Dupuytren's Contracture (Dupuytren Disease)

Definition and Pathophysiology

• Grayson's ligaments (volar) - ARE involved
• Cleland's ligaments (dorsal) - are NOT involved
• Spiral cord - associated with PIP joint contracture; the neurovascular bundle is displaced centrally and superficially, placing it at risk during surgery

Clinical Features

1. Nodular stage - firm subcutaneous nodules at the base of digits/palm; may never progress
2. Cord stage - thickened fibrous bands extend into the digit, pulling finger into flexion
3. Contracture stage - fixed flexion deformity at MCP and/or PIP joints

Epidemiology and Risk Factors

Note: Occupation has NOT been associated with Dupuytren disease (Miller's Review of Orthopaedics, 9e).

Dupuytren Diathesis

• Affects other fascial structures: soles of the feet (Ledderhose disease), popliteal fascia, knuckle pads (Garrod's pads), and penis (Peyronie's disease)
• Presents at an earlier age
• Higher risk of recurrence after treatment

Surgical Indications (Hueston Tabletop Test)

• MCP flexion contracture >30 degrees
• Any PIP flexion contracture (even mild PIP contractures are harder to correct and tend to progress)

Treatment Options

Conservative

• Mild disease: local heat, stretching exercises, protective gloves
• Splinting does not alter disease progression
• Intralesional corticosteroid injections for painful nodules (symptomatic relief only)

Interventional / Surgical

• Average MCP correction: up to 85%
• Average PIP correction: up to 60%
• Adverse effects: pain, swelling, bruising (temporary); skin tears more common than flexor tendon rupture

1. Recurrence (most common)
2. Digital nerve injury
3. Wound breakdown
4. Complex regional pain syndrome

Recent Evidence (2023-2026)

Prognosis and Recurrence

• Younger patients
• Bilateral aggressive disease
• Strong family history
• Fibrotic lesions elsewhere (diathesis)

Physiotherapy Management of Dupuytren's Contracture

1. Conservative / Pre-Procedural Physiotherapy

Physical Modalities

Important: Splinting does not alter disease progression in conservative management. It is not recommended as a standalone conservative strategy to halt the disease. - Rheumatology 2-Volume Set (Elsevier, 2022)

Exercise Therapy (Conservative)

• Active and passive ROM exercises for all finger joints - performed several times daily
• Palmar stretching - gentle, sustained extension of the affected fingers using the opposite hand
• Tendon gliding exercises - hook fist, full fist, straight fist, table-top position to maintain differential tendon gliding
• Intrinsic stretch - abduction/adduction exercises to maintain web space mobility
• Avoid aggressive forceful stretching - it does not reverse Dupuytren cords and may cause pain

Splinting in Conservative Management

• Night extension splints (custom thermoplastic) - worn to prevent further flexion during sleep
• Goal is contracture prevention rather than reversal
• Patient education: a splint that causes pain or circulatory changes must be loosened immediately

Functional / Adaptive Strategies

• Occupational therapy component: adaptive equipment (jar openers, modified grip tools)
• Gloves during activities - protective, reduce skin irritation over nodules
• Ergonomic modifications for daily activities

2. Post-Surgical Rehabilitation

Phase 1: Acute Phase (Days 0-5 post-op)

• Dorsal thermoplastic static extension splint (24 hours/day until wound healing)
• Oedema management: elevation, retrograde massage, compression bandaging
• Wound care: dressing changes, monitoring for signs of infection
• ROM exercises (remove splint once every 2 hours for gentle active digit exercises)
• Avoid applied mechanical tension in the early phase - studies show this reduces complications with no loss of extension range

Phase 2: Wound Healing Phase (Week 1-3)

• ROM exercises - 4 to 6 times per day (the standard NHS post-op set):
  1. Spread fingers apart as wide as possible, then bring together - 10 reps
  2. Make a fist (closing and opening fully) - 10 reps
  3. Passive extension stretch using the non-operated hand - 10 reps
  4. Table-top passive extension - palm up, gently press fingers flat, hold 2-3 seconds - 10 reps
  5. Dorsal passive extension - palm down on table, push fingers flat with other hand - 10 reps
• Active/passive ROM (A/PROM) exercises 8-10 times per day (protocol: once splint use transitions to nighttime only)
• Splint transition: once wound healed, move to volar thermoplastic static extension splint at night + 3 × 1.5-hour daytime periods
• Scar management: silicone gel sheets/dressings over scar to reduce hypertrophy; massage once wound fully closed
• Suture removal at 2 weeks (if non-dissolvable)

