Resistive Exercise

The purpose of resistive exercise is to produce sufficient muscle strength to allow maximum tendon excursion, full joint motion, and the execution of normal daily activities. This may be accomplished through purposeful graded activities and progressive resistive exercises. Strengthening is traditionally divided into isometric, eccentric, and concentric exercises. Emphasis includes improving endurance and/or strengthening. Caution is needed in adapting strengthening programs for patients with repetitive strain disorders, especially if pain is experienced for 1 to 2 hours after exercise. An external splinting force applied to a wrist or hand joint has little appreciable effect on improving muscle strength, since strengthening requires voluntary effort of muscles to enhance power. In addition to strengthening muscles, resistive exercises may be used to provide a form of biofeedback to the patient, allowing increased awareness of the position and function of key muscle groups (Fig. 15-6). Resistive exercises may be used at many stages of rehabilitation but should not be relied on solely to increase passive range of motion of stiffened joints. Mechanically, because of the angle of approach of a tendon to a given joint, the inherent strength of a muscle is often lost in translational force when attempting active mobilization of a stiff joint. From a physiologic viewpoint, the musculotendinous unit cannot provide the long-term tension on the joint needed to cause pericapsular remodeling. Splinting produces a more advantageous and sustained angle of pull because of its external position, producing better results with less force (Fig. 15-7).

Basic exercises may be effectively merged to meet the needs of the individual situation. For example, active assistive exercise is a combination of active and passive exercises in which the involved joint is moved actively as far as possible with passive completion of the remaining arc of motion.

A sequential program employing these basic kinds of exercises in a logical order eliminates many hours of nonproductive exercise for the patient. Achievement of passively supple joints is a prerequisite to the establishment of active range of motion and resistive exercises. It must be recognized that the active

Splinting Basics

Fig. 15-6 A, Specific graded activities are often coupled with projects that encourage gross and fine motion of the extremity. B, A thermoplastic hook attached to the splint allows the patient to perform shoulder strengthening exercises while protecting healing structures. Adding resistance to splints enhances patient endurance and strength. This technique is effective when treatment goals include strengthening while simultaneously protecting an injured adjacent joint or healing structure. (Courtesy (A) Joan Farrell, OTR, Miami, Fla.)

Fig. 15-6 A, Specific graded activities are often coupled with projects that encourage gross and fine motion of the extremity. B, A thermoplastic hook attached to the splint allows the patient to perform shoulder strengthening exercises while protecting healing structures. Adding resistance to splints enhances patient endurance and strength. This technique is effective when treatment goals include strengthening while simultaneously protecting an injured adjacent joint or healing structure. (Courtesy (A) Joan Farrell, OTR, Miami, Fla.)

motion of a joint cannot be greater than its existing passive range of motion, and, regardless of the strength or amplitude of the involved musculotendi-nous unit, absence of satisfactory passive joint motion will negate its functional effect. Adequate active joint motion depends on a minimum of fair grade muscle strength. In the presence of resistance-producing tendon adhesions, the involved musculature should be functioning on a good or normal level to effect excursion change.

Muscle atrophy, with or without myostatic contracture, will have a profound effect on the ultimate performance of a joint after it has been successfully mobilized. Therefore, it is essential to initiate and

Grades Passive Range Motion
Fig. 15-7 Because extrinsic digital tendons normally run parallel to the phalanges, their force angle of approach to the joints they cross is not as mechanically advantageous as that which may be achieved by an externally positioned splint.

maintain muscle-strengthening exercises early in the rehabilitation process, often well in advance of the ability of the muscle to effect appreciable motion at the joints it crosses. It is also important that these strengthening exercises be carried out in all extremity muscle groups, not only in those whose weakness or atrophy is obvious.

I TORQUE TRANSMISSION SPLINTS

A special group of splints transmit internal torque to joints that are situated, for the most part, outside the physical boundaries of the splint. Often dubbed "exercise splints" or "substitution splints," these sophisticated splints were only recently recognized by the authors as a uniquely different group of splints that encompass a fourth purpose classification to the expanded SCS. Proper use of these splints requires a thorough knowledge of normal anatomy and kinesiol-ogy, a comprehensive understanding of upper extremity pathology and its effect on functional patterns, and an in-depth proficiency in splinting. In hindsight, it is ironic that what is in all probability the most advanced of the splint purpose groups was not given due respect because of the simple external appearance of many of these splints. They often lack more complicated components like mobilization assists, outriggers, etc. Torque transmission splints position or control selected joints within a digital ray to allow predetermined internal muscle tendon units to create articular motion at joints lying distal or proximal to the controlled joint(s). Direction of the transmitted torque may be longitudinal or it may be transverse (Fig. 15-8). While all splints transmit torque to unsplinted joints, the differential factor between torque transmission splints and other splints that immobilize, mobilize, or restrict joint motion is that

Long Index Finger

Fig. 15-8 A, Index finger IP extension and flexion torque transmission splint, type 1 (3) B, Long finger MP extension and flexion torque transmission splint, type 1 (2)

Torque transmission splints generate motion at selected longitudinally (A) or transversely (B) oriented joints outside the physical borders of splints. [(B) from Thomas D, Moutet F, Guinard D: Postoperative management of extensor tendon repairs in Zones V, VI, and VII, J Hand Ther 9(4):309-14, 1996.]

Fig. 15-8 A, Index finger IP extension and flexion torque transmission splint, type 1 (3) B, Long finger MP extension and flexion torque transmission splint, type 1 (2)

Torque transmission splints generate motion at selected longitudinally (A) or transversely (B) oriented joints outside the physical borders of splints. [(B) from Thomas D, Moutet F, Guinard D: Postoperative management of extensor tendon repairs in Zones V, VI, and VII, J Hand Ther 9(4):309-14, 1996.]

the primary purpose of torque transmission splints is to internally conduct muscle-tendon moment to predetermined joints to bring about active motion at these joints. Because they often lack external mobilization components, these splints are the ultimate in "low-profile" splint designs.

