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Riv Chir Mano - Vol 38 (2) 2001


Study Physiotherapy and Rehabilitation of the Hand, Milan
Joint stiffness: rehabilitation. SUMMARY. The joint stiffness is one of the natu
ral complications more frequently Discovered in the traumas of the hand. The vic
ious Triad Composed by: lesion, edema, immobilization, inevitably Takes to joint
stiffness. A Preventive Measure is without a doubt to correct post-traumatic po
sition. It must approach the functional one as much as possible, to Avoid That s
tiffens the edema in the metacarpophalangeal joint and extension Therefore, That
a "negative hand scheme" is developed. Times of immobilization of the hand Shou
ld Be Short, But It Is Also appropriate to keep the joints at rest in the times
dictated by the biology of the tissues. Therefore it is Difficult to Establish t
he Right Balance Between rest and movement. Precocious Mobilization, The Only Wa
y To Avoid joint limitations, is not always compatible with the undergone damage
; Moreover not all the Patients are fit to Such therapy, in that They Might Be T
oo Anxious to recover and Hasty in executing the exercises at one's own domicile
. This kind of patient has Necessarily to Be Kept at rest for a Greater time, t
o Avoid a negative result of the intervention. Presumptively surgeon and therapi
st must agree upon times and precise rules of the rehabilitation program. The pa
tient must submit to the treatment and Understand These Principles, nothing has
to be fortuitous, accidental or improvised: specific exercises, exact number of
repetitions to Respect, times and modality of use of the splint must be quite cl
ear to the patient. A splint used badly not only does not care, But It damages;
an exercise Repeated too many times or too much strength Increases Executed with
the inflammation, edema know, I know the stiffness. There Are Few Principles Th
at mark this treatment, But They Must Be Respected scrupulously by the patient a
nd Strictly Monitored by the surgeon and the therapist. The joint evaluation gon
iometrical and the functional one will show if the set-up program is correct. Su
ch Evaluations will be of great help to the surgeon in Deciding a possible opera
tional technique. Even were the considerations on the Psychological and the Expe
ctations of the patient must not be Neglected, Since The Patient Could Be By Now
demotivated after months or years of Inability. As Regards The most technical a
spect of the rehabilitation of the stiff hand, i would like to point out the ana
lytical That mobilizations and the splinting constituta the key of the treatment
: ones prepare the soft tissues to the Mobilization, The Others concur to the Re
habilitation Program , speeding up the times and guiding the tissue recovery pro
cesses. Riv Chir Mano 2001; 38: 170-179 KEY WORDS joint stiffness, swelling, neg
ative hand, basic joint Mobilization, splinting ABSTRACT stiffness are one of na
ture's most commonly encountered complications in trauma of the hand. The viciou
s triad consists of: injury, edema, immobilization, inevitably leads to joint st
iffness. Preventive measure is undoubtedly correct posture post-trauma. It shoul
d come as close as possible to the practical, to prevent edema stifle the metaca
rpophalangeal joints in extension and, consequently, develops a pattern of "bad
hand". The times of immobilization of a hand should be brief, but it is also adv
isable to rest the joints in the time dictated by biological tissue. It is there
fore difficult to establish the right balance between rest and movement. Early m
obilization, the only way to avoid the limitations arctic-
Corrispondence: T.d.R. Urso Graziella - Piazzale Lugano 33, 20158 Milano Tel / F
ax +39 0239312171 - Email:
lari is not always compatible with the damage and it does not all patients are s
uitable for this treatment as too eager to heal and hasty in carrying out exerci
ses at home. This type of patient must necessarily rested more time to avoid an
unsuccessful intervention. Surgeon and therapist should agree in advance the tim
es and rules of the rehabilitation program. The patient should undergo treatment
and understand these principles, nothing should be random and improvised exerci
ses precise, exact number of repetitions to be respected, time and how to use th
e orthoses must be clear to the patient. Orthosis misused not only heals, but ha
rms, an exercise repeated too many times or run too hard increases inflammation,
and edema, and rigidity. The principles that distinguish this treatment are few
, but the patient must be scrupulously respected and strictly monitored by the t
herapist and surgeon.€The joint assessment and functional goniometric indicate i
f the program is set correctly. These assessments will also be very helpful to t
he surgeon in deciding on the possible intervention for resolution of rigidity.
