Management of wrist and hand disorders

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Management of wrist and hand disorders







Introduction


The bio-psychosocial role of the hand is greater than that of any other part of the body. Hofer (2009) has long recognized the role of the tactile kinaesthetic system (touch or feeling) in the development of mankind. The hand and the brain act as a functional unit. The hand occupies a central place and is highly represented within the sensory homunculus. The hand within the sensory homunculus plays an important role in maintaining internal homeostasis and balance relative to the socioemotional environment and functioning.


The development of mankind has been characterized by an interaction between man, as an individual, and his environment and an unlimited range of activities. The hand tells us about centuries of evolving sensations and functional applications of many different kinds.


Several professions are totally dependent on perfect function of the hand, including the requirement for great adaptability which, along with a great capacity for differentiation of a vast range of functions, is a development acquired over many years. All those qualities are found not only among artists (musicians, jewellers, etc.), but also in a range of professions including carpenters, watchmakers and surgeons. The hand is more than a tool – it is a means of expression and non-verbal communication. It is a means of being able to carry out work, which, in effect, represents the essence of life and which defines a person’s existence.


Manual therapists, too, are clearly a professional group whereby if they experience a small loss of function of the hand, there will be major consequences in terms of participation (job and hobbies) and quality of life (feeling of fulfilment). The effect of the smallest derangement or disease on functioning and disability is crucial. The International Classification of Functioning, Disability and Health (ICF) ( WHO 2001) provides an ideal framework for identifying the impact of hand disorders on functioning, participation and social and environmental factors in an individual’s life.


The consequences for the manual therapist of working within such a framework of clinical practice is that it forces the clinician to consider not only the input pain mechanism of nociception and peripheral neurogenic pain, but also the associated and consequential processing of the individual’s experience and how this impacts on their ability to lead a fulfilling life.


Where processing of the pain experience is concerned, chronicity will be a major factor resulting in sensitization of the central nervous system (CNS). This, in turn, adds to the factors perpetuating and contributing to the incidence and prevalence of hand disorders in populations. Understanding pain mechanisms and how they affect the patient experiences and responses will, therefore, play an important role in the management of hand disorders.


Moseley et al. (2008) suggest that chronic pain may lead to reduced tactile acuity and that a clear relationship exists between pain intensity, tactile acuity and cortical reorganization. Their research shows that when pain resolves, tactile function improves and cortical organization normalizes. This demonstrates yet again the close relationship between hand and brain.


If, in relation to pain mechanisms, the primary problem is one of nociception causing a localized pain experience, the aim of manual therapists is to reduce, relieve and put an end to it. If chronic central sensitization is driving symptoms in the hand, the aim of management is to try to allow the patient to cope with it, to accept it and to perform adapted functional exercises including automobilization.


The hand needs to be examined very specifically and in detail with an attention to differentiation testing wherever possible. Hand function is complex and fine-tuned with a multitude of adaptive capabilities which, for example, have to be able to enhance subtle and profound feelings for playing a melody on a piano, allow a capacity to build and move the same piano and even enable the chopping down of the tree which will eventually become the said piano.


The examiner will have to show a lot of creativity, flexibility of mind and imagination to reproduce the multitude of possible functions and they must have a deep commitment to review and analysing the great subtlety, fineness and vigour of hand function.


The complex and detailed role of the wrist and hand in both prehensile and non-prehensile functions and the fineness of this organ’s sensory and motor representation warrant attention to detail in the clinical study of the relationships between the joints, muscles and nerves of the wrist and hand.


Mobilization/manipulation has a place in the management of neuromusculoskeletal disorders of the wrist and hand alongside many other rehabilitation strategies. This chapter offers the clinician an opportunity to examine and physically treat the articular impairments of wrist and hand disorders and, at the same time, to recognize the influence of the neural, musculotendinous, fascial and vascular systems upon such disorders. The aim of the manipulative physiotherapist, therefore, is to contribute to the physical, psychosocial and socioeconomic rehabilitation of the patient with wrist and hand impairments.


To achieve the desired effects of intervention, the examination of the wrist and hand for the manipulative physiotherapist will have to take into consideration the points outlined below.




Finding consistency in functional demonstrations


There are an infinite variety of positions in which the wrist and hand can function. This makes consistency in the repeated measurement of functional demonstrations challenging. It is therefore essential to use functional demonstrations to identify the movement directions which make up the impairment. In this way a relevant and detailed model of establishing articular movement impairment can be developed.


