Hand Therapy Concepts and Treatment Techniques
I wish to thank Sandra M. Artzberger, MS, OTR, CHT, CLT, for reviewing this chapter and for providing me the impetus to explore chip bags in conjunction with upper extremity orthotics; Patricia Zarbock Fantauzzo, COTA/L, for her creative ideas for using chip bags on clients with upper extremity problems; and Joel Moorhead, MD, MPH, John L. Evarts, BS, Lisa Deshaies OTR, CHT, and Sharon Flinn, PhD, OTR/L, CHT, CVE, for reading and critiquing this chapter.
Hands are visible, expressive, and vulnerable. When clients use their hands to get dressed, eat, touch, gesture, or communicate, they are performing exquisite and complex movements. Limitations of motion or even a small scar can affect a person’s life in profound ways.1 When we touch our clients’ hands, we touch their lives. Although it is very important to be knowledgeable about the details of hand anatomy and to be structure specific in our treatment, it is equally important not to lose sight of the whole person whose extremity we are treating. We must continuously encourage clients to tell us about themselves and their needs so that their therapy can be relevant and successful. While getting to know the person we are treating, we can explain how our interventions and the client’s home programs will be helpful. As a rule, I find that if I listen well, clients frequently tell me in lay terms or even show me exactly what motion or function is missing. The challenge is to identify and treat clients’ specific tissues effectively while not losing sight of them as people.
The anatomy of the hand is complex. Many structures are multiarticulate (that is, they cross multiple joints), and little room is available for scar tissue or edema to develop without affecting function. Injury in one area of the hand can result in stiffness in other, uninjured parts. A good demonstration of this is the quadriga effect, which illustrates the interconnectedness of the digits. If you passively hold your ring finger extended with your other hand and then try to make a fist, you will notice how limited the whole hand can feel when just one finger is held stiff. In this example, the flexor digitorum profundus (FDP) tendons to multiple digits have a shared muscle belly. Restricting movement at one finger restricts the other fingers when they try to flex. This example reminds us that clients can be limited in motion in areas not originally injured. Therefore the therapist needs to evaluate beyond the isolated area of injury when treating clients with hand problems.
To be competent in hand therapy, therapists must be able to do more than just note decreased range of motion (ROM). They must be able to figure out what structures are restricted and how these restrictions affect function (for example, the client has decreased digital flexion due to FDP adherence, preventing him from holding the steering wheel); they then must be able to target treatment to those particular tissues. These three elements are part of all the decisions we make as hand therapists. As treatment continues, re-evaluation reveals new findings with different tissues to target, and appropriate modifications and upgrades are made. This chapter addresses treatment concepts and techniques of hand therapy and concludes with some provocative thoughts to stimulate clinical reasoning.
Tissues heal in predictable phases. However, the length of these phases varies depending on client variables, such as age and health. The three phases of healing are inflammation, fibroplasia, and maturation (also called remodeling). In the inflammation phase, vasoconstriction occurs, followed by vasodilation, with migration of white blood cells to promote phagocytosis in preparation for further healing. In this stage, which lasts a few days, immobilization often is advised, depending on the specifics of the diagnosis.2 If wound contamination or delayed healing is a factor, this phase can last longer.3
The fibroplasia phase begins about 4 days after injury and lasts 2 to 6 weeks. In this phase, fibroblasts begin the formation of scar tissue. The fibroblasts lay down new collagen, on which capillary buds grow, leading to a gradual increase in the tissue’s tensile strength. In this stage, active range of motion (AROM) and orthotics typically are used to promote balance in the hand and to protect the healing structures.2
The timeline for the maturation (remodeling) phase varies; this phase may even last years. In the maturation phase, the tissue’s architecture changes, reflecting improved organization of the collagen fibers and a further increase in tensile strength. The tissue is more responsive (that is, reorganizes better) if appropriate therapy is started sooner rather than later. In this stage, gentle resistive exercises may be appropriate, and the client should be monitored for any inflammatory responses (also known as a flare response). Dynamic or static orthoses may also be helpful.2
Predictable deforming forces act on an injured upper extremity (UE). Edema (swelling) routinely occurs after injury, creating tension on the tissues. The resulting predictable deformity posture is one of wrist flexion, metacarpophalangeal (MP) hyperextension, proximal interphalangeal (PIP) and distal interphalangeal (DIP) flexion, and thumb adduction.4 This deformity position occurs as a result of tension on the extrinsic muscles caused by dorsal edema.
Use of the antideformity (intrinsic-plus) position is recommended after injury unless it is contraindicated by the diagnosis (for example, it is not used after flexor tendon repair). The antideformity position consists of the wrist in neutral position or extension, the MPs in flexion, the IPs in extension (IPs refers to the PIP and DIP joints collectively), and the thumb in abduction with opposition (Fig. 1-1). The antideformity position maintains length in the collateral ligaments, which are vulnerable to shortening, and counteracts deforming forces.
