Hand Therapy - Continuous Passive Motion

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Hand therapy rehabilitation using a Continuous Passive Motion machine - painless passive range, swelling reduction and ultimate full active range of motion

Published in: Health & Medicine

Hand Therapy - Continuous Passive Motion

  1. 1. CONTINUOUS PASSIVE MOTION MACHINE AS AN INTEGRAL PART OF MANAGEMENT OF RANGE OF MOTION AND EDEMA IN HAND THERAPY Ms L Pringle Cape Town
  2. 2. “ Without passive motion there is no potential for active range..” J Colditz <ul><li>Active range of motion (AROM): </li></ul><ul><li>-contraction of muscle crossing a joint. </li></ul><ul><li>Passive range of motion (PROM): </li></ul><ul><li>-movement of a joint by an external </li></ul><ul><li>force. </li></ul>
  3. 3. Other definitions of PROM/CPM: <ul><li>Correct PROM: </li></ul><ul><li>Gentle encouragement of tissues  max. </li></ul><ul><li>available length. </li></ul><ul><li>CPM: </li></ul><ul><li>PROM continuously in a reciprocal fashion by a mechanical device which controls range, rate. </li></ul><ul><li>P La Stayo </li></ul>
  4. 4. <ul><li>CPM can be invaluable in management of a complex/crush injury. </li></ul><ul><li>Karen M Stewart </li></ul><ul><li>CPM can serve to reinforce weak muscle contraction or provide a “rhythm” to exercise. </li></ul><ul><li>CPM has proven to be clinically effective in reducing post-operative pain and edema. Nancy M Cannon </li></ul><ul><li>Joint stiffness – LLPS to tissues. </li></ul>
  5. 5. <ul><li>Coutts et al(1988) – knee CPM: general </li></ul><ul><li>use in orthopaedic problems: immediate post-op, 8hrs per day. </li></ul><ul><li>Akeson et al: no force; through comfort range, intermittent. Not to replace AROM, addition to rehab. </li></ul><ul><li>Some patients with stiffness of hand  </li></ul><ul><li>strong muscle pull.  pain/swelling = </li></ul><ul><li>excessive active exercise. CPM  able </li></ul><ul><li>to repeat. </li></ul>
  6. 6. Robert Salter: <ul><li>“ continues motion exerts a beneficially stimulating effect at the cellular level on the healing and regeneration of musculo-skeletal tissues… preventing joint stiffness and influencing adhesive formation.” </li></ul><ul><li>Dynamic loading of joints by CPM may stimulate cartilage growth and remodelling of soft tissues. </li></ul>
  7. 7. HEALING AND REGENERATION: <ul><li>Wound healing = production of new collagenous tissue. </li></ul><ul><li>Three phases of wound healing occur regardless whether incised/excised wounds and regardless of amount of tissue lost. </li></ul>
  8. 8. I. Early inflammatory phase: <ul><li>Usually over by day 5 </li></ul><ul><li>Vascular + cellular. </li></ul><ul><li>Wound cleaned . </li></ul><ul><li>Healing causes  osmolarity  further swelling. </li></ul><ul><li>Cells release growth factors + proteins </li></ul><ul><li> fibroblast proliferation + collagen production. </li></ul>
  9. 9. II. Fibroplasia phase: <ul><li>3 – 5 days post-op, can last 14 – 6/52. </li></ul><ul><li>Fibroblasts  glycosaminoglycans + collagen  granulation tissue. </li></ul><ul><li>Immobilisation helps prevent collagen fibre disruption = delay in  tensile wound strength. </li></ul><ul><li>Collagen accumulation – plateau.Tensile strength 15%.  linearly for 3/12. </li></ul>
  10. 10. III. Scar maturation + remodelling: <ul><li>3 weeks. </li></ul><ul><li>Fibroblastic activity and collagen  </li></ul><ul><li>Early: scar bulky – random collagen bundles. </li></ul><ul><li>Fibers along tension lines  compact. </li></ul><ul><li>More intermolecular cross-linkages </li></ul><ul><li>Optimum environment: </li></ul><ul><li>blood supply, oxygen, minimal edema, no ongoing inflammation process. </li></ul>
  11. 11. <ul><li>Newly formed scar shrinks, squeezing water out of extracellular spaces, making collagen more dense. </li></ul><ul><li>Any scar tendency to shorten unless therapeutic stretching. </li></ul><ul><li>Circumferential scars constrict conduction, flow or motion. </li></ul><ul><li>Tendon healing – Gelberman et al (1982) – tensile load values of repaired tendons > early mobilisation. </li></ul>
  12. 12. <ul><li>Peritendinous adhered tissues  restricted gliding. </li></ul><ul><li>Tight suturing/aggressive mobilisation  </li></ul><ul><li>ischemic tendon  stimulus  fibrovascular tissue around tendon juncture. (  tendon adhesions also occur with immobilisation). </li></ul>
  13. 13. Hand therapy: <ul><li>Restoration of function: manipulating healing tissues to promote differential healing and approximate regeneration. </li></ul><ul><li>Minimise restrictive regeneration adhesions – maximising tendon gliding, elongate scar adhesions progressively through motion and splinting. </li></ul>
