Management of stiff hand: an occupational therapy perspective

Research and Development of a 3D-Printed Dynamic Finger Flexion Orthosis for Finger Extension Stiffness-A Preliminary Study

Finger extension stiffness is a common post-traumatic complication that results in the hand's functional impairment. In clinical practice, a dynamic splint enables the patient to stretch the affected finger independently. However, current dynamic splints have drawbacks, such as limited stretching efficacy, and interfere with the hand's functional activities. Therefore, this study aimed to develop a dynamic finger flexion orthosis capable of stretching each finger joint using additive manufacturing (AM) technology, thereby enabling hand functional activity, and analyze the clinical improvement in the range of motion (ROM). One subject with a hand fracture was recruited while undergoing a 7-week home-based rehabilitation program for the orthosis. The outcome measurements included the total active motion (TAM), the tip-to-finger distance (TPD), and the score on the Disability of Arm, Shoulder, and Hand (DASH) questionnaire. The results show that the TAM of the participant's fingers increased by 72.7 degrees on average, the TPD decreased by 3.5 cm on average, and the DASH score decreased to 9.5 points. The 7-week home-based rehabilitation program for the orthosis resulted in a 53.6% increase in the TAM on average. The developed orthosis improved hand function and enabled a more complete ROM in finger flexion.

Burn Injury Cutaneous Functional Units: Allocating Occupational Therapy Resources and Influencing Practice

Burn injury severity is currently determined by estimating the total body surface area (TBSA) burned, but this method fails to capture the severity of subsequent functional consequences. Alternatively, cutaneous functional units (CFUs)--skin segments that accommodate for movement and commonly become contracted--can be used to more accurately estimate burn severity based on functional consequences. Bilateral hands account for 81.3% of the body's CFUs, though only account for 5% of TBSA. However, hand burn survivors can have worse physical outcomes (ie, contractures, deformities) after burn injury, leading to subsequent loss of function, global occupational participation deficits, and poor psychosocial outcomes. This study, conducted at a verified American Burn Association burn center, explores how CFU involvement among adult burn survivors with uni and bilateral hand and upper extremity burns influenced occupational therapy practice in regards to time spent completing scar and soft tissue elongation techniques from the elbow to the digit tips per patient. The data showed, on average, burn occupational therapists require 0.8 minutes per CFU for an average total of 38.7 (SD = 29.5) minutes each session to complete scar and soft tissue elongation techniques to the upper extremities. The results of this study can be used to educate burn centers on the clinical utility of CFUs, burn occupational therapists regarding best-practice in terms of utilization of therapist time and resources, as well as support the justification for increasing occupational therapy services for patients with upper extremity and hand burns, and increasing staffing to meet patient need.

Arthrodesis of the Proximal Interphalangeal Joint of the Finger—A Biomechanical Study of Primary Stability

Background: Osteoarthritis of the proximal interphalangeal (PIP) joint of the finger often leads to global hand-function detriment. Different techniques for the arthrodesis of the proximal interphalangeal joint have been described that all lead to union in a reasonable percentage of patients and period of time. This biomechanical study aims to analyze and compare the primary stability of different techniques of arthrodesis to render postoperative immobilization unnecessary. Methods: Arthrodeses of 40° of composite cylinders were tested with different techniques in four-point bending for stability in extension as well as flexion. Results: In extension, the compression screw and the compression wires showed the highest stability—whereas in flexion, plate fusion was superior. Tension band, cerclage or compression screw fusion showed the best compromise in flexion/extension stability. Conclusions: Fusion techniques that apply compression to the fusion show superior stability. Cerclage, tension band and compression screws might be able to provide enough stability to withstand the forces exerted during unencumbered activities of daily living. Arthrodesis with plates should be limited to patients with special indications and require immobilization during consolidation.

Post-arthrolysis rehabilitation in a patient with wrist stiffness secondary to distal radio-ulnar fracture: A case report

BACKGROUND

Arthrolysis is usually performed when stiffness has a disabling effect on quality of life and in cases where physiotherapy has not been effective. This report describes one patient with a chronic stiff wrist who underwent open arthrolysis. The purpose of this case report is to describe the rehabilitation following arthrolysis, in order to illustrate the effects of intensive physiotherapy for this patient.

