Dupuytren Contracture Rehabilitation Protocol

This protocol outlines a comprehensive physical therapy rehabilitation program for individuals with Dupuytren Contracture affecting the wrist and hand. The program is divided into three phases: Protection, Loading, and Return to Function. The specific interventions and progression will be tailored to the individual patient's presentation, pain levels, and progress. This protocol is a guideline and should be adapted based on clinical judgment.

Pathophysiology

Dupuytren Contracture is a fibroproliferative disorder affecting the palmar fascia of the hand. It involves the abnormal thickening and shortening of the palmar fascia, leading to the formation of nodules and cords. These cords gradually contract, pulling the fingers (typically the ring and little fingers) into flexion. The exact etiology remains unclear, but genetic predisposition, age, sex (male > female), and certain medical conditions (e.g., diabetes, epilepsy) are considered risk factors. The condition can affect one or both hands. Progression varies widely, from slow and painless to rapid and debilitating. Diagnosis is typically based on physical examination. Surgical intervention (fasciectomy or fasciotomy) is often considered when contractures significantly impact hand function.

Common Special Tests

• Table Top Test (Hueston's Table Top Test): The patient is asked to place their hand flat on a table. Inability to flatten the hand indicates a positive test.
• Grasping Assessment: Assessing the patient's ability to grasp various objects of different sizes and shapes to evaluate functional limitations.
• Range of Motion (ROM) Measurement: Goniometric measurements of metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint flexion contractures. Document wrist ROM as well to assess for co-existing limitations.
• Sensory Testing: Assess light touch, sharp/dull discrimination, and two-point discrimination to identify any nerve involvement.
• Edema Assessment: Volumetric measurements or circumferential measurements to quantify swelling.
• Pain Assessment: Using a Visual Analog Scale (VAS) or Numeric Pain Rating Scale (NPRS) to quantify pain levels.

Phase I: Protection (Post-Operative/Acute Phase – typically 0-4 weeks post-surgery or acute flare-up)

Goals:

• Control pain and edema.
• Protect surgical repair or limit progression of acute flare-up.
• Maintain or improve wrist and uninvolved digit range of motion.
• Initiate gentle range of motion exercises.

Interventions:

• Edema Management:
  • Elevation of the hand above heart level.
  • Retrograde massage (gentle distal to proximal stroking).
  • Light compression wrapping (coban or similar).
  • Contrast baths (warm/cold water immersion).
• Pain Management:
  • Ice packs (15-20 minutes, several times per day).
  • TENS unit (as appropriate).
  • Gentle massage around the surgical site (once sutures are removed).
• Wound Care:
  • Follow surgeon's protocol for wound care and dressing changes.
  • Monitor for signs of infection (redness, swelling, drainage).
• Splinting:
  • Extension splint worn at night (and sometimes during the day as prescribed by the surgeon or physician) to maintain MCP and PIP joint extension. The splint is critical to maximizing outcomes.
  • Splint should be custom-fitted to ensure proper support and comfort.
• Range of Motion (ROM) Exercises:
  • Gentle active ROM exercises for wrist and uninvolved digits.
  • Protected active ROM for involved digits within pain-free range (focus on extension).
  • Tendon gliding exercises (e.g., straight fist, hook fist, full fist) to promote tendon excursion.
• Patient Education:
  • Proper wound care and hygiene.
  • Splint wearing schedule.
  • Importance of adhering to the exercise program.
  • Activity modification to avoid excessive stress on the hand.

Phase II: Loading (Subacute Phase – typically 4-12 weeks post-surgery)

Goals:

• Improve range of motion and flexibility.
• Increase hand strength and dexterity.
• Reduce pain and sensitivity.
• Progress to functional activities.

Interventions:

• Range of Motion (ROM) Exercises:
  • Progressive active and passive ROM exercises for MCP and PIP joints, focusing on extension.
  • Joint mobilization techniques (Grade I-III) to address joint stiffness.
  • Static progressive splinting or dynamic splinting to further improve extension (as prescribed by the surgeon or physician).
• Scar Management:
  • Scar massage with lotion or silicone gel to improve scar mobility and reduce sensitivity.
  • Scar mobilization techniques.
  • Silicone sheets or gel pads to minimize scar hypertrophy.
• Strengthening Exercises:
  • Gentle grip strengthening exercises with a soft ball or putty.
  • Finger abduction/adduction exercises with resistance bands.
  • Wrist strengthening exercises (flexion, extension, radial/ulnar deviation) with light weights.
• Sensory Re-education:
  • Desensitization techniques using different textures (e.g., cotton, sandpaper, beans).
  • Two-point discrimination training.
• Functional Activities:
  • Gradual progression of functional tasks (e.g., writing, buttoning, picking up small objects).
  • Use of adaptive equipment as needed.

Phase III: Return to Function (Chronic Phase – typically 12+ weeks post-surgery)

Goals:

• Maximize hand function and dexterity.
• Return to pre-injury/pre-surgical activity level.
• Prevent recurrence.

Interventions:

• Advanced Strengthening Exercises:
  • Progressive resistance exercises for grip, pinch, and wrist strength.
  • Work simulation activities.
• Functional Training:
  • Activity-specific training to address individual needs and goals.
  • Ergonomic modifications to prevent re-injury.
• Maintenance Program:
  • Continued ROM and stretching exercises to maintain flexibility.
  • Regular self-massage of the scar tissue.
  • Splinting as needed to prevent recurrence.
• Patient Education:
  • Strategies for managing pain and stiffness.
  • Importance of proper hand hygiene and skin care.
  • Early recognition of recurrence signs and symptoms.

Progression Criteria: Progression through each phase is based on achieving the goals of that phase and demonstrating tolerance to the interventions. Pain levels should be well-controlled throughout the rehabilitation process. Regular communication with the surgeon or physician is crucial for optimal patient outcomes.