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    Therapist's management of the stiff hand

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    © All Rights Reserved
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    Download as pdf
    104 views32 pages

    The Stiff Hand

    Uploaded by

    Ana Isa Lopes
    Therapist's management of the stiff hand

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    © All Rights Reserved
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    Therapist’s Management of the Stiff Hand JUDY C. COLDITZ, OTR/L, CHT, FAOTA* THE CHALLENGE OF THE STIFF HAND DEFINITION OF STIFFNESS STIFFNESS AND THE STAGES OF WOUND. HEALING EVALUATION AND TREATMENT OF EARLY ‘STIFFNESS EVALUATION AND TREATMENT OF THE CHRONICALLY STIFF HAND SUMMARY mean * Effecove rehabilitation of the stif hand requires that the effects of immobilization be minimized while not overloading healing tissue, * Interosseous muscle tightness frequently contributes to limted finger flexion, One should assume that interosseous muscle tightness contributes fo the limited ‘mation until can be proven otherwise * In the chronically stif hand, tissue adherence and stifiness, chronic edema, and maladapted cortical patterning are interdependent problem's. To be successful regaining mobilty of the suff hand, all three problems must be altered simultaneously. The Challenge of the Stiff Hand Clinical experience confirms certain risk factors for stiffness the hand. The more tissue traumatized, the greater the likelihood of stiffness.’ Severe trauma injuring bone and mul- tiple soft tissue layers usually requires longer periods of smobilization because of the need 10 regain skeletal stabil- ity. The deercase i tissue elasticity that accompanies increas- ing age creates e insult of trauma, Infection that extends the wound beyond its mechanically created boundary creates adherence between multiple remote cehns lor chapter by Kew Park, OTIUL, CHT, Karen R Rocmiog, MA. OTR. CHT ind Ingrid Wade OTR. CHT 894 tissue planes. Although we know these hasie facts, many questions about stiffness in the hand remain unanswered: Why do some patients have great difficulty regaining motion Jong after others have returned to normal function? How can we identify what amount of motion, at what frequeney, and with what duration will maximize individual patient results? We do know, as did Sir Charles Bell in 1883, that "the ‘mechanical properties of the living frame, like the endow: ments of the mind, must not lie idle, of they will suffer * Prolonged immobilization is. the greatest andl mobility. Our challenge ts to devise a treat- ‘ment program that provides balanced stimuli to elicit a posi- tive response. Definition of Stiffness The term stiff is used commonly when describing the hand lacking full mobility: The word stiff is usually reserved to describe the physical property of matter whose close molecu: lar structure makes it rigid, resisting deformation when an external force is applied. Stiffness of the hand is not an increased rigidity of the tissues themselves’ but a constraint created by crosslinking of the previously elastic configuration of the collagen fibers." ‘Collagen provides most ofthe tensile strength of the tissue in the hand. Collagen fibers themselves are inelastic, but movement between the collagen fibers imparts elasticity 10 the tissue. Normal hand motion oceurs when these strong, dense connective tissue structures glide relative 10 one another Stfness is caused by the fixation of the tissue layers, 50 that the usual elastic relational motion is restricted by (im B Figure 67-9 A Ati crosslinking. Later in healing, when exeess collagen cross: finking limits motion, low-load, prolonged stress favorably modifies the crosslinks sn libris slip aver each This slippage is accomplished by provides concentrated force applica nieve mas Joint motion and soft tissue glide, which allows slippage of the cramslinks. This 1 wthotic mobilization that provales a gentle force for a longer period may he indieated. Ifthe stiffness ts pe sistent, a nonremovable cast promotes evelte mot to the stiffer joints. This concentration of active force a n mobilize even the most reststant of join Passive Range of Motion Although joint motion ean be paintained by either active oF passive motion,” passive movi tissue planes other than the periarticular structures. Ince ing passive motion does not necessarily increase active As with other therapeutic techniques, to dictate the ideal force. speed. Although passive joint motion often 8 preseribed ie joint stillness, no research sup ther intermittent passive mo no research 1 of passive a CPM to reduce joint stiffness, the hand is detrimental and should be avoided id should be defined as ach a maxtn The amount of force should respect the sistance of the tissues, and the position should be increased, only when the tissues relax and decreased resistance is felt When edema is diminished, any gentle passive joint motion should be done with accompanying gentle traction 1 the joint to allow room for one