Phase 3: Remodelling Phase (Weeks 3-6)

• Progressive strengthening: putty exercises, grip strengthening
• Scar massage - cross-friction massage to improve scar mobility and pliability
• Dynamic extension splinting may be used if residual extension deficit persists (spring-loaded or serial static splinting)
• Gradually decrease splint use - rehabilitation is a progressive increase in activity with decreasing splinting
• Return to work/daily activities guided by wound healing and ROM progress

Phase 4: Late Rehabilitation (6+ weeks)

• Strengthening continues
• Fine motor and dexterity tasks
• Work-specific or sport-specific rehabilitation
• Night splinting may continue for 3-6 months post-operatively to prevent recurrence of flexion contracture during scar maturation

3. Post-Collagenase (CCH / Xiaflex) Injection Rehabilitation

• Day 2-3 post-injection/manipulation: Fabricate digit extension orthosis (hand-based)
• Active/passive ROM exercises: 8-10 times daily, performed out of the splint
• Splint schedule: Nighttime initially; if flexion lag returns, reintroduce daytime wear
• Duration: Current standard recommendation is nighttime extension orthosis for 4 months post-CCH

Key RCT Evidence on Orthosis After CCH (2025):

• Orthosis group had significantly lower residual contracture at 4 months (11° vs. 20°)
• Benefit was mainly in PIP joints (19° vs. 36° at 4 months) - no significant difference at MCP joints
• Recommendation: Night orthosis after CCH for PIP contractures is recommended; optional for MCP contractures

4. Splinting: Current Evidence Summary

• No significant difference in total active flexion, extension, DASH scores, pain, or grip strength
• Splinting offered no added functional benefit to hand therapy alone post-fasciectomy
• However, orthotic regimes are still reasonable in patients who develop a post-op extension deficit

5. Physiotherapy Referral Criteria

• Recurrent Dupuytren's contracture
• Pre-op MCP or PIP contracture >40°
• Post-op extension deficit at any point
• Bilateral disease or Dupuytren diathesis
• Any wound complications (breakdown, infection, skin grafting)
• Patients with high recurrence risk (young age, strong family history)

Summary Table

TB Spine (Pott's Disease) - Physiotherapy Management

Brief Disease Overview (Context for Physiotherapy)

• Anterior vertebral destruction → spinal instability → kyphosis
• Paraspinal/psoas abscess → pain, hip flexion deformity
• Epidural pus/granulation tissue → cord compression → Pott's paraplegia (most feared complication)
• Disc involvement (in children) vs. disc sparing (adults)
• Neurological deficit in ~30% of patients in less developed countries
• Good prognostic indicators: intact motor function + normal rectal tone

Role of Physiotherapy in TB Spine

1. Pain management
2. Spinal protection and posture
3. Respiratory function (especially with thoracic involvement)
4. Neurological rehabilitation (paralysis/paresis)
5. Functional independence and mobility
6. Prevention of complications (contractures, pressure sores, DVT, pneumonia)

Phase 1: Acute Phase (Active Disease / Bed Rest Period)

Goals

• Protect the unstable spine
• Prevent immobilisation complications
• Maintain respiratory function
• Manage pain

1a. Spinal Protection

• Strict bed rest in supine (log-rolling for position changes) until spinal stability is confirmed by the treating physician
• No spinal flexion, rotation, or unsupported sitting until cleared
• Patient and carer education on proper positioning and transfers

1b. Spinal Orthosis / Brace

• Indicated for thoracolumbar TB in patients without neurological deficit
• Worn during any weight-bearing or ambulation
• Purpose: limit spinal motion, prevent kyphosis progression, reduce pain, allow early mobilisation
• Evidence supports a spinal brace + chemotherapy regimen for uncomplicated thoracolumbar TB, with good outcomes over 36-48 months follow-up - Spinal brace in TB of spine, NSJ
• Cervical TB: cervical collar or halo-vest depending on instability

1c. Respiratory Physiotherapy

• Diaphragmatic breathing exercises - retrain primary respiratory muscle
• Deep breathing and breath-holding techniques - maintain lung volumes
• Incentive spirometry
• Postural drainage and chest percussion if there is pulmonary TB co-involvement
• Segmental breathing to address localised lung areas
• Cough facilitation if secretion clearance is compromised (especially with thoracic kyphosis)

1d. Bed Exercises (During Bed Rest)

