Vol. 22 Issue 22
Occupational therapy intervention to restore mobility and function
Patients often tell their therapist that, before they were diagnosed by their physician, they had no idea as to why their fingers were slowly drifting down toward their palm. However, once the condition has progressed, therapists can usually spot Dupuytren's disease a mile awaythe obvious sign is the flexed posture, often of the fourth and fifth digits of the hand.
Dupuytren's is insidious in nature; patients only gradually become aware of the difficulty they encounter while using the affected hand in a variety of ADL–retrieving items from a pocket, holding golf clubs and, the oft-heard complaint, being unable to politely shake an acquaintance's hand.
Also known as fibromatosis, Dupuytren's disease causes the fascia itself to become diseased, changing normal tissue into fibrotic tissue and cords, which serve to limit movement.
MCP contractures are the most common sequelae of the disease, due to restriction of the pre-tendinous bands; PIP contractures are a result of involvement of the fascial bands and/or with the development of spiral, lateral, central or retrovascular cords. First web space contracture may occur when the natory ligament is impeded by the diseased tissue.2
Role of OT
The role of hand therapy is primarily to aid in wound, edema and scar management; and to restore function, mobility and strength postoperatively. Dupuytren's disease is progressive in nature, and generally not amenable to change via conservative means.
The only reason an occupational therapist may be consulted to intervene prior to the patient undergoing surgery would involve delaying progression of contractures. Temporarily reducing the degree of MCP/PIP flexion contracture by splinting and exercise may facilitate posture of the hand for surgery or may be useful in helping the patient delay surgery in cases where there may be other health concerns.
Without surgical correction, your therapeutic efforts are usually thwarted over time as the patient's fingers return to their flexed posture.3
The patient's physician may consider surgical repair in the otherwise healthy patient to correct flexion contractures of the MCP/PIP–generally MCP contractures greater than 20 degrees or PIP contractures greater than 30 degreesespecially if the contractures are significant enough to limit the patient's functional use of the hand.1 Other factors that need to be corrected are circulatory or sensory compromise from diseased tissue compressing the delicate neurovascular bundle.
Surgical removal of the diseased tissue is not without risk–loss of active flexion, infection, damage to the neurovascular bundle, hematoma, RSD (reflex sympathetic dystrophy)/CRPS (complex regional pain syndrome), poor/slow healing and recurrence of the disease. Typically, more radical approaches have a lower recurrence rate.2,3
Types of Surgery
Fasciotomy: The diseased tissue is cut into and separated via an incision in the palm. This approach is typically used to correct MCP contracture only, as there is no digital dissection performed. Comparatively, this is the more conservative approach used in the less advanced presentation of the disease and in cases when the patient may not tolerate more invasive approaches/longer rehabilitation.
Regional Fasciectomy: The diseased tissue is removed through an incision in the palm and involved digit(s).
Extensive Fasciectomy: The diseased tissue, as well as tissue suspected to be or become diseased, is removed. This procedure is more invasive and carries more risk of complications.
Dermofasciectomy: The diseased tissue and overlying skin are removed to reduce the likelihood of the contractures reoccurring. The wound is covered by a full thickness skin graft.2,3
The patient may also undergo manipulation of persistent PIP contractures and/or surgical release of adjacent contracted tissues during the aforementioned procedures. Closure of the wound may be primary/sutured, grafted or open-palm technique, in which the palmar incision is left to heal un-sutured, as to decrease the risk of hematoma and digital swelling. The wound is dressed, and a half-cast with elastic bandage is placed over the hand directly after surgery.2
The Therapist's Intervention
Typically, the physician will order an occupational therapy/hand therapy evaluation with subsequent treatment to commence at or after postoperative day 3 for procedures that do not entail a skin graft, and at or after postoperative days 7-10 for procedures that do entail a skin graft.
The therapist is usually consulted to replace the half-cast with a dorsal or volar thermoplastic splint at that time. The preferred wrist position of the splint ranges from either neutral or slight flexion, with the digits in tolerable extension. It is imperative that you maintain the position of extension without placing undue stress/stretch to the healing wound and neurovascular bundle.
The splint is worn continuously for three weeks, except during exercise and hygiene. Thereafter, it is gradually weaned for day wearing but worn at night for 3-6 more months to maintain surgical and therapeutic gains. A dynamic splint may be required, once healing is complete, to address limited extension/flexion.2,3
The timing of treatment should be commensurate with the physician's order and the state of healing. The therapist may then assist the patient to re-integrate his affected hand in functional activities by focusing on these key areas:
Wound care. Change the dressing as directed by the physician at each session. Assess for hematoma and signs of infection. Remember the four cardinal signs of infection: redness, swelling, warmth and pain.
Make sure to instruct the patient in the procedure for dressing changes and the normal healing process, especially for the patient with an incision healing by open-palm technique as this type of healing process can look quite scary to the patient. Sterile whirlpool at approximately 98-100 degrees may be indicated to facilitate healing of the open-palm wound.
Scar management. Scar massage and the use of silicone gel sheeting are indicated when wound closure is complete at or after 14 days. Massage should begin very gently over graft sites.
Physical-agent modalities such as paraffin and ultrasound may be used to provide comfort and assist in scar reduction and remodeling, but should be used at the discretion of the physician and therapist.
Edema management. Encourage frequent to occasional elevation throughout the day, tapering as healing progresses, with pillow elevation at night. Use self-adherent compression wrapwhich does not adhere to skinon swollen digits at night after wounds have healed. Severely swollen digits may require a schedule of compression wrapping during the day which does not further limit functional use of the hand. Provide retrograde massage to intact skin.
Range of motion. Active/active assistive ROM usually are initiated on or after postoperative day 3 for wounds that have not been grafted, and on or after postoperative day 710 for wounds that have been grafted. Make sure to address both flexion and extension, slowly advancing to passive stretching. Perform exercises with the hand elevated to reduce edema.
Strengthening. Begin gentle strengthening at approximately 3-4 weeks postprimary closure, at 4 weeks with self-adherent compression wrap to protect graft sites, and at 6 weeks for a wound healing by the open palm technique.2,3
Patients suffering from Dupuytren's disease must carefully weigh their options for treatment, in accordance with their goals for a therapeutic outcome. The severity of the disease and the overall health of the patient will affect his ability to appreciate symptom reduction and improved function. Our approach for hand therapy, in order to maximize the patient's outcome, is one of vigilance, diligence and timing.
References available at www.advanceweb.com/OT or upon request.
Amy Roux, OTR/L, CHT, has been an occupational therapist at University of Massachusetts Leominster Hospital since 1993 and became a certified hand therapist in 2001. She has worked with patients ranging in age from 3 months to 104 years.