joint surface to glide over the other without compression. One gentle, prolonged hold will allow the motion to he repeated actively more effectively than many repeated quick suelden passive stretches. Quick, fore ful stretches result in ussue damage and should be avoided all tunes Ind with more mature stiffness caused by inereased collagen crosslinking, the brief imtermitient nature of passive motion is ineffective and should he avoided. This se idictory, because one assumes that the stiffer the joint once is required to mobilize it, Rather thats increased force, itis the inereased duration of a low-level force th best creates change When patients with significantly still hhand joints undergo passive ROM during. a therapy session, there is an immediate response of tissue mobilization However, when the patient returns, the progress gained in the previous session has not been retained. A siudy of stiff ness in rabbits after tibia fracture compared ankle stiffness between joints undergoing CPM and joints that remained nmobile in a cast, The ankles receiving CPM demonstrated nmediate reduced stiffness, but over tine the siffiess ish CPM group was progressively and significantly greater th the group immobikzed” This study” suggests that further investigation ts warranted regarding the long-term effects of passive ROM on still joints Active Range of Motion Active ROM has multiple adv ROM Active motion stimulates the lymph ishing edema, and more quickly returns the hand (oa state of homeostasis. Active motion also requires tiormal reciprocal of soft ussue structures such as tendons and ligaments, tassive motion in the the gentle encourageme available length, santage of active motion is the continued associa. or cortex to the ng injury who are unable to use normal sms move in maladapted patterns. If aladapted movement continues, the the maladapted motion and defines it only 9 weeks will alter the moto earlier the patient ts able pattern, the greater the mobility Joint Mobilization Although mobil for the treatment of suf jon tive muscle contraction Patients, sust muscle recruttme OF cortex Tears A period of cortex patterning." Th appropriate muscle ents potential to recapture full 1 ts advocated by m the hand, mauusal mobi {von of the small joints of the hand is hest reserved lor specifi capsular tightness with no aecompanymg. inflame When motion is limited as a result of edema, manual joint ton may be ineffective and can lead to an increased matory response. Joint mobilization without accompa fying edema reduction does not increase the availa 1 joi (CHAPTER 67 — THERAPISTS MANAGEMENT OF THE STIFF HAND for movement. There are no published data on the elfetive- ‘ness of joint mobilization in reducing joim stiffness, Nor are there any data that suggest harm. Benefits of CPM Because joint motion is needed to preserve joint lub tion,’ CPM often is used postoperatively to treat jo pathology. Neither laboratory nor clinical studies have shown that CPM is useful for treating joint stiffness once has oceurred.""*" Therefore, CPM is. appropriately erved for the immediate postoperative period to prevent complications rather than to resolve stiffness. Readers are teferted to the archives on the companion Website for the chapter Continuous Passive Motion for the Upper Extremity Why, When, and How by LaStayo and Cass from the Sih edition Pathologic Patterns of Motion in the Early Stiff Hand Loss of Wrist Tenodesis Pattern The exquisite balance of muscle forces crossing the wrist and fingers creates a reciprocal motion called tenodesis. Finger extension oceurs with wrist flexion asa result of he inereased tension on the extrinsic extensor muscles when the wrist flexes, Conversely, when the wrist extends, tension is, increased in the extrinsic exor muscles that flex the fingers This reciprocal action establishes the normal grasp and release pattern of the hand, With stillness, the tenodesis balance in the hand fre- quently affected. In a minor injury, tenodesis is regained as motion at the tnjury site improves. In more severe injuries requiring long periods of immobilization, many: joints may become stiff and the muscles crossing them become weak, altering the reciprocal balanced motion, “The wrist is the key joint to reestablishing the tenodests balance in the hand. Without the ability to stabilize the wrist, inextension, the finger llexor muscles cannot transfer enough power to regain Finger flexion, Usually the primary goal is to regain digital flexion for grasp and manipulation of objec However, when the fingers and the wrist all have limited motion, active finger flexion ts not possible without fist ‘gtining some wrist extension (Fig. 67-10) IntrinsicPlus Pattern During normal finger flexion, IP joint flexion. dominates before significant MCP joint flexion begins."" If the hand is edematous and extrinsic flexor glide is limited (commonly: seen after immobilization of wrist fractures or flexor tendon repair), the patient will initiate finger flexion with MCP joint flexion, and file IP joint flexion oceurs. In this pattern of motion