CASE DESCRIPTION

A 54-year-old woman with chronic wrist stiffness secondary to a radio-ulnar fracture was described. The patient presented severe pain and unsatisfactory wrist range of motion and muscle strength almost 2 years after the traumatic event.

INTERVENTION

Post-arthrolysis rehabilitation was based on edema control, manual therapy, transcutaneous electrical nerve stimulation (TENS), static splinting and strengthening exercises. In addition, graded motor imagery and proprioceptive rehabilitation were included to address impaired motor control. Outcome measures of passive range of motion (PROM), active range of motion (AROM), grip and pinch strength, numeric rating scale (NRS), disability of the arm, shoulder and hand (DASH) and patient-rated wrist/hand evaluation (PRWHE) were recorded.

CONCLUSIONS

The outcomes of this case report suggest that arthrolysis combined with immediate and intensive physiotherapy were a suitable option for the treatment of post-traumatic wrist stiffness in this patient. The passive motion measured intraoperatively was maintained, while pain, functional active motion and strength were improved allowing for social reintegration.

Analysis of a New Artificial Muscle Type Dynamic Orthosis for Wrist Joint Disease Using a Three-dimensional Motion Analyzer

Objectives:

Recently, the dart-throwing motion (DTM) has attracted attention as a functional direction of wrist joint motion. Consequently, we devised a new artificial muscle-type dynamic orthosis (Dynamic Traction Splint by Artificial Muscle, DTSaM) to reproduce DTM. This study analyzed the automatic motion of the wrist joint using a three-dimensional motion analysis system to assess how closely the DTSaM replicates DTM.

Methods:

The DTSaM orthosis incorporates two McKibben-type rubber artificial muscles, and measurements were performed using image analysis software and a three-dimensional motion analysis system. The wrist radial angle (WRA) was defined as the angle between the line connecting the head of the index finger metacarpal to the radial styloid process and the line connecting the radial styloid process to the lateral epicondyle of the humerus. WRAs were investigated from 60° of palmar flexion to 60° of dorsiflexion.

Results:

For dorsiflexion, comparisons of radial deviation and wrist ulnar angle (WUA) between the motion obtained using the DTSaM orthosis and active DTM showed a significant difference (P <0.05) at 30° and 60°, respectively. For palmar flexion, the same comparison showed a significant difference for both the ulnar and radial deviations (30°, P <0.05; and 60°, P <0.01, respectively). Furthermore, WUA showed a significant difference at 50° (P <0.05). Intraclass correlation coefficient analyses yielded good reliability with an average value of ≥0.8.

Conclusion:

The DTSaM orthosis produces a motion similar to the DTM. It is hoped that the use of the DTSaM orthosis will help to shorten the treatment period for patients with wrist disease.

Recurrent calcifying aponeurotic fibroma of the hand: managing a rare hand tumour in an evolving healthcare landscape

Calcifying aponeurotic fibroma (CAF) is a rare benign tumour originating from the aponeuroses of tendons and their bony insertions. A 15-year-old student presented to his general practitioner with a 1-year history of a progressively enlarging painless finger swelling. The lesion was excised by the local paediatric orthopaedic service and recurred over the course of the following 4 months. Histology confirmed a diagnosis of CAF. He was referred to our specialist hand surgery service and the lesion was excised along with the ulnar lateral band and the overlying skin. At 9 months, there was no clinical evidence of recurrence. We are the first group to report the potential benefit of including of the overlying skin in the histological specimen to reduce the residual disease burden. Our case illustrates the technical challenges and considerations of removing a large, recurrent CAF of the hand and highlights the importance of centralised specialist care.

Case Report: The casting motion to mobilize stiffness technique for rehabilitation after a crush and degloving injury of the hand

STUDY DESIGN

Case report.

INTRODUCTION

This case report describes the use of the casting motion to mobilize stiffness (CMMS) technique in the management of a crush and degloving injury of the hand. The patient was unable to attend multiple hand therapy sessions due to geographic constraints. The CMMS technique involved the application of a nonremovable plaster of paris cast that selectively immobilizes proximal joints in an ideal position while constraining distal joints to direct desired motion over a long period. This uses active motion only. Traditional hand therapy techniques or modalities are not used. This treatment approach was beneficial to the patient as a minimum of 2 appointments per month were needed to regain functional hand use.