Considerations should not be neglected even psychological status and expectation
s of the patient, which could now be demotivated after months or years of disabi
lity. As regards the more technical rehabilitation of rigidity, I stress that th
e mobilization and preparation of analytical brace treatment is the key: each pr
epare periarticular soft tissue mobilization, the others competing in the rehabi
litation program by speeding and guiding the process of healing tissue. KEYWORDS
stiffness, swelling, hand negative mobilization analytical orthosis
INTRODUCTION joint physiology and pathological biological reactions of the hand,
lead inevitably to a very frequent complication natural: the stiffness. Avoid t
he restriction articular would mean less time can immobilize and protect positio
n. We know that is not always possible: the type of injury, associated injuries
and the type of patient sometimes impose different rules and time-consuming. Ede
ma is the natural response to trauma and hand, especially if long lasting, rigid
ity is an inevitable consequence. The degree and duration of stiffness are propo
rtional to the injury. If the damage is minor, reducing joint widths will be min
imal and will resolve in a few days. Will give a more important edema and theref
ore greater rigidity and spread on different tissues. This will last longer and,
at times, will be chronic and irreversible. The task of the surgeon and therapi
st will prevent chronic disease, guiding the patient during the healing and reha
bilitation in the proper use of tools. Although it was proved that
prolonged immobilization is detrimental to the hand, it is very difficult to est
ablish the right balance between rest and movement.
PATHOPHYSIOLOGY OF stiffness for stiffness means a decrease of motion of a joint
, whatever the cause. When a tissue is stimulated by trauma, there is an inflamm
atory response. Each fabric has a way to feel the forces acting on it. The elast
ic properties of tissue properties and viscosity of a joint, determine the degre
e and type of rigidity and, therefore, time and type of healing. For ease of exp
osition divide the stiffness in three stages. FIRST STAGE - EARLY. It is the nat
ural result of the rigidity inflammatory reaction to trauma. The vicious triad c
omposed of "injury - swelling - immobilisation inevitably leads to scar contract
ion, tendon adhesions, retraction and ligament contractures miostatiche.
In the first stage the tissues are painful, but treatable, palpation the joint c
apsule appears "rubbery". The end-feel (7) (sense of the therapist on the failur
e of the tissues after a passive movement) shows a block, but with additional pa
ssive margin thrust. These joints will respond well to therapy and the use of th
e brace. SECOND STAGE - LATE. It is the uncontrolled development of the first st
age. Edema persists and is rapidly replaced by scar tissue that leads to serious
and often irreversible contracture, the collagen is deposited around the collat
eral ligaments, flexor and extensor tendons, thus linking them to the surroundin
g fixed structures, with significant reduction of movement is passive active. It
is typical of patients who could not begin without delay the rehabilitation tre
atment for reasons related to associated injuries, severe polytrauma or, more si
mply, for lack of seats in the rehabilitation sites. At this stage the affected
joints are less painful and the pain is less acute and more widespread, the func
tional impairment is also evident in the proximal districts. At the joint capsul
e palpation gives a sensation "cuoiosa, kneading hard and deep. End-feel: this i
s a passive margin driven by the therapist, but often there is a return "spring"
with pain. In these cases the rehabilitation treatment is much longer, demandin
g and margin recovery is not complete. THIRD STAGE - CHRONIC. Is the restriction
articular left to itself. Often in patients with serious conditions, where the
treatment and the posture of the hands is the last trick to think about the medi
cal and nursing staff, or in patients who underwent more operations and long per
iods of immobilization.€There is no pain or swelling. The hand is almost always
in a "negative" (3). Palpation of the joint capsule is the "woody" or even "hard
ened". The feeling of endfeel is daunting for a joint recovery. Often leads glob
al functional assessment
the need for surgical tissue lysis hard hit.
Knowing the causes of joint stiffness due to stiffness is essential for the sett
ing of rehabilitation treatment and possibly surgery. The type of lesion and ana
tomical factors are often guided by the therapist to identify the cause of stiff
ness, but less important edema, fibrosis and abnormal collagen. For proper rehab
ilitation approach is also important to check if the joint is the primary limita
tion: due to the district where the injury occurred, or secondary: due to tendon
adhesions or skin damage even far from home.
