Therapeutic Exercise II: The Wrist and Hand - PDF

Therapeutic Exercise II PTA 1010 The Wrist and Hand ©Stanbridge University 2022 1  Road Map By the end of the presentation the students should be able to perform the following: Identify important aspects of wrist and hand structure and function...

Therapeutic Exercise II PTA 1010 The Wrist and Hand ©Stanbridge University 2022 1  Road Map By the end of the presentation the students should be able to perform the following: Identify important aspects of wrist and hand structure and function Describe structural and functional impairments that occur based on types of soft tissue lesions Implement therapeutic interventions to treat impairments and functional limitations in the wrist and hand that are related to stages of recovery after tissue injury Demonstrate exercise progression to develop and improve ROM, muscle performance, and functional use for non operative and post-operative conditions of the wrist and hand ©Stanbridge University 2022 2  Outline Structure & Gripping Joint Hypomobility Arthrokinematics Distal Radius Repetitive Trauma Tendon Rupture- Fracture and Sprains RA Carpal tunnel Techniques for syndrome & Ulnar Musculo- Nerve tendinous Mobility Compression ©Stanbridge University 2022 3  Structure and Function of the Wrist and Hand Joints of the wrist and hand Hand function Major nerves subject to pressure/trauma at the wrist and hand ©Stanbridge University 2022 4  Wrist and Hand - Function Wrist: final link of joints that position the hand for functional activities Hand: tool to control and manipulate our environment and express ideas and talents ©Stanbridge University 2022 5  Hand- Bones 5 Metacarpals 14 phalanges Scaphoid Lunate Triquetrum Pisiform Trapezium Trapezoid Capitate Hamate ©Stanbridge University 2022 6  Joints of the Wrist Osteokinematic motions: flexion, extension, radial and ulnar deviation Ligaments : – ulnar and radial collateral ligaments – dorsal and volar(palmar) radio-carpal ligaments – Ulno-carpal ligaments – intercarpal ligaments Distal RU joint: not considered part of the wrist joint but impairments here affect the wrist and vice versa ©Stanbridge University 2022 7  Joints of the Wrist: Radiocarpal Joint Characteristics: distal radius, radioulnar disk, (and) proximal surface of the scaphoid, lunate, and triquetrum ©Stanbridge University 2022 8  Joints of the Wrist: Midcarpal Joints Characteristics: 2 rows of carpals Distal surfaces of scaphoid, lunate, and triquetrum articulate with proximal surfaces of the trapezium, trapezoid, capitate, and hamate www.wellnessadvocate.com ©Stanbridge University 2022 9  Joints of the Hand: Carpometacarpal (CMC) Joints www.classes.kumc.edu ©Stanbridge University 2022 10  Joints of the Hand: Carpometacarpal (CMC) Joints CMC Joint of the Thumb: Saddle joint www.eorthopod.com ©Stanbridge University 2022 11 Muscles of the Wrist and Hand www.boneandspine.com Complex Intrinsic Extrinsic function muscles Muscles of the hand ©Stanbridge University 2022 12  Muscles of the Wrist and Hand Length-Tension Relationships: Position of the wrist controls the length of the extrinsic muscles of the digits To maximize grip strength: Synchronous wrist extension with finger flexion lengthens the extrinsic flexor tendons across the wrist maintaining favorable length tension of the muscles www.en.Wikipedia.com ©Stanbridge University 2022 13  Muscles of the Wrist and Hand Length- Tension Relationships: For strong finger and thumb extension: wrist flexor muscles either stabilize or flex the wrist so the EDC, EI, EDM, or EPL muscles can function more efficiently ©Stanbridge University 2022 14  Outline Structure & Gripping Joint Hypomobility Arthrokinematics Distal Radius Repetitive Trauma Tendon Rupture- Fracture and Sprains RA Carpal tunnel Techniques for syndrome & Ulnar Musculotendinous Nerve Mobility Compression ©Stanbridge University 2022 15  Important Hand Function Cupping/ arching hand: flexion of metacarpals and adduction of 5th MC improves grasp