Therapeutic Exercise: Wrist and Hand, Lecture notes of Anatomy

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THERAPEUTIC EXERCISES

2 ND^ SEMESTER – BSPT II

PREPARED BY: WRC, PTRP

MODULE 5

WRIST

and

HAND

THE WRIST AND HAND

JOINT HYPOMOBILITY: NON-OPERATIVE MANAGEMENT

Related Diagnosis and Etiology of Symptoms :

1. Rheumatoid Arthritis a. Signs and Symptoms:  Pain, swelling, warmth, LOM  Progressive muscle weakness  Carpal tunnel syndrome may occur due to compression of median nerve from the swollen tissue.  Muscle fatigue b. Advanced Stages  Joint capsule weakening, cartilage destruction, bone erosion and tendon rupture  Swan neck deformity(PIP hyperextension with DIP flexion)  Boutonniere deformity (PIP flexion with DIP extension)  Zigzag deformity of the thumb  Volar subluxation of the triquetrum on the articular disk and ulna.  Ulnar subluxation of the carpals  Ulnar drift of the fingers and volar subluxation of the proximal phalanx.
2. Osteoarthritis and Joint Trauma  Involves: trapezioscaphoid articulation, CMC joint of the thumb, DIP joints a. Acute Stage: swelling, warmth and restricted and painful motion b. Advanced Stages: i. Limitation of both flexion and extension in the affected joints ii. Generalized muscle weakness, weak grip strength iii. Poor muscular endurance
3. Post immobilization hypomobility
   • Decrease ROM - muscle weakness
   • decrease joint play - weak grip strength
   • poor endurance - decrease flexibility JOINT MANAGEMENT: PROTECTION PHASE
4. Joint Protection and Patient Education a. Splinting – to rest and protect involved joints

• instruct the patient to remove splint for brief periods b. Activity Modification – adaptations and assistive devices to minimize stresses on all joints (table 19.2 pg. 660)

2. Decrease Pain- aside from medication and modalities, Grade I and II distraction and oscillation techniques can be done.
3. Maintain joint, tendon and soft tissue mobility a. PROME, AAROME, AROME b. Muscle setting c. tendon gliding exercises JOINT MANAGEMENT: CONTROLLED MOTION AND RETURN TO FUNCTION PHASE
4. Increase joint play and Accessory motions
5. Improve joint tracking and pain free motion
6. Develop strength and function – coordination and finger dexterity JOINT SURGERY AND POST-OPERATIVE MANAGEMENT A. Soft Tissue Procedures (Box 11-3) p. 427 a. tenosynovectomy – chronic tenosynovitis of the flexor and extensor tendon of the wrist b. repair of ruptured tendons, capsulectomy/synovectomy of the wrist and finger joints B. Bony Procedures a. arthrodesis b. resection arthroplasty/implant arthroplasty

a. emphasis: maintain mobility in the fingers and shoulder and elbow when long-arm splint is cut down to a short arm splint b. minimize edema in the hand and maintain mobility of adjacent joints active ROM of the shoulder, active flexion/extension of fingers with hand elevated active ROM of thumb and elbow c. Maintain gliding of tendons that cross the wrist (tendon-gliding exercises) d. Restore mobility of wrist and forearm e. Prevent atrophy of finger musculature B. MINIMUM PROTECTION/RETURN TO FUNCTION PHASE (8-12wks post. op) a. Use cock-up splint at night – if px has wrist flexion contracture b. Regain functional strengths of the hand and wrist, increase ROM to functional level REPETITIVE TRAUMA SYNDROEMS/OVERUSE SYNDROEMS

1. CARPAL TUNNEL SYNDROME – median nerve a. ETIOLOGY OF Sx i. Synovial thickness and scarring in the tendon sheath ii. Irritation, inflammation and swelling as a result of repetitive wrist flexion, extension and gripping activities iii. Swelling due to fracture of carpals, pregnancy, RA, OA iv. Awkward wrist postures, compressive forces from sustained equipment Usage and vibration against the carpal tunnel b. COMMON IMPAIRMENTS : i. increasing pain ii. weakness/atrophy (thenar muscles, 1-2 lumbricales) ape hand deformity iii. tightness in adductor pollicis and extrinsic flexors of the thumb and digits 2- iv. sensory loss: median nerve distribution c. FUNCTIONAL LIMITATION AND DISABILITIES : i. decrease prehension in tip-tip, pad to pad activities ii. inability to perform provoking sustained/repetitive wrist motion