ADHERENCE tendon tendon adhesions and muscle-tendon retraction can be demonstrat
ed by the difference of mobility of the distal end when the proximal articulatio
n is positioned in flexion or extension. Stiffness and tendon adhesions are two
different but closely related phenomena that influence one another: one can lead
to another and vice versa.
SCARS retractile process is the result of proliferative connective tissue. Repre
sents the power-up of collagen fibers and fibroblasts. It seems a matter of prio
rity at the level of functional areas and is especially frequent in the backbone
. That actually seems to be movement and tensioning of the skin to determine the
source of scar retraction. The rigidity of the skin is evaluated by applying a
stretch in the skin tight and the scar area.
EVALUATION OF stiffness parameters important to constantly check are: • PROM (pa
ssive range of motion) • Aroma (active range of motion) for the measurement in t
he articular both passive and active, it is important to use a protractor suitab
le for small joints and take account of physiological variations of it in relati
on to different degrees in which it has positioned the proximal joint (wrist or
MF). These tests are also useful for identifying whether the joint restriction i
s primary, due to periarticular fibrosis, or secondary to a limitation of the sl
iding tendon.
REHABILITATION OF stiffness The stiffness of the rehabilitation treatment is clo
sely related to the type of lesion. But we can draw guidelines of behavior diffe
red according to the stage of stiffness. Basic Rule for the therapist is to reco
gnize the cause of stiffness before setting up treatment.
FIRST STAGE: REHABILITATION Reduction of pain control and treatment of edema: hi
gh posture, bandage "Coban", alternating baths, draining massage by the therapis
t, applying fresh. Active mobilization: in the case of complex trauma should tak
e stock of tissues and joints in recovery and make sure whom to mobilize. The mo
vements required to be simple, performed in high posture, associated with the ba
ndage "Coban" properly made with a block of the proximal joints, the patient sho
uld only move the joint desired, without compensating with the closest and most
dangerous and useless without initiating patterns of substitution. Must perform
these exercises several times a day independently. Orthoses may be helpful to us
e locking proximal wedges posture, or the patient's contralateral hand. Passive
mobilization: where it is necessary to avoid excessive force by the therapist an
d must respect the strength of tissues. Orthotics: the first stage, if necessary
, must be static. Complex trauma and packed as soon orthosis type Resting positi
on (wrist extension of 20 ° about MF in flexion of 50 ° -60 °, IF and thumb slig
htly down position of opponents). This avoids the risk of bad hand, and remain a
t rest the joints still swollen and inflamed. It should be alternated with activ
e movements in elevation, not flow continuously throughout the
Tendons and adhesions
The retraction muscle-tendon
The most proximal joint is the key to find the stiffness. With retraction of the
extrinsic extensor muscles, fingers will be unable to flex the wrist in flexion
and extension.€The opposite occurs with the retraction of the extrinsic flexor
muscles. With wrist extension, the extension of the fingers is limited dall'acco
rciamento flexor. When the wrist is in flexion instead, the fingers may extend.
To achieve an effective lengthening of the extrinsic flexors, the wrist must be
maintained in extension while the fingers are extended.
ASSESSMENT OF STIFFNESS skin and very important observation and palpation of the
scar, the area of skin grafting and to assess the degree of immobility of the s
kin. If the skin limits the stiffness of joints, placing the skin in its positio
n of maximum relaxation is obtained both proximal and distal articular range. Th
is ROM (range of motion) decreases as soon as you put tension on the skin.
day. If deemed appropriate orthosis stiffness carpal static serial that maintain
levels of passive movement produced during the rehabilitation session.
