Preventing and Treating Stiffness Flashcards
cycle of nonuse
edema - immobilization - joint stiffness/tissue adherence
evaluation of stiffness (10)
- Why is the stiffness occurring?
- Is it due to trauma?
- Is it due to systemic conditions (RA or scleroderma)?
- Is it CNS?
- Is is a peripheral nerve issue?
- Is it a neuromuscular junction problem (myasthenia gravis)?
- Observe the movement
- Are there signs of triggering?
- Inspect scars
- ROM
PIP stiffness (3)
- extrinsic finger extensor tightness
- intrinsic finger tightness
- capsule tightness
DIP stiffness (2)
- ORL tightness
2. capsule tightness
extrinsic finger extensor tightness (PIP)
MP flexion lessens available passive PIP flexion
intrinsic finger tightness (PIP)
MP extension lessens passive PIP flexion
capsule tightness (PIP/DIP)
position of other joints doesn’t influence tightness
ORL tightness (DIP)
oblique retinacular ligament
PIP extension limits passive DIP flexion
wrist stiffness (4)
- extrinsic finger flexor tightness
- extrinsic finger extensor tightness
- capsular tightness
- muscular tightness
extrinsic finger flexor tightness (wrist)
passive wrist extension that is not impaired with finger flexion, but is impaired when adding finger extension
extrinsic finger extensor tightness (wrist)
passive wrist flexion that is not impaired with fingers in extension but is impaired when adding finger flexion
capsule tightness (wrist)
passive wrist movement that is impaired but not impacted by the posture of the digits
muscular and capsular tightness (wrist)
passive wrist flexion less than the unaffected side regardless of finger or elbow posturing and further impaired by finger or elbow posturing in extension or flexion
differential gliding
???
alternative reasons for stiffness (2)
- edema
2. neurological tone (spasticity/flaccidity)
soft tissue mechanics
the therapist’s ability to stretch or prevent tightness relies heavily upon the relationship between stress and strain
stress
the amount of force per unit area (pressure) applied to soft tissue
strain
a result of stress and is expressed mathematically as the change in length of soft tissue/original length x 100
TERT
“total end range time”
the amount of time a contracted joint is placed at its maximal length
*longer TERT = better result
LLLD
“low load, long duration”
combined low stress, long TERT
best practice when attempting to resolve soft tissue contracture because it promotes reorganization of collagen fibers within their elastic range without undue strain
Tips: early active mobilization
do whenever possible
helps with edema-disuse-stiffness cycle
*if contraindicated work distal and proximal
Tips: most difficult ROM to get back (5)
- MP flexion
- PIP extension
- wrist extension
- elbow extension
- supination
Tips: using blocks
use isolation to effect the prime mover on the target joint
Tips: when to use orthoses
use when stiffness is present and use to prevent stiffness
Tips: Modified Week’s Test
measure, heat, ROM, re-measure
- if gain is 10-20: serial-static or dynamic
- if gain is less than 10: static-progressive
Tips: duration of orthosis
depends on type of stiffness
- PIP ext contracture responds 12 weeks, 6 hours TERT
- PIP flex contracture responds 17 weeks, 11 hours TERT
frequency of assessing outcomes
ideally weekly goniometric assessments of the targeted area
Functional AROM - MP flexion (2-5)
61 deg
Functional AROM - PIP flexion (2-5)
60 deg
Functional AROM - DIP flexion (2-5)
39 deg
Functional AROM - MP flexion (1st)
21 deg
Functional AROM - IP flexion (1st)
18 deg
Functional AROM - wrist flexion
40 deg
Functional AROM - wrist extension
0 deg
Functional AROM - ulnar deviation
40 deg
Functional AROM - radial deviation
17 deg
Functional AROM - supination
60 deg
Functional AROM - pronation
40 deg
Functional AROM - elbow flexion
130 deg
Functional AROM - elbow extension
-30 deg
what to do if progress is slow-going
when improvements in joint mobility are not accomplished after 2+ weeks, it may be necessary to re-evaluate you intervention plan
*last resort, refer back to physician
operative interventions for stiffness (6)
- capsulectomy
- tenotomy
- tenolysis
- surgical decompression of sheaths or pulleys
- surgical release and skin grafting
- palmar fasciotomy
capsulectomy
for capsular contracture that does not respond to conservative measures
*early hand rehab/mobilization
tenotomy
to release long standing musculotendinous tightness by “lengthening” the tendon through the surgical division of a tendon
tenolysis
the surgical removal of scar tissue impacting slide of a tendon
- pre-op therapy important for PROM
- early post-op therapy recommended
surgical decompression of tendon sheaths or pulleys
when stenosing tenosynovitis is the culprit of joint restriction
surgical release and skin grafting
when cutaneous scarring is impeding joint movement
palmar fasciotomy
may be used when diseased palmar fascia is restricting digital extension
therapeutic contracture
in some cases remediating stiffness is contraindicated
- joint fusion
- C6 tetraplegia - tenodesis requisite for hand function and requires shortening of long finger flexors and extensors to occur
