How Less is More When Treating Stiff Hands
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[00:00:00] A common question I've gotten this week has been about treating stiff hands, and I believe that when I get these types of questions, the therapist. They just are really frustrated that they're doing X, Y, Z, and they are throwing all the stuff at it.
[00:00:19] They're like, I'm stretching. I'm picking these exercises. I'm trying this one that's splint. And nothing seems to be working. And one of my principals, I have several. Principles when it comes to treating. Let me see. I think I have so far, like 12 treatment principles. I'm gonna share one of them with you today, and it's about how doing less is actually more.
[00:00:48] So we're gonna dive into how less is more when you're treating a sipan, if you're an occupational therapist, physical therapist, and working to develop your skills. In hand therapy. My name is Wong. [00:01:00] I'm an occupational therapist and certified hand therapist, and I mentor OTs and PTs so they can become a certified hand therapist.
[00:01:07] So here's the thing with working with stiff hands. I think that when we think about, when therapists think about everything they're doing, they often tell me that like immediately they talk about splints and I get it. Everyone loves making them. Everyone wants splints to be a cure-all for everything, but splints are not.
[00:01:38] Splints have a function, and I think one of the functions that it can provide for you. There's a couple of functions that could provide for you when you're working with stiff hands is you can look at splints or osis as to help you with a stiff hand or stiff finger in terms of a static progressive dynamic [00:02:00] capacity.
[00:02:00] So do you want to create splints that pull and push on the splints in a certain way in order to gain more motion? The other way that you can use splints is to make it static by blocking something to allow for another joint to move. You can block a joint to allow another joint to move. So splinting is one aspect of a whole treatment plan when you are working with a stiff hand, and when I say a stiff hand I'm talking about.
[00:02:30] Mps, pips, dps, thumbs like one or all of those are stiff. Now we can talk about one joint in particular as well, one finger in particular as well, and that's gonna change essentially the kind of orthosis or splint that you would recommend or make. Multiple finger ones are different than one finger, one joint, one finger, two joints type of issue.
[00:02:56] But I wanted to bring splinting up first [00:03:00] just because majority of the time people do jump right to it and they think about what kind of splints work and can it do, can it flex me? Can it extend me? And splints can't fix everything. So when it comes to splinting, you want to pick and choose what you want the job of the splint to do so that it offloads what your patient has to do, and then it allows you the capacity to work on other things.
[00:03:31] Does that make sense? So if I am looking at, let's say, I'm gonna give you an example of a P I p stiffness, because pips are often time the most commonly stiff joint in the hand. So that's your middle knuckle, your p i p, that one can get stuck in the middle. Which is what they would call a flexion contracture.
[00:03:54] It just means it's stuck in 30, 40, 50 degrees. So it cannot fully [00:04:00] extend and get to zero, but it also cannot flex. So you have to make a decision which direction you wanna work in, into in order for the splint and the patient to do their work. And then you can do your work as the therapist, right? So that's really key in terms of.
[00:04:19] Making a decision on the type of splint, and the reason why I say less is more when you're treating a stiff hand. It is because you have to think about that splint doing one particular thing for you so you can do something else. You can't expect the splint to do everything for you, and so that's why I want to encourage you to think about how less is more, right?
[00:04:45] So splinting is one aspect of a whole plan of care. Now let's go backwards a little bit. And think about, what do we do? What do we do when we see a patient? We evaluate them and we determine where they're stuck, where their problems are, [00:05:00] and then where they want to go, right? Most people are like I don't have any motion.
[00:05:04] I want all my emotion. I don't have any strength. I want all my strength. I can't functionally do this. But I want to be able to do it. For example, women who have hand issues. I can't open a jar, I can't grab my fingers around the the doorknob to pull and push. I can't I don't have the strength or the motion in my fingers to clasp my bra, things like that.
[00:05:28] I wanna be able to brush my teeth and I wanna be able to brush my teeth with my dominant hand that's injured, right? We think back to the evaluation and then we think about what kind of treatments that can we provide. There's manual therapy skills, right? And I think that's one of the most important.
[00:05:46] Techniques or skills that you want to bring into your plan of care when you're working with a stiff hand? I don't think that you can. I don't think that you can effectively treat a stiff hand [00:06:00] without the know-how of manual therapy skills. You have your manual therapy skills, and then you have to have you have to have the ability to pick the exercises or the activities, right?
