maanantai 16. huhtikuuta 2012

Improve the flexibility of your hand, fingers and wrist with easy exercises at home





Now a new, completed version:


Rehabilitation after plaster cast at home & 2 Hand rehabilitation cases

This book is based on the blog I started to write in 2011 concerning the rehabilitation and it’s progress, including the exercises that helped to eliminate the problems of my fingers, and mobilization exercises I got from hospitals.

However, this book contains more information, all stretching exercises for hand and fingers, more information concerning the first case, the new different second hand rehabilitation case, and instruction how to remove stiffness from hand and fingers and how to make yourself a PE foam disc, the best tool for elimination of stiffness from the fingers.

These stretching exercises may be used also in case in case you have feelings of tightness, cramps or pain in your hand, or in case of Dupuytren's contracture, in early stage, when the hand is still flexible.

Elisa Kirja, e-book (pdf), 42 pages, Price: 0,90 €

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Information in English: http://www.elisa.com/en/

Left hand two weeks after
finger operation,
September 2010

Left hand nine weeks after 
wrist operation,
March 2010

The hand on the left needed an operation, 6 months later.

The hand on the right needed stretching exercises and ring splints.

However, they look almost identical in these pictures...

In the case of Dupuytren's contracture, the doctors are right, when they say, that splinting or stretching  are not recommended.

Splinting or stretching do not help when the hand is stiffened, like my hand was in August 2010, but in early stage stretching exercises can prevent from stiffening, and remove the feelings of tightness and cramps from the hand. 
Left hand in August 2010

Most doctors recommend only observation in the early stage. However, in some cases stiffening can progress rapidly, in 3 or 4 months, and then it's too late.

In addition to the stretching exercises, there are instructions how to remove stiffness from a wrist, how to remove stiffness from fingers and how to make a PE foam disc at home.

The stretching exercises are recommended specially in the case there are feelings of tightness, cramps or pain in the hand, because they may indicate a tendency to bent fingers or other problems in the hand. 

Start the stretching exercises as soon as possible, when you have noticed the feelings and the first symptoms of future problems, with observation the best rehabilitation time will be soon over, and when the hand or fingers are stiffened, an operation is needed.  

Blog contents: 

I - Hand rehabilitation after plaster cast at home & in case of special problems

1. Plaster cast care, 
2. Exercises for a hand in plaster cast or wrist support
3. Mobilization exercises for hand and fingers after plaster cast, 
4. Wrist stretching and mobilization after plaster cast,  
5. Water gymnastic and swimming,  
6. Hand warming,  
7. Skin care & massage of the scar, 
8. Swelling, 
9. Strength training & gym, 

II -  Special problems after plaster cast or other trauma



1. Stiff fingers after injury or plaster cast &  pulling sensation or feeling of cramp or pain in the palm.  
2. Stretching eliminates pulling sensation, tightness and feelings of cramps or pain
3. Stiffness or tension removal (hand and fingers)
4. Finger splints help to straighten the fingers,
5. Stretches & finger splints help the fingers to bend 
6. Splints used in hospitals for knuckles and fingers
7. Sprained finger knuckle - active isolated stretching

III - The first hand rehabilitation case - my left hand


1. Injury and rehabilitation, 
2. Hand rehabilitation schedule was the following, 
3. Pain
4. Summary of the rehabilitation, 
5. Maintenance training,

IIV - The case of my right hand - Dupuytren's contracture?


1. Injury and rehabilitation, 
2. Orthopedic links, Dupuytren's contracture, vitamin D, 







I - Hand rehabilitation after plaster cast at home & in case of special problems

1. Plaster cast care 

Keep your arm or leg raised on a pillow for the first 12 hours and rest. This will help any swelling to go down. Continue to do this for another 12 hours if the cast still feels tight.

Don't get your plaster cast wet. This will weaken it and your bone will no longer be properly supported.

You can use a plastic bag to cover up the cast when you have a bath or shower. Try using sticky tape or a rubber band to seal the bag at the top and bottom, to make it as watertight as possible. Alternatively, it is possible to buy special covers for plaster casts to keep them dry. Ask your local pharmacist (chemist) for more information.
Always remove the bag as soon as you can, to avoid causing sweating, which could also damage the cast.

Even if the plaster cast makes your skin feel very itchy, don't be tempted to poke anything underneath it. This could cause a nasty sore. The itchiness should settle down after a few days.

More plaster cast tips

- Don't let any small objects fall inside your cast, as they could irritate your skin.
- Don't try to alter the length or position of your cast.
- Don't lift anything heavy or drive until the cast has been removed.
- Use crutches or a sling, as advised by your health professional.

Plaster cast problems

You should go to A&E (accident and emergency) if:
- plaster cast still feels too tight after keeping it elevated for 24 hours,
- fingers feel swollen, tingly, painful (even after taking painkillers) or numb,
- fingers turn blue or white,
- cast feels too loose,
- cast is broken or cracked,
- the skin underneath or around the edge of your cast feels sore, or
- there is an unpleasant smell or discharge coming from your cast.
 If you have any concerns about your plaster cast, you can call a doctor for advice.Source: http://www.nhs.uk/chq/Pages/2543.aspx?CategoryID=72&SubCategoryID=721

I would add the following reasons to contact a doctor:
- if the swelling appears after the plaster cast put in wrist operation is changed
- if the elevated position of the hand is the only comfortable position (after the first days)
- if you start to feel pulling or cramp in your finger(s)
- if your fingers start to bend and stay crooked

In case of a wrist operation, the fingers are usually not swollen, because there is gauze under the plaster cast. When this cast is taken away and changed to a new plaster cast or wrist support, you get under it a tubular bandage. If the swelling appears after the change of the cast or support, the tubular bandage is too tight. 

2. Exercises for a hand in plaster cast or wrist support

You can start the exercises as soon as the cast is dry. 
Repeat every exercise 10 times and 3 - 5 times per day. 