the inerosseous and lumbrical muscles are never clongated to their maximum length, and they adaptively shorten, making the mobilization of the IP joints even more diffu Early treatment—consisting of activities, exercises, and/or orthoses that block MCP joint llexion and require IP joint Hexion (unless contraindicated by surgical repairs)—can convert global finger lexion into specific glide across the IP joints (see Fig. 67-8). In the chronically stiff hand, longer 903 Figure 67-10 A ard 8. (oss of vst extersin crestes tension on the ‘enn exterior muscles, and Inger Reon fst © and, Win the tert exterson. the tensor on the frger exo acta dg eon {From Bunnies Surgery ofthe Harn. 29a ed Prasdoipna 18 upper 1945p 841 periods of intervention may be necessary to change the pattern of motion. (See section on “Evaluation and Treatmet of the Chronically Stiff Hand.”) IntrinsicMinus Pattern ‘When the imirinsic muscles are not actively participating digital flexion, isolated MCF joint flexion js absent. Flexion ‘occurs first at the IP joints, and only after full IF joint flexion do the extrinsic llexors pull the MCP joint into Mlexion, This may result from denervation of the intrinsic muscles, but in the stiff hand it is more commonly a result of isolated cap- sular tightness of the MCP joints or the restraint created by adherence of the extensor tendons on the dorsum of the hand. Blocking the wrist so that flexion forees from the extrinsic lexors can be directed (0 the MCP joints is required to actively mobilize the MCP joints. Without MCP joint flexion the intrinsic hand muscles cannot participate in the digital flexion Evaluation and Treatment of Joint Stiffness and Decreased Tissue Glide Joint Tightness Joint tightness is identified by manually examining the passive ROM of a joint 0 determine whether the passive ROM changes as proximal and distal joint positions are altered. Ifthe joint ROM does not change, solated jot tight- ness is present (Fig. 67-11) Clinical reality usually provides a combination of joi tightness and other external constraints, such as musch tendon unit tightness or tendon adherence, An experienced therapist can determine the balance and mix of the many 904 PART) — STIFFNESS OF THE HAND. feo passive joint motion. This soft end-feel joint tightness results tent low-load stress, the eapsniar joint str independent glide, Hunt end-feel joint tightness has less uares can regain cedenta present and is primarily a result of more mature col lagen crosslinking. When moved to its maximum ROM. there is an abrupt and well-defined end point to the passive test The hard end-feel joint req mobilization in an orthosis to gain motion oF more sust \ per ive motion. (See the section on "Eva ation and Treatment of the Chronically Sull Hand”) I is appropriate to apply manual yentle passive ROM to, joints with a soft end-feel. If the jomt edema is minimal _gentle prolonged passive stretching to soft end-Feel joints ean allow more active n tw be transi t. In many cases this is enough inf Jon! ighiness res more prolonged periods of ned ls of evel tissues that are Limiting motion, Accurate appraisal may be stiffness, In the joint sustaining minor trauma, early intern limited until certain joint motions have been regained, For tent gentle passive motion may produce full active motion example, PIP jomt flexion must be gained before the full without further intervention. extent of interosseouls muscle tightness can be determined Accurate. repeated ROM measurements must be the means Joint Mobilization via Use of an Orthasis. Ifa ‘of monitoring improvement." W there tsa lange discrepancy “passive mobi ot successful or if the berween the active and passive ROM, the emphasis should joint resistance is significant when initially evaluated, mobi pullthrough. Ifthe active and passive ROM are Tization onthotic positioning to regain capsular length in one ‘equal, may be appropriate wo gain passive motion via mobi- direction may be essential «0 regan joint motion, The m Hie on act lisation orthotic positioning, Increased passive motion can with thie reMtest resist he least likely. motion to be also be achieved by blocking the more flexible joints, allow- regained wath only acti nt passive stretching, ing aetive motion wo reduce joint stiffness, which im turn and this motion should be the ta jon via use rT increases passive ROM. of an orthosis, Wrist joint extension, MCP joint flexion IP joi extension a Manual Treatment. The degree of trauma to the joint capsule and: must be given orthotic priority tw balance the strength g determine whether the palpated of the more powerful opposing muscles, resistance 10 full-jomnt motion is the expected amount of joint Maihsing orthoses directed towa he stage of he f wolated joint tight ly the involved joint be included an the Orthoses may be applied that provide stilmness. When joint tightness Is ev reen a joint with a soft end-feel and one orthosis (Fig. 67-1 ated, a distinction des requites that g should he made bet Figure 67-12 A Aciynan CHAPTER 67 — THERARSTS MANAGEMENT OF THE STIFF HAND ‘4 