Can physical therapy (PT) help treat thumb osteoarthritis in older adults?

Physical Therapy for Thumb Osteoarthritis

Yes, physical therapy is highly effective for thumb osteoarthritis and should be considered for every patient, with exercises and manual therapy providing clinically meaningful improvements in both pain and function. 1

Evidence-Based Recommendation

The 2018 EULAR guidelines explicitly state that exercises to improve function and muscle strength, as well as to reduce pain, should be considered for every patient with hand osteoarthritis, including thumb base (CMC-1 joint) involvement. 1 This recommendation is supported by multiple randomized controlled trials demonstrating small to moderate beneficial effects on self-reported pain, function, joint stiffness, and grip strength. 1

What Physical Therapy Should Include

Exercise Components (First-Line Treatment)

Therapeutic exercises should target three specific goals: 1

• Joint mobility improvement - Range of motion exercises specific to the CMC-1 joint
• Muscle strength enhancement - Strengthening exercises for thumb stabilization
• Thumb base stability - Exercises differ significantly from those for interphalangeal joints

Key implementation details: 1

• Start with isometric strengthening when joints are acutely inflamed or unstable (produces low articular pressures and is well-tolerated)
• Progress to isotonic (dynamic) exercises as inflammation subsides
• Exercise resistance must remain submaximal - muscles should NOT be exercised to fatigue
• Warning sign: Joint pain lasting >1 hour after exercise or joint swelling indicates excessive activity

Manual Therapy (Strong Evidence)

Manual therapy combined with therapeutic exercise provides moderate-quality evidence for pain improvement at both short-term and intermediate-term follow-up. 2 High-quality evidence from meta-analysis shows that multimodal physical therapy (combining manual therapy with exercises) results in clinically worthwhile pain reduction of 2.9 points on a 0-10 scale at 4 weeks. 3

Proprioceptive Training

Proprioceptive exercises demonstrate statistically and clinically superior outcomes compared with standard care alone, with effect sizes of -0.76 for pain intensity at very short-term follow-up and -0.93 at short-term follow-up. 4

Treatment Algorithm

Step 1: Initial Phase (Acute/Inflamed Joint) 1

• Begin with isometric strengthening exercises
• Perform only a few repetitions
• Do NOT resist movements
• Apply superficial moist heat before exercises

Step 2: Progressive Phase (As Tolerated) 1

• Advance to isotonic (dynamic) strengthening
• Focus on exercises that correspond to everyday activities
• Include static stretching (hold 10-30 seconds)
• Perform daily when pain and stiffness are minimal

Step 3: Maintenance Phase 1

• Continue exercises indefinitely - beneficial effects are NOT sustained when patients stop exercising
• Combine with orthotic use for optimal outcomes

Expected Outcomes and Timeline

Short-term (4-6 weeks): 3, 5

• Pain reduction: 2.9-3.1 points on 0-10 scale (clinically meaningful)
• Function improvement: 6.8-20.5 points on 0-100 scale
• Effects are statistically and clinically significant

Important caveat: The evidence shows benefits are NOT sustained at mid- and long-term follow-up unless exercises are continued. 1, 4 This means lifelong adherence to exercise programs is necessary for maintaining improvements.

Delivery Options

Physical therapy can be delivered through: 1

• Physical therapists specializing in hand therapy
• Occupational therapists
• Trained nurses with specialized hand therapy training
• Home-based programs after initial instruction (as effective as intensive supervised programs for cost-effectiveness)

Combination with Other Modalities

PT should be combined with: 1, 5

• Thumb base orthoses for long-term use (≥3 months) - provides additional pain relief and functional improvement
• Patient education on self-management and ergonomic principles
• Topical NSAIDs (diclofenac 1% gel) as first-line pharmacological treatment when needed

A 2021 randomized trial demonstrated that combining education, splinting, hand exercises, and topical diclofenac provided significantly better hand function improvement (-1.7 units at 6 weeks, -2.4 units at 12 weeks) compared to education alone. 5

Common Pitfalls to Avoid

• Exercising to fatigue - This increases inflammation and pain 1
• Stopping exercises when symptoms improve - Benefits disappear without continued exercise 1
• Using only passive modalities - Active exercise is essential for sustained benefit 1
• Ignoring the need for long-term orthotic use - Short-term orthotic use (<3 months) shows no benefit 1
• Expecting immediate results - Clinically meaningful improvements require at least 3-4 weeks of consistent exercise 3, 5

Quality of Evidence

The recommendation for PT in thumb OA is based on: 1, 3

• Moderate-quality evidence from Cochrane review (7 trials)
• High-quality evidence from recent meta-analyses showing clinically worthwhile improvements
• Low to moderate certainty that benefits persist long-term without continued exercise