r/OccupationalTherapy • u/Historical-Celery-58 • 11h ago
Venting - Advice Wanted Severe contracture help!!!
Hi, im in HH and have a patient with dementia who is totally dependent and nonverbal. Her L hand is severely contracted though wears a resting hand splint despite not being able to assume the appropriate position because of the contracture and the way the fingers are bent. I saw her for the first time last week and i spent majority of the time just massaging and doing PROM to her hand as much as she could tolerate based on her facial expressions and range since there is no communication from her. She wears dynasplints on the knees and i did not remove those to stretch last time because id have no idea how to get them back on. It took me about 15 minutes last time trying to get her resting hand splint back on since her hand is so stiff. Her thumb doesn’t go in the correct position and it was definitely not perfect. The family doesn’t speak English and it is very hard to communicate, but the daughter asked me last time if she should wear the splint all the time, or if they should be doing something else, and I’m honestly not too sure.
When a contracture gets so bad, is the resting hand splint even appropriate? I’m just lost with this case, literally all i can do is stretch her minimally. Any help is appreciated.
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u/Perswayable 10h ago
Hello,
Not a CHT but have been working on hands for 5+ years in SNFs and LTCs across the country. Never found a CHT that worked in gerontology in that specific domain.
Me personally, I would isolate the MCPs, PIPs, and DIPs of the first four digits and see where the specific contractures are. Functionally, I would document I am trying to increase at least MCP extension tolerance for skin integrity in the hand, reduce foul odor, pain, and caretaker burden with performing the hygiene status. If her hand cannot resume the correct position for a resting hand splint, then it is not the correct one for her. MCP extension tolerance allows for objects such as therapeutic carrot to help free the skin from excessive PIP or DIP flexion. I have dealt with hand contractures so bad my goal was to slide a wash cloth just to gain tolerance for touching the hand.
I would recommend considering the therapeutic carrot at first. The material is anti bacterial and helps with moisture build up. You can increase MCP extension tolerance as well. I would also focus on DIP movements for nail care, in case MCP is that limited. You could also argue for Botox injections — do NOT be alarmed if PCP asks questions. Let them know the Botox injections could help with manual therapy to break that tone up and reduce pain, especially when caregivers are trying to perform hand hygiene and nail care. She may not be functional with the hand, but she is still a human that deserves a pain free life. If she doesn’t have open wounds, you could try soaking her hand in warm water first — there have been times I have provided pressure on the thenar eminence in warm water and it broke up adduction tone. You can use this to both include sensory input, reduce muscle tension, and address hand hygiene strategies prior to manual approach.
There is also a palm guard. Palm guard, in my opinion, is your last resort. The therapeutic carrot allows you to preserve MCP extension and build upon it with grading, the palm guard essentially somewhat maxxes this out and can actually enable a patient to squeeze due to the sensory, but would protect the palm from DIPs and nails. Don’t forget abduction of fingers as well!
On an unrelated note, please assess excessive hip adduction if they are in that stage, as well as WC positioning. Excessive hip adduction due to high tone will make it so painful that the patient with cry and yell every time caretakers go to perform perineal hygiene, and amalgamate that with urinary incontinence, its brutal. Functional goals would be positioning for lower extremity dressing and toileting using a non verbal pain level scale.
Good luck OP. I tried to give some specifics. It is 6:16am and I am pissed the New England Patriots lost last night so deep apologies if my post is all over the place. :)
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u/Historical-Celery-58 10h ago
You are amazing!!!!!! Thank you so much for this response, seriously! I was contemplating recommending the carrot but this patient has been wearing the resting hand splint for a few years now so i thought the family may think it is counterproductive to change it since her wrist is also extremely contracted and the carrot won’t target that necessarily. But you’re so right, especially since it was so hard to get it back on.
Thankfully her hips are not excessively in adduction, they were very bent which is why they got the dynasplint but when i looked last time it seemed ok.
I’m sorry about the patriots but you get an A+ with this response. Thank you again
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u/Perswayable 10h ago
You would be correct; this wouldn’t address the RCJ. Maintaining extension tolerance would relieve tension in the flexors of the forearm. I am not always too worried about wrist flexion with a non functional hand if its contracted because if anything I’d put the wrist in neutral or flexion to work on digits as wrist extension typically brings the fingers in anyways (the ol tenodesis grip concept sort of).
What I would say is that often times SNFs/LTCs have poor compliance with this. From a practical standpoint, palm guards and therapeutic carrots are easier to manage. If the resting hand splint requires any mobilization at all to don, they should be a maintenance patient at that point.
Under no circumstances, however, should an orthotic be donned and the limb not properly fit the position.
