Effectiveness of Eccentric Exercise in The Rehabilitation of Post-Immobilization Stiffness of Wrist: A Case Study

Introduction

Following immobilization of the wrist and hand, developing joint adhesions and stiffness is a common finding in physiotherapy rehabilitation settings. It significantly affects the patient’s ability to return to normal life. The human hand design comprises skin, soft tissues, bones, tendons, ligaments, and muscles which enables an individual to perform various gross and fine movements. Injuries around the wrist and hand are common and have to be managed according to the nature of the injury. Fractures and other soft tissue injuries require a period of immobilization that develops stiffness and affect the functional performance of the hand.¹

Distal radius fractures account for approximately onesixth of all fractures in the emergency department.² Around 20% of attendances to the emergency department are due to injuries to the hand and wrist. The young adult population between the age group of 19–49 is most affected by Barton fractures, with a greater predilection for males than females.³

The inflammatory and vascular events that take place during immobilization eventually lead to the development of adhesions around the tendon sheaths and joint capsules. Following immobilization, joints often demonstrate the weakness of muscles and joint stiffness associated with restriction in range of motion. In recently published studies,^4,5 it was reported that reduced range of motion and muscle weakness are positively associated to stiffness. To address this issue, an eccentric exercise that combines the effect of both stretching and strengthening could be beneficial in improving movement and muscle strength.⁶ An eccentric (lengthening) muscle contraction occurs when a force applied to the muscle exceeds the momentary force produced by the muscle itself, resulting in the forced lengthening of the muscle-tendon system while contracting.⁷

Case Description

A 27-year-old male visited the Alvas college of Physiotherapy outpatient department with complaints of pain and stiffness in his right hand. The patient was an electrician by profession, with the right hand as the dominant side. The patient was normal 2 months ago, he sustained an electric shock at his workplace and fell from a 10 feet height, landing on the floor with his hand hitting against the wall. He was admitted to Alvas Health Center, Dakshina Kannada, Karnataka, for first aid and further management. The radiologic findings revealed dorsal Barton’s fracture on the right side for which he underwent Open reduction internal fixation (ORIF) with a “T” buttress plate and screws. His wrist was immobilized for 6 weeks following the surgery. Due to his personal reasons, he did not undergo any physiotherapy exercises immediately after he was operated on. There was no significant past medical history. He was single and resided with his mother and was the only member to earn for his family. He was looking forward to returning to his work to manage his family expenses. He experienced pain and wrist joint stiffness and an inability to hold plates, and utensils, and also had difficulty in gripping activities at his workplace.

On observation, no postural abnormalities were found. A surgical suture mark measuring 6cm on the volar aspect of the wrist was present and the wrist joint deviated towards the ulnar side. There was mild swelling in the thenar eminence around the wrist joint extending halfway to the forearm. No abnormalities on palpation around the wrist were observed. The wrist was restricted to 5 degrees or no range in all the movements of the wrist. The patient had pain and stiffness in the wrist joint including mild pain and stiffness in the inter-phalangeal joint.

Outcomes such as the numeric pain rating scale and disabilities of the arm, shoulder, and hand (DASH) questionnaire were used in this case study to measure the effects of eccentric exercise. The numeric pain rating scale was used to assess pain intensity, it was 2 out of 10 at rest, and 7 out of 10 while performing movements. The DASH was used to record the functional status of the hand. A higher score indicated greater disability. The initial score was 39.25/100. Physiotherapy rehabilitation was started following the assessment with short-term goals to reduce pain and improve joint range of motion. Ultrasound therapy was administered in and around adhesions of tendons. Scar mobilization was performed and wrist flexors and extensors were stretched passively up to the tolerable range. Isometrics for wrist flexors and extensors, gripping, and releasing activities were included. The eccentric loading exercise program with level 1 theraband was performed for wrist flexors, extensors, and radial and ulnar deviators. The resistance offered by the theraband was modified by the therapist by altering its tension so that it helped to encourage movement in the available ranges of the wrist joint (Figure 1). Throughout the range, resistance was modified to allow the patient to perform the movement without any restriction. Functional training peg board activities, grasping and releasing objects, and spring resistance exercises were also modified to facilitate eccentric muscle activity. Gradual sustained joint muscle contraction with lengthening movement was elicited during these activities so that eccentric activity is induced.

Eccentric exercises using theraband were performed at mild to moderate difficulty perceived by him, for 6–8 repetitions in 3 sets. Initial sessions lasted for 45 minutes for 5 days a week. Hand grip activity performed using spring resistance was included and performed eccentrically. Additionally, the routine isometrics, passive stretches, passive movements, and active movements were continued.

After 3 weeks, he started simulating activities related to his workplace. By 4th week he started working with an assistant. He performed light works without much effort. Following 8 weeks post-treatment, outcomes such as numeric pain rating scale (Table 1), range of motion, (Table 2) muscle power (Table 3), and DASH(Table 3) were repeated. The DASH improved from 39.25 out of 100 at baseline to 23.5 out of 100 post-treatment.

Outcome measures

The following outcome measures were assessed at the initial evaluation and post-treatment.

Discussion

After 8 weeks of the eccentric exercises, there was an improvement in the outcomes such as pain, joint range of motion, muscle power, and hand function. Eccentric exercises cause a greater increase in eccentric torque that helps to build up strength and enhances flexibility. This makes eccentric training an interesting training adjunct in strength and conditioning programs.

In a study by Caputo et al., ⁸ it was evident that pain was associated with strength. In the present study, there was a significant reduction in pain associated with an increase in strength. Eccentric exercise decreases pain by promoting a range of motion. There is also evidence that the experience of pain is less, and the reversion of pain fastens with eccentric exercises than during the concentric ones.⁹

Eccentric exercise at low intensity reduces the energy requirement typically by 4 folds compared to the concentric exercise of the same intensity.¹⁰ This favors eccentric exercise in conditions with diminished muscle power and restricted joint range of motions. In the present case study, the implemented eccentric exercises were set at mild to moderate intensity, to encourage movement and to avoid the adverse effects of exercise-induced muscle damage. Performing eccentric exercise at high intensity generates greater eccentric forces in a muscle that is naïve to eccentric contractions and subsequent muscle damage is expected.

Following eccentric exposure adaptation, the muscles are well prepared to experience the higher forces that are characteristics of a progressive eccentric-negative work phase.¹¹ Earlier joint mobilization and manual therapy techniques were most commonly considered to increase joint movement. In addition to joint mobilization and manual techniques, eccentric exercise could be beneficial in accelerating the recovery process in rehabilitation. Eccentric exercise being actively performed by patients could provide effective outcomes in addressing the articular and extra-articular structures in post-immobilization stiffness.

Eccentric exercise could be beneficial in improving the range of motion of immobilized joints. Effects of eccentric exercise include reducing pain, improving movement and muscle power, and reduction in the severity of disabilities. Hence, eccentric exercise should be considered in addition to the conventional rehabilitation methods for post-immobilization joint stiffness.

Conflicts of Interest

Nil