dynamic, serial static, or static progressive force applied by rubber band or spring trac application of force appropriate for joints with a soft end-feel joint edema is present, serial Static orthoses can gain joint motion concurrent to providing edema reduction via gentle joint compression, Joints with greater resistance respond favorably 10 prolonged application of serial static arth ‘or may respond {0 static progressive orthoses. Serial st static progressive orthoses should he reserved for extension mobilization positioning, since compression of the jot in the maximally flexed position is poorly tolerated. A dynamic nfortable for the patient at the end- ‘static progressive force, because Mlexion dramatically inereases intra-articular pressure” (Fig. 67-128). (See Chapters 123 through 123 for further discussion regarding use of orthoses for mobilization of joints.) Muscle-Tendon Unit Tightness Muscle-tendon unit tightness is shortening of the muscle tendon wait from origin to insertion, Hinting full sil ‘ous motion of all joints crossed by the muscle-tendon un The muscle is the elastic part of this unit, which shortens with disuse. This tightness commonly occurs as a result of Immobilization or restricted motion following injury or surgery. Ifa muscle-tendon unit is left in a short position in the presence of tissue inflammation, the tendon will also hecome adherent along its entire path, even if there is no direct trauma to the tendon or yendon bed. Specific trauma to the tendon or tendon bed, however, creates distinet adher- ence at the site of injury. Tendon adherence thus may be isolated to the point of trauma or extend over a larger 31 ‘of more extensive trauma or immobilization in the presence of inflammation. Tendon adherence affects movement ‘only of the joint(s) distal to the point of adherence. Although both muscle unit tightness and tendon adherence may’ have similar clintcal presentations, careful examination idemifies the exact location af the problem. ore. Dynamic on is a soft Evaluation. Both tendon adherence and muscle-tend tightness are demonstrated by a distinct difference between the passive distal joint motion when the proximal joints are positioned in flexion versus extension (Fig, 67-13), Figure 67-14 A. Snetching ion feo bahar may combne oh B Apes! Wablacs vatous oes 0 lew the panent Py prolonged ce 905 Ger eaterton hte when the syst but Ure ner the wit et poi OF The most proximal joint crossed by the muscle-tendon unit is the key {o appraising tightness, For example, with tightness of the extrinsic extensor muscles, the fingers will be unable to flex as far with the wrist m flexion as when the ‘wrist is tn extension. The opposite is true for extrinsic flexor uscle tightness: with wrist exten: limi tendon anit(s). But when the wrist 1s flexed, the fingers ca To achieve an effective stretch of the extrinsic flexor smuscles, the weist must be held in extension while the fingers are also gently but firmly held in maximum extension (Fig, 67-148), The same principle holds for the interosseous muscles in the hand, with the MCP joint key to evaluating interosscous muscle tightness, Because the interosscous musele-tendon tunits run volar to the axis of the MCP joint and dorsal to the axis of the PIP joints, the maximum stretch of this muscle— tendon unit occurs when the MCP joint is held in maximum extension (eg. hyperextension) and the PIP joint is passively Nexed. If the range of passive PIP joint Hexion is less whe the MCP joint is held in full extension, the interosseous muscles are tight (Fig. 67-15). Examining the patient’ con- jured finger for interosseous muscle provides at individual's normal imterosscous muscle Po roc race te PART 11 — STIFFNESS OF THE HAND Figure 67-15 inceroscs muscle ghar «noted when PIP nt fastve enor less when the MCP jan i extended jor Mypereatended) than wen 1 Neve. tendon unit length." This varies considerably among normal individuals, Treatment. Tighiness. Because musele-tendon unit tightness usually results from immobility: of the hand, intermittent passive stretching following by active blocked motion often alleviates mild muscle-tendon unit tightness. This is true especially When stretching is started carly alter the injury or surgery. The stretch must be prolonged” and followed by active use af the muscle through the stretched range. Tendon adherence seen carly usually can be eliminated by 4 prolonged stretch to glide the tendon through its maxiroum range, Such stretching must be delayed if the tendon has been. repaired. If, when stretching tendon adherence, the therapist feels a palpable release of the adherence, the stretched posi- tion should be maintained and then slowly incrementally positioned until the response subsides. This sudden shipping of the tissue layers can be felt as the gentle force is sustained through the increasing range. It should be strongly empha- | that this prolonged manual stretching is a slowly applied force and is continued based only on a pasitive tissue response. The therapist can palpate the diminished resistance inthe