Judy C. Colditz, OT/L, CHT, FAOTA STIFFNESShandfoundation.org/wp-content/uploads/2015/02/CS25-Key-Concepts... · KEY CONCEPTS for Mobilizing the Stiff Hand Judy C. Colditz, OT/L,

KEY CONCEPTS

for Mobilizing the Stiff Hand

Judy C. Colditz, OT/L, CHT, FAOTA

www.HandLab.com

STIFFNESS

STIFFNESS

Difficult to

bend; rigid

– Lack of joint

movement

• Structures no

longer move

with respect to

one another

Watson: 1994

© HandLab, 2016 3

STIFFNESS

© HandLab, 2016 4

Injury

–Begins a cascade

of events to

create healing

© HandLab, 2016 5

STIFFNESS

Early Motion

Return to Normal Motion

Cortical

Response

Tissue

Response

INJURY

Immobilization

External

Internal

© HandLab, 2016 6

Key Concepts for Mobilizing the Stiff Hand Philadelphia Hand Meeting - March 2017


www.HandLab.com © HandLab, 2017 page 1

Early Motion

Mal-adapted Pattern of Motion

Cortical

Response

Tissue

Response

INJURY

Immobilization

External

Internal

© HandLab, 2016 7

Chronic

Edema/Fibrosis

Hard “end feel”

to PROM No progress

Early Motion

Mal-adapted Pattern of Motion

Cortical

Response

Tissue

Response

INJURY

Immobilization

External

Internal

© HandLab, 2016 8

STIFFNESS

Intra-articular stiffness

– Fixation of tissue layers

• Motion between tissue

layers not possible

– Basic changes

• Physical properties of

collagen tissue

Peacock: 1966

© HandLab, 2016 9

Cross-linked

collagen

New,

disorganized,

collagen

Injury & Immobilization

Stiffness

STIFFNESS

© HandLab, 2016 10

STIFFNESS

Edema

Immobilization

Joint Stiffness/

Tissue Adherence

Early

© HandLab, 2016 11

STIFFNESS

Early motion

– Soft tissue

• Movement without wound disruption

– Tendons

• Movement without rupture

– Fractures

• Movement without instability

© HandLab, 2016 12




STIFFNESS

Chronic edema;

fibrosis

Joint stiffness &

extensive tissue

adherence

Ineffectual pattern of motion:

re-patterned motor cortex

Chronic

© HandLab, 2016 13

Hard end-feel = P-U-S-H !!!

© HandLab, 2016 14

STIFFNESS

STIFFNESS

Response to

mobilization

Active ROM

unproductive

without blocking

PROM =

temporary response

© HandLab, 2016 15

STIFFNESS

Local tissue change

Mechanical change

Cortical change

PIP Dislocation

© HandLab, 2016 16

EVIDENCE

EVIDENCE

Systematic review: therapy

interventions for improving

ROM

– Moderate evidence after joint

injury/fx

• Use of splints or casts to

increase ROM

• Passive ROM to increase ROM

Michlovitz: 2004

© HandLab, 2016 18




EVIDENCE

Predictors of contracture

resolution with dynamic

orthosis

– Less pre-treatment stiffness

– Shorter time since injury

– Flexion rather than extension

deficient stiffness

Glasgow et al: 2011

© HandLab, 2016 19

EVIDENCE

Modified Weeks Test

– Angle measurement

– Heat & PROM (use of dynamic

orthosis)

• 30 minutes

Glasgow et al: 2011

© HandLab, 2016 20

EVIDENCE

Modified Weeks Test

– Large ROM improvement

• Small degree of stiffness

– Small ROM improvement

• High degree of joint stiffness

Glasgow et al: 2011

© HandLab, 2016 21

EVIDENCE

Modified Weeks Test

– Angle measurement, Heat 15 –

20 min & PROM

• 10-20 degree gain

– Serial-static or dynamic

orthosis

• Less than 10 degrees

– Static-progressive orthosis

Hand & Upper Extremity Rehab Specialists, Inc. in McMurray, PA

© HandLab, 2016 22

EVIDENCE

Are we asking the right

question?

– Which orthosis to increase

ROM

– Passive ROM to increase

ROM

© HandLab, 2016 23

EVIDENCE

1. Is orthotic mobilization, joint mobilization, and

exercise, better than no intervention?

2. Do these interventions improve the resolution

of impairments, functional limitation, and

disability?

3. Is one particular type of intervention more

effective than another?

4. What should be the intensity & frequency of

intervention?