  14. 14. Treating edema: <ul><li>Rest and motion balanced. </li></ul><ul><li>Squeezing action of muscles = retrograde venous + lymphatic movement. </li></ul><ul><li>Early control NB. Interstitional fluid  30 </li></ul><ul><li>to 50% before detection. </li></ul><ul><li>A Guyton (1977) </li></ul>
  15. 15. Randomised study – 6/12 <ul><li>10 - intermittent </li></ul><ul><li>Full spectrum of therapy: </li></ul><ul><li>- elevation, mobilisation, compression, MEM, massage, splinting, scar management, education, exercise (putty, hand exerciser). </li></ul><ul><li>Measurements: </li></ul><ul><li>ROM: goniometer </li></ul><ul><li>Edema: tape. </li></ul><ul><li>volumeter. </li></ul><ul><li>Pain: scale. </li></ul>
  16. 16. Pressure glove
  17. 17. Goniometer: Tape:
  18. 18. Volumeter:
  19. 19. Pain: <ul><li>Scale: </li></ul><ul><li>0 = no pain </li></ul><ul><li>1 = all the time </li></ul><ul><li>2 = with movement </li></ul><ul><li>3 = at end range </li></ul>
  20. 20. Indications: <ul><li>Edema  , limiting and managing. </li></ul><ul><li>Pain, paralysis, weakness -  AROM. </li></ul><ul><li>Commence ROM before close of phase I. </li></ul><ul><li>Prevent intra-articular + periarticular </li></ul><ul><li>adhesions. </li></ul><ul><li>Clear exudate from synovial cavity  </li></ul><ul><li>prevent adhesions. </li></ul><ul><li> nutrient diffusion – “pumping” action. </li></ul><ul><li> bloodflow + metabolic cell activity. </li></ul>
  21. 21. Indications cont.. <ul><li> Wound + tissue healing – “ work </li></ul><ul><li>hypertrophy”. </li></ul><ul><li>Joint mobs + stretching -  joint + soft </li></ul><ul><li>tissue mobility. </li></ul><ul><li>Early phase – gentle controlled PROM> </li></ul><ul><li>AROM . </li></ul><ul><li>Stretch contractures - > splinting </li></ul><ul><li> multiple joints, opposite directions. </li></ul>
  22. 22. Precautions: <ul><li>Insensate hand, pain 1. </li></ul><ul><li>Repetitions +++. </li></ul><ul><li>Not routinely. </li></ul><ul><li>Therapist’s direct control and handling. </li></ul><ul><li>Contractures – soft end feel. </li></ul><ul><li>Discontinue  AROM. </li></ul><ul><li>Severe pain with active/forced pass. </li></ul><ul><li>= tissue damage. </li></ul>
  23. 23. Prohibiting factors to AROM and patient compliance: <ul><li>Anxiety </li></ul><ul><li>Pain </li></ul><ul><li>Open wound </li></ul><ul><li>Edema </li></ul><ul><li>Fear of pain </li></ul><ul><li>Tender scar </li></ul><ul><li>Cold intolerance </li></ul><ul><li> understanding </li></ul><ul><li>and insight </li></ul><ul><li>Fear of snapping/breaking/ </li></ul><ul><li>tearing </li></ul>
  24. 24. Functional flexion ROM: <ul><li>Nancy M Cannon (1995): </li></ul><ul><li>MCP jt - 61° (MF-63º,RF-68º,SF-70º) </li></ul><ul><li>PIP jt - 60° </li></ul><ul><li>DIP jt - 39° </li></ul><ul><li>Th.MP jt - 21° </li></ul><ul><li>Th.IP jt - 18° (25º) </li></ul>
  25. 25. Results: <ul><li>Du puytren’s RF, SF non-dominant(L) </li></ul><ul><li>Du puytren’s RF,SF,Th dominant(R) </li></ul><ul><li># MF prox. ph. jt. –late non-dominant(R) </li></ul><ul><li>IF – FDP,FDS, SF-nerve dominant(R) </li></ul><ul><li>rupture at 6/52, secondary </li></ul><ul><li>IF – FDS,FDP secondary, nerve tenolysis dom(R) </li></ul><ul><li>SF –PIPjt arthroplasty non-dominant(L) </li></ul><ul><li>MF – EDC -dog bite,infection dominant(R) </li></ul><ul><li>MF – EDC –tooth,infection non-dominant(L) </li></ul><ul><li>IF – explosion,#’s,nerves,  skin ? Dominant(R) </li></ul><ul><li>RF – PIPjt arthroplasty,O.A. non-dominant(L) </li></ul>
  26. 26. <ul><li>Treatment sessions  <45 min, daily/3@week </li></ul><ul><li>Start small arc -  5-10º -  end range </li></ul><ul><li>Pause at end range,  LLPS </li></ul><ul><li>Range of movement: </li></ul><ul><li>session week </li></ul><ul><li>MCPjt 7º 12º </li></ul><ul><li>PIPjt 9º 10.8º </li></ul><ul><li>DIPjt 4.5º 8.1º </li></ul>
  27. 27. <ul><li>Edema: </li></ul><ul><li>Tape session week </li></ul><ul><li>PIPjt 2mm 6mm </li></ul><ul><li>MCP’s 3mm 10mm </li></ul><ul><li>Volumeter week </li></ul><ul><li>22ml </li></ul>
  28. 28. <ul><li>Pain: </li></ul><ul><li>phase I phase II phase III </li></ul><ul><li>0 - 3 4 5 </li></ul><ul><li>1 - 1 0 0 </li></ul><ul><li>2 - 2 0 0 </li></ul><ul><li>3 - 4 6 5 </li></ul>
  29. 45. Conclusion: <ul><li>The use of a CPM machine has proved a valuable adjunct to hand therapy, achieving goals such as the increase, maintenance and restoring of passive mobility, maintaining gliding, stimulating nutrient diffusion and decreasing edema and pain. </li></ul>

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