SECOND STAGE: Rehabilitation Treatment edema and active mobilization are constan
ts; the el'ortesi rehabilitative methods in this stage differ depending on the c
ause of stiffness. Capsular retraction mobilization analytical techniques: they
are crucial. They are preparing to mobilize joint tissues. Based on the anatomic
al and biomechanical principles, exploiting some simple rules: • physiological a
nd accessory movement: the physiological movements are those that the patient ca
n take an active role. The accessory movements are those that a person can not a
ccomplish alone, but that can be performed on him by another person. Example: th
e rotation of the MF. • Rule concave - convex: in a joint, when the concave surf
ace is in motion and the convex surface is stabilized, as in MF, rolling, slidin
g and angular movement in the same direction. However, when the convex surface i
s in motion and the concave surface is stabilized, as in the wrist, rolling it i
n the same direction of angular movement or slipping going backwards. In the wri
st, to perform a drop, you must slide up and lead the wrist downward. • End-feel
. Feeling of the therapist on the failure of the tissues after a passive movemen
t. With these mobilizations not research the angular motion. Each tour is either
parallel or perpendicular to the treatment plan. The movements are performed on
the articulation: distraction, sliding, rotation. The technical
that mobilization must be performed analytical alternate days. Muscle strengthen
ing: A weak muscle can not move a joint rigid. Functional electrical stimulation
: implemented by the Canadian joint proximal to the block. Help the weak muscle
to move the rigid articulation with greater amplitude articular. Must be precede
d by a session of analytical mobilization or active exercise. Orthotics: the dyn
amics indicated by the rules set out by Brand (2): moderate force applied for a
long time. The amount of force and duration of application will be determined in
relation to tissue response. Best if used by day alternating with a program of
active exercises. If you need to take advantage of the night, we opt for a brace
in extension. Tendinous retractions. If the healing time can allow you to imple
ment the tendon tension adhesive. It must be low level and should last a long ti
me. The feeling of tension should be low and should not cause pain. In these cas
es, treatment relies on the use of orthoses distal articular block associated wi
th passive movements of the proximal articulation. A retraction of the wrist fle
xors example can be treated with orthoses extension of long fingers associated w
ith Kinetec of continuous passive motion of the wrist for an hour three times a
day. Is important to properly assess the origin of adhesions. These techniques s
hould be preceded by Paraffinoterapia massage and soft tissue dissection. The tr
eatment concludes with the active mobilization. Musculotendinous retractions. If
the limitation is caused by articular adhesions localized to the muscle-tendon
junction to the above treatment are associated with proximal and stretching tech
niques Postural Global Reeducation. Skin adhesions. If the damaging insult cause
d an extensive skin damage is important to also deal with the treatment of scar
adhesions that limit joint. If applying stretching
skin appears white area around the scar,€this is adhering to plans for joint deg
rees and steals subcutaneous sliding failure of the tissues (1). Massage of the
scar. It is an essential tool to keep the tissue mobility, through the sliding o
f the skin and prevention plans and / or debridement of scar cords. If the skin
is already structured in a strong plot, the massage will be carried out with gen
tle pressure, making circular motions with your fingertips along the scar. The s
kin scar should be massaged twice a day for 5 / 10 min: after the massage you ha
ve to remove the excess cream. In this connection mention should Cyriax techniqu
e: mobilization of soft tissues in which they apply forces carrying out maneuver
s with a constant pressure for a long time, according to carriers of approximati
on, pulling and twisting, creating mobility between floors skin, subcutaneous an
d fascial. Massotherapy instrumental Traxator or Vacuum therapy finds its indica
tion in the resolution of edema, and adhesions in the treatment of fibrotic retr
actile cords. This is a skin undermining negative pressure with the operation of
a triple massage: sliding, pressure and suction. Acts on the lymphatic and bloo
d circulation and tissue elasticity. Unlike other tissues, the skin needs a very
long stretch associated with pressure. For this purpose tools rehabilitation ar
e: girdle: they apply on the skin scar a constant pressure of elastic type. This
pressure must be sufficient to slightly reduce the vascularization sottodermica
, yet not excessive to avoid creating areas of ischemia that could degenerate in
to tissue necrosis. It is currently considering the appropriate pressure gradien
t should be somewhere between 25 and 30 mmHg, and especially that it should be c
onstant and well distributed. Must be worn 20 hours on 24. They have a triple ac
tion: - reduce inflammation edema in the early stage of their use
- Reduce collagen synthesis by fibroblasts (for tissue hypoxia) - improve venous
return. Below the sheath is useful in areas identified as scar or between toes,