Michlovitz: 2004

© HandLab, 2016 24




EVIDENCE

Question

– Instead of

• What is the best orthotic

approach?

– Why not

• What is the problem & what is

the best solution?

© HandLab, 2016 25

COLLAGEN

COLLAGEN

Collagen

– Main component of connective tissue

• 25-35% of body protein

© HandLab, 2016 27

COLLAGEN

Greek ”kolla”

– “Glue”

Suffix ”gen”

– “Producing”

© HandLab, 2016 28

COLLAGEN

© HandLab, 2016 29

Elastic fiber Reticular fiber Macrophage Nerve fiber Lymphocyte Collagen fiber Neutrophil Plasma cell Ground substance

Mast cell Fibroblast

Fat cell Capillary © JColditz, 2014

COLLAGEN

Most numerous fibers

in connective tissue

Unique combination

of flexibility &

strength

Junquerira & Carneiro: 1995

© HandLab, 2016 30




COLLAGEN

Inelastic

– Tensile strength

greater than steel

Elastic quality

– Due to relationship

to other fibers

Junquerira & Carneiro: 1995

© HandLab, 2016 31

COLLAGEN

Like nylon

– Thread

• Relatively inelastic

– Knitted stocking

• Very elastic

Redrawn from: Akeson, et al, 1980

© HandLab, 2016 32

New,

disorganized,

collagen

Injury

Stiffness

COLLAGEN

© HandLab, 2016 33

COLLAGEN

New collagen

– Less cross-linked & organized

– Weaker

Noyes: 1977 McKee, Hannah & Priganc: 2012 © HandLab, 2016 34

COLLAGEN

© HandLab, 2016 35

New Collagen Maturing Collagen

– Alignment depends on stress

Cross-linked

collagen

New,

disorganized,

collagen

Immobilization Injury

Stiffness

COLLAGEN

© HandLab, 2016 36




COLLAGEN

Crosslinking

– Creates tensile

strength

– Can prevent

movement

Junquerira & Carneiro: 1995 McKee, Hanna & Priganc: 2012

© HandLab, 2016 37

Redrawn from: Akeson, et al, 1980

COLLAGEN

Joint stiffness

– Crosslinked collagen

due to immobility

and/or

– New, disorganized,

collagen

© HandLab, 2016 38

COLLAGEN

Collagen

Triple Helix

Cross-Link

© HandLab, 2016 39

From: Guimberteau, JC: New Ideas in Hand Flexor Tendon Surgery, 2001

STIFFNESS

© HandLab, 2016 40

COLLAGEN

Human tissue is viscoelastic

– Increased deformation under a constant stress

© HandLab, 2016 41

E

time

CREEP

COLLAGEN

“Soft end feel” “Hard end feel”

New collagen/edema Cross-linked collagen

© HandLab, 2016 42




STRESS

DEPRIVATION

Tissue Response

STRESS DEPRIVATION

Peacock-1966

– Joint stiffness caused by trauma + immobilization

Arem & Madden- 1976

– Elongation of new tissue subjected to stress

Akeson et al-1980

– Confirmed soft tissue primarily responsible for

joint stiffness

Light et al-1984

– Low-load, prolonged stretch more effective than

high load (knees)

© HandLab, 2016 44

STRESS DEPRIVATION

Prolonged joint immobility

– Non-physiological

– Excessive collagen cross-linking

Akeson: 1987 Meals: 1993

© HandLab, 2016 45

Stress Deprivation

Applied Immobilization

Joint Stiffness

STRESS DEPRIVATION

Mal-adapted Movement

Akeson et al: 1980 Akeson et al: 1987 Akeson et al: 1968 Amiel et al: 1983 Frank et al: 1984 Grauer et al: 1987 Meals: 1993 Noyes: 1977

© HandLab, 2016 46

STRESS DEPRIVATION

Even uninjured immobilized joint:

– Profound intra-articular & peri-articular

changes

• Histologically

• Chemically

• Mechanically

© HandLab, 2016 47


STRESS DEPRIVATION

Basic changes in the

physical properties

of collagen tissue

– Elastic factors

• Collagen

• Elastin

– Ground Substance

• Extracellular matrix

• Edema

Peacock: 1966

Extracellular Matrix

Cross-linked type I

collagen

© HandLab, 2016 48




Joint stiffness

– Increased cross-linking

– Decreased water &

glycosaminoglycan

– Increased collagen turnover

© HandLab, 2016 49


STRESS DEPRIVATION

Ligaments

– Lose fiber orientation

– Have diminished mechanical properties

– Effective shortening

• Fibers not properly aligned

Frank: 1984 Noyes: 1977

© HandLab, 2016 50

STRESS DEPRIVATION

Redrawn from Amiel et al: 1982

200 100

0 1.0 2.0 3.0

LO

AD

(N

ew

to

ns)

