Hand & Wrist Treatment Approaches (Lecture #5)

Question 1

What normally causes hypomobility? (4)

Answer 1

RA
OA
Trauma (Fx / Sprain)
Post operative/post immobilization

Question 2

KNOW: W/ joint hypomobility in the hand we hvae functional limitations in:
* Activities involving prehension, pinch or grippping / grasping
* Pain and/or weakness can also be a factor (these can lead to deficits in dexterity (find motor coordination)

Question 3

A pt comes in w/ joint hypomobility. Explain early stage treatment:

Answer 3

Start w/ joint protection
* Pateint education - say they cant grasp smaller objects - can we make the objects that they need bigger so they arent tensioning those hypomobile joints (put some kind of cover over pencile so they dont have to grasp something quite as small)
* Pain management (manual, medication, modalitites) - if highly irritable we need to try and reduce the pain as much as possible which will allow them to progress through interventions we do in the future
- think parafin / iontophoresis / ultrasound
* Orthoses - say were constantly stressing an area which led to the hypomobility - maybe having some kind of splint / orthoesis to keep us from going into that pain pattern over and over again would be helpful
* Activity modification: Balance activity and rest (relative rest = were resting the painful activity / avoiding it so that its not painful - however, you want to keep them as active as possible - so figure out a way to use affected side in a non-painful way) | Avoid prolonged periods of stress / strain on affected tissues (split up dishes if thats whats bringing on pain to avoid that prolonged period of stress) | Avoid painful resisted activities
* Patient to be as independent as possible w/ minimal pain and stress to joints - in the beginning we really want to calm down that area
* Respect pain
* Eventaully start moving into strengthen / ROM (remebering to respect pain) - we want to do this in a pain free way - we don’t want to exaserbate a highly irritable pt

The goal of this stage is to do pain management and maintaing as much function as possible

Question 4

KNOW: We often want to avoid going into the painful movement all the time w/ hypomobility OA / RA
* So we need things to are bigger to help us not go into that full finger flexion all the time

Question 5

KNOW: Joint hypomobility intial loading and mobility:

PROM –> AAROM –> AROM

Tendon gliding: Think about flexior digitorum profundus etc… They go through tendon sheaths and the slide forward and back through them. In someone who is hypomobile if they continue to not move through that full ROM they can develop adhesions between the tendons and the tendonsheaths which can lead to more painful hypomobility in the future. The idea with this is just to get it moving within its sheath so those adheasions dont form.

We can also use multiangle isometrics. This is doing isometrics at different points in that ROM. (next page)

TEndon gliding that hits all tendons in hand

Answer 5

The picture below is a multiangle isometric. She would progress into flexion from that fully exended position hitting it from multiple angles. This is a good way to prepare the joints for full AROM. Can do these w/ mcp joints or really and joints in the hand

Question 6

A joint is hypomobile. What is proably the BEST manual therapy approach here?

Answer 6

Joint mobilizations (glides / slides)

Movement w/ mobilization is also utilized to allow them to work into that movement is a distrated / glided state (helps improve those hypomobile pts)

Question 7

Who would be contraindicated for joint mobilizations?

Answer 7

RA pts in inflammatory phases
* The tissue can easily be torn here
* Theres a lot of tissue breakdown at this time before it “heals”

Question 8

I already know how to do this!

Question 9

Metacarpal arch = distal transverse arch
* This arch can become stiff over time

Question 10

What kind of glide is this?
* What is it used for?

Answer 10

Dorsal concave mobilization of the metacarpal arch
* Makes sense - the dorsal side of the hand is making a cave (and named “dorsal” to dilinate what side it is)

Improves gross extension (makes sense were extending the 2 fingers were mobilizing)

Question 11

What kind of glide is this?
* What is it used for?

