RGUHS Hariharasudhan R et al.

, RJPT 2022;2(3):20-24

Journal of Physiotherapy
CASE REPORT

Effectiveness of Eccentric Exercise in The Rehabilitation of Post-Immobilization

Stiffness of Wrist: A Case Study
Hariharasudhan Ravichandran, Deeksha Shettigar*, Kshama Susheel Shetty
Alvas College of Physiotherapy, Moodbidri, Dakshina Kannada, Karnataka, India
*Corresponding author:
Deeksha Shettigar, Alva’s College of Physiotherapy and Research Centre, Moodbidri, Dakshina Kannada, Karnataka,
India.
Received date: April 15, 2022; Accepted date: November 16, 2022; Published date: December 31, 2022
Affiliated to Rajiv Gandhi University of Health Sciences, Karnataka, India

Abstract
Post-immobilization deficiency in wrist motion is a common complication following distal radius fractures
and it interferes with daily life activities. The wrist and the hand play a vital role in the manipulation, grasping,
and releasing of objects. Achieving a functional range of motion and adequate muscle power to perform
daily activities remains a challenge for therapists involved in rehabilitation. The present case is a 27-year-old
electrician, who visited our outpatient physiotherapy department with wrist joint stiffness. He had a history of
falls and sustained a distal radius fracture on his right forearm, and was operated on with a buttress plate and
screws 2 months ago. In this case study, an eccentric exercise-based rehabilitation program was prescribed
in addition to conventional wrist and hand rehabilitation. An eccentric exercise program is modified and
progressed according to the patient’s tolerance. Pain, range of motion, muscle strength of wrist, and disability
of the arm, shoulder, and hand score were used as outcome measures. Following two weeks of the eccentric-
based rehabilitation program, the patient achieved improvement in wrist motions and disability of the arm,
shoulder, and hand score results. The eccentric exercise program is effective in improving wrist range motion,
muscle power, and hand function following stiffness.
Keywords: Barton fracture, Eccentric exercises, Rehabilitation, Stiffness, Wrist joint

Introduction Distal radius fractures account for approximately one-

Following immobilization of the wrist and hand,
developing joint adhesions and stiffness is a common
finding in physiotherapy rehabilitation settings. It
significantly affects the patient’s ability to return to
normal life. The human hand design comprises skin,
soft tissues, bones, tendons, ligaments, and muscles
which enables an individual to perform various gross
and fine movements. Injuries around the wrist and hand
are common and have to be managed according to the
nature of the injury. Fractures and other soft tissue
injuries require a period of immobilization that develops
stiffness and affect the functional performance of the
hand.1
sixth of all fractures in the emergency department.2
Around 20% of attendances to the emergency department
are due to injuries to the hand and wrist. The young adult
population between the age group of 19–49 is most
affected by Barton fractures, with a greater predilection
for males than females.3
The inflammatory and vascular events that take
place during immobilization eventually lead to the
development of adhesions around the tendon sheaths and
joint capsules. Following immobilization, joints often
demonstrate the weakness of muscles and joint stiffness
associated with restriction in range of motion. In recently
published studies,4,5 it was reported that reduced range of