Cast on the hand can complicate gripping, reaching, dressing, writing and eating. 
Try to use your hand as much as you can in normal activities, but avoid lifting heavy objects during the first 100 days after a fracture or bone operation.

In some cases you get, for the last weeks, a wrist support instead a plaster cast.

Exercise for the thumb 

Bend the thumb slowly towards the little finger (pinkie) base, and then extend the thumb to the side.  Repeat 10 times.
Touch with the thumb the tip of the finger, bending the finger at the same time, then extend the finger straight. 
Repeat 10 times with each finger.



Bend and extend the fingers

In case your fingers feel stiff or tense, keep the hand in vertical position, bend the fingers to tight fist and keep for 10 sec, then extend the fingers straight and keep for 10 sec.

Repeat the exercise a few times.


Extend the fingers wide apart

Extend the fingers straight and then wide apart, as much as possible and stretch during 10 seconds, then bring the fingers back together. Repeat the stretch a few times.

Shoulder

a. Lift your arm up so that your overarm touches your ear
b. Stand with your back against a wall. Lift your arm sideways up, straight. Let your arm glide downstairs touching the wall. 
c. Lift your arms up and bring them behind your neck, so that the fingers touch. Then, move your elbows backwards. 
d. Bring you hand in plaster cast behind your back and try to touch the shoulder blade on the other side of your back. 

Elbow

Bend the elbow, extend the elbow ( if not in plaster cast)

Swelling in plaster cast or wrist support

In case the hand is swollen, keep your hand as much as possible in vertical or elevated position. Repeat the exercise "Bend and extend the fingers" and try to pump away the swelling. This exercise doesn't always help. 

If the tubular bandage is unpleasant and you have a feeling that it is too tight, change the bandage, if possible. Sometimes hospitals have only on size of bandage, but they are sold in pharmacies.

3. Mobilization exercises for hand and fingers after plaster cast or wrist support

After a plaster cast, wrist, hand or fingers need workout, you will get the instructions from a physiotherapist specialized in hand rehabilitation. Physiotherapist in hospitals gave these instructions.

Hand and finger exercises are to do every day, a good rule is every two hours. Make the gymnastics very slowly, take the movement as far as possible and keep the end position for some time, and stretch.

In addition of the gym, use and move your hand as diverse ways as possible, but avoid lifting heavy objects during the first 100 days after a fracture or bone operation.
Check with a specialist physiotherapist, when you can start training with weights.

Thumb flexion 

Slowly bend your thumb toward the little finger base and hold for 5 to 10 seconds. Assist if necessary. Then extend your thumb to the side. Repeat 5 - 10 times.
Slowly, touch with the thumb the tip of each finger, and extend the finger after the touch. Repeat five times per finger. This exercise was given when my hand was still in the plaster cast. 
Exercise catching of small objects with the fingers.

DIP joint flexion. 

If you do not have the plastic disc, bend the DIP joint of a single finger and at the same time keep the PIP joint straight with the other hand. Keep the fingertip bent from 5 to 10 seconds and then extend the finger straight. Repeat 5 - 10 times for each finger. I got the yellow foam disc (7,5 cm x 2 cm / 2.92 inch x 0.78 inch) in Tunisia.

PIP joint flexion 

Make the same movement, each finger separately, but bend the PIP joint and hold the flexion of 5 to 10 sec period. Extend your finger straight. Repeat 5 - 10 times for each finger.

Bending one finger at a time 

Keep your fingers straight and slowly bend one finger toward the palm. The movement is easier to do, if you keep your other fingers in place with the help of the other hand. Keep the bend from 5 to 10 seconds and then extend your fingers straight. Repeat 3 to 5 times for each finger.

Note: If you fingers are bent, even slightly, after repeated bending they will be more bent. The counter movement is straightening stretch against a firm surface; the use of ring splints will help also.

Knuckles flexion

Bend the knuckles at right angle, keep the fingers straight, and hold for 5 to 10 seconds. Extend your fingers straight and hold for 5 - 10 seconds. Repeat 5 - 10 times.

Palm rolling with a ball

Put the hand on top of an appropriately sized ball and roll the ball with the palm, from the bottom of the palm up to the fingertips. Repeat 30 times.

Squeeze of a sponge or a ball 

A strong squeeze is an excellent way to increase strength in hand and fingers and to eliminate tension. 
Keep the wrist behind and squeeze the ball in slowly for 10 seconds, repeat 10 times. 
You may start with a sponge.
When you move to a ball, you need to find the right size and right flexibility, not too soft. I found this ball in a toy store and it's diameter is about 6,5 cm (2.53 inch). By squeezing it, I can flatten it out to a disc, which height is under 3 cm (about 1 inch).

When the hand and fingers become stronger, you need to change the ball to a firmer one.

The counter movements of squeeze are the straightening stretch against a table; and the stretch for cramp removal; make them, if necessary. 

Squeeze of grains

Put your hand inside a cotton pouch filled with 2 kg of grains (wheat), and squeeze the grains with your hand.  Ask a physiotherapist for further instructions. 

You can also warm can the pouch in micro-oven for 4 to 5 minutes, before you do this exercise. See section 6. Hand warming. The temperature is maintained for a long time in grains.

Stretching exercises for hand and fingers

Stretch wide apart 

Spread the fingers apart widely, stretch during 10 seconds, and then bring them back together. Repeat the stretch a few times.

Some time ago, and from time to time, the PIP-joint in my little finger in the right hand began to bend like a "gear". It was hurt in School, during a volley match, when I was 15 years old. When this happens, I do a stretch wide apart and it helps, at least for a while.

Hand cramp removal 

After the both surgeries, when the plaster cast was removed, I felt cramps in the hand and the fingers; and the fingers bended spontaneously. If you make precision
handwork for long periods without resting the hands, they can also cramp. For this reason, in some craft books there are stretching instructions for cramp removal.
For removal, stretch the palm and fingers using your other hand.  You can also push the fingers against the surface of a table and stretch. Do also other hand stretches and massage the hand. This stretch is an excellent counter movement after the bend/extend stretch or after squeezing a foam disc.