using sheets of silicon or other material that allows a uniform compression on
the concave surfaces also: this involves greater care by the patient, as these m
edia should be washed daily to prevent excessive sweating and maceration of the
skin. Silicone gel sheets: they are used more frequently and are effective both
in prevention and the treatment of hypertrophic scars and keloids, and increasin
g range of motion limited by contracture. Some studies have shown that the appli
cation of silicone gel, for at least twelve hours a day for a period of two mont
hs, has had positive results in increasing the elasticity of the skin scar, hype
rtrophy and well in the already stabilized, as a preventive measure, limit the w
idth and volume of surgical scars. Elastomer: it is a synthetic product with ela
stic properties similar to rubber. It is sold under various forms: the therapist
mixes the product with a catalyst, obtaining a homogeneous mixture of different
resistances, which can be shaped scar. Its ability to model exactly the configu
ration of the scar, adapting to ridges and folds, making it more effective nell'
imprimere a specific pressure than silicone gel. It is used to reduce scar forma
tion, alone or under gloves or compression splint, which seems to be better tole
rated by the patient. Absorbs vibrations during exercise or work can adversely a
ffect the injured area. Ultrasound Iontophoresis with 2.5% potassium iodide orth
oses: a simple and physiological scar process, determine the effect of retractil
e forces, dislocations of joints, bone deformities and muscle imbalance. The tra
ction dall'ortesi oriented collagen fibers and aligns the articulation
tions in a capacity. The orthosis must place the skin in moderate extension, wit
hin its elastic potential for a prolonged period. Thus, cells actively perceived
stress, degrading and releasing the second collagen patterns changed without ca
using inflammation (2). This is called tissue growth. Brand opposed the term str
etch, stretching the word growth,€growth in the stretching force is inherent ris
k of over-the joints and to tighten the skin up to the breaking point. If, on th
e contrary, we want to recover the normal length of a fabric that has been retra
cted due to lack of use, we must reverse this process and stimulate activity, or
rather, act in preserving the fabric of a moderate stretch for a significant ti
me. Time is a factor not only of several hours, growth is a matter of days and m
any hours each time a force is applied. Bearing in mind these concepts, there ar
e some principles that can help in choosing the most suitable orthosis to treat
skin adhesions: - Posture: can be static, dynamic or static-progressive. In the
early stages of treatment will require a static posture, which allows to restore
a balance between the forces. It may then be assumed a dynamic posture, which a
dapts to changes in position, thereby imparting a directional force constant. -
Compression: to compress the tissue to prevent excessive expansion. The brace ex
erts a compressive force constant is used to prevent and treat hypertrophic scar
s and keloids (9). - Voltage Skin ceiling: it is the power-up ceiling of the ski
n by maintaining a static posture. As we have seen, the scars will be hypertroph
ic scars or scars retractile is necessary to deal with these complications. The
orthosis static posture opposes retraction and compression zones tensioning coun
teracts hypertrophy.
- Mail scar hypertrophy in an area not articulate, requires the reinforcement of
compression (9) - a joint limitation, source skin (scar bridle) requires the us
e of an orthosis in order to obtain the maximum amplitude articulate possible, a
compression zone under tension and a progressive correction, with the packaging
of a series of static-progressive orthosis that adapt to evolving and the resul
ts - a limitation of joints, which originates from the joint itself or the muscu
lar system, is indicated in a dynamic orthosis that can recover the amplitude de
ficit. As the patient increases his ability to move, may decrease the time to us
e the orthosis, which is then removed with a program agreed to allow the executi
on of exercises, for activities of daily life and reapplied during the night, to
exploit the muscle relaxation induced by sleep. The therapist must be careful n
ot to delegate any brace treatment: excessive restraint can lead to adhesion of
soft tissues, joint stiffness and in some cases joint calcifications. It is impo
rtant that the patient understands exactly how to use the orthosis, respects pre
cisely the times indicated by therapist and learn to recognize signs of tissue d
istress. Active mobilization: In this stage the patient should engage not only t
he injured hand, but the entire upper limb. Global will also suggest exercises t
hat require the full participation of the subject: the trauma it may have change
d the lifestyle of the patient for months does not use his arm as usual, becomes
less active, receive back less sensory afferents and threatens to trigger a mec
hanism of repetitive motor deprivation, sensory and emotional. Each exercise sho
uld aim to tissue fiber direction you want to lengthen. Strengthening activities
should be dosed carefully exercises against resistance
tend thickening of the sheaths and subcutaneous tissues.