20

motion and muscle weakness are positively associated to
stiffness. To address this issue, an eccentric exercise that
combines the effect of both stretching and strengthening
could be beneficial in improving movement and muscle
strength.6 An eccentric (lengthening) muscle contraction
occurs when a force applied to the muscle exceeds the
momentary force produced by the muscle itself, resulting
in the forced lengthening of the muscle-tendon system
while contracting.7
Case Description
A 27-year-old male visited the Alvas college of
Physiotherapy outpatient department with complaints
of pain and stiffness in his right hand. The patient was
an electrician by profession, with the right hand as the
dominant side. The patient was normal 2 months ago,
he sustained an electric shock at his workplace and
fell from a 10 feet height, landing on the floor with
his hand hitting against the wall. He was admitted to
Alvas Health Center, Dakshina Kannada, Karnataka,
for first aid and further management. The radiologic
findings revealed dorsal Barton’s fracture on the right
side for which he underwent Open reduction internal
fixation (ORIF) with a “T” buttress plate and screws.
His wrist was immobilized for 6 weeks following the
surgery. Due to his personal reasons, he did not undergo
any physiotherapy exercises immediately after he was
operated on. There was no significant past medical
history. He was single and resided with his mother and
was the only member to earn for his family. He was
looking forward to returning to his work to manage his
family expenses. He experienced pain and wrist joint
stiffness and an inability to hold plates, and utensils, and
also had difficulty in gripping activities at his workplace.
On observation, no postural abnormalities were found. A
surgical suture mark measuring 6cm on the volar aspect
of the wrist was present and the wrist joint deviated
towards the ulnar side. There was mild swelling in
the thenar eminence around the wrist joint extending
halfway to the forearm. No abnormalities on palpation
around the wrist were observed. The wrist was restricted
to 5 degrees or no range in all the movements of the
wrist. The patient had pain and stiffness in the wrist joint
including mild pain and stiffness in the inter-phalangeal
joint.
Outcomes such as the numeric pain rating scale and
disabilities of the arm, shoulder, and hand (DASH)
questionnaire were used in this case study to measure
Hariharasudhan R et al., RJPT 2022;2(3):20-24
the effects of eccentric exercise. The numeric pain rating
scale was used to assess pain intensity, it was 2 out of
10 at rest, and 7 out of 10 while performing movements.
The DASH was used to record the functional status of
the hand. A higher score indicated greater disability.
The initial score was 39.25/100. Physiotherapy
rehabilitation was started following the assessment
with short-term goals to reduce pain and improve joint
range of motion. Ultrasound therapy was administered
in and around adhesions of tendons. Scar mobilization
was performed and wrist flexors and extensors were
stretched passively up to the tolerable range. Isometrics
for wrist flexors and extensors, gripping, and releasing
activities were included. The eccentric loading exercise
program with level 1 theraband was performed for wrist
flexors, extensors, and radial and ulnar deviators. The
resistance offered by the theraband was modified by
the therapist by altering its tension so that it helped to
encourage movement in the available ranges of the wrist
joint (Figure 1). Throughout the range, resistance was
modified to allow the patient to perform the movement
without any restriction. Functional training peg board
activities, grasping and releasing objects, and spring
resistance exercises were also modified to facilitate
eccentric muscle activity. Gradual sustained joint
muscle contraction with lengthening movement was
elicited during these activities so that eccentric activity
is induced.
Eccentric exercises using theraband were performed
at mild to moderate difficulty perceived by him, for
6–8 repetitions in 3 sets. Initial sessions lasted for 45
minutes for 5 days a week. Hand grip activity performed
using spring resistance was included and performed
eccentrically. Additionally, the routine isometrics,
passive stretches, passive movements, and active
movements were continued.
After 3 weeks, he started simulating activities related to
his workplace. By 4th week he started working with an
assistant. He performed light works without much effort.
Following 8 weeks post-treatment, outcomes such as
numeric pain rating scale (Table 1), range of motion,
(Table 2) muscle power (Table 3), and DASH(Table 3)
were repeated. The DASH improved from 39.25 out of
100 at baseline to 23.5 out of 100 post-treatment.
Outcome measures
The following outcome measures were assessed at the
initial evaluation and post-treatment.
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 Hariharasudhan R et al., RJPT 2022;2(3):20-24

Table 1: Numerical pain rating scale

Outcome Post-
Pre-Test
Measure Intervention
On
7/10 1/10
Numerical pain movement
rating scale
At rest 2/10 nil