Answer 11

Dorsal convex metacarpal arch mobilization

for improved gross hand grasp
* Primarly spherical grasp (makes sense - lookse like were holding a sphere w/ this grip) - when were really trying to get around something

Question 12

NOTE: We don’t just have to do metacarpal arch mobilizations - we can do mobilizations of each individual metacarpal

Question 13

KNOW:

This is mobilizing each individual metacarpal near the carpal bones

Proximal intermetacarpa mobilizations can be palmar or dorsal (both shown below)

They are both used to improve hand mobility w/ a variety of grips (so we would use it on our hypomobile pts, like those w/ OA / RA in a NON FLARED PHASE to avoid stressing that already very pathological capsular tissue)

Question 14

KNOW: We can perform traction at CMC joints like this (note we can also perform traction at the PIP / MCP / DIP joints as well if those areas are pathologic)
* good for pts to have that mid hand pain (typically linked to arthritis - aka distraction helps)
* Its also used to improve general mobility of the CMC joint

PAIN IN MIDDLE PORTION OF HAND ARE THE PTS WE PERFORM THIS ON

Question 15

What glide of the thumb is this? What motion does it improve?

Answer 15

This is a radial glide of the thumb

It improves extension

Question 16

What glide of the thumb is this?
* What motion does it improve?

Answer 16

Ulnar glide of the thumb

Improves thumb flexion

Question 17

This is 1st CMC distraction - used often for those OA pts (intracapsular pathology = traction pairs well w/)

Question 18

Thumb arthro
* note this is a saddle joint so the glide and slide are “interesting”

Answer 18

Question 19

A dorsal glide of the thumb improves what motion?

Answer 19

Improves abduction of the thumb

Question 20

A palmar glide of the thumb improves what motion?

Answer 20

Improves adduction

Question 21

Radiocarpal slide and glide in opposite directions
* Convex on concave

I don’t think the ulna interacts w/ the carpal bones

Question 22

Radiocarpal distraction

Question 23

What glide is this?
* What does it help with? Why?

Answer 23

Palmar glide

The radiocarpal joint is convex on concave

So, during extension we have a dorsal roll and a palmar glide
* This palmar glide portion is what happens during extension - so doing a palmar glides helps w/ extension

Its named for the way you’re pushing

Question 24

What kind of glide is this? (Note the palm is up)
* What movement does this help w/? Why?

Answer 24

Pushing toward dorsal side so its a dorsal glide (named for the way were pushing)

The radiocarpal joint is convex on concave. During flexion its a palmar roll and a dorsal glide
* So this being a dorsal glide helps w/ flexion

Question 25

This is how radial / ulnar deviation works * NOTE: were mostly focused on the proximal carpal bones on the radius

Question 26

**What kind of glide is this? What movement does it help w/? Why?**

Answer 26

Radial glide Radiocarpal joint is convex on concave (opposite) Roll = radial Slide = ulnar Helps w/ Ulnar deviation

Question 27

**What kind of glide is this? What movement does it help w/? Why?**

Answer 27

Ulnar glide Radiovarpal joint is convex on concave (opposite roll and slide) Roll = ulnar (duh) **Glide = radial (because they have to be opposites)**

Question 28

The elbow has a pathology that makes supination / pronation very painful. Originally you do a glide at the proximal radioulnar joint (primary place in the elbow for supination / proantion) and realize that its highly irritable and doesnt tolerate this movement well. What is the next joint you should move to to try and and improve supination / pronation?

Answer 28

Distal radioulnar joint

Question 29

When doing a distal radioulnar mobilization an anterior glide of the radius is perofrmed. Does this promote supination or pronation?

Answer 29

improves pronation (do it yourself)

Question 30

When doing a distal radioulnar mobilization a posterior glide of the radius is perofrmed. Does this promote supination or pronation?

Answer 30

Supination

Question 31

KNOW: The radius is better to mobilize than the radius at the distal radioulnar joint because its bigger and performs most of the movement

Question 32

KNOW: We still progressively load a hypomobile joint * Yes, we obivously do need to adress the mobility deficits as well * However, if someone cannot move a muscle through its correct ROM - they most likely are loading it incorrectly * we want to get their muscles balanced correctly (we want things like finger flexion vs extension to be correctly balanced to where it should be comparitvely) * we can work on opposition * Grip types * encourage pt to return to conditionoing / aerobic EX * Potentially activity modificaiton

Question 33

Whats stronger finger flexion or finger extension?