4. Wrist stretching and mobilization after plaster cast

After a plaster cast, the wrist may be stiff and needs stretching. 
Exercise and swimming in warm water is the best way to rehabilitate a stiff wrist and hand; it improves the movements and flexibility. 
If this isn't possible, you can do the following exercises:

Wrist rotation 

Place your forearm on a table palm down, then turn the palm up and hold for 10 seconds Repeat from 3 to 5 times. 
You can also do a stretch in such a way that you put your elbow to your side and slowly rotate your forearm so that palm looks alternately up and down, and hold the position for 10 seconds.

Wrist Stretch 

Pull the hand against a low table and then turn the arm to more upright position so that the stretch can be felt inside of the wrist; keep the stretch for 10 seconds. Repeat three times.


Wrist stretch backwards and forwards without a weight 

Place your the forearm on a table so, that the palm is outside the table edge and facing downwards. Bend your fingers in a fist and lift your wrist up (back) and hold for10 seconds. Extend your fingers and bend your wrist downward (forward) and hold for 10 seconds

Wrist stretch backwards and forwards with a weight 

To boost the wrist lift upwards and downwards do the exercise with a small weight, at most up to six pounds (500 g). The physiotherapist recommended this movement one month after the finger surgery. Check with a specialist physiotherapist, when you can start training with weights.

Stretch the wrists from side to side with interlaced fingers 

Put your elbows on the table, raise your hands and interlace your fingers.
a) Bend your wrists gently from side to side and front - back.
b) Turn the hands so that you see the back of your right and left hand alternately.
Repeat both exercises from 5 to 10 times.

Stretch the wrists with interlaced fingers 

Interlace the fingers so that the palms are towards yourself and then turn the hands slowly to opposite direction. Repeat a few times. 
The physiotherapist in Djerba / Tunisia asked me to do this exercise, and I wasn't able to do it the first day, but the next day I was.

5. Water gymnastic and swimming

Exercise and swimming in warm water is a very good way to rehabilitate a stiff wrist; it improves the flexibility. 
In Helsinki, there is a hydrotherapy pool in Mäkelänrinne, where the water is slightly warmer than in the normal pool.

This blue water gym equipment, stretching gently the palm, was in use in Djerba /Tunisia,  as well as the yellow foam disc. The Spa had a warm seawater pool at 30 ° C, and the possibility for individual rehabilitation.

My program included mainly two types of movements:

- I walked in the pool, bringing the knees up sharply, and at the same time I did twisting and turning movements with the wrists and hands, using a light tool to increase the resistance.
- I moved forward along the railing of the pool with the help of my hands, turning the wrist up and down alternately, in this exercise I did not touch the bottom of the pool with my feet.
The physiotherapist made the same movements and corrected immediately, if I didn’t do the movement properly.

With the help of water gymnastic, the flexibility of my wrist increased much more in one week than with mobilization exercises during the three preceding months.

6. Hand warming

Hand warming increases the mobility of the hand and fingers, remove the tension and increase the sense of flexibility in hands. 

Warming can be made with 2 kg of grains (wheat), in a cotton pouch, which is heated in micro-oven for 4 to 5 minutes. Put the hand in the pouch, do different movements and squeeze the grains. Ask a physiotherapist for further instructions. The temperature is maintained for a long time in grains.

Quick warming can also be made with a small heating pad (electric). 

Warm water increases the flexibility in the hand, and a warm shower directed to the hand activates the blood circulation. 

You get good exercise for the hand and fingers when you wash clothes by hand, in warm water. In case you need to increase the flexibility of your wrist, water gymnastic is much more efficient.

Keep the hands warm in draughty and air-conditioned areas by using gloves or fingerless gloves. Hands stay warm at night with woolen fingerless gloves; they also reduce the stiffness in the hands in the morning. Choose a model, which is not too tight.

7. Skin care & massage of the scar 

Rotate the scar

Skin care after plaster cast

If you have been in a cast for several weeks, “dead” skin can build up under the cast.  Once the cast is removed, you can remove part of the “dead” skin with oil. If the skin is very dry, you can also soak your skin in warm water twice a day, and then use some oil or a cream for dry skin.  Rub dry gently with a terry towel, and be careful not to damage the new skin.  

Massage of the scar

Massage improves the circulation of the hand and takes care of the scar. 
After an operation, you may initiate the massage of the scar after the removal of stitches. 

Rotate the skin of the scar, so that the scar is moving. If you do not rub the scar enough, this massage feels painful. After you have stopped the massage, check the condition of the scar from time to time. If the rotation of the scar starts to feel painful again, restart the regular massage. 
You can use a cream for dry skin or an oil to the massage.

You can prevent the hypertrophy of the scar with a silicone cream (Kelo-cote). Ask your physiotherapist for more instructions. 

8. Swelling

After surgery, the hand was swollen, specially the backside of the hand. About six months later it began to look better, except that the fingers were hooked.
The knuckles were also reddish for a few months. The physical therapist in hospital proposed some drugs, but because I had no pain, I didn’t try them.

After the finger and knuckles operation the hand and fingers were swollen again, and most of the swelling decreased after about four months.

Also the PIP-joints thickened in the finger surgery, especially the PIP joint of the little finger, which thinned slowly, taking 15 months. In the ring and middle finger the PIP-joints returned to the normal size after one year.

I didn’t do anything special because of the swelling, but I gave my hand a daily water jet massage. For more efficiency, alternate the temperature of the water, between warm and cold.
Water aerobics and swimming are also likely to be good activities to swollen hand.

9. Strength Training & gym

Hand rehabilitation specialist physiotherapist will give to you instructions and schedule for the strength training.
You can start workout in the gym quite soon after the plaster cast, but adapt the training for the hand, and ask advice from a trainer before you start. Strength training reduces stiffness.

Sometimes the wrist with titan may not like turning or twisting movements when you use bigger weights, in that case modify the exercise so that you keep the wrist straight.



