Stretching Exercises for the Hand and Face

(A video version of this information is available on www.youtube.com/sclerodermaUS)

January 2019

Janet L. Poole, PhD, OTR/L Professor, Occupational Therapy Graduate Program The University of New Mexico Why should people with scleroderma stretch? • In scleroderma, there is a build- • Certain joints in the arms and • The purpose of stretching or up of collagen, which is part of hands seem to get stiffer and range-of-motion exercises is to the connective tissue that makes lose motion more than others. prevent or slow down the loss of up the skin and tendons. With This loss of motion in a joint is motion in joints (contractures). a build-up of collagen, the skin referred to as a contracture. • There are many exercises that becomes tight and cannot stretch • The large knuckle joints, called you can do on your own to keep as easily over joints, which the metacarpophalangeal pha- your joints from getting stiffer. results in difficulty moving joints. langeal (MCP) joints of the hand, However, you may want to ask • Over time, the joints may begin can be hard to bend or flex. See your doctor for a referral to an to feel stiff and the skin may Figure 1. occupational or physical therapist feel ‘tight”. For example, it may • The smaller joints, the proximal who can get you started and can become hard to fully make a fist, interphalangeal or PIP joints, as set up and monitor your exercise straighten your fingers, bend shown in Figure 1, can be hard to program. your knees and elbows, and open straighten all the way. your mouth to floss or brush your teeth. The dentist or • It may also be hard to bend the hygienist may notice that it is thumb or move the thumb away harder to clean or examine from the hand, as if you are try- your teeth. ing to put your hand around a large glass.

HELPFUL HINTS WHEN STARTING STRETCHING/JOINT RANGE OF MOTION EXERCISES • Stretching/Range-of-motion exer- cises for finger joints and other NAMES OF THE JOINTS IN THE FINGERS joints must be started early before you see or notice loss of motion. • Sometimes using heat before Metacarpophalangeal joint (MCP) doing exercises can help relax the tissues. Heat can include the use Proximal interphalangeal joint (PIP) of paraffin wax baths for hands or feet, an electric moist heating Distal interphalangeal pad (e.g. the Thermophore), microwaveable hot packs, and warm showers or baths. These Figure 1 heat applications should be warm, but not hot, as you could burn If you have ulcers on your fingers, it Use the palm of the other hand your skin. Use these for 15 to 20 is still important to stretch. Ulcers to press down on the back of the minutes and no longer than half are very painful, and you may not fingers close to the joint, as shown an hour. Instructions for using be able to do as many repetitions, in picture. paraffin are included at the end of but it is very important to keep the the brochure. joints around the ulcer moving so • Stretching/range-of-motion that you do not lose more motion exercises should be done while the ulcer heals. Remember frequently (2-3 times/day) and to breathe when you stretch. beyond the point where you feel Specific exercises for some tightness. the hands Move the body part until you Do each exercise 5 to 10 times and have the first awareness that the hold each exercise for a count of 3 to muscle is being stretched and 5 seconds. hold it there until you feel the Exercise 1 muscle relax. EXERCISES FOR BENDING THE EXERCISES FOR BENDING ALL LARGE JOINTS ON THE FINGERS JOINT OF THE FINGERS • Hold the position of stretch where (metacarpophalangeal joints, MCP) you feel a stretch/pull on the skin Exercise 2 helps increase bending or muscles for 5-10 seconds, even Exercise 1 helps increase bending or flexion in the middle and last if the skin blanches (turns white). in the large knuckle joints of the joints of the fingers. Make a fist and Repeat each stretch about 5-10 fingers. Make a fist emphasizing try to touch the tips of all fingers times. flexion (bending) of the MCP joints. to the palm of the hand. Use your

2 (webspace) gets tight and it can be hard to hold large objects such as glasses. The next 2 exercises help stretch the webspace between the thumb and index finger, and should be done 5 to 10 times. Exercise 7. To maintain Exercise 2 thumb motion, other hand to help push to try to try to bend the bend the finger joints. The picture thumb so that above shows how to do this exercise. the tip touches Exercise 5 the bottom of EXERCISES FOR STRAIGHTING the little finger. THE MIDDLE JOINTS (PIP JOINTS) as shown in the picture to try to Hold for 3 to To encourage PIP extension or straighten the middle joint. The 5 seconds. If straightening of the middle joints finger that you are stretching may the tip of your Exercise 7 of the fingers (PIP joints), there are turn white. If this happens to you, thumb cannot reach that far, just several exercises you can do. If you repeat the stretch with another make that your can almost straighten the middle finger and keep repeating the goal. joints, do exercises 3 and 4 below. stretches until you have stretched all fingers. Then start with the first Exercise 8. To finger and keep repeating until you stretch out the have done about 3 to 5 stretches thumb away with each finger. from the hand, place the pads of the thumb and index fingers of both hands together Exercise 3 and push the Exercise 8 Exercise 3. Push your hand flat on thumbs away a hard surface like a table. Try to from the index fingers and hold 3 to get the entire surface of all fingers and the palm to touch the table. You can use the palm of one hand to push down on the back of the fingers. Exercise 4. Place the hands and Exercise 6 fingers of both Exercise 6. Another way to do the hands flat against same exercise for the PIP joint uses each other in a 3 points of pressure (see picture). “prayer” position. The first point of pressure is the Try to get the pad of the index finger on the palm palm sides of the side of the finger, just above the PIP fingers to touch joint. The second point of pressure Exercise 9 each other all is the pad of the third finger on the 5 seconds. along the length Exercise 4 palm side of the contracted finger of each finger. below the PIP joint. The third point Exercise 9. Another way to stretch If your fingers are bent or cannot of pressure is the thumb against the webspace is to find the largest straighten or if the middle joint of the back of the contracted PIP joint. cylindrical (round) object such as a one finger is much more bent than The thumb pushes against the joint water bottle, can (soda, soup, spice the others, do exercises 5 and 6. while the index and middle fingers jar, tomato paste, etc.) that will fit These exercises stretch one finger at apply counter pressure to attempt snuggly in the webspace. Make sure a time. to straighten the joint.Repeat until the object is in contact with all parts you have done 3 to 5 stretches per of the webspace as in the picture. If Exercise 5. Place your hand flat finger. there is a gap, the object is too big on the table. Use one thumb to and you might want to start with a press down on the back of the EXERCISES FOR THE THUMBS smaller object with the goal of being middle joint of one finger and use **In some people, the space able to hold the larger one, do 5 to the index (pointer finger) to lift up between the thumb and index finger 10 times and hold for 3 to 5 seconds. underneath the tip of the finger