Answer 33

Finger flexion

Question 34

KNOW: Post surgery pts will often have hypomobility

Question 35

There are some hand surgeries that dont fuse anything but have a period of immobilization post op. * maybe we do some partial ROM but we don't want to stress it at all - we need to let it heal * Because this immobilization adhesions can form between the tendons and the sheath (sticking together) or maybe we have scar tissue formation that can block movement or even potentaily a contracture These are reasons we might have hypomobility post OP w/o a fusion

Question 36

What is a synovectomy? * Why is it used?

Answer 36

When synovial sheaths of tendons are removed of tendons in the hand We would do this if the sheaths were chronically inflammaed (chronic tenosynovitits)

Question 37

What is a tenosynovectomy? * Why is it used?

Answer 37

Removal of the synovial sheaths of the tendon + the tendon itself in the hand * used to treat chronic tenosynovitits of tendons within the hand (chronic inflammation of the tendons / sheaths within the hand)

Question 38

What is a capsulotomy / tissue realease? * What are they typically used for in the hand?

Answer 38

Capsulotomy = removing part of the joint capsule to increase room Tissue release = releasing tisues to create more room Used for carpal tunnel to increase the amount of room in the wrist

Question 39

What is an arthroplasty in the hand? * whats it used for?

Answer 39

Can really be done at any joint. Its used to relaive pain but not actually fuse the joint

Question 40

What is a arthrodesis? * whats it used for?

Answer 40

Fusion of a joint Used to provide **stability** to a joint | This actualy spans multiple joints (very hypomobile)

Question 41

What kind of repair was likely done here?

Answer 41

Extensor tendon repair

Question 42

What is this surgery?

Answer 42

Carpal tunnel release * NOTE: bad outcomes due to double crush syndrome likely being the cause OR neural health is so bad already that getting the pressure off didnt really help

Question 43

What kind of repair was likely done?

Answer 43

Flexor tendon repair

Question 44

Post OP general goals: * Relieve pain * Restore normal function * Correction of any instability or deformity * Restore ROM (dependent on the surgery) - dont want to try to get all the ROM back on a fusion (this is impossible) * Restore strength

Question 45

This is how you should progress from post OP Dont forget you can load prox and distal to the problematic area

Question 46

KNOW: tendon loading principles apply in the wrist

Question 47

Does RA affect more proximal or distal extremitites?

Answer 47

Distal * think about that ulnarly deivated hand picture

Question 48

Tendinopathies in the hand can occur because of: * **Repetitive use w/o opportunity to adapt** (most common) * RA (note RA is worse in distal extremitties so it really causes issues in the hand) * Overloaded stress (traumatic) - think being in a situation that involves a lot more stress than most activites you need to do (think someone training for a marathon by doing short jogs then doing one traumatic massive run) * **Changes in tendon sheath - these can become inflamed and lead to a tendonpathy**

Question 49

Common presentation of a tendinopathy: (3)

Answer 49

Pain w/ muscle contraction or gliding of tendon through the sheath (that can be w/ contraction or relaxing abck - any time the tendon in gliding through) Warmth / tenderness in inflammatory state * if you've just made it mad Muscle imbalances * Think it being a muscle length issue - because they can't fully stretch that tendon * Could also be because they cant fully contract either

Question 50

A person w/ RA developes a tendinopathy. * There is synovial proliferation and swelling where? * Where is it most commonly found in the arm/hand? * Which tendons does it often affect at what location?

Answer 50

Synovial proliferation and swelling in affected tendon sheath Commonly found in dorsal wrist Affects flexor tendons in carpal tunnel

Question 51

When does pain come on w/ tendinopathies?