tissues. The patient should be comfortable throughout this procedure, feeling pulling and pethaps slight discomfort, hut never pain. Patients with early tendon adherence may experience a dramatic improvement in motion after such a prolonged stretch, More commonly, one does not see this sudden dramatic response but instead sees slow improve- iment over a longer time with repeated stretching. Both passive mobilization via an orthosis and active exer cise can elongate muscle-tendon tightness (see Figs. 67-12 and 67-14). Orthoses to diminish muscle-tendon unit tight- ness require that all joints rossed by the tightness be included im the orthosis. Orthoses for muscle-tendon unit tightness should be easily adjustable or replaceable as gains are made Mobilization via orthoses ts discussed mote fully later in this, chapter, Adherence. A tendon may be adherent anywhere along path, Motion to decrease the adherence ts accomplisted only by joint motion distal to the adherence. This ean be active motion of the joints distal 0 the adherence that actively pulls con the adherent tendon, or it can be passive motion of the joints distal to the adherence, which are moved in the diree~ tion opposite to the active motion (ie., passive extension if a flexor tendon is adherent), This insight allows correct posi- tioning for exercise and determines the joint(s) to be included in any orthosis. Mobilization via orthoses to decrease tendo adherence is effective only in regaining distal glide of an adherent flexor or extensor tendon. To gain proximal glide, the patient must isolate and strengthen the correct muscle 10 regain full excursion of the adherent muscle-tendon unit ‘Adherence after flexor tendon repair provides an example of the type of active motion necessary to gain proximal glide ofan adherent tendon. Commonly alter flexor tendon repair the patient Mlexes strongly: with the unimpeded interosseous muscles, and minimally glides the extrinsic flexor tendons, especially if the injury has been within the flexor sheath (zone ID, Commonly the MCP joint fully exes before the IP joints reach full flexion. When tendon healing permits, blocking the MCP joint in extension to demand flexor tendon excursion across the distal joints is mandatory 67-8A and Fig. 67-148). Tendon-gliding exercises require independent glide of the profundus and superficialis tendons relative to one another and of the profundus tendon relative to the underlying bone must be included. Early gentle resistance provides helpful feedback to ensure correct motion and begins to strengthen the weakest muscle unt When tendon healing is complete, neuromuscular cleetrical stimulation may be used if a feediack effeet ts desired and nuscle fiber recruitment is inadequate Mobilization via an Orthosis. Use of an orthosis to decrease tendon adherence need include only the joums distal to the site of adherence. An example would be dorsal adherence of ‘an extensor tendon over a healed metacarpal fracture, Orthotic positioning of all finger joints in flexion to glide the ndon distally would not require inclusion of the wrist, because the adherence is distal o the wrist. In contrast ifthe problem ts tightness of the extrinsic extensor muscles, the ‘wrist must be positioned in some flexion within the orthosis to effectively stretch the muscle-tendon unit Skin and Scar Tightness and Adherence All wounds heal with internal and external scar. Depending ‘on the size, location, and extent of scar, external scars (espe- cially linear scars) may limit joint motion, Even if the scar is not adherent (o the underlying joint(s). the length of the sea ‘may not allow multiple joints to move in the same direction simultaneously: For example, a split-thickness skin graft on the dorsum of the hand can tether the skin so that either 1P joint flexion or MCP joint flexion is possible, but simultane- ‘ous MCP and IP joint flexion is not possible Evaluation. Skin tightness is assessed by positioning joints so that the limiting scar must elongate to a maximum length Blanching, palpable tightness, or immobility of the scar oF skin displays the extent of tightness (Fig. 67-16). If skin tightness 1s limiting joint motion, placing the skin in its Whe sha the MCP jo seenentvates Sea and ugharess shortest position allows imereased joint motion proximally ‘or distally. This motion is ditminished as either joint is post tioned to elongate the involved skin. This limitation may be dificult o determine ina severe injury that creates both skin tightness and jun tightness Manual Treatment. External scars are visually evident but ‘must be palpated to determine their mobility and character, All new external scars will be adherent to the underlying bed and will have decreased oil and sweat production. In large scars, the lack of lubrication and adherence causes the scar to be dry and intolerant to frictional forces. As the scar reaches maturity and can tolerate [riction, gentle direct massage with an appropriate lubricant is the treatment of choice Orthotic Mobilization for Skin Tightness. Unlike other tughtness often