PURPOSE OF THE STUDY

To document the use of the CMMS technique as an effective treatment approach in the management of a crush and degloving injury of the hand.

METHODS

The CMMS technique was applied to the patient's left (nondominant) hand 8 weeks after injury. The technique's aim was to improve the 30° flexion deformity of the left wrist and flexion contractures of the index, middle, and ring fingers with a total active motion of 0°. Orthotic devices and traditional therapy were applied once joint stiffness was resolved, and a normal pattern of motion was reinstated.

RESULTS

At 6 months, substantial improvement was noted in wrist as well as metacarpophalangeal and interphalangeal joints. Total active motion exceeded 170° in all fingers excellent functional outcome resulted as measured with the upper limb functional index short form-10. The upper limb functional index increased from 0% to 55% of preinjury status (or capacity) over the 18 months of therapy.

DISCUSSION

Brief immobilization through casting causes certain functional losses, but these are temporary and reversible.

CONCLUSION

Finger stiffness, edema, and tissue fibrosis were successfully managed with the CMMS technique without the need for attendance at multiple hand therapy sessions.

LEVEL OF EVIDENCE

Level V.

Combined treatment with paraffin, manual therapy, pegboard and splinting in a patient with post-traumatic stiff hand

Background

The stiff hand is a still common, severe complication of hand injuries.

Case presentation

We report here the case of a 56 year-old woman, professional goldsmith, who suffered a distal radius fracture of her right hand. The patient was treated with surgery followed by four weeks of immobilization, and developed a stiff hand. Physical examination showed mild inflammatory signs, pain and a major limitation in the extension and supination of the wrist, and in the mobility of the II, III, IV and V metacarpophalangeal (-5° and 32° of average passive extension and flexion, respectively) and interphalangeal (-35° and 73° of average passive extension and flexion, respectively) joints. There was a lack of slip of the flexor tendons. The diagnosis of complex regional pain syndrome was considered although it could not be definitely established. After five months of adverse evolution the patient was referred to our center where a combined intervention with paraffin, manual therapy, prolonged active and passive stretch on a pegboard, and splinting was applied. After initiation of this therapy, a marked change in the evolution of the pain, the mobility and functionality of the hand was observed. At the end of the rehabilitation program the patient was able to fully resume her job.

Conclusion

The present case illustrates the need of intensive treatment for post-traumatic hand stiffness, and describes, as an original contribution, a combined intervention therapy including paraffin, manual therapy, pegboard and splinting.

Extension orthoses and the stiff proximal interphalangeal joint following hand trauma: A review of current clinical practice in the Australian context

Introduction

Extension orthoses are frequently prescribed by hand therapists to treat fixed flexion deformity of the proximal interphalangeal joint. A wide variety of proximal interphalangeal joint extension orthoses exist, but there is limited research evidence to guide implementation in clinical practice. Consequently, effective management of fixed flexion deformity of the PIP joint remains a challenge.

Method

An electronic survey was distributed to members of the Australian Hand Therapy Association. The survey included two case scenarios, (including a fixed flexion deformity of 30° and 55°) and participants were asked to identify their preferred orthosis for each case. Responses to closed questions were analyzed descriptively. Thematic analysis for open-ended questions was completed by two experienced hand therapists.

Results

One hundred ninety-five therapists completed the electronic survey. Handmade capener (21.7%), pre-fabricated capener (22.2%), and static finger troughs (21.1%) were the preferred orthoses for treatment of contractures of 30°. Serial casts (60.9%) were the preferred choice for a contracture of 55°. Key themes influencing choice of orthosis reflected an evidence-based practice approach to clinical reasoning that combined use of available evidence with therapists’ experience and the needs of the patient. Therapists’ interpretation and application of research differed according to their unique situation.

Conclusion

Orthotic prescription is a multifaceted process that combines therapists’ interpretation of evidence with their experience and the needs of the patient. Further research is needed to evaluate and clarify current theories that are used to guide intervention.