STAGE THREE: REHABILITATION At this stage it is essential collaboration between
the patient, therapist and surgeon. Dominance, age, occupation, habits of the pa
tient and the operational budget of the therapist, will help the surgeon in the
operating program for solving stiffness irreversible. Even in the chronic phase
if there is joint ankylosis, contains analytical techniques of mobilization, sta
tic progressive orthosis, active mobilization of the entire upper limb, muscle s
trengthening. The pre-operative treatment will prepare the tissues in and will u
se most of the techniques mentioned above depending on the cause of stiffness.
Post-operative treatment after artrolisi Rehabilitation - Guidelines The first 1
5 days post-op are crucial to maintain the grades obtained during joint surgery.
€Treatment should be started 24 hours after surgery. It consists of 2 / 3 sessio
ns per day of passive motion alternating use of an orthosis in static position a
s close as possible to the desired result. At this stage it is important to redu
ce the swelling, pain and avoid the increase of inflammation, the sessions will
be brief, about 10 to 15 minutes and will conclude with the application of ice.
The active mobilization will be the active client. From day 15 the static orthos
es is taken only at night. During the days the patient uses dynamic orthosis for
active exercises alternating selective and global mobilization with the therapi
st. At this stage, the sessions become longer and more intense, the pain will be
decreased edema, but will always be lurking in the formation of adhesions. Trea
tment should continue for at least three months.
CONCLUSION stiffness are almost all post-surgical failures and not the hand. Whe
n the outcome of orthopedic surgery or rehabilitation is not satisfactory, the o
utcome can be: functional impairment, or persistent pain or joint instability, s
welling, or blemishes. Ironically all these signs lead to rigidity: if a hand is
weak the other tends to be used less, if a finger is painful or hypersensitive,
are excluded, becomes unstable if a pulse is weak, so impotent, if a hand is sw
ollen becomes rigid and even a blemish of a finger can lead to the same rigidity
and fingers close. It is also impossible that a trauma can always give back a "
restitution ad integrum", especially in hand the results almost always lead to r
igidity. When the damage is minimal, if interested in a person psychologically u
nstable, it can lead to stiffness, we all know what fear stifle, if the patient
is afraid to feel pain, does not move the injured part and tends to iperprotegge
rla. We have seen however that excessive uncontrolled use can lead to stiffness,
increasing the inflammation edema. As often happens, the key is to lead the pat
ient to face his injury with the right balance between protection and movement.
Surgeon and therapist should also reach a compromise between the time of immobil
ization to promote healing and time to start the movement to prevent stiffness f
rom non-use. But rehabilitation is not always moving, initially, the therapist s
hould not be mobilized, should guide the patient in the post trauma with advice
on the control of edema on the mobilization of the proximal shoulder and elbow j
oints, the correct posture day and night, with small adjustments to become famil
iar with his injured hand foiling fear of pain, or to restrain the patient is to
o reactive. The patient should know that there are specific rules and deadlines
to be met so that they achieve recovery. If the therapist and patient engage in
this task and the surgeon, if possible, choose a pic-
• Orthotics static surface pressure with large well-distributed. • Orthotics dyn
amic low profile, well-distributed block proximal pressure, voltage and prolonge
d constant weak strength and well-balanced to prevent swelling, pain and sufferi
ng skin; determining force in relation to pressure. Force perpendicular to the l
ongitudinal axis of the bone distal to be treated. • Control joints compass to c
heck the progress of treatment and constant supervision • Adaptation Program • o
rthosis brace exercises associated
Dosage: The guidelines orthoses, especially if static, should not be confused wi
th chalk. Use of any brace must always be intermittent, alternating with active
exercises and activities of daily life. Brand recommends no more than two consec
utive hours for dynamic orthosis with moderate force, then rest. Attention to dy
namic orthosis to bring along for a long time: Weeks (2) studied the collateral
ligaments when subjected to an increasing load, reaching lengths proportionately
greater than the tendons, the joint may appear to improve because, as a result
of ' elongation of the ligaments, could turn around a new axis corresponding to
the focal point of the articular surfaces, instead of slipping on each other, co
llide. Orthosis night: you use when you want to increase the plastic response of
the joint; inactivity sleep normally decreases the elasticity of tissues (1). T
his process, on a rigid articulation,€causes during the day is more difficult to
treat. Stretching night creates the potential for maximum movement active durin
g the day.
stabilization when approaching the functional posture, could reduce the number o
f hands between negative outcomes after traumatic, it would be too ambitious to
claim that it would prevent stiffness. REFERENCES
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