Joint tightness is confirmed if the passive range of motion (PROM) of a joint does not change despite repositioning of proximal or distal joints. Musculotendinous tightness is confirmed if the PROM of a joint changes with repositioning of adjacent joints that are crossed by that particular muscle-tendon (musculotendinous) unit.5
Joint tightness and musculotendinous tightness can be treated with serial casting, dynamic orthoses static progressive orthoses or serial static orthoses (see Chapter 7 and also the “Orthotics” section later in this chapter). With joint tightness, splinting can focus on the stiff joint, and less consideration is needed for the position of proximal or distal joints. With musculotendinous tightness, because the tightness occurs in a structure that crosses multiple joints, the orthotic must carefully control the position of proximal (and possibly distal) joints to remodel tightness effectively along that musculotendinous unit.
The client in Fig. 1-2, A, had an infected PIP joint in the index finger. He was treated with hospitalization, intravenous administration of antibiotics, and joint debridement. He arrived for therapy 2 weeks later than his physician had ordered; he had no orthotic, significant edema, and a severe flexion contracture of the PIP joint. Because the stiffness was localized to the PIP joint, he needed only a digit-based extension orthosis for that joint. Fig. 1-2, B, shows his progress after 2 weeks of edema control and serial static digit-based orthoses.
Musculotendinous tightness can be a cause of joint tightness. Clients with tightness of the extrinsic flexors (that is, lacking passive composite digital extension with the wrist extended) are at risk of developing IP flexion contractures. Instruct these clients to passively place the MP in flexion and then to gently, passively extend the IPs to maintain PIP and DIP joint motion. In these cases, although you should consider night orthoses in composite extension to lengthen the extrinsic flexors, the better course may be to splint in a modified intrinsic-plus position with the MPs flexed as needed to support the IPs in full extension. This helps prevent IP flexion contractures.
Intrinsic muscles are the small muscles in the hand. Extrinsic muscles are longer musculotendinous units that originate proximal to the hand. Intrinsic tightness and extrinsic extensor tightness are tested by putting these muscles on stretch. This is accomplished by comparing the PROM of digital PIP and DIP flexion when the MP joint is passively extended and then passively flexed. With interosseous muscle tightness, passive PIP and DIP flexion is limited when the MP joint is passively extended or hyperextended (Fig. 1-3). With extrinsic extensor tightness, PIP and DIP flexion is limited when the MP joint is passively flexed (Fig. 1-4).5
To treat intrinsic tightness, perform PIP and DIP flexion with MP hyperextension. Functional orthotics are very helpful for isolating specific exercise to restore length to the intrinsics while performing daily activities (see the “Orthotics” section). To treat extrinsic extensor tightness, promote composite motions (that is, combined flexion motions of the wrist, MPs and IPs) with orthotics, gentle stretch, and exercise. Instruct the client that performing these exercises with the wrist in a variety of positions is helpful.
Extrinsic tightness can involve the flexors or the extensors. To test for tightness, put the structure on stretch by positioning the proximal joint crossed by that structure. With extrinsic extensor tightness, passive composite digital flexion is more limited with the wrist flexed than with the wrist extended. With extrinsic flexor tightness, passive composite digital extension is more limited with the wrist extended than with the wrist flexed.5
A client with a PIP extensor lag is unable to actively extend the PIP joint as far as is possible passively (which may not necessarily be full extension). Lags may be caused by adhesions, disruption of the musculotendinous unit, or weakness.
Joint contractures can be caused by collateral ligament tightness, adhesions, or a mechanical block. A joint flexion contracture is characterized by a stiff joint in a flexed position that lacks active and passive extension. A person with a joint flexion contracture whose passive extension improves may progress from having a flexion contracture to having an extensor lag. In your treatment communications and documentation, it is important to identify such changes, to use these terms correctly, and to be joint specific and motion specific. For example, you should note, “The client has full PIP passive extension but demonstrates a 30-degree PIP extensor lag.”
When a lag is present (PROM exceeds AROM), treatment should focus on promoting active movement. Blocking exercises (Fig. 1-5), differential tendon gliding exercises (see Fig. 1-18), place and hold exercises (see Fig. 1-19), and dynamic or static functional orthotics can be helpful (Fig. 1-6). If a contracture is present, promote both PROM and AROM with the same exercises and with corrective orthoses, which may be the dynamic, static progressive, serial static, or casting type.
A joint with a soft end-feel has a spongy quality at the end-range. This is a favorable quality that indicates a potential for remodeling. Orthoses for soft end-feel may be the static type or the low-load, long duration type (see the “Orthotic” section and Chapter 7).
A joint with a hard end-feel has an unyielding quality at end-range. This is a stiffer joint, and correcting it may require serial casting or static progressive orthoses with longer periods of splint wear.2 Documenting the end-feel and explaining the implications of your findings to the client are very important.