II - Special problems after plaster cast or other trauma


1. Stiff fingers after injury or plaster cast &  pulling sensation or feeling of cramp and pain in the palm.   

  • In case you feel tightness or pain in the tendons of your palm or fingers when the hand is in cast or wrist support, or after it, it can lead to an inability to extend or bend the fingers well and cause later permanently bent fingers, if nothing is done. 
  • There can be stiffness in the fingers after an injury or plaster cast. It can be removed with right stretches.

Instructions are in the book:

2. Stretching eliminates pulling sensation, tightness and feelings of cramps or pain

In case you feel pulling sensation, tightness or pain in the tendons of your palm or fingers when the hand is in cast or wrist support, or after it, it can lead to an inability to extend or bend the fingers well and cause later permanently bent fingers, if nothing is done. If you have feelings of cramp in your hand, the result may be the same. 

You may also have difficulties when you extend your hand, your palm may stay a little bit bent and one of the fingers may be out of align.
In case you have also some tendons of your hand forming higher spots in you palm, you may see the first symptoms of Dupuytren's contracture in your hand.

Observation isn't recommended, because during the observation the hand and fingers may stiffen and your palm contract, then the only option is a surgery, one ore more times. 
Instead, start daily stretching exercises as soon as possible, because they help only when your hand and fingers are still flexible.

Stretching help the fingers to straighten and to bend better. 

The bending of the knuckles and the wrist can also be improved by stretching; and the feeling of a cramp can be removed. 
Regular stretching exercises helps to keep your hands and fingers elastic and flexible.
Stretching can be active or passive, performed with stretching exercises or with splints.





Instructions are in the book:


3. Stiffness or tension removal (hand and fingers)

After a plaster cast, hand and fingers may be stiff. Finger can stiffen also after an injury.
The use of finger splits and the stretching of the fingers straight against a table stiffen the hand and fingers; likewise the hand can be rigid or there can be a feeling of tension in the fingers for other reasons.

There are two different exercises which help to remove stiffness:
  • Bend / extend stretch
  • Foam disc squeeze
You can find more information in the book:

Left hand in August 2010

4. Finger splints help to straighten bent fingers


In addition to stretching, finger splits may be needed for the straightening of the fingers. Sometimes, the best results are obtained by combining the both, at least in the case the fingers have already been bent for some time.
However, finger splints do not straighten stiffened fingers.
Hand in February 2012

Wear the splints at least half an hour at a time three, times a day.
Note: the use of finger splints stiffen the fingers, so that after their use, it is important to do the bend/extend stretch, as well as other hand-and finger exercises.
If the use of a finger splint begins to feel painful, try a different model or take a break and make different hand exercises.

Spring splints and ring splints

Finger splints with a spring 

Splints with Velcro fastening suit even crooked fingers. The correct length of the splint is important, if too long, it does lift the fingertip upward. Small sizes, suitable for little finger, can be difficult to find. The stretch of a spring may be quite strong; they cannot be used for long periods of time. Spring splints are usually not used simultaneously at adjacent fingers.

Ring splints 

If the fingers have enough flexibility, and are only slightly bent, ring splints are a good option. Ring splints exist in small sizes; they can be used in adjacent fingers, and under a glove.

Oval-8 Ring splint are made of plastic and a splint fits two sizes, depending from the side. Stretch the finger a little before putting the splint on; or use a cream to facilitate it. You may start with the bigger size, and after a while you can change the splint the other way. Ring splint can be adjusted with the help of health care professionals and special tools.

You can find more information in the book:


5. Stretches & finger splints help the fingers to bend 


If the deficiency in extension and flexion is the problem, the stretching is the first treatment method, if there is no physical trauma in the fingers.

Finger splints with a spring
Bend to fist
If the fingers do not bend well, they need both stretching straight and bend / extend stretch. 

After a wrist fracture and 7 weeks in plaster cast, my fingers didn't bend well. Finger splints with a spring helped my fingers to bend before the finger operation, however, they didn't  straighten my fingers anymore, because they were stiffened.

Start the stretching as soon as possible, otherwise the fingers may become so stiff, 
that they need an operation.

You can find more information in the book:





6. Splints used in hospitals for knuckles and fingers

If the fingers are stiff, and there is a pulling sensation on the backside of the hand and fingers when you bend them, the reason can be also in the knuckles, they do not bend well. 





My left hand needed a finger operation, because the splints didn't work well, either they didn't fit or they were too unpleasant to use. You can see some of the problems below, and more pictures  in: 


Splints for knuckles


In hospital, the occupational therapist will make personal knuckles splints and straps. It may help if you get it soon enough.
I got this customized thermoplastic splint in august 2010, on month before the finger operation, and it was much too late.
Splint for knuckles

The design of the splint is also important, it has to be ergonomic and easy to use. If the tension of the loops or straps is too strong, the instrument may feel painful, and cannot be kept a sufficient time in the hand.

If you need to strengthen the effect of the stretching, knuckles splint or rubber straps, or finger flexion gloves can be used. Use the aid half an hour, three times a day.
A physiotherapist specialized in hand rehabilitation may give you appropriate instructions.


You can find more information in the book:

The curve of the fingers is convex

Splints for fingers - night splints

Customized thermoplastic splint may be able to straighten the fingers when it is properly made, and if the fingers are not too stiff. Occupational therapist in hospital will make the customized thermoplastic splints.

Although from the hospital's point of view, customized thermoplastic splint is the traditional tool for straightening the fingers, it is not enough alone, at least when three fingers are hooked. In addition, daily stretching and regular use of ring splints are needed, as soon as possible.
Good fit, but
too flexible splint

Customized thermoplastic splint is a good if it is sufficiently stiff and fits well in your hand, the arch for the fingers and the angle for the wrist and knuckles must also be correct.