For example, a patient may complain of wrist pain upon opening a jam jar. On analysis of the functional movement concerned it can be established that pronation of the wrist and hand is the painful movement. Through differentiation of this painful movement, it will be possible to establish whether the inferior radioulnar joint, radiocarpal, intercarpal or metacarpophalangeal joint is the source of the pain. If the radiocarpal joint is the source, further differentiation will establish whether it is movement between the scaphoid, lunate or triquetral bones and the radius or radius fibrocartilaginous disc which is painful. In this way a specifically directed mobilization technique is more likely to influence the joint signs. But it could also be observed that this local pain on the wrist in pronation is increased when the elbow is in extension. Further differentiation using the scapular/thoracic depression or contra-lateral cervical lateral flexion will help to find a peripheral neurogenic participation and will determine if treatment should be applied in the hand or in the cervical spine or whether the therapist should look for other adverse mechanical interface on the course of the nerve.


Another example could be a patient’s activity limitations of non-prehensile function, being unable to fully extend the hand (e.g. when waving). Pain and stiffness across the back of the wrist would suggest a local impairment. Firstly, differentiation would allow the therapist to differentiate between muscular or tendinous, neural and articular origins of the symptoms. Secondly, differentiation would also indicate which further tests are required to determine whether the origin is radiocarpal, intercarpal or carpometacarpal.



Defining the dominant pain mechanism


Reflecting the history of manual therapy in the last decades, the last two points concerning the origin of the symptoms have been purely tissue related. With hand disorders, it is postulated epidemiologically that pain is the number one reason for consulting a health care practitioner. However, as outlined in the introduction to this chapter, it is evident that pain perception should be considered within a more bio-psychosocial context. An increased mechanosensitivity, due to mechanical and/or chemical processes, may also influence joints and soft tissue pathologies of the hand.


The clinical reasoning process should integrate the different pain mechanisms, which are always present in different combinations and are constantly evolving, dynamically changing and switching in importance:


A painful and debilitating musculoskeletal condition is mostly a combination of three mechanisms: input, output and processing.



Input




1. Nociceptive pain: recent onset symptoms which correspond to a traumatic or injurious event, normally accompanied by the cardinal symptoms of inflammation, such as swelling, heat, redness and signs of sympathetic activity (e.g. sweating), which brings us immediately to the next category – output (see below).


2. Peripheral neurogenic mechanisms: not only paraesthesia or atrophy suggest a pathological process in the nerve, but also factors of a vascular, mechanical (stretching, compression) or systemic nature. All will increase the chemical or mechanical sensitivity of the nerve and implicate it as the source of pain or movement dysfunction. The hypothesis of double crush, as described by Upton & McComas (1973) (of 115 patients with carpal tunnel syndrome, 81 had a cervical origin), is particularly relevant for the upper extremity with canal syndrome or entrapment neuropathy. Mumenthaler (1979) found that of 4958 carpal tunnel operations 9% of patients had a painful shoulder and Narakas (1990) found that of 1916 carpal tunnel operations 26% had a painful shoulder.





Deciding the normal range or ideal range for wrist and hand movement ( Fig. 6.1)


Kapandji (1982) has suggested that the following ranges of movement are considered as normal average values for the wrist and hand:




The carpal bones can be described in terms of their rows for examination, differentiation and localization of treatment ( Fig. 6.2): the proximal row of carpal bones consists of the scaphoid, lunate, triquetrum and pisiform; the distal row of carpal bones consists of the trapezium, trapezoid, capitate and hamate. These rows therefore are components of the radiocarpal, midcarpal and carpometacarpal joints.



The carpal bones can also be described in terms of pillars ( Fig. 6.3): the lateral pillar consists of the scaphoid and trapezium or trapezoid, the central pillar consists of the lunate and capitate and the medial pillar consists of the triquetrum, pisiform and hamate. The value of this is that, ideally, the mobility within the central pillar should be greater than the medial and lateral pillars when individual carpal mobility is tested ( Kapandji 1982).



The intercarpal joints and intermetacarpal joints also exhibit a degree of hollowing and flattening which, in this text, is described as horizontal flexion and extension.


The metacarpophalangeal (MCP) joints can flex on average to 90° (similar to the interphalangeal (IP) joints) and can be passively rotated by 60°. The sequence for examination and treatment of the MCP and IP joints is described in detail on pages 363– 369.


A good working knowledge of surface anatomy ( Hoppenfeld 1976, Kesson & Atkins 1998) will enhance the clinician’s accuracy in localization and application of forces during movement analysis of the wrist and hand.