Pneumatic-type dynamic traction and flexion splint for treating patients with extension contracture of the metacarpophalangeal joint

BACKGROUND

Collateral ligament shortening causes extension contractures of the metacarpophalangeal joint, and dynamic flexion splinting has been widely used to treat these contractures; however, there are various problems with these approaches. We developed a novel, pneumatic-type dynamic traction and flexion splint to solve these problems.

CASE DESCRIPTION AND METHODS

A total of 25 fingers were treated with the dynamic traction and flexion splint for 8 weeks. Every 2 weeks, the average metacarpophalangeal joint flexion angle, total active motion, grasp strength, and pain scores were assessed.

FINDINGS AND OUTCOMES

The finger flexion angle was significantly greater at the final evaluation, starting after 6 weeks of treatment (p < 0.05), than prior to treatment. Similarly, the total active motion results improved significantly over 8 weeks.

CONCLUSIONS

Our results show that use of the dynamic traction and flexion splint improves patient finger functioning and flexural angle.

CLINICAL RELEVANCE

The dynamic traction and flexion (DTF) splint appears to be effective for treating patients.

Management of complications relating to complex traumatic hand injuries

Complex hand injuries result in local trauma to osseous, neurovascular, and soft tissue structures. The large amount of energy imparted to these tissues may result in complex regional pain syndrome, stiffness, or infection. Unfortunately, a good outcome may not only depend on the technical aspects of the procedure but on the expectations, occupation, age, and other factors that are out of the surgeon's control. The best treatment for these complications is prevention; however, this review offers strategies to combat the complications once they arise.

Pathomechanics of the wrist following fractures of the distal radius

Introduction

The wrist positions the hand in space and allows load transmission from the hand to the forearm. This research study aimed to explain the biomechanical changes that occur at the wrist following a fracture of the distal radius and to explore the effect of this fracture on wrist and hand range of motion and muscle strength. It was hypothesised that a fracture of the distal radius interferes with the biomechanical integrity of the wrist limiting the available wrist and hand range of motion. This in turn affects hand muscle strength.

Methods

This prospective research study adopted a quantitative quasi-experimental time-series design where 109 patients followed an occupational therapy programme for 12 weeks. Measurements of forearm, wrist and hand range of motion and hand muscle strength were taken on the initial assessment, and on the 6th and 12th weeks of intervention. A standard evaluation procedure was followed to ensure reliability of the results. Data were analysed using SPSS (PASW version 18).

Results

Forearm and wrist range of motion and muscle strength were significantly impaired. Hand range of motion was also affected even though the hand itself was not directly involved in the injury. Improvements in range of motion were accompanied by an increase in hand muscle strength. Patients with intra-articular fractures experienced greater limitations compared to their counterparts.

Conclusions

These results supported the initial hypothesis. Clinically, this highlights the need for orthopaedic management and rehabilitation to be based on a sound knowledge of the biomechanical interaction of the different structures involved.

A dowel exercise tool to improve finger range of motion

A new clinical and home dowel exercise tool to reduce joint stiffness of the fingers is introduced, along with the fabrication and the exercises that are used with it. Patients may utilize it to improve their finger joint range of motion, and facilitate tendon glide by isolating the targeted stiff joints of the fingers.

Hand reanimation

Brachial plexus disruption, major traumatic amputations, and Volkmann's contracture are all devastating injuries that present difficult reconstructive challenges. Advances in our understanding of nerve injury, regeneration, and refinement of microsurgical techniques have given rise to a number of therapeutic avenues over the last 4 decades. Hand reanimation aims to provide strength, stability, and mobility to a sensate hand. How this is achieved depends on a thorough understanding of the underlying pathophysiology, which in turn dictates what surgical modalities are suitable. Common to all reanimation procedures is the need to ensure full passive range of motion of the target joints prior to definitive surgery. Hand therapy is essential to prevent deleterious sequelae of injury, and to maximize rehabilitation following surgical reconstruction. Options for reanimation include nerve repair, nerve grafting, nerve transfer, tendon transfer, and free functioning muscle transfer.

Functional reconstruction of the hand: the stiff joint

Proper hand function relies on a combination of strength and mobility. The intricate architecture that allows for hand mobility includes the articular surfaces of joints, periarticular ligamentous structures, tendon mechanisms, and the soft-tissue envelope. These structures are subject to injury and scarring. The net effect of a variety of etiologic factors is stiffness of the hand with diminution of hand function. This article reviews the biology of healing, pertinent anatomy of the hand, and operative and nonoperative treatment of the stiff hand.