Flattening of hand: extension of the metacarpals release of objects Thumb CMC joint: allows opposition in prehension tasks Thumb MCP joint: reinforced by two sesamoid bones (volar surface) improves the leverage of the flexor pollicis brevis muscle ©Stanbridge University 2022 16  Gripping and Prehension Patterns Nature of the intended activity dictates the type of grip that is used ©Stanbridge University 2022 17  Gripping and Prehension Patterns Power grip: requires ulnar n. innervated muscles – Spherical – Cylinder – Hook grip (PIP flexion) Precision grip: median n. innervated muscles – Pad to pad – Tip to tip – Pad to side Combined grip: utilizes both- lateral prehension ©Stanbridge University 2022 18  Gripping and Prehension Patterns Power grip: Precision grip: ULNAR N. innervated muscles MEDIAN N. innervated muscles 2 extrinsic flexors of the Extrinsic muscles anterior forearm: Finger and wrist flexors FCU 2 medial FDP HILA muscles: LOAF muscles of the hand Hypothenar eminence 2 lateral lumbricals Interossei Opponens pollicis Lumbricals 1 &2 Abductor pollicis brevis Adductor Pollicis Flexor pollicis brevis ©Stanbridge University 2022 19  Gripping and Prehension Patterns Lateral prehension Newer name for this grip: intermediate Requires thumb adduction (from ulnar nerve- part power) Requires CMC medial rotation which mimics a precision grasp Requires some flexion of the IP joint of the thumb Requires stabilization from the remaining fingers and palm when increased force is needed Digits 1 &2: precision, digits 3-5: power supplementation Example: Using large force to open a door lock that was difficult needs power, whereas dipping a tea bag with the same position of the hand would not. ©Stanbridge University 2022 20  Outline Structure & Gripping Joint Hypomobility Arthrokinematics Distal Radius Repetitive Trauma Tendon Rupture- Fracture and Sprains RA Carpal tunnel Techniques for syndrome & Ulnar Musculotendinous Nerve Mobility Compression ©Stanbridge University 2022 21  Joint hypomobility Joints of the wrist and hand can be affected by arthritis Rheumatoid arthritis MCP, PIP of hands, wrists Osteoarthritis DIP, PIP, 1st CMC of hands Hypomobility can occur after immobilization (tendon repairs, fractures, etc.) ©Stanbridge University 2022 22  Review from TE I What are the major differences between RA and OA? ✓Onset ✓Extra vs intraarticular ✓Risk factors ✓Length of morning stiffness ✓Symmetry ©Stanbridge University 2022 23 ©Stanbridge University 2022 24  Joint Hypomobility- RA Acute Stage: pain, swelling, warmth, decreased mobility due to: Synovitis and tissue proliferation (MCP, PIP, wrists) Tenosynovitis and synovial proliferation Progressive weakness and muscle imbalance (extrinsic & intrinsic muscles) General systemic muscular fatigue ©Stanbridge University 2022 25  Joint Hypomobility- RA Advanced Stage: Joint capsule weakens Cartilage destruction Bone erosion Altered muscle tension balance leads to joint instability, subluxations, dislocations ©Stanbridge University 2022 26  Joint Hypomobility- RA Advanced Stage deformities: Ulnar subluxation of the carpal bones causes radial deviation of the wrist Ulnar drift of the fingers Swan neck deformity Boutonniere deformity Zig zag deformity of the thumb ©Stanbridge University 2022 27  Joint Hypomobility: Osteoarthritis Due to: Age Repetitive joint trauma Post-traumatic arthrosis from fracture or fracture dislocation www.quizlet.com ©Stanbridge University 2022 28  Joint Hypomobility: OA Acute Stage Impairments: Achiness, stiffness that decrease with movement Swelling, warmth, restricted and painful motion with stressful activities or trauma Thumb CMC: accessory hyper-mobility – Most ligaments are taut with thumb in abduction, ext and opposition Neumann et al, JOSPT, 2003 – Balance forces of muscles are needed for thumb pinch (adduction and flexion) ©Stanbridge University 2022 29  Joint Hypomobility: OA Advanced Stages: Initial capsular laxity, resulting in hypermobility and instability Progresses to