Torque transmission splints are used to transmit internal forces to supple joints to produce motion or to contracted joints to affect soft tissue remodeling. Splint configuration is the same for both purposes; only the condition of the target joint(s) differs.

From experience in casting Hansen's disease patients' hands, Brand noted that prolonged use of torque transmission splints can result in gradual correction of contractures through soft tissue remodel-ing.6-10 This technique differs from serial casting to correct joint contracture in that the plaster cast is not changed sequentially. Instead, the plaster splint is worn for a long duration, holding key joints in predefined postures, allowing extrinsic tendons to affect motion at contracted joints outside the splint itself. With functional use and over time, the pericapsular structures around these external-to-the-splint joints remodel, and range of motion improves. Described by Brand* in the 1950s, and routinely used by many clinicians, Colditz has further popularized this technique the past few years.24

Historically, torque transmission splints are not new. They have been used for centuries to improve function. The only difference is that these splints have not previously been classified as a separate group. Torque transmission splints are included in the exercise section of this chapter because they frequently are used to maximize active tendon excursion and articular motion. (For other torque transmission splints in this chapter, see Figures 15-5, A-D; 15-8, A,B; 15-14, B-I; 15-15, A, C-G; 15-16, A-C; 15-18, B-D; 15-19, F-J; 15-22, A; 15-24, B; 15-31, H.)

I TIMING AND TYPE OF EXERCISE

Exercise, like splinting, should be adapted to correspond to the physiologic stages of wound healing. Knowledge of the inflammatory process and the repar-ative schedule of the various tissue types found in the hand are paramount to successful therapeutic intervention. Individual factors such as anatomic structures involved, etiology, surgical procedures, concomitant patient risk factors, medications, age, intelligence, motivation, and prognosis all influence the timing and form of exercise used. For example, although tension may be applied to some cutaneous and soft tissue repairs within a few hours postopera-tively, the use of full-range active exercise may be con-traindicated for tendon or ligament repairs. Resistive exercises are frequently delayed until tissue tensile strength is sufficient. Some exercise routines, such as early passive or active mobilization of tendon repairs, are used for adults, but they are inappropriate for young children or those whose motivation or abilities are limited. And, although full active motion may be attained quickly, unrestricted use of the hand may not be permitted at 12 weeks in a flexor tenolysis patient who has a history of previous rupture.

Throughout the rehabilitative period care should be taken to ensure that the implemented splinting and exercise program is truly effective. Range of motion measurements provide numeric verification of the progress being made and assessment of volume; skin

*See Chapters 1 and 3.

color and skin temperature ensure that detrimental ramifications such as local inflammation or increased edema are prevented.

I COORDINATION OF EXERCISES AND SPLINTING SCHEDULES

The coordination of exercise and splinting schedules is dictated by individual patient requirements. Although general guidelines based on diagnosis must be followed, the rigid adherence to a predetermined routine without consideration of specific patient factors produces less than desired results. It is important to remember that, although they may have similar diagnoses, no two patients respond to therapeutic intervention exactly alike. The astute upper extremity specialist has an overall concept of the course of treatment to pursue, but this is guided, refined, and adapted to meet the unique needs of the patient.

Before a schedule is devised, splinting and exercise parameters must first be defined with measurements obtained from precise and accurate assessment instruments. Some schedules are straightforward and fairly routine; many others require experience and open-minded creativity on the part of the upper extremity specialist. For example, if three weeks after PIP joint capsulectomy, a patient has greater limitation in active and passive extension than in flexion, then, to focus on the extension problem, the patient may be instructed to wear his extension splint twice as long as he wears his flexion splint while at the same time continuing his active flexion and extension exercises on an hourly basis (Fig. 15-9, A). If, after a week, routine goniometric measurements indicate that passive and active flexion has improved considerably but passive extension has plateaued, the patient is instructed to further increase the amount of time in the extension splint, and the flexion splint time and frequency of active exercise are relatively decreased. Splint care and wearing instructions help ensure that patients understand proper care and use of the splint (Fig. 15-9, B). If the patient does not progress as expected, the use of additional treatment techniques or modalities may be considered, providing no contraindications are present (Fig. 15-10).

Assessment data provide guideposts for coordinating splinting and exercise programs. Without evaluation, splinting and exercise programs are directionless and limited in their effectiveness. Each tied to the other, assessment, splinting, and exercise play unique and critical roles in the rehabilitation process of a diseased or injured upper extremity.

SPLINT-EXERCISE SCHEDULE

Wear splint 4 hour, minutes.

Exercise minutes. Hear eXTZAS&jj; spllnt hour> minutes.

Exercise /¿> minutes. Hear ^Sd&jAS splint hour, ^ minutes.

Exercise S0 minutes.

Repeat schedule throughout day. Sleep in A^dryyT' splint. Call Hand Rehabilitation Center if you have questions.

SPLINT-EXERCISE SCHEDULE

Exercise minutes. Wear ¿ZTfU&M/splint _/_ hour, minutes.

Exercise /Q minutes. Wear /•¿¿fstfjC splint £) hour, minutes. Exercise minutes.

Repeat schedule throughout day. Sleep in At/fitf/" splint. Call Hand Rehabilitation Center if you have questions.

Splint Wearing Schedule Form
C

Fig. 15-9 A-C, Examples of splint care and wear instruction forms. A,B, By increasing the periods of extension splinting while decreasing flexion splinting and exercise times, passive joint extension is emphasized.

I SPECIAL PROBLEMS ACCORDING TO ANATOMICAL STRUCTURE

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