Answer 51

Prolonged / sustained activity * Think recreational, work or leisure activities "I can do this activity for a certain amount of time but once i do it for awhile it really starts to hurt" "I can do 6 or 7 turns of my screw driver then it really starts bothering me" Should be very specific pain that comes on at a specific time or amount of tendon loading

Question 52

**Tendinopathy: Inital stage of treatment** Patient education * Activity modification (dont want to overload it) * relative rest Tendon mobility: * Transverse/cross friction massage over tendon in sheath (if there is one - not all tendons have this sheath but most do) - because these tendons are moving through sheaths - **note this doesnt feel great while its happening - but the idea is that you're breaking up and ahesions or decreasing the liklihood that they will form** * Tendon glides, gentle stretching (improves that mobility) Multi-angle isometrics * Pain free * moving through that ROM and doing isometrics there

Question 53

Tendinopathies: Middle stage of treatment: Exercise progression * Increasing mobility during exercise (getting closer to full ROM) * Increasing resistance, intensity and other parameters * Really trying to ahdere to tendon laoding principles (moving into slow heavy --> fast light) Assess biomechanics of daily activity requirements * What is required? How can we get the pt there? * Moving into activities that are required in everyday life --> think pooring coffee * breakdown activities that they're going to need to do in life - figure out what the limiting factors are - then work on the limiting parts * So make an activity thats like the activity they need to do and see whats going on Prevention of regression * pt education of self-assessment of symptoms during activity * So in this middle stage we've gotten their symptoms under control but we want to be careful and make sure they dont over do activity again * Keep them mindful of not overdoing it but progressively increase the amount they're doing **Joint mobilizations may help to restore mobility and reduce excessive stress on the tendon** * MWM at wrist w/ De Quervains

Question 54

Why does MWM at the wrist help De Quervains syndrome?

Answer 54

We have a reduction in pain because were helping to restore normal motion and decrease stress on that tendon * However, reason it helps is kind of unknow

Question 55

MVM where helps De Quervain's?

Answer 55

At the wrist

Question 56

There are lots of ligaments in the wrist - HOWEVER, they are named where its super easy to figure out based on their names

Question 57

KNOW: W/ a wrist sprain ROM was taken to the extreme and the ligments were stress / torn * In a non operature wrist sprain the tare is very minor or there is no tear at all Typically w/ wrist sprains they're going to have pain w/ stressing the involved ligament * For example - if the triquetrocapitiate ligament was sprained there would be pain when i press / move the capiatete or the pisiform * We would also likely see laxity (hypermobile) - espeically fi there is a tare or a rupture

Question 58

**There is a sprain of a wrist ligament. What are the first few things we should do? What do we do after that acute phase?**

Answer 58

So in the intial stages of ligamentous healing we use PEACE & LOVE Protect (think cast / brace) - allowing ligament to heal and not have stress going through it Educate pt on safe recovery (think realtive rest - continue to move while we rest it - do non painful movements w/ wrist in brace) - Don't use loads of NSAIDs we want the natureal healing process to occur A? Compress (Aleviate swelling) Elevate (alieviate swelling) After the acute phase we get into love Load the tissue (improve strength / stability) Optimism Vascularization improvement through EX / generalize wellness Exercise

Question 59

NOTE: For ligamentous sprains we only immobilize involved joints in a way to remove potential stress to involved ligament if needed * meaning if I sprain one ligament I just want to stabilize this ligament not the ones around it (so you can keep the other ligaments moving)

Question 60

KNOW: Flexor tendon repairs are exactly the same as extensor tendon repairs * She focuses on flexor repairs (which is more common)

Question 61

KNOW: Whenever you have a flexor tendon pathology it is labled in a "zone" which will allow us to know what possible tendons were affected For example if we stay "zone 1" we know that flexor digitorum superficialis is not affected (because it doesnt cross the DIP joint)

Question 62

What bones are in zone 3?