Subjective examination (C/O)


Procedural and interactive reasoning allow the therapist to build hypotheses to identify the problem. Information from the subjective examination of the patient with wrist and hand symptoms will help to establish the kind of disorder being presented, the source and dominating pain mechanism of the patient’s symptoms and the degree to which daily activity is limited by the severity, irritability and nature of the disorder. Information about the history of the symptoms will help to establish the nature of the onset, the directions and degree of injuring forces and the present stage of the disorder’s natural history. Special questions will establish any precautions and contraindications to treatment and whether there are any intrinsic or extrinsic predisposing factors or barriers to an ideal rate of recovery.




Areas of symptoms


As discussed earlier in this chapter, a large or ‘real size’ wrist and hand chart should be used so that the precise area of the patient’s symptoms can be represented more accurately ( Fig. 6.4). In this way the area which the patient describes as being painful is often diagnostic in itself. A band of pain across the wrist is common in radiocarpal joint disorders; inferior radioulnar joint pain is usually felt locally and deep. Any referred pain is usually felt to spread from the joint towards the elbow. Pain arising from any of the intercarpal joints is always felt locally, although it may radiate out from a central point of the disordered joint. Pain from the intermetacarpal joints will be felt locally at their bases and over the joint. Pain and swelling over the abductor pollicis longus or extensor pollicis brevis tendons indicates a diagnosis of de Quervain’s tenosynovitis. Paraesthesia of the thumb, index, ring and half the middle finger is a common presentation in carpal tunnel syndrome ( Figs 6.5 and 6.6).





A large diffusion of symptoms in the whole hand, occasionally accompanied by heaviness and tiredness of the whole hand, forearm, or whole arm, may lead to suspect a TOS (thoracic outlet syndrome) or a T4 syndrome ( Maitland et al. 2001, Jeangros, 2011) with the output as the dominant pain mechanism.



Behaviour of symptoms


If activities increasing the symptoms are numerous and easy to find, it is helpful to establish the common characteristics of the mechanical disorders, which also confirm a dominant input mechanism of pain and support our hypotheses about the treatment and prognosis.


If the wrist and hand are the source of the patient’s symptoms, hand functions will be compromised or restricted by pain, stiffness, protective spasm or other associated signs such as weakness, pain inhibition or loss of feeling.


Prehensile functions which may be compromised include forearm twisting (pronation, supination), wrist flexion, extension, ulnar and radial deviation, the function of opposition and manipulative or gripping activities; non-prehensile functions which may be compromised include pushing, pulling or weight-bearing activities.


The stage of the disorder and the severity and irritability of the symptoms will determine the degree of impairment experienced by the patient. For example, a patient who has a one-week history of a badly sprained wrist will use the hand less than someone with stiffness 12 weeks after a Colles’ fracture.


As already seen in the introduction, the loss of hand function may also impact on the cognitive and emotional dimensions of the patient’s experience of impairment. As an important sensory and communication organ, the impaired hand will affect many aspects of the patient’s daily life.


Night-time is usually a time of relief from mechanical nociceptive symptoms. However, patients with peripheral neurogenic mechanisms often suffer more from their symptoms at night. With osteoarthritic or degenerative disorders, morning stiffness would be expected, as would morning soreness with inflammatory components.



History (present and past)


Information from the recent and past history of the patient symptoms will provide valuable evidence about the sensitized status of the central nervous system on the one hand, and the bio-psychosocial impact of this sensitization on the other. Such information helps to support the clinical diagnosis and prognosis


Often, the history of the patient’s symptoms will correspond to the different recognizable patterns as described by Corrigan & Maitland (1983):





Planning the physical examination (P/E)


When planning the physical examination, the therapist must first determine which structure should be examined on day one. With a hypothesis of peripheral neurogenic mechanisms, the cervical spine may be included in the examination and treatment on day one. In such cases, it is important to examine the neurological conduction status of the limb (sensation, reflexes and motor power), something which is not always necessary as part of the physical examination of the wrist and hand. Before examining the cervical spine, it is useful to see an active movement of the hand or to look at a functional demonstration involving the hand. The reassessment of the hand movement reproducing the symptoms, or being a comparable sign, could then show the influence of the treatment of the spine on the hand.


If the hypothesis is suggestive of a nociceptive origin of pain, the focus will be directed onto the structure that is most affected, local or remote: joint, tendons, muscles or ligaments.


With a hypothesis of output pain mechanisms, it may be necessary to decide to treat the thoracic spine at the first treatment, either by mobilization or manipulation with the aim of calming down the sensitivity of the sympathetic trunk. This treatment could also be performed in a sympathetic slump position ( Jeangros 2011).