[00:06:12] So that's what I call exercise prescription. So you, once you provide certain manual therapy skills, you have to now then pick the appropriate exercises or activities that you want. That patient to be able to do in order to start working towards that goal of getting all their emotion, getting all their strength, and being able to functionally move their hand from your exercise prescription.
[00:06:39] That you do in the clinic now you have to provide that in terms of a, what we're so commonly known for, which is home exercise programs. So let's dive into those three things a little bit and talk about how doing less is actually more when you're treating this type of stiff hand. [00:07:00] So if we're talking about p i P contracture, I'm gonna just give you a clear, I'm gonna just give you a simple example.
[00:07:07] Working with a P I P fracture, who is really stiff at the P I p now, they can't flex, they can't extend. And now it's interfering with how the little knuckle, the D I p is moving. So when you applying a manual therapy, Techniques and manual therapy skills. I think one thing to think about, to do less instead of doing more is to work in a certain direction and majority of the time you're gonna wanna work an extension because, and one of the reasons why I say you wanna work an extension is cuz if you take a look at the anatomy of your hand, if you go and you stretch that person into extension, then what happens on the flexor side?
[00:07:54] You're stretching all those structures, right? So if you stretch all those structures and then when you go [00:08:00] into flexion, wouldn't they be able to move better now? So when you're applying the manual therapy skills, Think about slowing down your movements as the therapist providing the manual skills.
[00:08:17] It's one of the most common things that I coach on, that I mentor on when I'm working with my therapist when I'm teaching a class. How do you slow down what you're doing as a therapist? If you are desperate to get movement and your patient's desperate to get movement, then you're both desperate and the desperation just starts to elevate.
[00:08:45] Elevate and then everyone gets really frustrated. But if you understand fundamentally that pips, by its nature is stiff, that's what gives it such stability [00:09:00] that the ligaments are taught right, quote unquote tight, in exception and inflection. Those joints are naturally very strong, very sturdy, and when they get injured, they're easily fall into a tight pattern.
[00:09:19] So if you understand that fundamentally as a therapist, then it's something I think that you can continuously go back to and remind yourself that's normal in this joint. And then you have the opportunity to educate your patient to say, Hey, I know you're frustrated. I. I know that this seems like it's taking a really long time, but this is the nature of this joint and the nature of your injury, X, Y, Z, you gotta fill in the blanks, means that this, your joint is stiff and it's gonna take some time.
[00:09:57] How much time how much time are [00:10:00] you going to allot and devote to this rehab process, right? Because it takes two of us tot, I can't be the only one working on it. All right, but you as a therapist can do less when treating. So when you stretch somebody, you go for longer periods of time. You go for the low, slow sustained movements versus just cranking them out.
[00:10:26] You work towards directionality that provides them less pain so that they are not so guarded. Majority of the time, pips are extremely painful no matter how slow you go. So you can't go that slow. But then it's, you're required then to explain the process so that your patient better understands.
[00:10:50] When they better understand, then they'll know what they're supposed to do in their home program. Go slower, right? Go slower in your manual therapy [00:11:00] skills. When it comes to picking an exercise or an activity, when you're working with a stiff hand, Stiff hands by their nature are very difficult and frustrating.
[00:11:14] So in the clinic, I will focus on one or two things that are just, I know will get me results, right? But now you have to do them effectively. If you're doing them and you're not doing it effectively, then you're not gonna get the results that you want. So for example, I'm gonna give you an example of blocking.
[00:11:35] Blocking majority of the time can be really challenging to do with a stiff hand, right? Ideally you want to keep the mps at zero and you want get the pips. The P I P in as much extension as possible. Let's say you can only get it to 20, right? And you have to block the MP and the p I P from flexing and only allow the D I [00:12:00] P to move.
[00:12:01] Now, even if that means that they pull a little bit less, but they're more targeted to the D I P, you're better off the d i P also moves. Via the profundus, right? The profundus muscle divides the muscle divides into four tendons and goes to each of the dps or the small finger. And that muscle holds, that muscle moves essentially together.
