2/4/2019 1 Hand Therapy Management of Wrist Instability Aviva Wolff, EdD, OTR, CHT Clinician Scientist Leon Root, MD Motion Analysis Laboratory Hospital for Special Surgery Impairment Mechanism Design Testing Functional Improvement Development of Rehabilitation Approach Impairment Mechanism Design and testing Improvement in function Science informs practice WRIST INSTABILITY Rehabilitation Science of proprioception E Hagert Roles of the muscles in carpal stability M Garcia-Elias Wrist Kinematics and DTM Wolfe Individual occupational needs/expectations Mancuso How can an understanding of wrist motion lead to better treatment and rehab? Why is it important to understand carpal motion? • Understand effect of injury on motion Surgical planning • Surgical approach selected based on motion Early rehab • Minimize motion at repaired/injured structures Late rehab • Maximize path of motion First, Know and Understand the SCIENCE
18
Embed
Hand Therapy Management of Wrist Instabilityhandtherapyhub.com/2019_AAHS_Wrist_Instability/docs/AAHS_Wrist... · carpal DRUJ Instability Patterns Courtesy of Primal Pictures carpus
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
2/4/2019
1
Hand Therapy Management of Wrist Instability
Aviva Wolff, EdD, OTR, CHT Clinician Scientist
Leon Root, MD Motion Analysis Laboratory Hospital for Special Surgery Impairment Mechanism
Design
Testing
Functional Improvement
Development of Rehabilitation Approach
Impairment
Mechanism
Design and testing
Improvement in function
Science informs practice
WRIST INSTABILITY
Rehabilitation
Science of proprioception
E Hagert
Roles of the muscles in carpal
stability
M Garcia-Elias
Wrist Kinematics and DTM
Wolfe
Individual occupational
needs/expectations
Mancuso
How can an understanding of wrist motion lead to better
treatment and rehab?
Why is it important to understand carpal motion?
• Understand effect of injury on motion
Surgical planning
• Surgical approach selected based on motion
Early rehab
• Minimize motion at repaired/injured structures
Late rehab
• Maximize path of motion
First, Know and Understand the SCIENCE
2/4/2019
2
Anatomy Biomechanics Kinematic
Studies (DTM)
Proprioception Dynamic
Carpal Stability
ANATOMY
Scapho-Lunate
Mid-carpal DRUJ
Instability Patterns
Courtesy of Primal Pictures
carpus
DRUJ
metacarpals
radius ulna
R wrist,
palmar
view
Distal row
Proximal row
RC Joint
MC Joint
1. Motion occurs primarily at RC and MC joints 2. Ligaments are important primary stabilizers
Proximal Row = “intercalated segment” Motion is dependent on mechanical signals from ligaments
Limit motion at S-L joint (biomechanics) Splints that limits motion to DT plane ONLY radial extension to neutral in SL acute injury and early post-repair
Courtesy of Hamish Anderson Lynn Feehan, JHT 2016 Federica Braidotti, JHT 2015
Rigid tape for pre-dynamic S-L instability
Poretto-Lourke, JHT 2016
Limit activities to DT plane Limit to radial extension to neutral in early phase
Proprioception
Begin proprioceptive training for injured ligaments
Goal:
Increase/develop proprioceptive awareness
and joint position sense
Mirror therapy
Contralateral
Creates illusion of motion
Stimulates somatosensory
cortex
Visual occlusion exercises
Eliminate visual and auditory
cues
Motor imagery
Hagert, JHT 2010
2/4/2019
11
Smartphone Apps
Alger and Valdes, JHT 2016
Dynamic Muscle Stability
Case Example 1
56 y/o, female
10 months radial wrist
pain
Full ROM
Her midcarpal joint is only
minimally maligned
Isometric stabilization exercises in PRONATION
ECRB APL
FCU
Case Example 2
60 y/o, male, Orthopedic Surgeon
6 month old injury to non-dominant right wrist, hit backhand shot, felt sharp pain
Pain with resistive activities, able to work with moderate ache, and able play golf.
Worried about progression and potential inability to play sports during retirement Left and right wrist neutral laterals,
both demonstrate 10 deg RLA, 70 deg SLA and no dorsal scaphoid translation
2/4/2019
12
Right injured wrist PA
Right injured ulnar dev PA
Right injured grip
Template
vSLIL intact but stretched
dSLIL intact but stretched RSC and LRL intact and robust
Consecutive cuts of radioscaphoid fossa showing no dorsal translation
Cartilage-sensitive sequencing showing no cartilage loss
2/4/2019
13
DRC intact and robust.
DIC attenuated but intact and lunate and scaphoid attachments on sagittal images appear to be intact.
DIC
DRC
Template
DIC attenuated but intact and lunate and scaphoid attachments on sagittal images appear to be intact. Distal band of DIC robust and intact
DIC distal band. dST?
Later Phase
Later phase (stable joint and healed ligaments)
Biomechanics
Activities that maximize
circumduction envelope
Begin strengthening in DT plane
Proprioception
Isokinetic – BTE CPM PRIMUS
Isokinetic exercises
Neuromuscular Rehab
Reactive muscle activation (RMA)
Perturbation exercises
(plyometrics)
Oscillatory Devices (body blade, weighted
pipe, power ball (Balan et al 2008)
Circumduction
Maximizing Circumduction Envelope
2/4/2019
14
Strengthening in DT plane
Holmes et al, 2016
Proprioception
Kinesthetic awareness
Smallest change in joint angle needed to
elicit a conscious awareness of joint
motion
BTE PRIMUS – CPM
Passive mode
Isokinetic mode
• Performed at constant angular speed
Neuromuscular Purpose
Promote motion in muscles that are joint protective while avoiding activation of muscles that are joint damaging