A decision should be made whether to respect irritability or whether it will be difficult to find the symptoms and therefore if the hand should be treated gently or with vigour. In some instances, such as in cases of rheumatoid arthritis, more forceful mobilization is contraindicated. In such cases management should be directed towards ergonomic issues, exercise and automobilization and stabilization strategies.



Physical examination (P/E) (Boxes 6.1–6.9)



Observation






image Box 6.3


Physical examination of the wrist joint


The routine examination of this joint must include the inferior radioulnar joint and intercarpal joints.



Observation



Brief appraisal


Active movements (move to pain or move to limit)


    Routinely



Isometric tests


Other structures in ‘plan’


    As applicable



Passive movements


    Physiological movements


    Routinely



Accessory movements


Routinely: image image, image image, image ceph and caud


As applicable




Reproduced by kind permission from Maitland (1992).



image Box 6.4


Physical examination of the intercarpal joints


The routine examination of these joints must also include examination of the wrist joint, carpometacarpal (C/MC) joints and pisiform movements.**



Observation



Brief appraisal


Active movements (move to pain or move to limit)


Isometric tests


Other structures in ‘plan’



Passive movements


    Physiological movements


    Routinely



Note range, pain, resistance, spasm and behaviour


Accessory movements


Routinely




Reproduced by kind permission from Maitland (1992).






image Box 6.8


Physical examination of the carpometacarpal joint of thumb


The routine examination of this joint must include the adjacent intercarpal joints and wrist.



Observation



Brief appraisal


Active movements (move to pain or move to limit)



Isometric tests


Other structures in ‘plan’



Passive movements


    Physiological movements


    Routinely



Note range, pain, resistance, spasm and behaviour


Accessory movements


Routinely



Note range, pain, resistance, spasm and behaviour


As applicable




Reproduced by kind permission from Maitland (1992).





Functional demonstration




• Let the patient demonstrate the activity reproducing their pain or producing a degree of discomfort which is considered as abnormal, limited or impairing.


• Look for alignment faults with grip, including the ability to fully oppose the thumb and the range of finger flexion.


• Look for gripping with the wrist in flexion or gripping with the wrist deviating (usually radial because of overpull of extensor carpi radialis brevis).


• Analyze and record the ranges of movement, the symptom response and the quality of movement.


• Pain increased by weight-bearing activities could confirm a more intra-articular participation.


• For pain arising from the inferior radioulnar joint the functional demonstration may involve the action of turning on a tap. The point at which the pain comes on with supination is determined and in this position the ulna can be moved further into the range to determine any increase in pain.




If necessary tests



Isometric tests (grip strength test)




• Indication for using these ‘if necessary tests’ would be, on the one hand, to recognize the typical pattern (for example, pain after repeated movement and stiffness after rest) or localization of a muscle or tendon (knowing that most of the strains occur at the musculotendinous junction).


• On the other hand, as it is nearly impossible to mobilize a joint of the wrist without having the fingers of the therapist affecting a tendon, it seems important to differentiate first if the pain is coming from a tendon or another structure.


• Other indications for using isometric tests would be a diagnosis of de Quervain’s disease, Dupuytren’s contracture, a past history of overuse (secretary with mouse), a recent overstretching, a traumatic event or a muscle strain confirmed by an MRI or not.


• Finkelstein’s test is, for example, used when considering dysfunction of the abductor pollicis longus and the extensor pollicis brevis suggesting a de Quervain tendinopathy: flexion (and adduction) of the thumb combined with a strong ulnar deviation. This test is very similar to the neurodynamic test ULNT 2b ( Butler 1991) for testing the radial nerve, and will need further differentiation with elbow extension, scapular elevation or lateral flexion of the cervical spine. Symptoms are seldom related to a single structure.


• Most of the muscles and tendons in the hand cross more than one or two joints and perform eccentric contraction. This means the hand contains a greater proportion of mobilizing rather than stabilizing muscles.


• Isometric tests are first performed in neutral and then in the functional position. The localization of symptoms and direct palpation (or deep friction) can help to differentiate beween muscles and tendons.


• Tendons are tested by full stretching, maximal elongation. Further differentiation between the tendon and the sheath of the tendon (tenosynovitis) can be made by compressing the tendon at the painful spot and letting the tendon move through range.


• The grip strength test can be used for re-evaluation, but is not pathognomonic.






Differentiation of movements reproducing pain




• Pronation and supination: differentiate between inferior radioulnar, radiocarpal, midcarpal and carpometacarpal (Figs 6.10–6.15).







Aug 28, 2016 | Posted by in RHEUMATOLOGY | Comments Off on Management of wrist and hand disorders
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