Effect of passive stretching on simple camptodactyly in children younger than three years of age

PURPOSE

To present the effectiveness of passive stretching as a treatment for camptodactyly, without any other form of physiotherapy or splinting.

METHODS

From May 2003 to August 2008, 61 digits of 22 patients were treated conservatively using passive stretching exercises. All children were less than 3 years old and had no other anomalies. Flexion contractures before and after treatment in mild, moderate, and severe groups were measured and changes were analyzed statistically. The correlations between various clinical factors and treatment outcome were also analyzed statistically. The average follow-up period was 26 months (range, 12-47 mo).

RESULTS

Mean flexion contracture improved from 20° to 1° in the mild group (p < .001), from 39° to 12° in the moderate group (p < .001), and from 75° to 28° in the severe group (p < .001). Of the clinical factors examined, only initial flexion contracture was found to be significantly correlated with treatment outcome (r = -0.287, p = .0025).

CONCLUSIONS

Passive stretching can effectively improve flexion deformity in camptodactyly in infants and young children.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Mechanical feasibility of immediate mobilization of the brachioradialis muscle after tendon transfer

PURPOSE

Tendon transfer is often used to restore key pinch after cervical spinal cord injury. Current postoperative recommendations include elbow immobilization in a flexed position to protect the brachioradialis-flexor pollicis longus (BR-FPL) repair. The purpose of this study was to measure the BR-FPL tendon tension across a range of wrist and elbow joint angles to determine whether joint motion could cause repair rupture.

METHODS

We performed BR-to-FPL tendon transfers on fresh-frozen cadaveric arms (n = 8) and instrumented the BR-FPL tendon with a buckle transducer. Arms were ranged at 4 wrist angles from 45 degrees of flexion to 45 degrees of extension and 8 elbow angles from 90 degrees of flexion to full extension, measuring tension across the BR-FPL repair at each angle. Subsequently, the BR-FPL tendon constructs were removed and elongated to failure.

RESULTS

Over a wide wrist and elbow range of motion, BR-FPL tendon tension was under 20 N. Two-way analysis of variance with repeated measures revealed a significant effect of wrist joint angle (p<.001) and elbow joint angle (p<.001) with significant interaction between elbow and joint angles (p<.001). Because the failure load of the repair site was 203 +/- 19 N, over 10 times the loads that would be expected to occur at the repair site, our results demonstrate that the repair has a safety factor of at least 10.

CONCLUSIONS

Our tendon force measurements support the assertion that the elbow joint need not be immobilized when the BR is used as a donor muscle in tendon transfer to the FPL. This is based on the fact that maximum passive tendon tension was only about 20 N in our cadaveric model and the failure strength of this specific repair was over 200 N. We suggest that it is possible to consider performing multiple tendon transfers in a single stage, avoiding immobilization, which may adversely affect functional recovery. These results must be qualified by the fact that issues unique to living tissues such as postoperative edema and tendon gliding cannot be accounted for by this cadaveric model.

Restorative physical and occupational therapy: a critical need for patients with chronic kidney and end-stage renal disease

Patients with CKD and ESRD present with many health problems, which may lead to increased mortality and dysfunction. Numerous comorbidities may contribute toward physical, emotional, and social problems and a decreased quality of life. Difficulty ambulating, balance deficits, joint pain and stiffness, muscle spasm and weakness, fatigue, neuropathy, and difficulty with activities of daily living (ADLs) may contribute to a decrease in functional independence. Physical therapy (PT) and occupational therapy (OT) aim to restore physical functioning, facilitate independence in ADLs, and promote functional independence by using various therapeutic procedures. PT and OT are the usual services of choice to address impaired function associated with acute and chronic pathology. The purpose of this article is multifold: (1) to describe specific interventions provided by PTs and OTs that may be beneficial to individuals with CKD and ESRD, (2) to identify and describe the potential benefits of rehabilitation for these patient populations, and (3) to provide programmatic rehabilitation recommendations for patients with CKD and ESRD.