alleviated by intermittent stretch, skin tight- ness usually requtites prolonged holding of the skin at its maxinmum length. Use of an orthosis is mandatory to accom- plish this, Prolonged serial static orthotic pesitioning with a pressure interlace mold provides the hest force to orthosis to elongate skin and sear tightness must also post q and distal ends of the tightness tallow full elongation of the tissue. In the hand such protonged posit the longest position is difficult 10 achieve. The need for ty and strengthening of the hand must be the need for prolonged sear elongation. At a minimuan, stich mobilization positioning orthoses should be ning with the skin in (CHAPTER 67 — THERAPISTS MANAGEMENT OF THE STIFE HAND 907) worn during sleep, tn the initial stages of wound contraction the omthosis may be required 23 of 24 hours ifthe graft o: scar covers 3 large area andor multiple joints. AS tiss matures, the duration of orthosis wear may he slowly decreased wo nighttime only. The rigid effect of an onthosis counteracts myofibroblast pull” andl decreases scar prolifer tion and contraction General Principles of Passive Orthotic Mobilization of the Early Stiff Hand Therapists must have a wide spectrum of treatment skills to ibilize stiffness in the hand. Ifthe patient 15 seen early alter ‘simple injury, often no passive mobilization with an ortho: sis is required, However, patients with greater tissue damage commonly require orthotic positioning tw wptimize tune tional motion, It must he emphasized that use of an orthosis, alone is not adequate treatment but must always be in con jumetion with an individualized exercise program, Becas sear can be modified by stress application,’” passive ortho! ‘mobilization may be an important part of regaining mobil ‘of the severely injured hand. Unfortunately, all orth even those applying passive mobilization, impose immobili- and constriction, and the good of the orthosis must gh the negative effects of restriction and immobiliza tion,* Orthotic mobilization applied early postinjury t repositions joints with serial application is the safest extly means of mobilizing healing tissue. Each orthosis applied to the injured hand must be designed, hased on the mobilization goals for that hand.”’ Therapists must possess analytic skills, manual construction skills, and biomechanical knowledge to apply welling and wel: designed orthoses. Adequate discussion of orthotic labrica- tion far exceeds the scope of this chapter, but important points are discussed in the following sections Tissue Response to Orthotic Mobilization Human tissue responds to the application of mechanical force, Because collagen tissue is elastic by virtue of the weave configuration of the larger subunits,” short-duration foree applied cl ‘no alteration of the colla response.” I the force is applied over « prolonged pertod the plastic response occurs. The tissue retains all or part of the elongated position, The amount of temporary verses long-term change of tisses depends on the intensity: and duration of the applied load." Optimal deformation is with the application of an inter- rmitient low-load stress for defined periods of time." (One can understand this prineiple by thinking how a rubber band, when quickly stretched, returns to its original length: a rubber band held stretched does not retuen to its original length as quickly or as completely The dilemma is that prolonged pesitioning imposes immo. bilization, The challenge is to balance periods of passive orthotic mobilization with penods of active movement (0 ensure the maintenance of passive gains, Passive orthotic mobilization rust apply a low magnitude of force stimulation of the inllammatory response that ‘edema and fibrosis, PART 11 — STIFFNESS OF THE HAND poser ats, Force Application in Orthotic Mobilization Although its possible to measure the amount of force being applied with an orthosis, there is currently no way of measur ing either the optimal amount of stress needed or the optimal application time of the stress to bring about the most rapid agreeable scar modification. The critical question is not 1 amount of force we are applying but the pressure exerted on. the skin where the force is applied.” This point-of-force appli- cation becomes the limiting factor. Although one can measure how much presstire can be tolerated before skin necrosis, ‘oceutrs, this ts of indirect value because mobilization orthoses are applied intermittently. Pressure becomes relatively unim- portant in the presence of intermittent application.” Fess is demonstrated that experienced therapists consistently choose greater amounts of force for application 10 more mature scar.” Flowers and LaStayo have introduced the id of total end-range time (the amount of time a restricted joint is held at maximum length), suggesting that Future orthosis prescriptions will specify both the amount and duration of force application. Glasgow et al. demonstrated a statistically significant greater effect of longer versus shorter applications of total end-range time in resolving joint coruractures