I'm going to have surgery to remove tight cords in my palm from Dupuytren disease. The surgery is covered by insurance but the hand therapy and splinting afterwards is not. Can I get along without these treatments?
This is a good question and one that hand therapists are actively researching. With the new push for evidence-based outcomes, investigations are ongoing comparing different treatment approaches for various hand conditions including contractures caused by Dupuytren disease.
Dupuytren contracture is a fairly common disorder of the fingers. In this condition, the fascia (connective tissue) of the hand is transformed into shortened cords. The first symptom is often a thick nodule (knob) or a short cord in the palm of the hand, just below the ring finger.
More nodules form, and the tissues thicken and shorten until the finger cannot be fully straightened. This contracture is like extra scar tissue just under the skin. As the disorder progresses, finger becomes more and more bent (the contracture), which limits the motion of the finger. Dupuytren's contracture usually affects only the ring and little finger. The contracture spreads to the joints of the finger, which can become permanently immobilized.
Without treatment, the contracture can become so severe that the affected finger(s) cannot be straightened. Eventually loss of motion leads to loss of hand function, including grip strength. Surgery is often required when the contractures are severe.
Removal or release of the diseased tissue can be done surgically with a procedure called palmar fasciectomy. Bracing and stretching of the fingers alone has not been proven to help in the long term progression of this condition. And according to the results of a recent study from New Zealand, night splinting after surgery may not be any more effective than not splinting.
The hand therapists randomly divided patients with Dupuytren contracture who had surgical release into two groups. The patients in one group received a custom-made night extension orthosis along with hand therapy. The second group just had hand therapy (no splint).
Both groups were treated for three months. Results were measured and compared for the two groups using finger extension, finger flexion, grip strength, and hand function as the final outcomes. Motion measurements were taken before surgery, at the first visit with the hand therapist after surgery, six weeks after surgery, and one last time three months after surgery.
They found out that splinting did not improve results following surgical release for this condition. The practice of routinely holding fingers in an extended position at night did not prevent loss of motion -- at least not after three months' time. Contracture recurrence is common (more than half of all patients experience this problem) and wearing a night splint didn't seem to help.
It's possible that wearing the splints for a longer period of time may be helpful. Perhaps the use of night positioning during the formation of new scar tissue requires longer time to change tissue length. It is also possible that the type of splint makes a difference. A different design may provide more optimal joint motion. Since there are three joints in each finger, it is possible that the joints respond differently from one another in the type of splinting used in this study.
The study did not include a group of patients who did not receive hand therapy since this is a form of withholding available treatment and is not considered ethical. So, we don't have studies to show what would happen without the hand therapy. And it is not clear based on just this one study that the routine use of hand splinting after contracture release can be eliminated.
If your surgeon advises hand therapy and splinting, you should be able to work out a payment agreement with the therapist. A program that has more emphasis on a home program (you do more of the work) may also reduce the total cost of your rehab. Be sure and talk with both the surgeon and the therapist before surgery to see what is possible.