Figure 1: Eccentric loading exercise

Table 2: Range of motion
Pre-Test Post-Test
Joint Movements Right Left
Active Passive Active Passive
Flexion 0–120 0130 0-130 0-140
Elbow
Extension 120–0 130-0 130-0 140-0
Supination 0–40 0-70 0-70 0-90
Forearm
Pronation 0–0 0-75 0-75 0-90
Flexion 0-10 0-30 0-40 0-50
Extension 0-5 0-10 0-50 0-60
Wrist
Radial deviation 0-2 0-5 0-5 0-10
Ulnar deviation 0-5 0-10 0-20 0-25
Palmar adduction 0-30 0-35 0-45 0-45
Palmar abduction 0-30 0-35 0-60 0-60
Thumb basal joint
Radial adduction 0-40 0-45 0-60 0-60
Radial abduction 0-40 0-45 0-60 0-60
Hyperextension 0-15 0-15 0-15 0-15
Thumb IP joint
Flexion 0-80 0-80 0-80 0-80
Hyperextension 0-10 0-10 0-10 0-10
Thumb MCP joint
Flexion 0-40 0-45 0-90 0-90
Hyperextension 0-35 0-40 0-45 0-45
Finger MCP joint
Flexion 0-75 0-80 0-90 0-90
Flexion 0-85 0-90 0-100 0-100
Finger PIP joint
Extension 0 0 0 0
Flexion 0-80 0-80 0-80 0-80
Finger DIP joint
Extension 0 0 0 0
Table 3: Manual Muscle Testing (MMT)
Pre-test Post-test
Joints Muscles
Right Left Right Left
Flexor 4+ 5 5 5
Elbow
Extensor 4+ 5 5 5
Flexor 3+ 5 4 5
Extensor 2+ 5 4 5
Wrist
Supinator 3+ 5 5 5
Pronator 3+ 5 5 5

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Table 4: DASH
Outcome Initial
8th Week
Measure Assessment
DASH 39.25/100 23.5
Discussion
After 8 weeks of the eccentric exercises, there was an
improvement in the outcomes such as pain, joint range
of motion, muscle power, and hand function. Eccentric
exercises cause a greater increase in eccentric torque that
helps to build up strength and enhances flexibility. This
makes eccentric training an interesting training adjunct
in strength and conditioning programs.
In a study by Caputo et al.,8 it was evident that pain
was associated with strength. In the present study, there
was a significant reduction in pain associated with an
increase in strength. Eccentric exercise decreases pain
by promoting a range of motion. There is also evidence
that the experience of pain is less, and the reversion of
pain fastens with eccentric exercises than during the
concentric ones.9
Eccentric exercise at low intensity reduces the energy
requirement typically by 4 folds compared to the
concentric exercise of the same intensity.10 This favors
eccentric exercise in conditions with diminished muscle
power and restricted joint range of motions. In the present
case study, the implemented eccentric exercises were set
at mild to moderate intensity, to encourage movement
and to avoid the adverse effects of exercise-induced
muscle damage. Performing eccentric exercise at high
intensity generates greater eccentric forces in a muscle
that is naïve to eccentric contractions and subsequent
muscle damage is expected.
Following eccentric exposure adaptation, the muscles
are well prepared to experience the higher forces that
are characteristics of a progressive eccentric-negative
work phase.11 Earlier joint mobilization and manual
therapy techniques were most commonly considered
to increase joint movement. In addition to joint
mobilization and manual techniques, eccentric exercise
could be beneficial in accelerating the recovery process
in rehabilitation. Eccentric exercise being actively
performed by patients could provide effective outcomes
in addressing the articular and extra-articular structures
in post-immobilization stiffness.
Hariharasudhan R et al., RJPT 2022;2(3):20-24
Eccentric exercise could be beneficial in improving
the range of motion of immobilized joints. Effects of
eccentric exercise include reducing pain, improving
movement and muscle power, and reduction in the
severity of disabilities. Hence, eccentric exercise
should be considered in addition to the conventional
rehabilitation methods for post-immobilization joint
stiffness.
Conflicts of Interest
Nil
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