in a prospective randomized trial.” Until we have a means of ‘measuring the amount of resistance in the tissues and devel- a rationale for the maximum desirable force, the tissue response to the force application remains the primary guideline to force application. The patient rust understand that the goal 1S not to toler ate inereasing amounts of tension but rather to tolerate low tension for longer periods. Alter an intial adjustment period, «4 patient’ tissues should comfortably increase tolerance to the prolonged passive The patient should the aware g while wearing the orthosis but should no ‘A motivated patie will eagerly wear an effective, well-itting orthosis. Types of Mobilization Orthoses A therapist can choose from three types of passive mobil tion orthoses (serial static, dynamic, and state progressive) 7 A.A sit PP jon wth a fexon contracture can be ested eflecWely by Seri estension mebilza9On Cast 0 eB 1B Writ exersion espana by seri appleaton of darsal and vol ‘or can choose a splint that provides aetive redisection, In the carly stiff hand, active redirection can be accomplished by a ovable exercise orthosis (sce Fig. 67-8). and more chronic stiffness requires a nonremovable cast. Understanding the ‘mechanical effect of each type of orthosis allows the therapist to choose the most effective means of regaining motion while facilitating healing Serial Static Mobilization Orthoses. A serial static orthosis immobilizes joints in a stationary position. The orthosis is applied with the tissue at its maximum length and is worn for long periods of time to allow the tissue to adapt" (Fig, 7). After a period of tissue accommodation, either a new orthosis is applied or the old orthosis is remolded to hold the tissue at a new maximum length. Although the orthosts is stationary, the repeated repositioning of the joint(s) increases the length of the tissues, Dynamic Mobilization Orthoses. dynamic orthosis applies foree to a specific joint or joints. A stretched rubber band, spring, or wire coil generates the continuous force (see Fig 67-12). As joint motion changes, the force of the orthosis cont tly pulling while the orthosis is applied, the application of force is intermittent because the orthosis is periodically removed." In the early stiff hand where collagen crosslinking is immature, intermit- tent dynamic force appl ly restores tissue mobility. In the hand with more mature stiffness, the inter: mittent nature of the force application ts often inadequate to «lfect desired change. For dynamic force application io mobilize the tightest structures, the hand must at times be positioned awkwardly in the orthosis, The intermittent nature of dynamic force application allows such awkward positions to be tolerated, because active therapy combines with the orthotic position ing program to regain balanced motion. Use of a dynam ‘orthosis #s the technique of choice when passive motion of the joints is responsive to manual stretch and inflammation has subsided." A period of therapy to regain active tendon pull-through and edema reduction while increasing the tolerance to stress the hand for dynamic mobilization in an orthosts. If mic orthosis 1s applied too early or with too much te the inflammatory response. the dyn Static Progressive Mobilization Orthoses. Static progressive von orthoses may. appear identical to dynanwe mn orthoses, but the applied force ts not dynamic 67-18). Instead of the constant pull of a rubber band or the once. via hook-ankl-loop lastener-or with components that adjust in. small tension ts applied, the jomt is positioned at its maximum end-range, The force ts adjusted when the to a new length efetive for joints with 0 When there is significant resistance at the end reich, Static progressive orthoses are espe ¢ small joints of the hand (see Fig, 67-18C and D). As with other passive mobilization orthoses the patient removes the orthosis and works on active glide for may use another orthosis t gain another direction of otion. Prolonged stretch gives the joint its full easy motion in both directions, The varlier the hand is ready for static progressive positioning, the shorter the time requited to regain motion. The longer alter injury that positioning is initiated, the longer the ortho- sis will have to be worn to regain the movon (CHAPTER 67 — THERAPISTS MANAGEMENT OF THESTIFF HAND 909 Figure 67-18 A wt & progres crt force 10 gan MCP yore Reon Cand D Seri sims or Gans enctrange prosrnal I ort feuemion becace whe pee ccrencs of PIP moos Spina Ord Hered Ther 2000, 5.65, Copyiate 2000) Choosing Mobilization Orthoses Based on the Stage of Healing The stress appropriate to mobilize tissues differs in each clinical stage of healing. Static immobilization splints rest inflamed tissues during 1 18 t0 provide protection and (o allow inflammation to subside. Ifthe desired position of immobilization cannot be obiained initially, serial stave mobilization orthoses can safely reposition joints of the hand without providing undue stress to healing tissues. When, injury is extensive and inflammation is prolonged, the