlled oservational study involving 20 patients diagnosed with stage I or II trapeziometacarpal osteoarthritis according to the Eaton scale. Participants were aged 40 to 82 years, and those with prior hand surgeries or comorbidities affecting hand function were excluded. Ethical approval was not necessary because this study is observational and was conducted as part of a therapist’s dissertations. all participants provided informed consent before enrollment.

Participants were casually assigned to one of two groups:

Group 0 (Control): Received standard care, including gesture education, manual therapy, dynamic bracing, and assigned exercises.

Group 1 (Experimental): In addition to the standard care provided to the control group, this group utilized the Hand Rehab tool, a digital application that delivered personalized exercise programs, video tutorials, and progress monitoring.

The treatment spanned 3 months and was divided into three phases:

Phase 1 (Acute Phase): Weekly sessions for the first three weeks, focusing on pain management, edema control, ergonomics, passive mobilization, and functional exercises.

Phase 2 (Gesture Re-education Phase): Sessions every 15 days for seven weeks, aimed at restoring hand functionality through controlled movements in activities of daily living (ADLs) and instrumental ADLs (IADLs).

Phase 3 (Maintenance Phase): Two follow-up sessions at 5 and 12 weeks to sustain results through muscle strengthening, stretching, and gradual return to activity.

Outcome Measures

Outcomes were assessed using a range of validated scales, including the Visual Analogue Scale (VAS), Functional Index for Hand OsteoArthritis (FIHOA), goniometric evaluation, dynamometer measurements, and pinch tests. The primary outcomes were pain reduction (VAS) and functional improvement (FIHOA). Secondary outcomes included joint range of motion and grip strength.

Treatment Sessions

Each session incorporated:

Education: Joint economy concepts and ergonomic principles were reinforced.

Therapeutic Exercises: Progression of exercises tailored to each phase of rehabilitation.

Manual Therapy: Passive mobilization, massage, and other manual techniques were applied as needed.

Behavioral Guidance: Patients were advised to avoid activities requiring strong grip or radial wrist flexion, use soft braces as necessary, and avoid prolonged repetitive gestures.

APP-Based Exercise Protocol

The experimental group’s treatment was augmented by an app-based protocol, which provided:

Instructional Materials: Customized exercise programs, a booklet, and video tutorials for each phase of rehabilitation.

Progress Monitoring: Regular assessments to track improvements and adjust exercises as needed.

Precautions and Safety: Alerts within the app to guide safe practice and prevent overexertion.

Statistical Analysis

Data were analyzed using R software (version 4.3 1), with results summarized as mean ± standard deviation. Normality of data distribution was assessed using the Kolmogorov-Smirnov test. Differences between groups were evaluated using repeated measures ANOVA, while intra-group effectiveness was assessed using paired t-tests or the Wilcoxon Rank test for non-normally distributed data. Missing data were addressed using multiple imputation techniques, and corrections for multiple comparisons were applied where appropriate.

Results

2 study groups of 20 patients with Eaton stage 1-2 trapeziometacarpal osteoarthritis diagnosed by x-ray and visit to the hand surgeon were taken into consideration.

10 patients were treated with manual therapy, pumps, massage and functional and proprioceptive exercises explained verbally.

10 patients were treated with manual therapy, pumps, massage and functional and proprioceptive exercises using a specific App.

Both groups were treated with 1 session per week for 3 weeks, 1 session every 15 days for 3 times and the last one at 3 weeks for a total of 7 sessions in 3 months including follow ups at 5 and 12 weeks.

Both groups underwent: functional assessment, functional neoprene brace for activities of daily living, education, manual therapy and exercises.

GROUP 0

The control group (T0) consists of 10 patients (3 male and 7 female) with an average age of 68 (ranging from 52 to 82 years). The affected hand is the right hand for all patients, and 6 out of 10 do not report pain at rest. During Activities of Daily Living (ADL), 9 patients report varying levels of pain on the Vas scale ranging from 5 to 10, with 3 patients at a level of 10 and only 1 at a level of 0. Nighttime pain is reported by 6 patients, ranging from 5 to 8, while 4 patients do not experience pain. On the FIHOA scale (where a score of 0 means no movement difficulty, 1 means slight difficulty, 2 means significant difficulty, and 3 means impossible), the average score is 18.2, with scores ranging from 7 to a maximum of 30. Thumb opposition, measured using the K scale (where K10 is the maximum score), shows that only 1 patient had a score of K1, and 4 out of 10 patients scored K9. The remaining patients had scores ranging from K3 to K7. Active range of motion (ROM) for thumb flexion (measured with a finger goniometer) ranges from 40 to 60 degrees for the metacarpophalangeal joint, and from 40 to 75 degrees for the interphalangeal joint. Grip strength, measured in kilograms with a Jamar dynamometer, shows an average strength of 17.5 kg, ranging from 5 to 22 kg, with only 1 patient at 0 kg. Pinch Test results show that the average strength for the tip-to-tip pinch is 2.9 kg (ranging from 2 to 4 kg), for the lateral pinch it is 1.85 kg (ranging from 1 to 3 kg), and for the three-jaw chuck pinch it is 0.85 kg (ranging from 0 to 2 kg).