Answer 62

Metacarpals

Question 63

Which two zones are at risk for adhesions

Answer 63

zone 2/4 due to how close the tendons are packed together

Question 64

**Which zone is considered "no mans land" and has poor vascularization?**

Answer 64

Zone 2 very poor healing time due to poor vascularization

Question 65

This is a direct tendon repair or "end to end repair" It is typically done when the tendon quality is good and there is a straight tear across

Question 66

This is a tendon graft Used when the tendon quality is poor or if the tare isnt straight across / frayed * they cutt off all the frayeed ends before attaching We typically use an autograft from the palmaris longus (makes sense its got the biggest amount of fascia at the end)

Question 67

Tendon surgery timing is really importants Tendons retract and deteriorate in _ days which means most surgiers should be performed within _ days and we see poorer outcomes if done after _ days

Answer 67

>10 days within 10 days w/ poor outcomes after 2 weeks

Question 68

KNOW: Our goal in therapy for tendons it: * Strong well healed tendon that glides freely (no adhesions)

Question 69

what are 6 factors that contribute to adhesions following tendon injury/repair?

Answer 69

1) Location (zone 2) 2) High extent of trauma 3) reduced blood supply 4) Poor surgical procedure (bad surgery) 5) Prolonged immobilization 6) Excessive early stress to tendon

Question 70

There are 2 appraoches to post operative tendon management. What are they?

Answer 70

1) Early controlled motion (more widely accepted) 2) Delayed motion (worse)

Question 71

What are the 3 things that make it likely that delayed motion will be utilied w/ a post operative management of a tendon?

Answer 71

Children <5 Extensive injuries Those unlikely to adhere to early controlled motion protocol * Cognititve limitaitons * unmotivated overzealous

Question 72

What is the early controlled motion method? * In animal studies what has it been shown to prevent? * Does it pull or push the tendon?

Answer 72

Early controlled AROM (for tendons) Prevents adhesions * The idea is that by doing AROM we are allowing the tendon to NATURALLY move through the sheath. It **pulls** the tendon through the sheath (muscle contration) instead of pushing it through w/ PROM and forcing it to go where it may not be ready to go

Question 73

For early controlled motion what is there are 3 exercises we do. Name the 3 * note these are for tendons

Answer 73

**PLace and hold** * MP's in flexion * PT will passively and partially flex both IPs * Pt holds 5 seconds w/ minimum flexion contraction (isometric) * Wrist is in extension to avoid passively insufficiecy of ED Dynamic approach: * Short arc, minum tension * wrist is in extension * MCP joints all in flexion * And do some flexion then move back to extension Combined apprach * Progress from place and hold to dynamic based on criterion * Not time based (move to the other ones once you can do this)

Question 74

After a flexor tendon repair the wrist is allowed to go into about 30 degrees of extension but not full extension. but can do full wrist flexion * we don't want to stretch out the flexor tendons during extension

Question 75

PHASE 2: Moderate protection (tendons) Place and hold EX AROM Tendon gliding EX (moving it through the sheath) blocking EX (think holding MCP / PIP still and just moving DIP) * its an isolation of a joint

Question 76

Phase 3: return to function Progressive strengthening joint mobilizations / manual interventions as needed functional activities dexterity

Question 77

What position would someone wear a night splint for who has carpal tunnel syndrome? * What level evidence is this?

Answer 77

Would sleep w/ it in neutral (this is for short term pain releif) This is because most people sleep w/ wrist flexion and that compresses carpal joint which causes pain * the orthoesis keeps this from happening This is B level evidence

Question 78

Why would we put someone in a daytime splint for carpal tunnel syndrome? What level evidence is this?

Answer 78

We would put them in a splint to allow for every day activities * used for mild to moderate carpal tunnel * allows them to remain active C level evidence

Question 79

What level evidence are orthesis good for pregnancy w/ carpal tunnel? Why would we use them?

Answer 79

C level evidence Theres a high level of carpal tunnel during pregnancy but its unknown why (maybe increased blood volume during pregnancy which causes more compression here)

Question 80

What 3 modalitites do we use for carpal tunnel? What is their level of evidence?