DEFORMATION (mm)

Immobilized

Control

Lateral Collateral Ligament

© HandLab, 2016 51

STRESS DEPRIVATION

Fixation of tissue layers

Photo courtesy of Marc Garcia-Elias, MD, PhD Peacock: 1966

Example: dorsal apparatus

© HandLab, 2016 52

STRESS DEPRIVATION

STRESS DEPRIVATION

Flexion of IP joints allowed by gliding

– Laterally & distally

Extension Flexion

Tubiana: 1981 Garcia-Elias et al: 1991 Schultz: 1981 Rosenthal: 1997 Landsmeer: 1949

© HandLab, 2016 53

STRESS DEPRIVATION

Injury Tissue

adherence

NO CHANGE

Mal-adapted

movement

Cortical

Remapping

© HandLab, 2016 54

???




STRESS

DEPRIVATION

Cortical Response

STRESS DEPRIVATION

Motor Cortex

Sensory Cortex

© HandLab, 2016 56

STRESS DEPRIVATION

Representational area in brain depends on

amount of stimuli

Changes quickly!

© HandLab, 2016 57

STRESS DEPRIVATION

Nerve injury & repair

Early

• “Silent” cortical

area, deprived

of sensory input

Late

• Functional

reorganization

of cortical hand

map due to

axonal

misdirection

58

Redrawn from Silva et al: 1996 Merzenich & Jenkins: 1993

© HandLab, 2016

STRESS DEPRIVATION

Changes in input creates….

“Cortical

Competition”

© HandLab, 2016 59

STRESS DEPRIVATION

Learned non-use

– Monkeys with one forelimb denervation

• “Get along quite well on 3 limbs and positively

reinforce this pattern of behavior”