Not all pain is the same physiologically or symptomatically. Nociceptive pain is caused by structural dysfunction, such as an arthritic wrist. Providing an orthotic to support the involved structures reduces the pain. Neuropathic pain is caused by some form of peripheral nerve dysfunction and is typically a sensory pain that is difficult for patients to describe in words. It may be burning or electrical. Providing sensory protection and minimizing peripheral nerve irritation reduces this type of pain.
Hand therapy patients may have nociceptive pain or neuropathic pain or a combination of the two. It is important to address this with patients so that your treatment targets their unique pain quality and can be most successful.
Precaution. Pain with therapy is a signal that injury is occurring. Irreversible damage can result when clients or their families or, worse, therapists injure tissue by using painful force and PROM. Avoid pain in your hand therapy treatment. Being overzealous and ignoring objective signs of tissue intolerance is inexcusable.
Teaching clients and their families that painful therapy is counterproductive can be a challenge. Often clients come to therapy with a “no pain, no gain” mentality. To make matters worse, this philosophy frequently is reinforced by their physicians and friends. Therapists have a duty to explain to their clients that imposing, prolonging, or aggravating pain slows the healing process, fosters more scarring and stiffness, and delays or eliminates opportunities to upgrade therapy.
Precaution. PROM can injure swollen and inflamed joints and tissues. Colditz5 cautions that the only joints for which manual PROM is safe are joints with a soft end-feel. Nevertheless, clients may request more aggressive therapy. They may even be passively stressing their swollen, stiff hands at home. It is very important that the therapist inquire about this and put a stop to it. Explain to your client how injurious and counterproductive it is, emphasizing that delicate hand tissues are all too easily injured (see Chapter 12).
Precaution. PROM can trigger inflammatory responses, causing additional scar production, pain, and stiffness. PROM used inappropriately or painfully can incite complex regional pain syndrome (CRPS), which is also known as reflex sympathetic dystrophy (RSD).
Dyscoordinate co-contraction is a poor quality of movement that can result from co-contraction of antagonist muscles. Clients may demonstrate dyscoordinate co-contraction when they use excessive effort with exercise or when they fear pain with exercise or PROM, or it may be habitual. The resulting motion looks unpleasant and awkward. For example, you may feel the extensors contract as the client tries to activate the flexors. It is important not to ignore dyscoordinate co-contraction. Instead, teach the client pain-free, smooth movements that feel pleasant to perform. Replace isolated exercises with purposeful or functional activities and try proximal oscillations (small, gentle, rhythmic motions) to facilitate a more effective quality of movement. Biofeedback or electrical stimulation may also be helpful. Imagery offers additional possibilities (for example, ask your client to pretend to move the extremity through gelatin or water).7 Do not bark at the client to “Relax!” Instead, be gentle with your voice and your verbal cues.
Superficial heating agents can have beneficial effects on analgesic, vascular, metabolic, and connective tissue responses. Analgesic effects are seen in diminished pain and elevated pain tolerance. Vascular effects are evidenced by reduced muscle spasms and improved pain relief. Metabolic effects are related to an increased flow of blood and oxygen to the tissues with improved provision of nutrients and removal of byproducts associated with inflammation. Connective tissue effects include reduced stiffness with improved extensibility of tissues.8
Many clients feel that heat helps prepare the tissue for exercise and activity. The safest way to warm the tissues of hand therapy clients is aerobic exercise, unless this is contraindicated for medical reasons. Tai chi, for example, provides multijoint ROM, relaxation, and cardiac effects.
Application of external heat (for example, hot packs) is a popular method in many clinics. Although the use of heat is fine if it is not contraindicated, be mindful that heat increases edema, which acts like glue, and this may contribute to stiffness. Heat can degrade collagen and may contribute to microscopic tears in soft tissue.9 For these reasons, be very gentle and cautious if you perform PROM after heat application. Monitor the situation to make sure that the overall benefits of heat outweigh any possible negative responses. Measuring edema is a good way to objectify these responses.
Cold therapy (also called cryotherapy) traditionally has been used to relieve pain and to reduce inflammation and edema after injury (and sometimes after overly aggressive therapy). Cryotherapy typically is used after acute injury to reduce bleeding by means of vasoconstriction. Cold therapy reduces postinjury edema and inflammation and raises the pain threshold. However, remember: cold therapy can be harmful to tissues; be cautious with this modality.
Precaution. Do not use cryotherapy on clients with nerve injury or repair, sensory impairment, peripheral vascular disease, Raynaud’s phenomenon, lupus, leukemia, multiple myeloma, neuropathy, other rheumatic disease, or cold intolerance.
Other modalities used in hand therapy include therapeutic ultrasound, electrical stimulation, and iontophoresis (provision of an agent such as an anti-inflammatory medication into tissue through use of low-voltage direct current). Therapists should study these topics further. However, they also must abide by their practice acts and the regulations of their state licensing agencies regarding the use of modalities. Never use a modality for which you cannot demonstrate proper education and training.