The best place for the straps is between PIP-joints and knuckles, if the straps run the over the PIP joints, the stretching is less efficient. The user is able to detect if the splint doesn’t fit, or it is very uncomfortable to wear. Sometimes the splint does not function well, and this can be seen only when after some time.
Good ergonomics,
convex curve

I got  this light blue customized thermoplastic splint in June 2010. The fit was perfect, but the plastic used was too flexible, and after two months use my fingers were more bent. I understood the connection only when a person with a crooked finger in the Health Care Shop confirmed me, that the stretching against a flexible surface does not straighten the fingers. My fingers were already stiff, so I got it also too late.

Bad fit, curved
forearm support
In September 2010, after the finger operation I got a new customized thermoplastic splint as soon as the plaster cast was removed, but the fit was bad (the beige/rosa splint). 
The first version had a curved forearm support and didn't fit to my hand, I had to take it back to the occupational therapist for repair.
The second wasn't much better, the ergonomics was still bad with a concave curve under the fingers.
Even the third version had the same problem. 
Finally, I did some modifications to the splint myself, and the finger surgery doctor inspected it. With the help of the self modified splint, I was able to straighten my middle finger, which was less bent, but not the ring and little finger.
Bad ergonomics,
concave curve

Hospitals are bureaucratic and splints are available only when doctors prescribe them, and the use of customized thermoplastic splints may be an old tradition.
It is easy to see and feel, if a customized thermoplastic splint fits well, but the results are visible only after a time.

It may take a long time before you receive a customized thermoplastic splint which is fit for your hand, and if you don’t do any other stretches, or use ring splints during the waiting period, it is difficult or impossible to obtain a good result.

An ergonomic, and stiff enough customized thermoplastic splint, straightening three fingers at the same time, is also very difficult to do.

Crooked fingers, May 2010 
Self-modified splint
It is important, that the straps stretch the first phalange, not the PIP-joints. If the curve for fingers is concave, the fingers are in a bad position and then the stretching is not effective.

If the PIP joints are inflexible, the use of a customized thermoplastic splint can produce a permanent hyperextension in the DIP joints (see the picture of crooked fingers May 2010), in case the ergonomics is bad.

In case the the ergonomics isn't good, a customized thermoplastic splint doesn't give any results, it's only a waste of time and money.



7. Sprained finger knuckle - Active Isolated Stretching

End of July 2012, I sprained the middle finger knuckle of my right hand. At first hand it felt completely normal, but a few hours later, the middle finger began to feel stiff and extension painful. Flexion went well and without pain.
There had just been a mention about Active Isolated Stretching in a newspaper, and I searched more information online. I began to stretch out my hand, using the same movements as in case of stiff hand rehabilitation, but at a fast pace.
Extension of fingers 2 sec
Flexion of knuckles 2 sec
I alternated extending the fingers straight and bending the knuckles, using a slightly flexible support under the hand, and hold both positions for only 2 seconds.
I also applied a dry cold pack for 10-15 minutes, but only once.

When I repeated these stretches, the pain disappeared from the hand in the same evening, and the next morning my fingers stretched easily and without pain. Middle finger knuckle was swollen and red, and in certain hand positions I felt pain, for example, when opening a jar lid.
On the third day, the finger was already almost normal, redness and swelling had decreased; yet I continued to stretch the fingers and knuckles from time to time.
On the fourth morning, the swelling and redness had gone and I was able to put a ring on this finger.
If the finger does not improve, it is important to consult a health care professional.
You can find more instructions for Active Isolated Streching here:




III - The first hand rehabilitation case - my left hand

1. Injury and rehabilitation

My left wrist was broken in Christmas Eve 2009 and the diagnosis was a fracture of ulna and radial bone, S52.6. 

Since the fracture was splintery, it was operated in another hospital 11 days later.
One bone got a titanium plate and two K-spikes were placed in the second. The plaster cast was quite long, it went over the knuckles, and the given the exercise program was minimal. 

When, two and half weeks later the plaster cast was replaced the doctor noticed that the spikes had pressed the skin. I didn't like the new, lighter cast, made with a tight tubular bandage, two plaster slabs and elastic bandages, which felt like a too tight ribbing, and caused swelling and problems in fingers.  Altogether, the hand was in a cast during seven weeks.

In February 2010, when finally the cast and the spikes were removed, the little finger was bent. I asked the doctor whether the spikes were placed through the tendon, because I felt tension in the tendon of the little finger. The answer was: NO.

After the removal of the cast, physiotherapists gave me instruction for mobilization of the hand and fingers. There were some wrist stretches (see chapter 5.); and one ineffective stretching instruction for bent finger. Effective stretching instructions for fingers and finger splints were missing completely.

Hand in the evening,
March 2010
Hand in the morning,
March 2010
In March 2010, one month after the removal of the cast, I met the surgeon for the first time after the wrist surgical operation. Because of the wrong plaster cast and/or long time spent in plaster cast, or some internal injury, and the lack of proper rehabilitation, my hand looked like this, fingers extended.
The finger were slightly less bent in the morning, but the during the day the fingers crooked again, and I had a feeling of a cramp. The wrist was also stiffened after a long period in plaster cast.
I showed the pictures that I had taken the night before and the same morning to the surgeon and I got an appointment to occupational therapists the following week.
The surgeon didn't know stretching or finger splints and in her opinion the deficiency in bending was a bigger problem than deficiency in stretching straight. Therefore, I got first a wrist support, which kept the wrist in back position and straps, which were pulled over the fingers and knuckles, in order to make the knuckles and fingers to bend more.

Crooked fingers, May 2010
In April 2010, 2 months after the removal of the plaster cast, I got the first customized thermoplastic splint for the night, which was supposed to straighten the fingers. The splint was very stiff, and there were two straps for the fingers, one for the index and the middle finger and a second for the ring and the little finger. Since the straps ran the over the PIP joints, the splint straightened only the index and middle finger, where the PIP joints were alongside and less bent. The common strap for the ring and the little finger did not get the stretching done, because the PIP joints were out of align and the fingers were more hooked.

In May 2010 my fingers were bent and already so stiff, that when I pressed the hands together, the fingertips of my little, ring and middle finger turned upwards. I do not recommend this exercise, it can produce a permanent hyperextension in the fingers. This picture was taken in Djerba, Tunisia.