Taub: 1977 & 1980

© HandLab, 2016 60




redrawn from Dancause & Nudo: 2011

© HandLab, 2016 61

Nonresponsive Elbow/shoulder Face Digit Wrist/Forearm

Prelesion

Spontaneous

Lesion

Therapy

STRESS DEPRIVATION

Beyond 9 days,

motor cortex

representation

diminishes with

immobilization

Kleim et al: 1998 Liepert et al: 1995

© HandLab, 2016 62

STRESS DEPRIVATION

Immobilization

– Somatosensory

cortex

• Impaired tactile acuity

• Reduced activation of

finger representations

• Compensatory effects

contralateral side

Lissek et al: 2009

© HandLab, 2016 63

STRESS DEPRIVATION

Human immobilized

ankles

– Longer the

immobilization,

greater the decrease

in cortex area size

Liepert et al: 1995

© HandLab, 2016 64

STRESS DEPRIVATION

Liepert et al: 1995

Unaffected muscle

Immobilized muscle

Cortical representation

Tibialis anterior muscle

© HandLab, 2016 65

1

1

3

5

4 5 6 cm

cm

STRESS

DEPRIVATION

Edema




EDEMA

© HandLab, 2016 67

Does not cause stiffness

– Prevents motion

–Which creates stress

deprivation

© HandLab, 2016 68

EDEMA

EDEMA

Initial effect of edema

– Stiffness

Prolonged edema

– Chronic inflammation

• Due to accumulation of

plasma proteins

© HandLab, 2016 69

Mortimer: 1997 Casley-Smith: 1986 Guyton & Hall: 1997

Edema

Stiffness Inflammation

© HandLab, 2016 70

Injury

Edema

EDEMA

INTEROSSEOUS

MUSCLE

TIGHTNESS

INTEROSSEOUS MUSCLE TIGHTNESS

Single greatest contributor to prolonged

digital joint stiffness

© HandLab, 2016

72

Extension Flexion




+8

68

73

© HandLab, 2016

INTEROSSEOUS MUSCLE TIGHTNESS INTEROSSEOUS MUSCLE TIGHTNESS

Elongate interosseous muscles

– Passively

– Actively

74 © HandLab, 2016


75

© HandLab, 2016

Active

– MP Joint blocked in hyperextension

– EDC cannot hold


76

© HandLab, 2016

Active

– ONLY means to elongate the lumbrical

muscle


Blocking allows both interosseous &

lumbrical elongation

© HandLab, 2016 77


Active FDP

– Elongates interosseous

& lumbrical muscles

– Increases joint ROM

– Decreases edema

© HandLab, 2016 78





© HandLab, 2016 79

TISSUE

RESPONSE

TO STRESS

TISSUE RESPONSE TO STRESS

RAT: Subcutaneous

sponges & magnets in

electromagnetic fields

– Early mechanical force

elongates newly

synthesized collagen

© HandLab, 2016 81

Peacock & Cohen: 1990


New collagen

– Mechanical stimuli affects crosslinking

• Arrangement

• Number

• Thickness

© HandLab, 2016 82

Noyes: 1977

RABBITS: wounds stressed

by CPM compared to

immobilization

Wounds stressed by CPM

significantly stronger,

stiffer, & tougher

Structural organization of

collagen fibers superior

Grauer et al: 1987

© HandLab, 2016 83

TISSUE RESPONSE TO STRESS TISSUE RESPONSE TO STRESS

PROM only 5

min/day increased

cellularity at 6 wks

– Healing tissues

extremely sensitive to

stress & motion

© HandLab, 2016 84

Gelberman et al: 1982 Frank & Akeson et al: 1984




TISSUE RESPONSE TO STRESS TISSUE RESPONSE TO STRESS

Modulates proteoglycan synthesis

Akeson et al: 1977 Akeson et al: 1980 Donatelli & Owens-Burkhart:1981 Frank et al: 1984 Noyes: 1977

© HandLab, 2016 86

Elastic fiber Reticular fiber Macrophage Nerve fiber Lymphocyte Collagen fiber Neutrophil Plasma cell Ground substance

Mast cell Fibroblast

Fat cell Capillary


Movement

1. Maintains lubrication

within the collagen

cell matrix

2. Prevents abnormal

cross-link formation

3. Orients new collagen

fibers to resist stress

Akeson et al: 1977 Akeson et al: 1980 Donatelli & Owens-Burkhart:1981 Frank et al: 1984 Noyes: 1977

© HandLab, 2016

“Low-load prolonged stress”

No formula for amount or duration

Brand & Hollister: 1999 Colditz: 1983 Donatelli & Owens-Burkhart: 1981 Kottke et al: 1966 McClure, et al: 1994 Noyes: 1977 Weeks & Wray: 1978

© HandLab, 2016 88



Rx duration & contracture resolution with

dynamic orthosis

– Flexion gains faster than extension

– Duration of treatment key to contracture

resolution

Glasgow et al: 2012

© HandLab, 2016 89


(Visco-)Elastic response

Collagen “stretched” returns to

original length & shape

Plastic response

Collagen is deformed by stress

applied

© HandLab, 2016 90





“The reality of visco-elastic behavior is what

dooms stretching techniques (e.g. joint

mobilization) to a very limited application in

managing joint stiffness.”

Flowers: 2010

© HandLab, 2016 91

TISSUE

RESPONSE

TO

PROM

PROM

Most therapists

believe stiff joints

must be passively

mobilized to create

potential for active

motion

© HandLab, 2016 93

PROM

Viscoelastic

– Creep

• Constant load

• Deformation

(elongation) over time

– Stress relaxation

• Load held constant

• Tissue elongates

• Stress (resistance)

decreases

© HandLab, 2016 94

Deformation

Time

Force

Time

m U

N

PROM

“…while it is broadly

accepted that contracted

tissues will elongate with

stress, the body of literature

is inconsistent with respect to

the definitions of creep and

stress relaxation as they

pertain to living tissues.”

© HandLab, 2016 95

McKee, Hannah & Priganc: 2012

PROM

“PROM is the gold standard in monitoring

joint stiffness---rather than AROM.”

© HandLab, 2016 96

Glasgow et al: 2011

GOLD

STANDARD




TERT

(Total End-Range Time)

Positive relationship between time stiff joint is

held at end range & improvement in PROM

No proven correlation between increases in

PROM & increases in AROM

Flowers & LaStayo: 1994

© HandLab, 2016 97

PROM PROM

0

20

40

60

80

100

120

Total ROM

Increase

Days Casted

6 days

3 days

Total End Range Time (TERT)

Flowers & LaStayo: 1994

© HandLab, 2016 98

PROM

TERT not found to be associated with

contracture resolution

Glasgow et al: 2011

© HandLab, 2016 99

PROM

Injured elbow: 3

weeks of

immobilization

After Novocain: initial

ROM

Repeated at weekly

intervals; response

progressively less

Dehne: 1971

© HandLab, 2016 100

PROM

“I never said joint

mobilization was a

treatment for joint

stiffness.”