• Ankle pump exercises - DVT prophylaxis
• Isometric quadriceps and gluteal contractions
• Upper limb ROM and strengthening (if no cervical involvement)
• Static core activation - gentle transversus abdominis activation in supine
• Avoid any manoeuvre that loads or rotates the unstable spine

1e. Positioning and Skin Care

• Pressure area care - 2-hourly turns using log roll technique
• Foam/air mattresses to prevent pressure ulcers
• Limb positioning - splints/pillows to prevent foot drop, hip flexion contractures (especially with psoas abscess)
• Anti-foot drop splints if lower limb weakness is present

Phase 2: Subacute Phase (Disease Stabilising, Brace Prescribed)

Goals

• Gradual mobilisation with spinal protection
• Strengthen spinal and peripheral muscles
• Normalise gait and posture
• Manage neurological deficits

2a. Mobilisation Progression

• Supervised sitting → standing → walking with spinal orthosis
• Parallel bars initially for weight-bearing
• Gait training with appropriate assistive device (walking frame, elbow crutches)
• Staircase training as strength improves

2b. Core and Spinal Stabilisation Exercises

• Transversus abdominis activation in crook-lying
• Bridging exercises (gluteal + spinal extensor co-activation)
• Prone hip extensions (avoiding spinal hyperextension)
• Bird-dog exercises (supine/quadruped contralateral arm-leg raises)
• Pelvic tilts in supine
• Avoid loaded spinal flexion (sit-ups, toe touches) until fully healed

2c. Postural Correction

• Thoracic extension exercises - supported prone lying over a pillow, wall-supported thoracic extension
• Scapular retraction exercises (rhomboids, mid-trapezius) to combat the forward-rounded posture
• Chin tucks for cervical posture
• Mirror biofeedback for postural awareness
• Advise against prolonged sitting or spinal flexion activities

2d. Hip Flexor and Psoas Stretching

• Supine Thomas test position stretching
• Prone lying to stretch hip flexors passively
• Progress to standing hip extension stretches once allowed to weight-bear

Phase 3: Neurological Rehabilitation (Pott's Paraplegia)

• Type A (early onset, active disease) - due to inflammatory exudate, granulation tissue; more reversible with medical/surgical treatment
• Type B (late onset) - due to bony deformity, fibrous tissue; less reversible

Assessment Tools Used in PT

• ASIA Impairment Scale (A-E) - for spinal cord injury classification
• Frankel grading - older scale for neurological deficit in TB spine
• Modified Barthel Index - functional independence
• Berg Balance Scale - balance assessment
• MRC grade - individual muscle strength

3a. Lower Limb Rehabilitation (Paraplegia/Paresis)

• Passive ROM exercises for all lower limb joints - started from day 1 to prevent contractures
• Facilitation techniques (PNF patterns, Bobath) to stimulate weak muscles
• Active-assisted → active → resisted exercises as recovery progresses
• Stretching of spastic muscles (hamstrings, hip flexors, plantar flexors)
• Electrical stimulation (NMES/FES) to maintain muscle bulk and facilitate weak muscles
• Hydrotherapy - buoyancy reduces spinal load; excellent medium for early mobilisation

3b. Gait Rehabilitation

• Parallel bars → walking frame → crutches → stick → unaided
• Tilt table - for gradual re-introduction to upright in complete/severe paraplegia (prevents orthostatic hypotension)
• KAFO (knee-ankle-foot orthosis) if knee extension is weak
• AFO (ankle-foot orthosis) for foot drop
• Gait re-education - heel strike, push off, weight transfer

3c. Sensory Re-education

• Texture discrimination exercises
• Weight-bearing sensory input through feet (vibration, proprioception)
• Balance training in standing with sensory perturbations (foam surface, eyes closed)

3d. Bladder and Bowel Management

• Coordinate with nursing team for bladder programme (intermittent catheterisation if needed)
• Pelvic floor muscle training where neurologically possible
• Bowel management and positioning advice

3e. Upper Limb Strengthening (for Paraplegia Patients)

• Intensive upper limb strengthening for wheelchair use and transfers
• Push-up blocks, resistance bands, shoulder press
• Transfer training (bed to wheelchair, wheelchair to toilet)

Phase 4: Late Rehabilitation and Community Reintegration

Goals

• Maximum functional independence
• Prevent deformity recurrence
• Return to activities of daily living and work/school

Outcome Measures Used in TB Spine Rehabilitation

Important Precautions in TB Spine Physiotherapy

Evidence Base