contractures and limited motion Joints become enlarged, may subluxation (common at 1st CMC) General weakness: grip strength Poor endurance, pain with pinching & gripping www.orthobullets.com ©Stanbridge University 2022 30  Joint Hypomobility: Post Immobilization Post Immobilization Signs & Symptoms: Decreased ROM & joint play Firm end feels and pain with overpressure Tendon adhesions due to inflammation in the tendon or it’s sheath Decreased muscle performance: weakness, weak grip strength, decreased flexibility & endurance ©Stanbridge University 2022 31  Joint Hypomobility- General Management Acute Phase: Control Pain & Protect Joints: Patient education Pain Management Splinting 1st web space splint to stretch adductors and maintain CMC abduction (most congruence), Valdes et al, JHT, 2012 More effective in earlier stages of disease- Day et al., J Hand Surg2004 Activity Modification External support may be needed ©Stanbridge University 2022 32  Joint Protection in the Wrist & Hand Box 19.1 Respect pain Maintain strength and ROM Balance activity level and rest Avoid deforming positions or one position for prolonged periods Pellegrini et al, Orthopedic Clinics of North America, 1992 Avoid using strong grasping activities that facilitate deforming force (especially lateral pinch) ©Stanbridge University 2022 33  Joint Hypomobility- General Management Acute Phase Maintain Joint & Tendon Mobility and Muscle Integrity PROM, AAROM, AROM – Aquatic therapy: non-stressful, NWB exercise combined with heat Tendon gliding Multiple-angle muscle setting – Address common muscle impairments of APL, APB and opponens m. to stabilize the CMC joint. Valdes et al. JHT, 2012 – Isometrics in correct arch of pinch position – AVOID lateral pinch strengthening!!! ©Stanbridge University 2022 34  Joint Hypomobility- General Management Acute Phase maintain joint & tendon mobility MWM treatments for the wrist Kisner & Colby, 7th edition Figure 19.7 ©Stanbridge University 2022 35 Flexor Tendon Gliding ©Stanbridge University 2022 36  Flexor Tendon Gliding A. Ability to open hand- MCP and IP extension B. Hook fist: Lumbrical extensibility and maximal differential gliding of FDS and FDP C. Full fist: maximum FDP tendon gliding D. Lumbrical position E. Straight fist: Elicits maximal FDS tendon gliding ©Stanbridge University 2022 37  Joint Hypomobility- General Management Subacute & Chronic Phases: Increase joint play & accessory motions Improve joint tracking and pain free motion Improve mobility, strength, function: specifically address the impairments of each patient – APL helps maintain joint stability unless poor alignment of joints, then it contributes to deformity – In the presence of a fixed deformity in the later stages of arthritis, stretching is NOT appropriate ©Stanbridge University 2022 38  Joint Hypomobility- General Management Subacute & Chronic Phases: Improve mobility, strength, function- APL, APB, dorsal interossei Neuromuscular control and strength Conditioning exercises Joint protection Functional activities ©Stanbridge University 2022 39  Surgical Interventions for the Wrist with advanced OA Arthrodesis remains most common wrist surgical intervention for late-stage arthritis Indications: severe pain in the wrist with joint deterioration of the articular surfaces, deformity, marked muscle imbalances Works with low demand functional UE needs 3 approved implant designs if arthroplasty is indicated ©Stanbridge University 2022 40  Wrist arthroplasty Different wrist arthroplasty implants exist Each has a different level of functional mobility Not common surgery ©Stanbridge University 2022 41  Wrist Arthroplasty- Arc of motion Universal 2 ReMotion Maestro Kisner & Colby, 7th edition Figure 19.8 ©Stanbridge University 2022 42  Review What are the various types of grips and the nerves that need to function to perform them? What structural impairments are seen in the acute vs the advanced stage of RA? What structural impairments do you see in the acute and chronic phase with OA in