In June 2010, four months after the removal of the cast, I met the surgeon for a second time. In this meeting her opinion was, that only my little finger needs a surgical repair, not the two others which were also bent. In the statement she also confirmed, that the bending of the fingers was no caused by Dupuytren's contracture.
On the same day, I got a new splint, with separated straps for the ring and little finger. The splint was a perfect fit, but the material was thinner and more flexible than in the first one, and after a while, my fingers were even more bent.
Bend to fist
before operation

Spring splints
In July 2010, six months after the surgery I met a physiotherapist outside the hospital and she made a recommendation for finger splints with a spring, and with them the bend of the fingers improved; three weeks later I got the middle finger to touch the bottom of the palm, for the first time after the operation.

I used the splints for half an hour at a time and three times a day. Because the splints could not be kept in adjacent fingers, one stretching treatment took one hour. Since I got the spring splints six months after the surgery, they did not straighten the fingers anyway.

August 2010
In August 2010, six months after the removal of the plaster cast, my left hand looked like this, fingers extended as straight as possible.
August 2010
The PIP joints were more and more bended, and so stiff that it was impossible to stretch the fingers straighter.
The extension deficiency in the little finger was 70 degrees, in the ring finger 60 degrees and in the middle finger 40 degrees.
The knuckle of my little finger (pinkie) had "disappeared" and the PIP-joint was sore.

It was the time to change the doctor and the hospital (private clinic).

Finger and knuckles surgery:

In this surgery, in September 2010, the tendons of the three fingers and two knuckles were cleaned. I was very surprised, that I didn't need any painkillers after this operation. According to the surgeon, the extension deficiency would be maximum 20 degrees after the operation.

After the surgery, the hand was in plaster cast for one week and then started a new rehabilitation.
I met the physiotherapist and the occupational therapist immediately after the removal of the plaster cast, and got workout instructions and a customized thermoplastic splint for the night. PIP joints were still a little bent, from the old memory; I also experienced a feeling of a cramp in the hand.

Finger Surgery was very well done, and the biggest surprise was, that I didn’t need any painkillers after the operation.
However, the rehabilitation was still a problem: the splint for the night did not fit, even after two corrections. Also the proper stretching instructions were missing from the workout program. I continued to use my old spring splints, but the physiotherapist's opinion was that they were wrong size. There were no better size available in the clinic, and no ring splints either.

In December 2010, almost one year after the injury, I found the ring splints by change in a shop, and got from a person with a crooked finger the right stretching instructions (straightening stretch); two weeks later I could put a ring in my ring finger. The hospitals didn't have ring splints available, and didn't even know them.

Spring splints can be found in hospitals, but selection can be very small, so that the correct size may not be found.  If you know that splints are also available in shops, outside the hospital, you can try on different models and find the best suited.

Bend to fist 3 weeks
after operation
Rehabilitation is also a tool discipline and bad equipment does not give good result. Equally important are the correct instructions. I got the right instructions for the straightening of the fingers by accident, in a store, but not from the hospitals.
However, there are lots of things that can be done at home and which do not cost anything, or just a little.

Bent PIP joints need for rehabilitation: stretching, splints, hand exercises and massage, on a daily basis. Rehabilitation should also begin immediately, since if it starts too late, it does not produce expected results, and then the only solution is a new surgery. Even repeated surgeries do not help, if the correct rehabilitation is missing, and the result can be worse. I'm convinced that with the right stretching instructions after the removal of the plaster cast, the finger operation could have been avoided.

More information:

2. Hand rehabilitation schedule was the following

Hand rehab is an endurance discipline, it can take a long time, specially when you get older. I was 64 years old when I broke my wrist.
Since the fracture was splintery, it was operated 11 days later, the 5th january 2010.
In February 2010, the cast and the K-spikes were removed.
In August 2010, six months after the removal of the plaster cast, the PIP joints were more and more bended, and so stiff that it was impossible to stretch the fingers straight or bend them to fist.
In September 2010, the tendons of the three fingers and two knuckles were cleaned in another operation.

Wrist

After 7 weeks in plaster cast, my wrist was stiff. I got mobilization exercises from the physiotherapist but the stiffness disappeared slowly. I was more worried about my fingers.

In May 2010, three and half months after the plaster cast was taken away, I went for one week in a spa in Djerba / Tunisia.  Because I had complications after the operation, I got every day half an hour personal physiotherapy in warm seawater pool.
The physiotherapy was very good, with the help of water gymnastic, the flexibility of my wrist increased much more in one week than with mobilization exercises during the three preceding month.
Little finger and knuckle position
before finger operation
After my return home, I continued for a while swimming and water gymnastic in a warm water pool in Helsinki, and therefore I purchased some tools, for ex HipperSmile.

Knuckles

I got the first flexion straps in March 2010, but they were uncomfortable to use and I didn’t like them.
I got an other splint in August 2010, this time with flexion loops (the picture), but because I got it too late, it wasn't any help.

After the finger surgery in September 2010, I started to use a splint for the knuckles again. It was quite uncomfortable; some loops were too small and thus laborious to put in the fingers. The stretch of the loops was too strong, and I had to take the splint away from the hand after a 15-minute use.

Little finger knuckle 6 months 
after finger operation
Little finger knuckle 3 weeks
after finger operation
Approximately one month after the finger surgery, I started stretching the knuckles with HipperSmile and a foam disc, and 6 months after the finger surgery the knuckles bent well.

Later, I found the right way to stretch knuckles against without any splint, and I continue to do the stretching in order to maintain the result.




Incomplete extension of the fingers 

In February 2010, when the plaster cast was taken away, the little finger was crooked.
Hand in August 2010
In August 2010, already three fingers were crooked: middle finger, ring finger and little finger, they were also so stiff, that an operation was the only possibility. Fingers were operated in September 2010.

In November 2010, after I had modified the customized thermoplastic splint, the middle finger straightened so that I could put a ring in it.
The ring and little finger were more severe cases. Two months after the operation, they started to look crooked again.