rest provided by the orthosis ts of continuing value. The process oft ling and maturation proceeds at variable rates in ‘nuividuals, and many patients may:have a prolonged inflam: Alter the initial ation subsides, od tissues begin the proliferative stage of healing ¢ muliplying at a rate higher than normal. During this stage. correctly applied stress has its optimal benefit in determining the length, orientation, and relationship of the collagen fibers. If paticnts donot respond sulficiently to gentle manual passive stretching and active exercise, the gentle force of a dynamic orthosis is usually all that 1s required, Ifthere is any indication of a continuing inflamma tory response (e48, Hluctuant edema, reddened joints, pain ‘ith joint motion), serial static orthosis should be chosen to provide a balance of rest while also repositioning joints. AAs the tissue matures and joint motion has signiic resistance with a hard end-feel, the protonged force of se static or static progressive orthoute positioning is necessary Avtruly resistive joint is best trated with a senal static ortho- 910 PART 11 —STIFFNESS OF THE HAND. Figure 67-19 & the ttece points force for AP jon extenson enthone postioning places the mdale pore of foyce drecdy on Ue extensor Suri ofthe pan ar he bo BppaSKE Forces Parana ae Hom Phe Jovnt as posse The three points of force fer AIP ox heen ont otc [posting se te same locition. but on oppaste surfaces to 1hose for extersion From Cote JC Effient mechanics of PIP mobuscon spaning) Be) Hand Trey 2000.5'65-71 Copyright 2000 sis that is not removed by the patient. Although thé sfatic progressive arthosis also provides prolonged positioning. at the maximum passive length, its periodic removal allows the tisstte to resume the original resting length, These révom- ‘mendations are hased on clinical experience and not on ‘empirical research results. A recent study comparing dynamic to statie progressive elbow mobilization via orthotic position- ‘ing demonstrated no difference between these two methods.” ‘A new technique of mobilizing stillness, casting, motion to mobilize stilfness (CMMS). is appropriate for the chront- cally stiff hand unresponsive to traditional therapy tech- rmiques. This is discussed in a subsequent section. Basic Principles of Orthotic Mobilization Because passive orthotic mobilization is often an integral part of effective therapy for the stiff hand, the basic principles of ‘mobilization by orthosis are discussed in this section. The reader ts directed to more in-depth information on this topic available from numerous sources." The electiveness of any mobilization orthosis is limited by the accuracy of the design, fit, and force application. Every orthosis that immobilizes or mobilizes a joint must use three points of pressure for each joint.” The middle force is applied directly at the axis of the joint. Without crossing another joint, the two opposite forces are placed as far away from the tidal force as possible for maximum efficiency (Fig, 67-19). Orthotic fabrication for extension mobilization oF immo- bilization places the middle force over the dorsum of the joint axis, and the opposing forces are placed on the volar surface as far away as possible without erossing over another mobile Joint (sce Fig. 67-194), Because there is litle natural padding ‘on the dorstim of the hand, pressure over the joint must be carefully placed and be well molded to be comfortable The three points of pressure for flexion mobilization ‘orthotic fabrication are the reverse of those used lor exten- sion: Volarly over the axis of the joint with the two opposing forces applying pressure dorsally as far away from the joint as practical (see Fig. 67-198). The difficulty in llexion mobi lization orthotic fabrication is the impossibility of applying force directly over the volar aspect of a joint while also allow- ‘ing room for the joint 10 fully flex Unlike extension mobilization orthoses, where the forces are almost in direct opposition, the forces may be almost at right angles in flexion mobilization orthoses. This is espe- cially true when flexing the joints of the hand (Fig. 67-20), i the forces are at a right angle, the orthosis hase shifis dis- tally before the stiff joint moves unless the orthosis hase ts adequately secured. Distributing Pressure Evenly. The palmar suriace of the hand, with its thicker and more adherent skin and with the presence of the thenar and hypothenar muscles, can tolerate pressure more easily than the dorsum of the hand. The skin ‘on the dorsum of the hand is thin and highly mobile. The dorstum of the hand also has multiple bony prominences that tolerate pressure poorly: For example, in low-profile dynamic orstatic progressive PIP joint extension mobilization designs, the orthosis is molded contiguously over the MCP joints to distribute pressure over as much of the dorsal surface as pos- sible, The leading edge of the block ends exactly at the joint axis $0 that all the force is specifically directed ta the precise

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