Static progressive splinting for restoration of rotational motion of the forearm

This study examined the use of a bidirectional, patient-directed orthosis that used the principles of static progressive stress to improve forearm rotation. Thirty-eight patients who had limited pronation and supination motions after injuries and who failed other physical therapy techniques underwent a 30- to 60-minute stretching protocol with the orthosis one to three times per day. The mean arc of rotation increased by 42 degrees (range, 0-122) after a mean treatment duration of 12 weeks (range, 3-57). The mean patient satisfaction score was 8.1 points on a scale of 0-10 points. All of the patients completed the treatment and no short-term complications were reported. The gains in motion were comparable to the published results of other orthoses as well as surgical procedures such as external fixators and closed manipulation, but fewer complications occurred with the static progressive stress technique. This orthosis is a useful treatment for patients who have limitations of forearm rotation.

The diabetic hand: a forgotten complication?

The manifestations of diabetes in the hand were much discussed in the 1970s and 1980s. The present review aims to revisit the diabetic hand and to discuss the pathology of the hand that may be clinically important in diabetic patients. In the strict sense of the term, the "diabetic hand" encompasses the three most widely studied conditions which have traditionally been associated with diabetes, namely limited joint mobility, Dupuytren's contracture and trigger finger. There is evidence that these entities are significantly more frequent in patients with diabetes and also that they may be associated with diabetes duration, poor metabolic control and presence of microvascular complications. In a more general sense, though, there are other conditions affecting the hands, which also occur more frequently in diabetes. From a practical point of view, increased alertness both for neuropathic hand ulcers in patients with profound neuropathy and for diabetic hand infections is absolutely necessary. Recently, reduced hand strength is beginning to be recognized as a further complication of diabetes. Thus, the hand may reveal substantial pathology in diabetes, and ideally, clinical examination should not ignore it.

Which Splint? Dynamic versus Static Progressive Splinting to Mobilise Stiff Joints in the Hand

Mobilising splinting is a common tool used by hand therapists to improve movement in stiff joints, by holding them at the end of available range of motion (ROM) under light tension, for extended periods of time. Both dynamic and static progressive splints are classified as mobilising splints. Many clinicians believe that static progressive splints are more effective than dynamic splints for improving ROM in particularly stiff joints. This paper reviews the limited available research evidence behind the assumptions that currently guide splint choice in clinical practice. Joint stiffness theory and the visco-elastic nature of the soft tissue response to stress are also revised. A rationale for the use of dynamic splints in preference to static progressive splints to mobilise the chronically stiff joint is presented. The need for further research, ideally in the form of a randomised controlled clinical trial, is highlighted.

Evaluation of static progressive stretch for the treatment of wrist stiffness

PURPOSE

Decreased wrist flexion and/or extension after trauma or surgery can be a challenging problem. Physical therapy, orthoses, and additional surgical interventions may not restore the desired range of motion or functionality. The purpose of this study was to assess the total arc of motion and the satisfaction scores of patients who had wrist stiffness and who were treated with a bidirectional, patient-directed orthosis that used the principles of static progressive stretch.

METHODS

Forty-seven patients who experienced posttraumatic or postsurgical wrist stiffness were treated with a patient-directed orthosis. Treatment consisted of a 30- to 60-minute stretching protocol performed 1 to 3 times per day. Compliance with the device, treatment duration, mean total arc of motion, patient satisfaction, and complications were evaluated.

RESULTS

The total arc of motion increased by a mean of 35 degrees (range, 5 degrees to 100 degrees ) after a mean of 10 weeks of treatment (range, 5 to 26 weeks). The mean flexion and extension increased by 18 degrees (range, 1 degrees to 50 degrees ) and 17 degrees (range, 3 degrees to 50 degrees ), respectively. Assessment of age, gender, and time before commencement of treatment showed that these factors did not significantly affect the magnitude of improvement or the final arc of motion. The mean patient satisfaction score was 8.2 points on a scale of 0 to 10 points. All patients completed the treatment, and there were no complications reported with use of the device.

CONCLUSIONS

All of the patients who used this protocol improved their total arc of motion. A splinting device that uses the principles of static progressive stretch is a useful treatment for patients who have posttraumatic or postsurgical wrist stiffness and whose progress has plateaued after a course of conventional physical therapy.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.