The control group (T1) consists of 10 patients (3 male and 7 female) with an average age of 68 (ranging from 52 to 82 years). The affected hand is the right hand for all patients except 2, who do not report pain at rest. During ADL, 5 patients report varying levels of pain on the Vas scale ranging from 5 to 8, while the other 5 report no pain. Nighttime pain is reported by 2 patients at levels 5 and 6 on the Vas scale, while 8 patients do not experience nighttime pain. On the FIHOA scale, the average score is 8.2, ranging from 3 to 17. Thumb opposition, measured using the K scale, ranges from K7 to K10. Active range of motion shows that thumb flexion ranges from 50 to 72 degrees for the metacarpophalangeal joint and from 45 to 82 degrees for the interphalangeal joint. Grip strength, measured with a Jamar dynamometer, shows an average strength of 20.1 kg, ranging from 5 to 35 kg. Pinch Test results show that the average strength for the tip-to-tip pinch is 3.3 kg (ranging from 2 to 4 kg), for the lateral pinch it is 2.4 kg (ranging from 1 to 3 kg), and for the three-jaw chuck pinch it is 1.4 kg (ranging from 1 to 2 kg).

The control group (T2) consists of 10 patients (3 male and 7 female) with an average age of 68 (ranging from 52 to 82 years). The affected hand is the right hand for all patients, and none of the patients report pain at rest. During ADL, 3 patients do not experience pain, while the other 7 report varying levels of pain on the Vas scale ranging from 2 to 5. No patients report nighttime pain. On the FIHOA scale, the average score is 2.5, ranging from 0 to 7. Thumb opposition, measured using the K scale, ranges from K9 to K10. Active range of motion shows that thumb flexion ranges from 50 to 75 degrees for the metacarpophalangeal joint and from 47 to 80 degrees for the interphalangeal joint. Grip strength, measured with a Jamar dynamometer, shows an average strength of 25.3 kg, ranging from 7 to 40 kg. Pinch Test results show that the average strength for the tip-to-tip pinch is 4.1 kg (ranging from 3 to 5 kg), for the lateral pinch it is 3 kg (ranging from 1 to 4 kg), and for the three-jaw chuck pinch it is 2.2 kg (ranging from 1 to 3 kg).

Table 1. T0 in group 0.

Table 2. T1 in group 0.

Table 3. T2 in group 0.

GROUP 1

The control group (T0) consists of 10 patients (2 males and 8 females) with an average age of 63 (ranging from 53 to 76 years). The affected hand is the right hand for 8 patients, with 5 out of 10 not reporting pain at rest. During activities of daily living (ADL), all patients report varying levels of pain on the Vas scale, ranging from 1 to 3, with only 1 patient at 10. Nighttime pain is reported by 3 patients, ranging from 1 to 4, while 7 patients do not experience pain at night. On the FIHOA scale (where a score of 0 means movement possible without difficulty, 1 possible with slight difficulty, 2 possible with significant difficulty, and 3 impossible), the average score is 13.3, ranging from 4 to 20. In thumb opposition measured on the K scale (where K10 is the maximum), the range is between K5 and K9. In active range of motion (ROM), flexion (measured with a finger goniometer) of the metacarpophalangeal (MF) joint ranges from 40 to 60 degrees, while flexion of the interphalangeal (IF) joint ranges from 52 to 74 degrees. Jamar strength in kilograms (Kg): the average grip strength measured with Hand Grip is 13.2 kg, ranging from 2 to 32 kg, with only 1 patient at 0. Pinch Test results: Tip Grip (TG) strength has an average of 3.5 kg, ranging from 2 to 5 kg; lateral pinch strength (TL) has an average of 3.3 kg, varying between 1 and 6 kg; terminal pinch strength (TT) has an average of 2.15 kg, varying between 0 and 5 kg.

The control group (T1) consists of 10 patients (2 males and 8 females) with an average age of 63 (ranging from 53 to 76 years). The affected hand is the right hand for 8 patients. Resting pain is reported by only 3 patients at 2 on the Vas scale. During ADL, 9 patients report varying levels of pain on the Vas scale, ranging from 2 to 8. Nighttime pain is reported by 2 patients at 4 and 2 on the Vas scale. On the FIHOA scale, the average score is 9.6, ranging from 3 to 15. In thumb opposition measured on the K scale, the range is between K6 and K10, with 2 patients reaching K10. In active ROM, flexion of the MF joint ranges from 50 to 60 degrees, while flexion of the IF joint ranges from 52 to 74 degrees. Jamar strength in kilograms: the average grip strength measured with Hand Grip is 14.6 kg, ranging from 2 to 35 kg. Pinch Test results: TG strength has an average of 3.9 kg, ranging from 2 to 5 kg; TL strength has an average of 2.4 kg, ranging between 1 and 6 kg; TT strength has an average of 1.4 kg, ranging between 0 and 5 kg.

The control group (T1) consists of 10 patients (2 males and 8 females) with an average age of 63 (ranging from 53 to 76 years). The affected hand is the right hand for 8 patients. Resting pain is reported by only 1 patient, during ADL 8 patients report varying levels of pain on the Vas scale, ranging from 2 to 4, with two patients at 0 on the Vas scale. Nighttime pain is not reported. On the FIHOA scale, the average score is 4.4, ranging from 1 to 10, with only 1 patient at 0. In thumb opposition measured on the K scale, the range is between K7 and K10, with 5 patients reaching K10. In active ROM, flexion of the MF joint ranges from 55 to 70 degrees, while flexion of the IF joint ranges from 60 to 80 degrees. Jamar strength in kilograms: the average grip strength measured with Hand Grip is 16.2 kg, ranging from 4 to 40 kg. Pinch Test results: TG strength has an average of 4.6 kg, ranging from 2 to 6 kg; TL strength has an average of 4.4 kg, ranging between 2 and 6 kg; TT strength has an average of 3.3 kg, ranging between 1 and 5 kg.

Table 4. T0 in group 1.

Table 5. T1 in group 1.

Table 6. T2 in group 1.