In December 2010, when the finger operation was 10 weeks away, I found ring splints in a shop and I got the right stretching instructions from a person with a bent finger, and a couple of weeks later I got a ring to go in the ring finger. I started with size No 9 in the ring finger, and size No 7 in the little finger.

In January 2011, the swelling had decreased so much that I had to change splints to a smaller size, No. 8 to ring finger and No. 6 to little finger, and I used them also during the night.
I used the splints for about 6 months, and the ring finger stabilized after some months.
Then I stopped the use of ring splints, even thought I didn't get my pinkie completely straight and the thickened PIP joint accentuated it.

The result wasn't permanent, in December 2011, about 6 months after I stopped the use of the ring splint, the little finger began to look more bent again, so I started to use the ring splint again.

In January 2012, I noticed that the PIP joint had gradually become thinner and my little finger could accommodate a smaller size, No. 5, which also fitted better, without customization.

I have already seen results, because now I have kept the ring splint during the night, and done the straightening stretch several times during the day, stretching the fingers between knuckles and PIP-joints, instead of stretching the PIP-joint. This seem to be a good combination.

I still use the ring splint No 5 every day, as night splint, and this way I can maintain the result.

Stiffness and incomplete bending of the fingers

Fingers bent, September 2010
Through trial and error I found the right way to bend and extend my fingers with bend/extend stretching, and the bending began to improve.
Fingers bent, February 2012

10 months after finger surgery fingers bended and extended well, and I could touch the lines of the palm with fingertips.

In my case, these instructions worked so well that the finger surgery doctor was surprised in the annual inspection of the hand in September 2011.

Stiffness in the hand is lost very slowly; it can take up to two years.

Swelling and thickening of joints

After the wrist operation, the back of my hand was swollen, but most of the swelling decreased after about four months.

The PIP-joints thickened in the finger surgery, especially the PIP joint of the little finger, which thinned slowly, taking 15 months. 
In the ring and middle finger the PIP-joints returned to the normal size after one year.


3. Pain

I didn't have much pain in my hand, but I used painkillers after the wrist operation. After the finger operation I didn't take them, because I didn't feel any pain.

Acupuncture can help in case of pain, but if there are no results during the 5 first sessions, there is no reason to continue it.

More information concerning pain relieving: http://orthoinfo.aaos.org/menus/treatment.cfm

4. Summary of the rehabilitation 

Wrong plaster cast, too tight tubular bandage and wrong rehabilitation, as well as too late started use of the splints or  wrong splints,  and too late started or wrong stretching may create entirely new, different problems.

Straightening of the fingers is easiest during the first few weeks, and after 4 months it is very difficult to achieve any results, if the fingers are stiffened. However, a skillful physiotherapist will be able to show short-term results.
If you feel that your fingers are completely stiff, it's time to go see (another) doctor.

Rehabilitation is, a know-how, an equipment and an endurance discipline, this rehabilitation has gone for more than two years. With right instructions for stretching and right splints, the rehabilitation could have been considerably faster. You may know that you need splints and stretching, but if the know how is missing, things can go wrong.

Hits:
  • If I had not found a shop (Health Care shop, Mannerheimintie 69, 00250 Helsinki) ring splints and received from a person with a crooked finger better stretching instructions (straightening stretch), the ring and little finger would have stayed more crooked.
Misses:
  • Both hospitals missed the best rehabilitation time. In the first hospital they first observed the situation, and I got the first splint 6 weeks after the plaster cast was removed, and this splint was supposed to bend my fingers even more. The first splint for the straightening of the fingers was made 2 weeks later, but it didn't work well. After the finger operation, I got the first splint immediately after the removal of the plaster cast, but the splint wasn't good and the best rehabilitation time was used for reparations, without result.
  • Both hospitals missed the knowledge about splints. Hospitals didn't know the ring splints at all, and many of the splints I got, were unsuitable for the case, or with bad ergonomics.
  • Both hospitals missed the stretching instructions for fingers. They had correct instructions only for the wrist. The instructions I got for the fingers gave only temporary results and delayed the rehab.
In my experience, the most important things in the rehabilitation of the hand are:

1. The fastest possible start


The best results are obtained during the first weeks. The later the treatment is started, the more time will be needed to get results, and it is less certain to get good results.

2. Stretching


Proper and regular stretching keeps the fingers and knuckles flexible, straighten the fingers, and help also stiff fingers to bend more. This happens only when the stretching is done the right way and early enough, and in this case the first results should be visible in two weeks. 
If not, the instructions may be incorrect or the stretching exercises are done too late, when the hand or fingers are already stiffened.

You may get from hospitals stretching instructions for bent fingers giving only short-term results. In that case, the only long term result can be a new surgery.

3. Splints


In addition to stretching, splints, which help to keep the right stretch for longer periods, may be needed. The splint should be appropriate for the case, well fitting and ergonomic. Improper splint or bad fit do not give good results.

4. Mobilization exercises


To exercise the hand with versatile but slowly made movements is also important. Too fast, or one-sided movements, can lead to entirely new problems in the case of a stiff hand or bent fingers.

5. Maintenance training

Daily: 
I use the ring splint in my pinkie during the night, with fingerless woolen gloves
I start the day by bending the fingers properly, and keeping them bent for 20 seconds, then I extend the fingers straight.
Thereafter I stretch knuckles against the mattress.
I also do strength training using 2 kg weights, and have noticed positive results. It reduces the stiffness.

Regularly:
I do the straightening stretch, and stretch the first phalange of the fingers against a table for 10 sec, especially the little finger.
I do bend / extend stretching and keep both stretching for 10 sec.
These stretching maintain the flexibility of the hand and fingers, and keep the fingers straight.

When necessary:
I squeeze the foam disc to keep the stiffness away.
I do stretching wide apart.
I do scar massage to the scar of the knuckles.