Answer 80

Superficial heat: Short term symptoms relief Microwave/diathermy * Short term relief for mild to moderate carpal tunnsel syndrome Interferential current (IFC) * Short term relief, mild to moderate CTS C level evidence

Question 81

While there are several modaltities that are listed that have C level evidence what 4 modaltities are we instructed NOT to use that have B level evidence?

Answer 81

1) Low level laser therapy 2) Thermal ultrasound 3) Iontophoresis 4) Magnets NOTE: Theres some evidence that supports NON-thermal ultrasound (but its conflicting evidence [D level] so were probs not gonna use it)

Question 82

The manual therapy we do for carpal tunnel is cervical / UE manual. We see short term effects for mild to moderate CTS What level of evidence is this?

Answer 82

B level evidence

Question 83

Are neurodynamic mobilizations effective for CTS?

Answer 83

D-Level or conflicting evidence (some pts have double crush and this may help while others have it actually blocked at the wrist and this will do nothing for them) The thought was that these pts have abnormal neuraldynamics

Question 84

W/ carpal tunnel we can use orthotic and stretching program. What level evidence do these have?

Answer 84

C

Question 85

What is often mixed up w/ carpal tunnel?

Answer 85

Cervical radiculopathy However, sometimes they can both be going on at the same time * this would be called double crush syndrome where there are 2 seperate areas causing the pathology * We might treat the carpal tunnel area and see no relief because its also being pressed on higher up

Question 86

What two muscles would we do tendon gliding of as an intervention for CTS?

Answer 86

Tendon gliding of FDS / FDP This would improve vascularization to the median n and reduce swelling of the median n * this is because both of these muscles are innervated by the median n - so moving them around increases that vascularization and decreases swelling

Question 87

What two things indicate that a CTS pt needs surgery?

Answer 87

Atrophy of thenar region (more innervated by median n - so if median n is entrapped [CTS] than this region would be very degenrated) Altered sensation

Question 88

KNOW: Someone w/ CTS: You could start w/ activity modification then slowly return to function * adpative devices initally * Wrist splint * Progressive resistive EX * ROM EX

Question 89

KNOW: there are 3 buckets that any of these conditions talked about pts can fall in - and they might start in any of these phases **Protection phase:** Think about the tissue you're treating - what is happening at the body at this time and how do we reduce stress on this tissue while maintaing function throughout the body. - Allow this tissue to heal - give it some rest then were going to load it - let your body heal then well do x,y,z. * Typically early post op, highly irritable pts * Reduce/eliminate stress on affected tissue (activity modification) * Maintain, improve function throughout body * Maintain or improve mobility of affected region * Prevention of contracture / adhesions * Pain / symptoms management * Manual/modalities **Graded Exposure Phase:** * Progressive resistive EX / ROM (introduce load, then progress. PROM / AAROM / AROM) * Tendon glides * Introduction to or assessment of functional tasks (appropraite for level of recovery. Make a plan) * Continue to re asses (activity modification / HEP) * Pain / symptoms management * Not really working that much on strenghtening just introducing to some load and progressing and building your resistance off of there (this will also show us where their deficits are) - this is where we can really truely start to see weakness and make that plan **Return to Function Phase:** Start w/ the end in mind. Where do we want them to be - what activities do we want them to do * Functional goals (How far do they have to go? How can we get them there?) * Targeted interventions for the individual. (look at ADLs / recreational activities / what do they have to do ona. regular basis) * Progressive resistive EX - move into more power, endurance relative to pts needs (increased saliency) * Functional task simulation (ask pt what tasks are still difficult for them and then simulate them) * Find an activity and break it down and figure out what part of the activity is causing the problem for them and then work on that bit

Question 90

Big diagnosies for the wrist down * Wrist sprain * Tendinopathies * OA * RA * Carpal Tunnel Syndrome * Post OP: Flexor tendon repair / Fracture

Question 91

Question 92