– Comment by

John Mennell

Flowers: 2010

© HandLab, 2016 101

PROM

Cycling of ligaments

resulted in the load

required to stretch

the ligament a

given distance

decreased during

the time of cycling

Weisman et al: 1980

© HandLab, 2016 102




DOCTORS DEMYSTIFY BLOG

Roy Meals, MD

QUESTION (12/26/13)

– Do you have a good explanation for

patients as to why their fingers loosen

up with heat/stretch and then within 2-3

hours go back to being stiff again?

© HandLab, 2016 103

DOCTORS DEMYSTIFY BLOG

Roy Meals, MD

ANSWER:

– It is likely a relocation of extracellular fluid

in the ligaments and joint capsules. When

we do stretching exercises, we actually do

not stretch the ligaments but just make them

more supple with less extracellular fluid.

When they are left alone for a while, fluid

tends to re-accumulate, especially in areas

recently inflamed. Patients with trigger

fingers frequently comment that the

triggering is worst in the morning and

subsides as the day progresses.

© HandLab, 2016 104

PROM

Cartilage

– Requires slow cyclical

compression &

decompression

• To absorb nutrients &

expel waste

© HandLab, 2016 105

McKee, Hannah & Priganc: 2012

PROM

CPM: joint regeneration

– ORIF of fractures

– Joint injuries

– Arthrolysis

– Synovectomy

– Septic arthritis

– Joint release

– Total arthroplasty

– Tendon repair

– Ligament reconstruction

Meals: 1993 O'Driscoll et al: 1983 Salter: 1989 Van Royen et al: 1986

© HandLab, 2016 106

PROM

No laboratory or

clinical studies have

demonstrated

effectiveness of

CPM for treating

joint stiffness

© HandLab, 2016 107

Meals: 1993 O'Driscoll et al: 1983 Salter: 1989 Van Royen et al: 1986

PROM

Rabbit model- 3 wks post fx

– Daily PROM: CPM

– Contralateral ankle

immobilized

– Stiffness measured weekly

Grauer et al: 1987

© HandLab, 2016 108




Results

– Ankle stiffness:

• Significantly reduced immediately post

PROM (p <0.01)

• Exercised limbs (between sessions)

significantly stiffer than immobilized

limbs (p <0.01)

Grauer et al: 1987

© HandLab, 2016 109

PROM PROM

Results

– PROM limbs

• Progressively & significantly stiffer (3 wks)

than contralateral unexercised limbs

• Increased limb swelling

Grauer et al: 1987

© HandLab, 2016 110

PROM

Same model as Grauer

– Tested ankle joint stiffness & limb

volume

– Drugs, intra-articular hematoma,

pressurization (10mmHg) & CPM

Meals et al: 1993

© HandLab, 2016 111

PROM

Groups: 3 Weeks of CPM

4 hrs/day

8 hrs/day

12 hrs/day

16 hrs/day

24 hrs/day

Meals et al: 1993

© HandLab, 2016 112

PROM

Time Limb Swelling Joint Stiffness

4 hrs.

8 hrs. 12 hrs. 16 hrs.

24 hrs.

Meals et al: 1993

© HandLab, 2016 113

Negative response?

© HandLab, 2016 114

PROM




© HandLab, 2016 115

PROM

PROM

Applying a mobilization orthosis is not

movement!

© HandLab, 2016 116

PROM

Early stiffness

–Gentle PROM

Stiffer the hand

–PROM less effective

–Prolonged/repeated active stress

• To change tissue

• To change cortical representation

© HandLab, 2016 117

CORTICAL

RESPONSE

TO AROM

CORTICAL RESPONSE

Movement

– Magnifies cortical

representations

Lack of use

– Decreases cortical

area

Jenkins et al: 1990 Liepert et al: 1995 Byl et al: 1996 Kleim et al: 1998 Nudo et al: 1996 Pascual-Leone et al: 2000 Donoghue & Sanes: 1987 Nudo et al: 1990 Recanzone et al: 1992 Braun et al: 2000 Elbert et al: 1995 & 1997

© HandLab, 2016 119

CORTICAL RESPONSE

Active ROM with

joint stiffness

– Unproductive without

blocking

– Magnifies cortical

representation of the

wrong muscles!