There can be backtracking, if you have stopped to exercise your hand or if it has been exposed to cold. Then there is no help other than exercise more for a few days, do the slow bend / extend stretching, and keep the stretching for 10 seconds. Do also squeezing, if you feel tightness in the hand.
The heating of the hand and massage of the fingers can relax your hand.
Stretching of the knuckles may also help.

I have a feeling, that I shall continue the stretching program the rest of my life, otherwise my hand may stiffen again. And I know, that it will help.

In case you have questions or comments ( in English or in French), you can send also an email: lpuranen(at)elisanet.fi


IV - The case of my right hand - Dupuytren's contracture





1. Injury and rehabilitation

In mid February 2013 I stumbled on a street and the radius of my right hand broke, but not the ulna. For first-aid, I went to the same hospital where my fingers were operated in 2010. 
The first plaster cast didn’t fit very well, my fingers tended to stay bent and if I wanted to extend them, I needed to help with the other hand.

The radius was fragmented and it was operated 9 days later, and the plaster cast was taken away 15 days later. This time I didn’t get a new cast; instead I got a wrist support I could take away when I exercised the hand. 
After the first week I used it only during the night and when I went out. Because the first model caused pain in my hand, I changed the wrist support after one week. 
I used the wrist support until mid April 2013, when I met the hand surgeon for the third time and had a X-ray.

The rehabilitation schedule was the following:

Wrist

This time my wrist was much less stiff and two months after the operation, the flexibility was good, because I could start the mobilization earlier and exercised also in a swimming pool.
In mid May 2013 the fingers bent slightly
However, I had some problems with my fingers and the major knuckles:

Fingers

When I used the wrist support, I felt sometimes cramps or pulling sensation in my right hand and my fingers started to bend slightly, but they straightened with straightening stretch and bend/extend stretch, in 2 months. I didn’t use any finger splints.

Major knuckles

Until November 2013 my right hand didn’t tolerate a strong handshake, but I have a noticed that the PE foam disc squeeze helped. 

Stiffness

The morning stiffness diminished, when I made myself a new, more rigid polyethylene foam disc and started to use fingerless woolen gloves at night. 

Swelling

In September 2013, 6 months after the operation, the fingers started to return to normal size.

First symptoms of Dupuytren's contracture

The first symptoms of
Dupuytren's contracture

In September 2013 I noticed in my right hand  callus-like nodules under the ring and middle finger, and in the beginning they were tender to the touch. 

After I carried some heavy stuff out, I noticed that I couldn't extend my right hand straight without extra effort, otherwise it stayed a little bent. My little finger had a tendency to be bent more forward than the other fingers, but the PIP-joint isn't bent, like was in my left hand in 2010. When I did stretching exercises for the hand, I felt pulling sensation specially in my little finger. 

First contractions
There was a period when if I did ironing or vacuum cleaning, I had the feeling that I still had the device in my hand, even though I had stopped the ironing or cleaning. 
When I had this kind of feelings, I did some stretching exercises immediately, and it helped. During this period, which lasted few weeks, I avoided carrying heavy loads.
I searched in the internet for the early signs of Dupuytren's contracture and found that they were quite similar. Because the stretching exercises helped my left hand, I tested if I can get positive result with daily stretches, even though some web sites warn against them. The problems of my right hand were somewhat different, than in left hand, but I believe that in both cases the reason was the disposition to Dupuytren's contracture in the family, activated with physical trauma and age.




My right hand Dec 2013
In December 2013, I can see that the daily stretching exercises have had a positive  effect. I could see the first results in two weeks, because the stretching exercises were suitable to my hand,  If not, the exercises give only temporary results. The callus-like nodules stayed, but I'm able to extend the fingers straight.

When the hand or fingers are too contracted or stiffened, the stretching exercises doesn't help anymore.


When I had problems with the bent fingers of my left hand, I noticed that the rehabilitation and stretching exercises should start as soon as possible, because my fingers stiffened in three months and then they had to be operated. 

After the operation fingers started to bend again, but two moths later I found the right stretching instruction for straightening, early enough to give results. Now my left hand look's like this, the picture is taken the same day than the pictures of my right hand.

An evident case of of Dupuytren's contracture in the family





All orthopedic links recommend operation, and if nothing else is done, there may be need for several operations. My cousin has this problem also, and he has had together 11 hand operations. He didn't get any instructions for stretching but used splints made by hospitals.

Left hand
Right hand








2. Orthopedic links, Dupuytren's contracture, vitamin D

Information on orthopaedic conditions and treatments, injury prevention, wellness and exercise, and more. Without advertisement.
American Academy of Orthopaedic Surgeons. http://orthoinfo.aaos.org/menus/hand.cfm
Information about fractures, injuries, pain relieving and different hand problems: Arthritis of the Thumb, Boutonnière Deformity, Dupuytren's Contracture, Trigger Finger; ...

Orthogate and the Internet Society of Orthopaedic Surgery and Traumatology (I.S.O.S.T) http://www.orthogate.org/patient-education/hand/
Patient Education Guides about hand pain and problems, and anatomy.

Orthogate website is certified by the The Health on the Net Foundation http://www.hon.ch/

Dupuytren's contracture: 

There are many opinions concerning the treatment of a Dupuytren's contracture before operation, but they do not mention stretching

Splinting does not prevent increased bend in the finger. Forceful stretching of the contracted finger will not help either, and may speed the progression of contracture.

For a severe problem, a therapist may be able to make a custom splint or brace to stretch the fingers out a little more straight. If surgery can't be done, this may help regain some movement of the fingers, but requires using the splint every day.

Splinting and hand therapy are often required after surgery.

Splinting or stretching and local steroid injections are not recommended.

Although injury and excessive hand use are not believed to cause Dupuytren’s, higher rates of Dupuytren’s disease have been observed in people with hand trauma.

Osteoporosis risk factors

800 IU = 20 mikrog vitamin D
Vitamin D supplement is best absorbed when you take it with food containing fat.

© Copyright Leena Puranen 2012 - 2013




© Copyright Leena Puranen 2012 - 2013