Why Rehabilitation? ?The purpose of rehabilitation is to return an injured person to a normal and optimal functioning level in all areas of activity. ?It?s personalized to you. ?After dealing with a broken radius and immobilized wrist for 6 ? weeks (which I?ve posted about??here and here)?and after the cast was removed, I found rehabilitation to be both physically and mentally challenging. ?To attain optimal function and an ideal level of activity, I discovered creating a base line (see below), creating realistic goals, and celebrating the little improvements were quite helpful to my psyche. This was particularly important in the weeks following my cast removal to reassure myself that I was making gains. ?Don?t get me wrong, I?ve had ups and downs. I?ve had times when my wrist throbbed from doing too much (could be from some activity at the gym, or some days it could have been from working on one part of the body on a few clients that day). ?I found having an understanding of the tissues involved (bone, nerve, tendons, ligaments, fascial sheets, blood vessels etc.) and how long it takes the tissues to heal helped me in the rehabilitation process. ?It was a balancing act. I push the boundaries, to make gains in flexibility, strength and muscle endurance, but I also need to be vigilant at listening to my body as too much would have consequences such as throbbing sensations, and soreness, to name a few.
After the removal of my cast, I touched the pasty white and waffled skin and it felt delicate and thin. The skin was adhered to the superficial and deeper layers of tendons, muscles and other connective tissue of my wrist and palm. As I pushed the skin around my wrist, nothing moved; it was one solid mass. There was no differentiation between the various layers between the skin, fascial sheets, tendons, and ligaments, nor could I see the tendons in the carpal tunnel when flexing the wrist. The blood vessels were invisible on the back and on the palmer side of the wrist. The hand, especially around the thumb the soft tissue (muscles & fascia) was hard and thick, similar to the soft tissue around the wrist. The left palm was hypersensitive compared to the right palm. And the muscles of my hand and forearm had atrophied quite significantly.
White and Waffled Skin
Waffled skin and atrophied muscles.
White skin and atrophied muscles.
Immediately after the cast was removed, the orthopaedic physician assessed the movement and tissue health. ?I moved the wrist through the range of motion (ROM), where I felt pain, achiness, and stiffness. ?According to the physician, the ROM was greater than expected, which was a good start. ?Within a day of removing the cast I saw Clare Palmer, a physiotherapist at the Westside Physiotherapy and Hand Clinic. ?She took measurements in all movements of the hand. See table below on the second day and a week after the removal of the cast. ?Within a week I had full functional range in various movements. ?I was on my own to rehabilitate the sprained and strained wrist and to regain full range in flexion and extension, flexibility, strength and endurance.
Table: Movement Assessment Results
| ? Assessment Left Wrist | ? ?Active Range of ?? Motion?(AROM) in degrees One day after cast removal ? | ? ?Passive Range?of ? Motion (PROM) in degrees One day after cast removal | ? AROM in degrees One week later ? | ? PROM in degrees ?One week later |
| Flexion | 32 | 40 | 55 | 60 |
| Extension | 42 | 50 | 65 | 70 |
| Radial Deviation? | 10 | 12 | 15 | ?full |
| Ulnar Deviation | 15 | 20 | 25 | ?full |
| Pronation | full | full | full | full |
| Supination | 60 | 65 | 90 | ?full |
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There were a few rules. I could not do any maximum gripping (mountain biking, heavy weight lifting, Olympic lifting, and pull ups were out), not that my hand would have allowed me to do this. I could only return to work gradually. And I had to expect that it would most likely take 12 weeks to be fully functional and able to participate in various activities after being in a cast for 6 ? weeks.
I made a treatment plan:
- ? To decrease stiffness in the carpal joints and wrist joints.
? To increase tissue health, increase flexibility, strength, and endurance.
? Activities of Daily Living (ADL?s): open doors with my left hand, carry bags of groceries, lift a cast iron pan, to name a few.
? Return to work (gradually of course) I started with 2 people after the cast was removed and after 11 weeks I am able to work on 5 clients/day.
? Return to the gym (Crossfit). I?ve returned but I am doing modifications to many exercises and so far so good.
? Eventually return to riding a bike (road or mountain).
Massage therapy and self-treatment. Following are the techniques I found most helpful:
- ? Tissue mobilization: apply pressure on the muscle (soft tissue) and move the joint through the range of motion. You can add some over-pressure at the end of range. Stay within a manageable discomfort level (you?re not making a pain face! and you are not holding your breath). Repeat ? many times or for a minimum of 2 minutes.
? Dynamic stretching (Active Isolated Stretching, Contract-Relax- PNF) to the muscles of the neck, the shoulder, elbow, wrist, and fingers.
? Trigger point therapy to the flexors and extensors of my hand, wrist and elbow.
? Heat, water baths or heat pad, helped decrease the stiffness of the connective tissue and pain, and facilitate joint mobilizations.
? Friction massage to soft tissue (muscles and connective tissue) at attachment points in the palm of hand especially around the thumb and at the elbow at the common extender tendon (tennis elbow area) and common flexor tendon (golfer?s elbow area).
? Joint mobilization, with the help of a physiotherapist and self-joint mobilization.
? Movement, movement, movement. I found that typing at the computer leaves my hand stiff and less mobile.
? Strengthening and endurance: Return to work gradually. I found that working with my hands helps increase the strength and endurance of the intrinsic and extrinsic hand muscles.
? Nerve mobilizations (nerve flossing). We found the median nerve being entrapped and showing signs in the carpal tunnel. Nerve flossing helps with that.
I think time is a factor in the healing process. As for massage therapy treatments, I think it helped with pain perception and helped the tissues slide and glide over each other to increase flexibility (That?s not to say that this would not have happened with time but massage therapy may have helped speed the recovery).
Left Wrist the day the cast was removed.
Left wrist at eleven weeks after the removal of the cast.
Within the first 3 weeks of removing my cast, my sprained and immobile wrist became more flexible. The soft tissue became more resilient and I could see them glide and slide over each other and under the skin with more ease. At 8 weeks post cast, I had soreness at the end of the day after working out and seeing clients. I took time off at the gym and focused on legs. At 10 weeks, I did a 30 repetitions push jerk with 45 lbs (shoulder to overhead with a weighted bar) without any ill effects. I was now able to work on 4-5 people per day. ?At 11 weeks, the size of my muscles of my left thumb and my hand are quite similar to the right hand and the bulk of the extensors and flexors along the forearm have somewhat returned. The skin looks healthy, I can feel and pick up the tendons of my wrist, the various layers are mobile and I can see and feel the blood vessels. I have complete range of motion in the wrist except flexion, which improves on a daily basis. The next step is to work on loading the hand (like in a push up) and practicing grip strength to eventually do pull-ups.
As flexibility, strength and endurance improve gradually, I celebrate the gains I?ve achieved and I remember to be patient.
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Source: https://www.aloemassage.ca/2012/11/wrist-rehabilitation-and-massage-therapy/
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