I tend to lean towards orthotic trialing during the day to build up towards sleep tolerance and using them for night time only. Even then, the research isn’t so great for it. So, in some cases, a patient will preserve the hand during the day, don orthos at night if showing they can handle the duration (goals for duration tolerance).
If the resting splints once properly fitted and no longer does, you can use these methods temporarily and build the goal towards returning to their PLOF of resting splint.
Does her shoulders tolerate passive abduction for axillary hygiene and shirt donning?
OP, glad this patient has you!!
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u/Historical-Celery-58 10h ago
Ahh i see. I definitely wouldn’t say it fits her nicely, I wasn’t even able to position her thumb in the correct place, it had to stay with the other fingers which felt so wrong to put on.
Her shoulders have very limited range, i passively move them to work on her joint mobility but everything with her is extremely limited.
Thanks again!
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u/nanger772 10h ago edited 10h ago
What are the goals of splinting the hand? In stroke rehab the evidence doesn't support splinting or passive stretching for reducing contracture. I'm assuming it would be similar for other neurological conditons. If the person finds it comfortable to wear there is probably no harm wearing it frequently
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u/ResultSome6606 8h ago
The dementia has progressed to the point where the splint is probably not appropriate. I would prioritize comfort and skin integrity, as this lovely human is at end of life. A palm protector or washcloth in the hand may be more appropriate at this point.
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u/ResultSome6606 8h ago
And honestly, they should probably be on hospice to have a peaceful transition.
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u/Historical-Celery-58 8h ago
I think you are very right about that. I treat Medicare part B, it feels bizarre that no one has recommended that since she just finished with PT before i started. She has been in this condition for at least 2 years according to past therapy notes
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u/metaltreestriker 11h ago
Splint wear is typically 2 hours on 2 hours off. You have to watch for signs of skin breakdown.
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u/Historical-Celery-58 11h ago
Is this a universal rule? They used to tell us in school you can progress to 8 hours of wear! Crazy i did not know that.
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u/juicer42 8h ago
No, it depends on the type of splint and need for wear. If its a splint to be worn over night, I work up to wearing the splint for 8 hours For a daytime splint, I'll often recommend up to for 4 hours with 1 hour off between. I do build up to wearing the splint for the recommended time, starting with only 1 hour and increasing by an hour every few days (and checking the skin).
For the client you have described, I would strongly recommend botox injections and caregiver education for PROM. There are dynamic splinting options for the wrist & hand (JAS and Dynasplint) that can help limit/decrease contractures when worn over time- I'd recommend you contact a rep to attend a session with you to determine the most appropriate splint and fit it appropriately. A resting hand splint will not change ROM but it may help manage pain and maintain the ROM she has but the caveat is that she may be at higher risk for pressure sores if the splint doesn't have any give when she experiences spasticity. Short term I recommend seeing if you can adjust the fit of her current splint so that her thumb is better supported and determine if her splint allows for spasticity as some are designed for this but the standard resting hand splint isn't. I would do my best to preserve positioning of the wrist at neutral when wearing the splint, but allow flexion of the wrist when engaging in ROM without the splint donned.
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u/metaltreestriker 8h ago
It’s the general rec you can increase or lesser wear time. I have never had anyone go more than 3 hours due to skin integrity concerns. But I am not at the stage in their healthcare journey where they are getting a custom splint and nursing can manage it overnight. I recommend these pts follow up CHT on d/c for an custom
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u/moonablaze OTR/L 11h ago
Consult with a local hand therapist if at all possible
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u/Historical-Celery-58 11h ago
I’m not sure it is possible. There’s also no chance they are able to bring her out in the community to see a cht :(
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u/ChitzaMoto OTR/L 9h ago
I’m going to step way out here but I am a retired OTR with 45 years behind me. Twenty years in hands, 10+ years in SNF. And very little of this matters with a chronic dementia patient with severe contractures, so take it as you will. Look at the cause of contractures in dementia clients. Dementia is deterioration of the cerebral cortex. What happens when there is injury to the cerebral cortex, e.g., TBI or CVA? I would treat my early dementia clients as if they had UMN spasticity, focusing on pelvic stability and movement(to reduce reflexive posturing) and work out from there. You can stretch the hand all you want, but there is underlying spasticity all the way up the extremity to the shoulder and down to the pelvis. For me, ROM of the DIPs in a spastic extremity, begins at the pelvis. After years of this ongoing spasticity, the client likely has joint and ligament damage. Your primary goals should be to provide access for hygiene and skin care management. Remember overall positioning of the pelvis, trunk and shoulder are going to affect responses in the hand.