Hand Therapy - Stiff Small Joints Of The Fingers

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Hand Therapy and rehabilitation for stiff small joints for fingers - SASSH Durban February 2009

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Hand Therapy - Stiff Small Joints Of The Fingers

  1. 1. Hand therapy for stiffness of small joints of the hand SASSH Durban 2009
  2. 2. Stiffness <ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Immobilisation </li></ul></ul><ul><ul><li>Edema </li></ul></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Balance disturbed </li></ul></ul><ul><ul><li>Mechanical </li></ul></ul><ul><ul><li>Loss of range of motion </li></ul></ul>
  3. 3. Therapy aims – stiff small joints <ul><li>reduce edema </li></ul><ul><li>restore & re-establish tissue glide </li></ul><ul><li>ROM </li></ul><ul><li>function </li></ul>
  4. 4. Modalities <ul><li>Elevation </li></ul><ul><li>Immobilisation </li></ul><ul><li>Splints/casts </li></ul><ul><li>Compression </li></ul><ul><li>Thermal </li></ul><ul><li>ROM exercises </li></ul><ul><li>CPM </li></ul><ul><li>Massage </li></ul>
  5. 5. <ul><li>Paul Brand: “many hands become stiff from a dangerous mixture of over treatment and disuse.” </li></ul><ul><li>30 min to  ROM……… </li></ul><ul><li>… ..thereafter patient relaxes into disuse </li></ul><ul><li>With such intense stress, inflammation occurs and fibrinogen formation with disuse, these fibrin strands shorten and tighten </li></ul>
  6. 6. <ul><li>Compliant pts – too vigorous  pain and edema </li></ul>
  7. 7. <ul><li>Therapy encompasses 24 hrs in healing and rehabilitation </li></ul><ul><li>As therapists, pts reveal hopes, wishes, dreams, fears and worries, pain and resentments </li></ul><ul><li>Understand underlying emotional factors </li></ul><ul><li>LISTEN…. </li></ul><ul><li>GUIDE…. </li></ul><ul><li>EDUCATE…. </li></ul><ul><li>INSPIRE confidence </li></ul>
  8. 8. <ul><li>Immobilise digits initially </li></ul><ul><li>Rest </li></ul><ul><li>Reduce edema </li></ul><ul><li>Balance between rest and motion for healing </li></ul><ul><li>Patients expect an increase in tissue mobility after exercise </li></ul><ul><li>May be  swelling and  ROM resulting from excessive exercise </li></ul>
  9. 9. Splinting Static splints: <ul><li>Rest (acute stage) </li></ul><ul><li>Support </li></ul><ul><li>Decrease pain </li></ul><ul><li>Remember that ALL splints must be comfortable, easy to apply. </li></ul>
  10. 10. <ul><li>Full extension allows edema reduction & assists weaker extension motion gain </li></ul><ul><li>Positions joints for function </li></ul><ul><li>Prevents deformity </li></ul><ul><li>Provide blocking/stabilising force </li></ul><ul><li>Removed for mobilising </li></ul>
  11. 11. <ul><li>Elastic human tissue stretches when mobilised </li></ul><ul><li>Returns to its resting length once force released </li></ul><ul><li>If held in elongated position for length of time, there is plastic response and </li></ul><ul><li>tissue deforms and growth takes place </li></ul><ul><li>This tissue maintains all or part of this stretched position once force released </li></ul><ul><li>Recaptures elasticity, ultimately allowing motion </li></ul>
  12. 12. <ul><li>Tension must be of low magnitude & </li></ul><ul><li>tolerated for  periods of time </li></ul><ul><li>Never painful </li></ul><ul><li>Patients do feel a slow stretch </li></ul><ul><li>When we use patients tissue response as a guideline, </li></ul><ul><li>the amount of force becomes relatively unimportant with intermittent and gentle application </li></ul>
  13. 13. Dynamic splints: <ul><li>splint base + outrigger </li></ul><ul><li>Stretching force to specific joint </li></ul><ul><li>Correct angle perpendicular to long bone axis </li></ul>
  14. 14. ?
  15. 15. <ul><li>Even if motion  , force continues </li></ul><ul><li>Too early – may prolong inflammatory phase </li></ul><ul><li>Intermittently – balance </li></ul><ul><li>Not nocte </li></ul><ul><li>Contra-indication: healing structures strong enough to withstand stress, however gentle </li></ul>
  16. 16. Serial/Progressive static splints: <ul><li>Prolonged low-intensity stretch encourages  length (collagen fibres do not actually stretch). However, as old fibres are degraded, tissue adapts and new fibres are laid down in an extended manner (Tillmann & Cummings) </li></ul>
  17. 17. <ul><li>Similar to dynamic – force not dynamic, constant </li></ul><ul><li>Adjust force as tissue adapts </li></ul>
  18. 18. Skin tightness/stiffness <ul><li>Skin tightness limits jt ROM – prolonged and progressive static splints provide a force for reorganising collagen fibres and allowing jt motion </li></ul>
  19. 19. Flexion straps
  20. 20. Serial Plaster of Paris <ul><li>Inexpensive </li></ul><ul><li>Circumferential </li></ul><ul><li>Easy to apply </li></ul><ul><li>Guarantees slow stretch </li></ul><ul><li> edema </li></ul><ul><li>Re-apply 3 to 4 days </li></ul>