the hand and wrist? What are the appropriate exercise treatments for each stage for the above pathologies? What muscles are typically the focus of strengthening? Why? ©Stanbridge University 2022 43  Outline Structure & Gripping Joint Hypomobility Arthrokinematics Carpal tunnel Tendon Rupture- Distal Radius syndrome & Ulnar RA Fracture Nerve Compression Techniques for Musculotendinous Mobility ©Stanbridge University 2022 44  Tendon Rupture From RA Etiology: Chronic tenosynovitis causes a tendon to rupture Extensor tendons> flexor tendons Most common extensor tendon: Extensor tendons to the small and ring finger and EPL Most common flexor tendon: FPL ©Stanbridge University 2022 45  Tendon Rupture From RA Surgical options 1. Tendon graft reconstruction: often autograft from PL creates a “bridge” between the ruptured ends 2. Tendon anastomosis: ruptured tendon is sutured to an adjacent tendon 1. Direct end to end repair: two opposing ends are sutured together ©Stanbridge University 2022 46  Tendon Rupture From RA Post Op Management Immobilization Wrist is held in a position that minimizes stress to the repair Maximum Protection Phase Maintain mobility of the surrounding joints Re-establish mobility and control of the repaired or transferred extensor muscle-tendon units Regain active flexion of the digits ©Stanbridge University 2022 47  Tendon Rupture From RA Post op Management Moderate – Minimum Protection Phases Starts at 6-8 weeks Continue to increase active mobility of the operated digits Regain strength, control and functional use of the hand ©Stanbridge University 2022 48  Traumatic Lesions in the Wrist and Hand Lacerated flexor tendons of the wrist and hand: surgical and postoperative management Lacerated extensor tendons of the wrist and hand: surgical and postoperative management Just like RA tendon repairs- Early motion is key ©Stanbridge University 2022 49  Flexor Tendon Rupture and Repair Post op Management Dorsal block splint: wrist at 20° flexion Metatarsal phalangeal joints at 80-90° Interphalangeal joints in full EXT 3rd day post op begin exercises to perform Q 4 hours: a. 2 reps of PROM finger flex b. 2 reps AROM finger flexion c. Active finger ext into splint Full finger flexion expected at 12 weeks ©Stanbridge University 2022 50 Flexor Tendon Rupture and Repair Post op Management Kisner & Colby 7th edition figure 19.13 B: PROM exercises into flexion C: AROM into flexion Dorsal blocking splint ©Stanbridge University 2022 51 Flexor Tendon Rupture and Repair Post op Management Resisted Isolated Joint Motion Resisted Hook and Straight Fist Resistive Composite Fist Discontinuation of Protective Splint Isolated Joint Motion Hook and Straight Fist Active Composite Fist Place and Hold Passive Protected Extension ©Stanbridge University 2022 52  Review What are appropriate activities in the Maximum protection phase after an ORIF of a distal radial fracture? What are the different surgical options for tendon repair? What is/are the most common flexor and extensor tendon(s) in the wrist and hand affected by RA? Why is tendon gliding important during the rehab of the hand? ©Stanbridge University 2022 53  Outline Structure & Gripping Joint Hypomobility Arthrokinematics Distal Radius Repetitive Trauma Tendon Rupture- Fracture and Sprains RA Carpal tunnel Techniques for syndrome & Ulnar Musculotendinous Nerve Mobility Compression ©Stanbridge University 2022 54  Distal Radius Fractures Brotzman and Manske; Clinical Orthopedic Rehabilitation MOI- FOOSH – Elderly women; osteoporosis – Younger adult- high energy trauma Fractures in wrist/hand: may not show on radiographs for 2 weeks Signs: swelling, muscle spasm, pain with stress, tenderness over fracture site Healing Goal: maintain bony alignment without restricting gliding structures – MCP motion must remain free – Avoid distracted or flexed position of the wrist ©Stanbridge University 2022 55  Distal Radius Fracture General management guidelines Acute phase (0-6wks): Minimize edema Light activities (