Managing the Chronically Stiff Hand
By Judy C. Colditz, OT/L, CHT, FAOTA
Certainly not my last, but definitely my most significant deviation from standard practice, was some years ago when I casted a patient with a chronically stiff hand. Having been taught to never immobilize any part of a stiff hand and especially never to block the MP joints in extension, why would I choose such a ludicrous approach?
Here is my logic:
- Change the cortical pattern of active motion
A chronically stiff hand is commonly characterized by an inability to initiate finger flexion with the extrinsic flexors; the MP joints flex first (opposite from normal) and limited IP joint flexion follows. This intrinsic-plus pattern results primarily from the adaptive shortening of the interosseous muscles.
Repetition of this maladapted pattern redefines finger flexion in the motor cortex, becoming the patient’s new normal. Therapy to improve finger flexion is futile because the patient is unable to reproduce extrinsic flexion upon leaving therapy and stiffness returns, and without a locus of stiffness, surgery has no productive role.
Both wrist and MP joints are included in the cast to require the extrinsic flexors initiate finger flexion. By re-directing the active motion to the IP joints, these joints mobilize, and with the MP joints blocked, the interosseous muscle elongate. This approach improves finger flexion with active motion only!
- Dramatically improve tissue quality (reduce edema and tissue inflammation)
The first time I casted a chronically stiff hand and examined the hand upon cast removal I felt weak in the knees as I did not think it was physiologically possible for tissue to change so dramatically in such a short time. The firm, thick, tight, inflamed hand I had casted was now a soft, pliable, and unreactive hand. The hyper-sympathetic (my term) response had calmed dramatically.
Because of its intimate molding capabilities, plaster of Paris (POP) casting maximizes this positive response. Many clinicians have abandoned POP in favor of newer, less compliant materials which cannot provide total contact with the small contours of the hand: a key factor in this technique’s success.
- Offer pain free success for patients who feel they have failed themselves and their surgeon/therapist
Most patients with chronically stiff hands have undergone passive motion exercises, with pain and inflammatory response persisting. The protective, warm, comfortable cast allows them pain-free progress with only active motion. Especially for hyper-sympathetic individuals, the cast is a momentous revelation of another route for improvement.
The next time you have a patient with a chronically stiff hand for whom surgery is not the solution, you may want to find a therapist/surgeon team who uses this technique called CMMS (Casting Motion to Mobilize Stiffness) and ask their opinion. Because it contradicts traditional teaching about regaining motion, I tell therapists they are not doing it right if a bead of sweat does not roll down their spine as they proceed (there is usually some temporary reduction of MP joint motion).
The casting must continue (hands-off!) until motor cortex repatterning occurs and then slow weaning out of the cast (converting it to a bi-valve removable cast) to maintain the gains. The greatest challenge this technique requires is to abandon the idea that we as therapists (or surgeons!) can make the tissue change; we can only create the environment to let the change occur.
To learn more about this technique, you may wish to read the final section of the Therapist’s Management of the Stiff Hand Chapter in the 6th edition of Rehabilitation of the Hand and Upper Extremity which you can access here: https://bracelab.com/wp/wp-content/uploads/The-Stiff-Hand.pdf.