© HandLab, 2016 120




CORTICAL RESPONSE

Squirrel monkeys

trained on a small

object retrieval task

– Showed expansion of

digit representation

within the primary

motor cortex

Nudo: 1996

© HandLab, 2016 121

CORTICAL RESPONSE

Squirrel monkeys: retrieval training

Nudo et al: 1996 © HandLab, 2016 122

Image: © American Physiological Society

CORTICAL RESPONSE

Beginning of activity

– Brain more active

Habit set

– One unit of behavior

with limited brain

activity

© HandLab, 2016 123

Graybiel & Smith: June 2014

CORTICAL RESPONSE

Constraint induced

therapy

– Overcome learned

non-use

– Create plastic

reorganization

through use

Uswatte & Taub: 2013 © HandLab, 2016 124

CORTICAL RESPONSE

Cortical maps remain stable

unless monkeys are required to

learn a NEW motor skill Plautz et al: 2000

© HandLab, 2016 125

© Elsevier © Elsevier

CORTICAL RESPONSE

Constraint induced

therapy

– Increased use of arm in

2 weeks

• Retained when tested at

2 years

Taub et al: 1993

© HandLab, 2016 126




CORTICAL RESPONSE

Stroke patients: 72 hours

– Improvement 2PD in non-immobilized hand

– Redistribution of hemispheric dominance

Confirms

– Rapid inter-hemispheric plasticity

Weibull et al: 2011

© HandLab, 2016 127

CORTICAL RESPONSE

Constraint induced therapy

– Shaping

• “Desired motor behavior approached in small

steps”

1. Explicit feedback

2. Verbal reinforcement

3. Appropriate task selection

Uswatte & Taub: 2013

© HandLab, 2016 128

© Elsevier

CORTICAL RESPONSE

4 Components

1. Intensive

training/multiple days

2. Use of small steps

3. Behavior techniques

• Designed to transfer gains

to real world use

4. Restraint of other arm

© HandLab, 2016 129

© Elsevier

Uswatte & Taub: 2013

CORTICAL RESPONSE

Reactivation previous

cortical mapping

– Original cortical

patterns persist

– Can be easily re-

activated

Kaas: 1991 Liepert et al: 2000

© HandLab, 2016 130

QUESTION

If we can change the brain with direct

injury…why not harness the uninjured

brain to reduce motor reorganization

in the stiff hand???

© HandLab, 2016 131

TRADITIONAL

TREATMENT




TRADITIONAL TREATMENT

9 stroke patients

– 1 wk usual physiotherapy

– Then 1 wk constraint

• Motor output of APB prior to & after treatment

Liepert et al: 1998

© HandLab, 2016 133


Before treatment

– Cortical representation

significantly smaller on affected

side

After 1 wk conventional therapy

– No change

After 1 week constraint

– Motor output map significantly

enlarged & significant

improvement in dexterity

Liepert et al: 1998

© HandLab, 2016 134


Stress alters

collagen

NO basic research

supports any

particular

treatment regimen

for joint stiffness

Grauer & Kabo et al: 1987 Meals: 1993

© HandLab, 2016 135


Example: PIP joint stiffness

– Hyperextension of MP joint

© HandLab, 2016 136


EDC pull proximal to MP

– MP extension/hyperextension

– Slight PIP extension

– Very slight DIP extension

Kaplan: 1959

© HandLab, 2016 137


Example: PIP Joint Stiffness

– Hyperflexion of MP joint

© HandLab, 2016 138





Static

Serial Static

Static Progressive

Dynamic

© HandLab, 2016 139


1. Passive force

2. Immobilization

3. Constriction

4. No cortical involvement

© HandLab, 2016 140

Based on an unproven assumption

– PROM is necessary to gain AROM

© HandLab, 2016 141


CASTING MOTION

TO MOBILIZE

STIFFNESS (CMMS)

CMMS

Active Passive

© HandLab, 2016 143

– 9 months following distal radius fracture

CMMS

Active

© HandLab, 2016 144

– 9 months following distal radius fracture

3 days in cast




CMMS

Old Ideas

– PROM before AROM

– Never immobilize MP

joints in extension

– Never lose motion in

one direction to gain

another

– Never immobilize any

part of a stiff hand

© HandLab, 2014 145

“It’s not that we need new ideas, but we need to stop having old ideas.”

Edwin Land

Creator of Polaroid

CMMS

Cyclical active motion

– Mobilizes stiff joints

– No previous model

© HandLab, 2016 146

CMMS

Plaster of Paris casting

– Selectively immobilizes proximal joints to

direct distal joint motion

© HandLab, 2016 147

CMMS

What other treatment can gain flexion &

extension simultaneously?

