4.18: Dupuytren's Disease

Dupuytren’s disease (also known as Dupuytren’s contracture) is a progressive fibroproliferative disorder of the hand that eventually can cause contractures of the affected fingers. Typical presentation is a gradual onset in males over 50 years of age. At first people may not notice the development of changes in their palms, the condition may even go dormant, but if the palmar fascia begins to thicken and contractions develop, the condition is recognizable – this is the ideal time to seek help from massage therapy.

Pathophysiology

The progression of the disease is a complicated process, involving a cascade of molecular and cellular events, in which the cytokines transforming growth factor beta (TGF-β) and tumor necrosis factor (TNF) play a fundamental role during the course of Dupuytren’s disease. Elevated levels of TGF-β & TNF contribute to the contractile activity of myofibroblasts, which drives disease development, in patients with Dupuytren’s contractures (Hinz & Lagares, 2020). This leads to a thickening of the tendons of the forearm and the palmar fascia.

Examination

A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

• Self-Rated Recovery Question
• Patient-Specific Functional Scale (PSFS)
• Brief Pain Inventory (BPI)
• Visual Analog Scale (VAS)
• DASH Outcome Measure
• Upper Extremity Functional Index
• Patient-Rated Wrist Evaluation (PRWE)
• Patient-Rated Wrist/Hand Evaluation (PRWHE)

Physical Examination

Incorporate one or more of the following physical examination tools and interpret examination results in the context of all clinical exam findings.

• Allen Test
• Tinel’s Sign
• Froment’s Sign (Pinch Grip Test)

Treatment

Education

Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.

Manual Therapy

Studies have demonstrated that non-operative treatments such as massage therapy combined with active and passive stretching may affect progression (Christie et al., 2012). As a therapeutic intervention massage therapy has the potential to attenuate TGF-β1 induced fibroblast to myofibroblast transformation. Recent studies have looked at the effect of modeled massage therapy and mechanical stretching on tissue levels of TGF-β1. In these studies, it was demonstrated that manual therapy has the potential to attenuate tissue levels of TGF-β1 and the development of fibrosis (Bove et al., 2016; Bove et al., 2019). This is potentially impactful in the treatment of Dupuytren’s disease because TGF-β1 plays a key role in tissue remodeling and fibrosis.

Treatment focus is on the intrinsic hand muscles and carpal bones of the wrist, while also addressing areas of compensation, such as the flexors and extensors of the forearm. Massage therapy may delay the progression of contractures and decrease recurrence in post-operative patients. Massage therapy treatment for Dupuytren’s disease should not be vigorous and stretching should be a gentle exploration of range of motion. A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. Structures to keep in mind while assessing and treating patients suffering from Dupuytren’s may include neurovascular structures and investing fascia of:

• Biceps Brachii (bicipital aponeurosis)
• Triceps Brachii
• Common Extensor Tendon (extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris)
• Common Flexor Tendon (pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor carpi ulnaris)
• Anterior Interosseous Membrane
• Palmar Aponeurosis
• Carpal Bones (trapezium, trapezoid, capitate, hamate, scaphoid, lunate, triquetrum, pisiform)
• Lumbricals

Self-Management Strategies

Tension and compression orthotic devices and splinting is often used after surgery in the short term. This has been shown to reduce the chances of recurrence in some people. Long term use of orthotic devices and splinting has mixed evidence. There have been modeled experiments to demonstrate the impact of stretching on inflammation-regulation mechanisms within connective tissue. Patients should be educated on the benefits of gentle stretching routines. Stretching should not be vigorous, it should be a gentle exploration of range of motion.

Prognosis

There is a high rate of recurrence in the post-operative population. In the early stages a trial of conservative care is the preferred treatment approach, this often includes physical therapy, night splinting, and home hand exercises. Persistent inflammation has the potential to interfere with the tissue remodeling, early conservative interventions may serve to interrupt the sequelae of pathological healing.