  21. 21. ROM / Exercise <ul><li>Prevention better than cure - early </li></ul><ul><li>At intermediate phase wound healing (3-4 days), inflammatory phase ending </li></ul><ul><li>Able to  mobilisation </li></ul><ul><li>Active and Passive must go through the full range in order to propel fluids and return flow circulation </li></ul>
  22. 22. Active Range of motion AROM <ul><li>Contracting muscles – joint through arc of motion </li></ul><ul><li>Promote tendon glide </li></ul><ul><li>Elevation </li></ul><ul><li>Avoid quick repetitive motions </li></ul><ul><li>Stretch and hold to end range </li></ul><ul><li>MP flexion – intrinsics assist IP ext </li></ul>
  23. 23. <ul><li>Gentle isolated muscle contraction </li></ul><ul><li>Stiffness not primarily due to decreased muscle strength </li></ul><ul><li>Strength comes later </li></ul><ul><li>Move within pain tolerance </li></ul><ul><li>Don’t just wiggle – see blanching over knuckles </li></ul><ul><li>Measure & record (PROM & AROM) </li></ul>
  24. 24. Blocking <ul><li>Isolation of proximal digit  isolates motion of the joint. FDS & FDP </li></ul>
  25. 25. Buddy strapping <ul><li>Encourage ROM </li></ul>
  26. 26. Passive range of motion PROM <ul><li>Joint motion by external force (eg manual pressure) </li></ul><ul><li>Slow motion in increments – as tissues relax, no pain, greater gain </li></ul><ul><li>Measure & record </li></ul><ul><li>Gentle traction to distract jt surfaces </li></ul><ul><li>Passive finger flexion stretches dorsal apparatus of jt surfaces  ext tendons sufficiently healed (6/52) </li></ul>
  27. 27. Continuous Passive motion CPM <ul><li>Increases and maintains passive mobility </li></ul><ul><li>Gliding structures nutrient diffusion to articular surfaces </li></ul><ul><li> edema and pain </li></ul>
  28. 28. Heat / Cold <ul><li>Superficial heat  temperatures of deeper structures of joints and digits </li></ul><ul><li>Relatively thin layers of adipose tissue of hand </li></ul><ul><li> bloodflow and nutrition </li></ul><ul><li>Aids healing </li></ul><ul><li> extensibilty allows pt to temporarily and safely stretch </li></ul><ul><li>Cold may  pain </li></ul>
  29. 29. <ul><li>Paraffin wax baths (no open wounds) </li></ul><ul><li>Heatpacks </li></ul><ul><li>Fluidotherapy </li></ul><ul><li>Ultrasound </li></ul><ul><li>Caution & elevation: may  edema </li></ul><ul><li>Contra indication: vascular/sensory compromised </li></ul>
  30. 30. Retrograde massage <ul><li>Distal to proximal </li></ul><ul><li> MEM </li></ul><ul><li>Teach patient &/or family member </li></ul><ul><li>Elevation </li></ul><ul><li>sling – mobilise elbow & shoulder </li></ul>
  31. 31. Compression <ul><li>Finger pressure sleeve </li></ul><ul><li>shotgun </li></ul>
  32. 32. <ul><li>Anti-inflammatory medication used for short period may decrease joint stiffness and swelling </li></ul><ul><li>Teach pts to watch for edema when exercising </li></ul><ul><li>Gradually  repetitions & frequency </li></ul><ul><li>Reduce should pain & swelling occur </li></ul>
  33. 33. Resistive <ul><li>After 6/52 </li></ul><ul><li>Exercise putty </li></ul><ul><li>Elastics </li></ul><ul><li>weights </li></ul>
  34. 34. Meaningful activity <ul><li>Avoid overwork </li></ul><ul><li> endurance ability </li></ul><ul><li>Address difficulties in ADL – adaptive techniques & equipment </li></ul><ul><li>Blocking & resistive </li></ul>
  35. 35. Persevere………..
  36. 36. <ul><li>Hidden agendas: </li></ul><ul><li>- WCA: retention stiffness serves as useful, unpleasant job, </li></ul><ul><li>or home, hopes compensation awards </li></ul><ul><li> - NO pain meds help </li></ul><ul><li>- unable to exercise </li></ul><ul><li>- exercise all the time to no avail </li></ul><ul><li>- too busy to exercise </li></ul><ul><li> - family commitments </li></ul>
  37. 37. Conclusion <ul><li>Learn difference – post-traumatic pain & discomfort vs sharp pain (excessive force) </li></ul><ul><li>Educate in controlled sessions – written home programme </li></ul><ul><li>Spesific – rep’s, frequency </li></ul><ul><li>Regular short > 1 or 2 intense long sessions </li></ul><ul><li>AROM & PROM – simple, comprehensive, mobilising all necessary structures </li></ul>
  38. 38. <ul><li>Dynamic splinting must not  pain </li></ul><ul><li>Avoid overwork &  endurance slowly </li></ul><ul><li> edema and balance rest with motion </li></ul><ul><li>Preferred splinting – LLPS </li></ul><ul><li>Address underlying emotional issues & concerns </li></ul>
  39. 39. <ul><li>Incorporate mobilising, spesifically blocking, in ADL </li></ul><ul><li>PROM alone does not end with functional motion </li></ul><ul><li>Function requires full and pain free range of motion of small joints of the fingers </li></ul>
  40. 40. Thank you ! Lynne Pringle Cape Town http://www.lynnepringle.com

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