[00:12:30] So if you hold one finger, the other one moves a little bit as well. So it's relevant to work on adjacent fingers. Even if the adjacent fingers, they're like, oh, those fingers are fine, you can still block, you can still hold. So let's say for example, I move the, I'm working on the ring finger. So I block the ring finger and I get them to move. Now I can block the ring finger and block the I'm sorry. I can block the [00:13:00] long finger and move the long finger and then I can still block the long finger if I'm working on the ring finger. And the long finger will secondarily work. If you're gonna do blocking ex exercises, you can do them, pay attention to doing them more effectively.
[00:13:21] Communicating with your patients in terms of how they're supposed to move it or how they're supposed to pull through, or how they're hand placement is supposed to be if you're trying to. Get them to do it on their own. You can be very intentional about how you're teaching it. So it's not that they have to do three sets of 10 sloppy, but let's say they do two sets of 10 more intentionally, so that if they're more effective with their exercises, they're gonna see gains faster.
[00:13:53] So that's just another example. So less is more. We talked about manual. We [00:14:00] talked about picking an exercise. Now I know therapists tend to think oh my God, I have to write a ton of stuff when I'm documenting to quote unquote, prove that I've done it something. But it's okay if you only do two to three exercises or movements or activities, but you're more deliberate about them.
[00:14:22] It could take that long to actually do your exercise as well, versus being sloppy and doing 10 of them. Maybe you can pick only two or three and do them really well All right. And when it comes to fingers and it comes to stiff hands, I really, this is also a principle of mine. The less is more principle.
[00:14:44] When I go to giving home exercise programs for my patients, nobody wants homework. Who wants more stuff that they have to do, right? Most of the time they don't. And so I wanna [00:15:00] encourage you to think about if I'm going to give my patients a home program I wanna make sure that they're successful with it.
[00:15:09] So ask yourself, how can my patient be more successful with their home program? They're not successful if you give them a whole book of crap and they don't know what order to do it, how to do it well, and then how to check themselves if they're doing it right. I remember going to therapy myself and this, so many of my principles come from the fact that I required therapy at some point in my life.
[00:15:32] Early on I had surgery and I didn't like the fact that the therapist gave me a book full of exercises and told me to do it on my own. And listen, when I. Started out as a therapist, I did what every therapist did, which is to give inundate my patients with home exercise programs and majority of the time they can't be successful with it.
[00:15:55] That's why they're coming to you. That's why they're coming to you so that you can [00:16:00] hold them, be account so that you can hold them accountable so that you can help them focus on the key movements that are gonna help the key exercises. That will help cuz not all of them help. Some of 'em are just playing crap.
[00:16:13] So I'm gonna, out of all my stuff, I might teach them one manual thing. I want them to be able to stretch. Now your patients will copy what you do, so if you're too fast in your stretches, they will do too fast. If you're really hard on your extra, your stretches, they will be too hard on themselves and then they cannot do it later.
[00:16:35] If you give them wrong exercises and you're not intentional on how you're doing your exercises, they too will not pay attention. Now, some people just don't pay attention. Some people are just not really good at follow through, and that's okay. That's why they're coming to you as the specialist, as the expert, right?
[00:16:52] And it's okay if you have to say things over and over. That's our job. Don't get frustrated. Don't get [00:17:00] frustrated because that's part of your job. We are, supposed to repeat ourselves over, over, and over, right? So don't get frustrated. You wanna get great results on that stiff hand.
[00:17:13] On that stiff finger. You're gonna have to repeat yourself and you're gonna have to be okay with that, right? That is some taking one treatment principle, one treatment principle of mine, right? How less is more. And I am helping you apply it to how to treat a stiff hand or a stiff finger with the principle of less is more.
[00:17:37] But you can take this principle and you can apply to any other injury that you have, right? So I hope this helps you. Can I give you a little insight into how you can make your treatments more effective as a hand therapist, as an occupational therapist, a physical therapist working with an example of a stiff hand.
[00:17:58] My name is Hoang Tran. I'm an [00:18:00] occupational therapist, certified hand therapist, and I have several. Various mentorship programs to help you advance your career. And you can comment below if you found that this video has helped you, this podcast has helped you. Let me know if you wanna hear and see more things like this.
[00:18:18] And if you need my help, the links are below in the description. And wanna know what else? Let me know if this no. If videos like this, no
[00:18:36] thanks for tuning in and I will see you next time. Bye.