The ideal treatment for patients with progressive Dupuytren’s disease would be at the early stage to prevent or delay the development of flexion deformities and loss of manual dexterity. Prophylactic massage therapy treatments may inhibit inflammatory processes and affect the development of fibrosis by mediating differential cytokine production. Consequently, this may stabilize the progression of contractures and in some cases ameliorate the degree of deformity.

Niel Asher Education: Detailed Palm Massage – Dupuytren’s Contracture

Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for Dupuytren’s disease based on patient-specific assessment findings including, but not limited to:

• Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
• Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
• Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
• Hydrotherapy (hot & cold)
• Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

References and Sources

Bove, G. M., Harris, M. Y., Zhao, H., & Barbe, M. F. (2016). Manual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury. Journal of the neurological sciences, 361, 168–180. doi:10.1016/j.jns.2015.12.029

Bove, G. M., Delany, S. P., Hobson, L., Cruz, G. E., Harris, M. Y., Amin, M., … Barbe, M. F. (2019). Manual therapy prevents onset of nociceptor activity, sensorimotor dysfunction, and neural fibrosis induced by a volitional repetitive task. Pain, 160(3), 632–644. doi:10.1097/j.pain.0000000000001443

Christie, W. S., Puhl, A. A., & Lucaciu, O. C. (2012). Cross-frictional therapy and stretching for the treatment of palmar adhesions due to Dupuytren’s contracture: a prospective case study. Manual therapy, 17(5), 479–482. doi:10.1016/j.math.2011.11.001

Dutta, A., Jayasinghe, G., Deore, S., Wahed, K., Bhan, K., Bakti, N., & Singh, B. (2020). Dupuytren’s Contracture – Current Concepts. Journal of clinical orthopaedics and trauma, 11(4), 590–596. https://doi.org/10.1016/j.jcot.2020.03.026

Hinz, B., & Lagares, D. (2020). Evasion of apoptosis by myofibroblasts: a hallmark of fibrotic diseases. Nature reviews. Rheumatology, 16(1), 11–31. doi:10.1038/s41584-019-0324-5

Huisstede, B. M., Gladdines, S., Randsdorp, M. S., & Koes, B. W. (2018). Effectiveness of Conservative, Surgical, and Postsurgical Interventions for Trigger Finger, Dupuytren Disease, and De Quervain Disease: A Systematic Review. Archives of physical medicine and rehabilitation, 99(8), 1635–1649.e21. doi:10.1016/j.apmr.2017.07.014

Karpinski, M., Moltaji, S., Baxter, C., Murphy, J., Petropoulos, J. A., & Thoma, A. (2020). A systematic review identifying outcomes and outcome measures in Dupuytren’s disease research. The Journal of hand surgery, European volume, 45(5), 513–520. https://doi.org/10.1177/1753193420903624

Kitridis, D., Karamitsou, P., Giannaros, I., Papadakis, N., Sinopidis, C., & Givissis, P. (2019). Dupuytren’s disease: limited fasciectomy, night splinting, and hand exercises-long-term results. European journal of orthopaedic surgery & traumatology, 29(2), 349–355. doi:10.1007/s00590-018-2340-6

Soreide, E., Murad, M. H., Denbeigh, J. M., Lewallen, E. A., Dudakovic, A., Nordsletten, L., … Kakar, S. (2018). Treatment of Dupuytren’s contracture: a systematic review. The bone & joint journal, 100-B(9), 1138–1145. doi:10.1302/0301-620X.100B9.BJJ-2017-1194.R2

Stecco, C., Macchi, V., Barbieri, A., Tiengo, C., Porzionato, A., & De Caro, R. (2018). Hand fasciae innervation: The palmar aponeurosis. Clinical anatomy (New York, N.Y.), 31(5), 677–683. doi:10.1002/ca.23076

van Kooij, Y. E., Poelstra, R., Porsius, J. T., Slijper, H. P., Warwick, D., Selles, R. W., & Hand-Wrist Study Group (2020). Content validity and responsiveness of the Patient-Specific Functional Scale in patients with Dupuytren’s disease. Journal of hand therapy: official journal of the American Society of Hand Therapists, S0894-1130(20)30040-5. Advance online publication. https://doi.org/10.1016/j.jht.2020.03.009