3 EXERCISES TO STRETCH THE Exercise 14 SPACE BETWEEN YOUR FINGERS Pucker up your The spaces between the fingers are lips like you are also called web spaces and can get going to kiss tight in people with scleroderma. something or The two exercises below will help blow out a candle stretch these spaces to make it and hold the easier to use a keyboard, play the pucker. Count to 5 to yourself, piano or other instruments or put Exercise 15 on gloves. relax and repeat. Exercise 15. Puff Exercise 12 out your cheeks with air and hold. Exercise 13 increases the motion Count to 5, relax to bend the wrist. Turn one hand and repeat. so the palm is facing down. Now bend your wrist so your fingers Exercise 16. are pointing down to the ground or Smile, a real floor. Use the other hand to push, cheesy smile Exercise 16 VERY GENTLY, on the back of the showing off all hand for 3 to 5 seconds. Do not push your teeth. Hold Exercise 10 hard or for very long. Repeat with and count to 5, the other wrist. relax and repeat. Exercise 10. Interlace your fingers Exercise 17. and try to slide the fingers all the Open your mouth way down so that the web spaces as wide as you are touching like in the picture. can and hold. Hold the stretch 3 to 5 seconds. You Count to 5, relax can see from the picture that the and repeat. Exercise 17 person cannot slide their fingers all the way down, but that is still the Exercise 18. goal. Manual stretch- ing uses the fingers to stretch the mouth. The right thumb is Exercise 13 placed in the EXERCISES FOR THE FACE corner of the left AND MOUTH side of the mouth Exercise 18 These exercises are important for while the left facial expression and teeth and thumb is placed in the corner of the mouth care. Sometimes mouth right side of the mouth. The mouth opening slowly decreases. You is stretched to the sides by the might not notice this until you visit thumbs. Hold for 5 seconds, relax Exercise 11 and repeat. Exercise 11. Another way to your dentist or dental hygienist, stretch the web spaces is to put the who might have a harder time top of a water bottle between two working on your teeth. You may of your fingers and slide it down as notice that it gets harder to floss far as the bottle will go and hold it your teeth. there for 5-10 seconds. You can then The first 4 exercises (14-17) work slide the bottle in between the next on stretching the skin on your face two fingers and so on. and consist of exaggerated facial movements. You can do these EXERCISES FOR THE WRISTS exercises in the shower where the Exercise 12 is for straightening the warm water may wrist. Turn one hand so the palm is warm and relax Exercise 19 facing up. Then straighten the wrist the skin. Exercise 19. Oral augmentation is an exercise that consists of tongue so the fingers point down to the Do each exercise floor. Take your other hand and try depressors inserted between the 5 to 10 times teeth from the left premolar area to push on the palm to get the wrist and hold for a to straighten more and hold for 3 to the right molar region. The count of 3 to 5 position is held for several seconds. to 5 seconds. Repeat. Then do the seconds. other wrist. Additional tongue depressors are Exercise 14 added as motion increases.

3 4 INSTRUCTIONS FOR PARAFFIN WAX

What is needed: Paraffin wax unit, Saran wrap or plastic bags, and terry cloth towels.

Preparation: After you have followed the manufacturer’s instructions to melt the paraffin, insert the thermometer; the temperature should read 125/126 degrees F. If it is too hot, turn temperature down to LOW and test again with thermometer. When temperature is 125/126 degree F, you are ready.

Treatment: Roll up sleeves of your shirt, remove all jewelry, wash & dry hands. Spread your fingers apart and slowly put your hands in the wax.

DO NOT TOUCH THE SIDES OR BOTTOM OF THE PARAFFIN UNIT. Remove hand right away but be gentle. Count to five and then put hand back in the wax. Repeat, 5 more times. Cover your hands with plastic bags and then wrap in a towel. Wait 20 minutes. Remove towels. Remove plastic bags and throw away. Peel the paraffin wax from your hands and return paraffin to unit as it can be used again. TURN OFF UNIT. DO HAND EXERCISES WHILE HANDS ARE STILL WARM.

NOTE: DO NOT use paraffin if you have open wounds or cuts on your hands. If this occurs, call your health professional. When wax in the unit starts to look dirty or no longer white, clean the unit and change the wax. Paraffin units can be purchased from pharmacies, and discount stores such as Wal-Mart, Target, K-Mart, Costco, Sam’s Club or on-line.

5 The Scleroderma Foundation’s mission is three-fold: a To help patients and their families cope with scleroderma through mutual support programs, peer counseling, physician referrals, and educational information. a To promote public awareness and education through patient and health professional semi- nars, literature, and publicity campaigns. a To stimulate and support research to improve treatment and ultimately find the cause and cure of scleroderma and related diseases.

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Text and logo © 2019, The Scleroderma Foundation, Inc. January 2019 – Rev. 1