Colditz, 2011

© HandLab, 2016 148

0

20

40

60

80

100

120

140

0 8 14 25 35 60 110 215 321

Degrees o

f M

otio

n

Days

TC: TAM vs TPM of Long Finger

Long-TPM Long-TAM

CMMS

© HandLab, 2016 149

CMMS

Chronic edema;

fibrosis

Joint stiffness &

extensive tissue

adherence

Ineffectual pattern of motion:

re-patterned motor cortex

Chronic

Stiffness

© HandLab, 2016 150




CMMS

Active motion

– Mechanical mobilization

– Cortical re-patterning

– Lymphatic stimulation

© HandLab, 2016 151

CMMS

1. Active motion mobilizes stiff joints

© HandLab, 2016 152

CMMS

2. Active motion re-patterns the cortex

© HandLab, 2016 153

CMMS

3. Active motion pumps stagnant lymphatics

© HandLab, 2016 154

CMMS

Mechanical

CMMS - MECHANICAL

Redrawn from: Arbuckle JD, McGrouther DA: Measurement of the arc of digital flexion and joint movement ranges. J of Hand Surg [Br], 1995

© HandLab, 2016 156




CMMS - MECHANICAL

Abnormal pattern of

movement

© HandLab, 2016 157

CMMS - MECHANICAL

© HandLab, 2016 158

0

10

20

30

40

50

60

70

80

90

100

0 2 3 5 8 18 50

Degrees

Weeks

Index

Long

Ring

Little

Active MP Joint Flexion

CMMS - MECHANICAL

Joint blocking

– Force directed to stiffest joints

© HandLab, 2016 159

CMMS - MECHANICAL

Normal Balanced

Motion

Re-Balancing Phase Mal-adapted Pattern

of Motion

© HandLab, 2016 160

F E F

E F

E

CMMS

Cortical

CMMS - CORTICAL

Once novel motor task is learned, functional

topography remains altered for long time

Repeated motion over time is required for

effective re-patterning

© HandLab, 2016 162

Nudo: 1996 Kaas: 1991 Merzenich et al: 1983




CMMS - CORTICAL

1. Conscious attention

2. Re-activate previous representations

3. Requires time

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Merzenich et al: 1993 Liepert et al: 2000 Kaas: 1991 Byl et al: 1996 Nudo: 1996

CMMS - CORTICAL

Repetitive, passive

motion without

attention

– insignificant changes

Focused attention

with motion required

Byl et al: 1996 Merzenich et al: 1993

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CMMS

Lymphatic

CMMS - LYMPHATIC

Limited AROM

restricts pumping of

lymphatic system

– May or may not be

injury to lymphatic

system

© HandLab, 2016 166

CMMS - LYMPHATIC

Excess fibrosis

caused by high-

protein edema

impedes flow of

fluid & proteins

to the initial

lymphatics

Casley-Smith & Casley-Smith: 1986

Valves Endothelial cells

© HandLab, 2016 167

Anchoring

filaments

CMMS - LYMPHATIC

Stagnant lymphatic system mobilized by:

1. Active motion

2. Consistent light pressure

3. Warmth

4. Light massage/pressure

© HandLab, 2016 168




CMMS - LYMPHATIC

1. Active motion

– The SINGLE most effective stimulator of the

lymphatic system

Ryan and Mortimer et al: 1986 Leduc et al: 1988 Casley-Smith & Casley-Smith: 1986 Guyton: 1987 Mortimer: 1997

© HandLab, 2016 169

CMMS - LYMPHATIC

1. Active motion

– Increases flow 10 to 30 times!!!