1. fine tool manipulation/typing NON-OPERATIVE MANAGEMENT:
   1. splinting
   2. joint mobilization
   3. biomechanical analysis
   4. tendon-gliding exercises
   5. median nerve mobilization (figure 11-4)
   6. px education
   7. muscle setting
   8. strengthening and endurance POST-OPERATIVE MANAGEMENT :
   9. rest and edema control
   10. active tendon and nerve gliding exercises MODERATE AND MIN. PROTECTION PHASE o stitches removed: 10-12th^ post-op day o px return to full activity by 6-12 wks.
   11. scar and tissue mobilization
   12. progressive stretching and joint mobilization
   13. strengthening exercises
   14. dexterity exercises
   15. sensory stimulation and re-education

6. px education 2. COMPRESSION IN THE TUNNEL OF GUYON – ulnar nerve (b/n hook of hamate and pisiform)  prolonged handwriting/leaning forward onto extended wrist while biking, gripping activities of the 4th-5th^ fingers (knitting, using pliers and staplers, trauma: falling on ulnar border of the wrist) A. COMMON IMPAIRMENTS : a. Pain and paresthesia b. Weakness and atrophy (hypothenar, interossei, ulnar 2 lumbricales, adductor pollicis, deep head: flexor pollicis ( bishop’s/benediction hand deformity) c. Tightness d. Restricted mobility of pisiform B. FUNCTIONAL LIMITATIONS/DISABILITIES a. Pain that worsens with the provoking activity of the fingers, thumb/wrist that affect grip/repetitive hand motions MANAGEMENT: PROTECTION PHASE :
7. splint
8. cross fiber massage
9. muscle setting
10. tendon-gliding exercises MANAGEMENT: CONTROLLED MOTION/RETURN TO FUNCTION PHASE
11. progress intensity of massage, exercises, stretching techniques
12. assess biomechanical activity provoking the sx
13. design a program to regain balance in length and strength and endurance of muscles **TRAUMATIC LESIONS IN THE HAND
14. SIMPLE SPRAIN: NON-OPERATIVE MANAGEMENT** A. Etiology of Sx: a. trauma –blow/fall b. fx, sublaxation/dislocation B. Impairments a. pain at involved site b. hypermobility/instability in related joint C. Functional limitations / Disabilities a. pain may interfere with functional use of the hand b. instability NON-OPERATIVE MANAGEMENT - cross fiber massage, avoid position of stress 2. LACERATED FLEXOR TENDONS OF THE HAND A. Surgical and Post-operative Management Volar surface of the wrist, palm and fingers are divided into 5 zones: a. I – from insertion of FDP to just distal of FDS insertion on middle phalanx b. II – distal insertion of FDS to level of distal palmar crease (prox. to neck of metacarpals) c. III – neck of MC to distal border of carpal tunnel d. IV – carpal tunnel e. V- proximal to wrist up to musculotendinous junction of xtrinsic flexors in the distal FA The thumb in 3 zones: a. T-I – distal insertion of FPL to distal phalanx of thumb to neck of proximal phalanx

T-II – proximal phalanx T-III – MCP joint region T-IV – metacarpal TV – CMC joint region

CONSEQUENCES:

Zone I and II

- inability to extend DIP joint (extension lag) - DIP contracture and deformity (Mallet finger) - Result f closed rupture rather than a laceration Zone III and IV - inability to actively extend the PIP joint from a 90degrees flexed position - flexion contracture of PIP joint and eventually boutonniere deformity develop Zone V - damage to EDC, extensor indicis propius and extensor digiti minimi – causes inability to actively extend the MCP jonts, eventually resulting to MCP flexion contracture Zone VI and VII - damage: juncturae tendium(VI) dorsal retinaculum (VII) - bowstring effect occurs if retnaculum is lacerated - loss of extension of digit and wrist T1 and T2 – EPL and EPB – loss of hyperextension of the IP joint, weakened MCP extension T3 and T4 – EPB damage leads to weakened MCP extension POST-OP MANAGEMENT:

1. Immobilization – use volar splint
2. Exercise – Delayed Mobility approach a. Delayed for at least several weeks after surgery b. Resistance to repaired muscle-tendon unit is not initiated until 8-12 weeks post-op c. After 10-12 weeks low intensity resisted grasp and pinch is initiated to gradually strengthen the flexors if no extensor lag is present
3. Exercise – Early Mobility approach a. Because the flexors of the hand are so much stronger than the extensors, there is continued concern that if the immobilization is removed in early phase of rehab, uncontrolled grasping could easily cause gapping/rupture of a recently repaired extensor tendon b. For carefully selected patient But act as a dynamic spacer to maintain joint alignment during healing - Overtime, it becomes encapsulated as a new fibrous capsule forms.