Musculoskeletal physical therapy The wrist and Hand Musculoskeletal physical therapy Dr. Sarah Ehsan (BSPT, PP-DPT*)

Major nerves subject to pressure and trauma at wrist and hand Nerve disorders in wrist Median nerve – CTS Ulnar nerve – compression in ulnar tunnel (Guyon’s canal) Referred pain and sensory patterns

Carpal Tunnel Syndrome Etiology Compression of median nerve due to inflammation of tendons and sheaths of carpal tunnel Result of repeated wrist flexion or direct trauma to anterior aspect of wrist Signs and Symptoms Sensory and motor deficits (tingling, numbness and paresthesia); weakness in thumb Management Conservative treatment - rest, immobilization, NSAID’s If symptoms persist, corticosteroid injection may be necessary or surgical decompression of transverse carpal ligament

MANAGEMENT OF WRIST AND HAND DISORDERS

JOINT HYPOMOBILITY RA DJD Fractures Trauma Post surgical

Common pathologies and impairments Rheumatoid arthritis Acute stage Advanced stages Capsule weakness, cartilage destruction , bone erosion, tendon rupture instability, subluxations, deformities Common deformities Swan neck deformity Boutonnier’s deformity Zig-zag deformity of thumb

Common pathologies and impairments Osteoarthritis and post traumatic arthritis Trapezioscaphoid articulation, 1st CMC and DIP joints – sites for OA PIP – site for fracture and subsequent arthritis Acute stage Advanced stage Post immobilization hypomobility

Common functional limitations/ Disabilities Dressing Eating Grooming Toileting Gripping Fine-finger dexterity Loss of grip Precision handling

Joint hypo mobility: Management PROTECTION PHASE Control pain and protect joints Patient education Pain management Splinting Activity modification Maintain joint and tendon mobility and muscle integrity PROM, AAROM or AROM Tendon gliding exercises Multiple angle muscle setting ex.

What guidelines would you give to the patient with RA regarding joint protection?

Joint hypo mobility: Management CONTROLLED MOTION PHASE 1. increase joint play and accessory motion Joint mobilization techniques Precautions: be cautious in patients of RA as the connective tissues are weakened because of steroids 2. Improve joint tracking and pain-free motion 3. Improve mobility, strength and function NM control and strength Functional activities Conditioning Joint protection

Techniques for musculo-tendinous mobility Immobilzation after trauma or surgery, NM control, coordination Place – hold ex. Tendon –gliding Ex.

Techniques for musculo-tendinous mobility Flexor tendon-blocking exercises

Techniques for musculo-tendinous mobility Exercises to reduce extensor lag Scar tissue mobilization for tendon adhesions

DEFORMITIES AT WRIST AND HAND

Swan neck Boutonniere Ulnar drift Claw hand Trigger finger Ape hand Bishop’s hand Drop wrist deformity Z- deformity Dupuytren’s contracture Mallet finger

Specific conditions and their management

Dupuytren’s Contracture Etiology Nodules develop in palmer aponeurosis, limiting finger extension - ultimately causing flexion deformity Signs and Symptoms Often develops in 4th or 5th finger (flexion deformity) Management Tissue nodules must be removed as they can ultimately interfere w/ normal hand function

De-quervain’s disease (Hoffman’s disease) Etiology Stenosing tenosynovitis in thumb (EPB & APL) Constant wrist movement can be a source of irritation Signs and Symptoms Aching pain, which may radiate into hand or forearm Positive Finklestein’s test Point tenderness and weakness during thumb extension and abduction; painful catching and snapping Management Immobilization, rest, cryotherapy and NSAID’s Ultrasound and ice are also beneficial Joint mobilizations have been recommended to maintain ROM

Mallet finger Etiology Signs and Symptoms Management Caused by a blow that contacts tip of finger avulsing extensor tendon from insertion Signs and Symptoms Pain at DIP; X-ray shows avulsed bone on dorsal proximal distal phalanx Unable to extend distal end of finger Point tenderness at sight of injury Management RICE and splinting for 6-8 weeks

Wrist ganglion Etiology Signs and Symptoms Management Synovial cyst (herniation of joint capsule or synovial sheath of tendon) Generally appears following wrist strain Signs and Symptoms Appear on back of wrist generally Occasional pain w/ lump at site Pain increases w/ use May feel soft, rubbery or very hard Management Old method was to first break down the swelling through distal pressure and then apply pressure pad to encourage healing New approach includes aspiration, chemical cauterization w/ subsequent pressure from pad Ultrasound can be used to reduce size Surgical removal is most effective treatment method

Trigger finger or thumb Etiology Repeated motion of fingers may cause irritation, producing tenosynovitis Inflammation of tendon sheath Thickening occurs w/in the flexor tendon sheath which causes sticking of the tendon when patient attempts to flex Signs and Symptoms Resistance to re-extension, produces snapping that is palpable, audible and painful Palpation produces pain and lump can be felt w/in tendon sheath Worse in the morning Management Same treatment as de-Quervain’s disease -- if unsuccessful, injection and surgical release are last options

Assignment Practice ex. To increase flexibility and ROM Practice Ex. To develop and improve muscle performance ,NM control and coordinated movements