– During rest is sluggish

Guyton: 1987

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CMMS - LYMPHATIC

2. Consistent light pressure

– Lymphatic vessels

Weak, thin, fragile structures

Ryan et al: 1986

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CMMS - LYMPHATIC

© HandLab, 2016 172

CMMS - LYMPHATIC

3. Warmth

– Direct relationship

between

• Ambient temperature

• Permeability of initial

lymphatics

Xujian: 1990 Ohkuma: 1990

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CMMS - LYMPHATIC

4. Light massage

– Initial lymphatics (in

skin) require minimal

pressure

• Movement

• External compression

• Arterial pulsation

– Gentle compression/

relaxation is best

Ohkuma: 1990 Ryan et al: 1986 Miller & Seale: 1981

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ACTIVE

REDIRECTION

ACTIVE REDIRECTION

New belief

– Active motion can increase passive motion

© HandLab, 2016 176

Adherence

Passive ROM/Orthosis

Flexion Extension

Flexion Extension

ACTIVE REDIRECTION

© HandLab, 2016 177

Active Redirection

Flexion Extension

Adherence

Flexion Extension

ACTIVE REDIRECTION

© HandLab, 2016 178

Active Redirection

Flexion Extension

Passive ROM/Orthosis

ACTIVE REDIRECTION

© HandLab, 2016 179

Flexion Extension

ACTIVE REDIRECTION

© HandLab, 2016 180




ACTIVE REDIRECTION

© HandLab, 2016 181

ACTIVE REDIRECTION

© HandLab, 2016 182

ACTIVE REDIRECTION

ICAM (Immediate Controlled Active Motion)

– Relative Motion Orthosis

– Yoke Orthosis

– Merritt Orthosis

Howell et al: 2005

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© Elsevier

ACTIVE REDIRECTION

© HandLab, 2016 184

ACTIVE REDIRECTION

PIP FLEXION

© HandLab, 2016 185 © HandLab, 2016 186

ACTIVE REDIRECTION

PIP EXTENSION




ACTIVE REDIRECTION

© HandLab, 2016 187

ACTIVE RE-DIRECTION

© HandLab, 2015 188

ACTIVE REDIRECTION

Example

– Increased participation

by the lateral bands

© HandLab, 2016 189

-24° -9°

ACTIVE REDIRECTION

Directing FDP power

to IP joints

– Mobilizing joints

– Elongating interosseous

muscles

© HandLab, 2016 190

ACTIVE REDIRECTION

Orthosis

– Only one direction

– Edema increased?

– No cortical change

Active Redirection

– Differential glide

– Edema reduced

– Cortical re-mapping

© HandLab, 2016 191

THE

FUTURE




THE FUTURE

Cortical re-patterning as part of rehab of

stiff joints

© HandLab, 2016 193

THE FUTURE

Silver nanowires

– New wearable, stretchable, multifunctional

sensor

North Carolina State University

© HandLab, 2016 194

© Royal Society of Chemistry

THE FUTURE

Mirror visual feedback (MVF)

Ramachandran et al: 1996

© HandLab, 2016 195

THE FUTURE

Nature documentary

Action

observation Motor

imagery

Bassolino et al: 2013

Cerebral Preparation During Immobilization

© HandLab, 2016 196

© Oxford Journals (open access)

THE FUTURE

Nature documentary

Action

observation Motor

imagery

Before

After

(10 hrs.)

Bassolino et al: 2013

© HandLab, 2016 197

© Oxford Journals (open access)

THE FUTURE

Roll et al: 2012

© HandLab, 2016 198




http://www.gizmag.com/silver-nanowire-sensor/30497/pictures

THE FUTURE

8 Subjects

– Full immobilization

• Vibration: fingers & wrist

to simulate movement

perception

– Controls

• No stimulation

After 5 days

– Immobilization group

• fMRI: preserved

sensorimotor networks

– Control group

• Significantly altered

Roll et al: 2012

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© Elsevier CONCLUSIONS

CONCLUSION

The question is no longer

just about passive dosage

Active (redirected) motion

–Provides ideal dosage

• Mechanical stress

AND

• Cortical stress

© HandLab, 2016 201

CONCLUSION

Actively change the mechanics to

change the motor cortex

© HandLab, 2016 202

CHALLENGE

I dare you

to prove

it!!

© HandLab, 2016 203

ADDITIONAL INFORMATION

www.HandLab.com Colditz, JC: Therapist's Management of the Stiff Hand. In:

Rehabilitation of the hand and upper extremity. Ed: Skirven et

al. 6th ed. Philadelphia: Elsevier Mosby, 2011. 894-921

Colditz JC: Plaster of Paris: The forgotten splinting material. J

Hand Ther 2002; 15(2):144-57

Clinical Pearls explaining interosseous & lumbrical muscle

tightness testing

Conflict of Interest Nuances of Mobilizing the Stiff Hand: Online Course

© HandLab, 2016 204




Documents

Judy C. Colditz, OT/L, CHT, FAOTA STIFFNESShandfoundation.org/wp-content/uploads/2015/02/CS25-Key-Concepts... · KEY CONCEPTS for Mobilizing the Stiff Hand Judy C. Colditz, OT/L,