Proceedings of the ASHT 25th Annual Meeting

Proceedings of the ASHT 25th Annual Meeting

2002 ASHT PROCEEDINGS Proceedings of the ASHT 25th Annual Meeting The ASHT 25th Annual Meeting, ‘‘Touching the Past, Sculpting the Future,’’ was held...

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2002 ASHT PROCEEDINGS

Proceedings of the ASHT 25th Annual Meeting The ASHT 25th Annual Meeting, ‘‘Touching the Past, Sculpting the Future,’’ was held September 19–22, 2002, at the Ottawa Congress Centre in Ottawa, Ontario, Canada. Every year, the ASHT Call for Abstracts provides an opportunity for authors to submit original research to the ASHT for presentation at the clinical and scientific paper sessions of the Annual Meeting. Abstracts are submitted to the ASHT early in the year and are reviewed by a panel of experts. Authors of papers selected by the panel are invited to present their papers at the meeting. The following author-prepared abstracts are of papers presented at the 2002 meeting. Prevention of Pillar Pain following Endoscopic Carpal Tunnel Release. Jane Cox, BScOT, CHT, Kara Ludlow, BScOT, CHT, Leann Merla MSc, L.N. Hurst, FRCS(C), FACS Purpose: To report the results of a study that explored the effects of postoperative immobilization on the development of pillar pain following endoscopic carpal tunnel release (ECTR). Pillar pain, which is defined as pain in the thenar and/or hypothenar eminences of the hand, has been identified as a complication that can delay return to functional activities including work, thereby increasing the potential costs of treatment and the stress of the patient. Based on the results of this study, the impact of pillar pain on strength and function is also discussed. Description of methods, materials, principles, clinical application, and rationale: A retrospective chart audit carried out at this facility showed a significantly lower incidence of pillar pain in patients who had been immobilized for ten days after ECTR than for those patients who had not

been immobilized. Following this audit, a prospective study was initiated to compare the effect of ten days’ immobilization of the wrist following ECTR with the effect of non-immobilization on the development of pillar pain. One hundred four patients who had elected to undergo ECTR by one surgeon at this facility were randomly assigned to either the immobilized group or the non-immobilized group prior to undergoing surgery. Patients in the immobilized group had a bulky dressing applied by the surgical team in the operating room. All other aspects of surgery and postoperative treatment were the same for both groups. Occupational therapy assessments were conducted preoperatively and at ten days, three weeks, and six weeks postoperatively. This assessment included an assessment for pillar pain, measures of upper extremity function, range of motion, grip and pinch strength, and sensibility. Patients were also asked about return to work status, presenting symptoms, and any ongoing concerns. Results of the assessments were analyzed using a chi square to determine if differences in the incidence of pillar pain development existed between the two groups. An ANOVA was used to analyze the other factors measured in the assessments. Observations: Approximately 36% of patients undergoing ECTR developed pillar pain postoperatively. No statistically significant differences between the immobilized and nonimmobilized groups in the development of pillar pain, function, or strength, were found in this study. There was a statistically significant difference in grip strength between those who developed pillar pain and those who did not.

Conclusions: The results of this study do not support the use of postoperative immobilization following ECTR. Study results also suggest that pillar pain, although disconcerting to the patient, does not have a significant impact on function by the six-week postoperative mark. Relevance to hand therapy: The study provides a description of pillar pain and objective information regarding the postoperative course for ECTR patients. This information will assist therapists who are treating those patients who develop pillar pain to measure their progress and provide reassurance that a good functional result can usually be expected within six weeks.

Impact of Splinting the Thumb Carpometacarpal Joint with Osteoarthritis. Cynthia L. Hanson, MA, OT, Pamela D. Wright, OTR/L, CHT, Laura Loeding Bechtold, OTR/L, CHT, Nancy Flinn, MA, OTR/L Purpose: Osteoarthritis (OA) of the thumb carpometacarpal (CMC) joint is a very common condition. Conservative treatment typically involves splinting to support the CMC joint to decrease pain and improve functional ability. However, few studies have been published that support this treatment. Many patients are provided with a splint and not seen in the clinic again to assess compliance, fit, comfort, and impact on function. The purpose of this study was to determine if subjects found splinting of the osteoarthritic CMC joint beneficial. Subjects were followed for six months to assess their splint wearing time/schedule, effect on joint pain, and how splint wear affected their performance of activities of daily living (ADLs).

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Method, materials, principles, clinic application, and rationale: Subjects were a convenience sample of patients diagnosed with CMC joint OA referred for splinting by five physicians. Patients with diagnoses of deQuervain’s, carpal tunnel, or trapezioscaphoid OA were eliminated. There were 22 subjects, 17 females, five males, ranging in age from 42 to 74 years. Ten were diagnosed with moderate OA; 12 with severe OA. The Human Subjects Committee, College of St. Catherine, approved the study procedures. Subjects filled out questionnaires at the initial visit, four weeks, 12 weeks, and six months. Questionnaires contained three sections including demographic data, ADL difficulty scale, and questions regarding symptoms/ pain. The four-week questionnaire additionally asked about wearing time during the first two weeks. Subjects were fit with a custom MP/ CMC immobilization splint. All splints, using the same pattern, were fabricated by one CHT with the exception of two, which were fabricated by other CHTs within the same clinic. Subjects were given joint protection principles and instructions in splint care. They were advised to wear the splint(s) during activities that cause pain and to contact their therapist for adjustments. Observations: At two weeks, 90% of subjects with moderate OA were wearing their splints an average of eight hours per day. At six months, 70% were wearing their splint an average of four hours per day. At two weeks, 100% of subjects with severe OA were wearing their splints an average of nine hours per day. At six months, 50% were wearing their splints an average of eight hours per day. When asked if overall, the splints were helpful in performing ADLs, 90% of those with moderate OA and 55% of those with severe OA reported them to be helpful. At six months, 55% of subjects with moderate OA reported decreased pain, and 33% reported no change. Conclusions: The majority of subjects with moderate OA found the splints to be helpful, reporting continued use. Slightly more than half of those with severe OA found the splints to be helpful, reporting continued use.

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Subjects tended to create selfsculpted wearing patterns to meet their needs. One subject had difficulty wearing the splint while working, but found symptom relief by wearing the splint at night. Others wore their splints for specific activities or lifting. Relevance to hand therapy: Results of this study indicated that overall, many patients with thumb CMC OA find immobilization splints to be beneficial in reducing pain and making ADLs easier. This study has helped to validate using this treatment. Comments regarding comfort of splints are also helpful in encouraging patients to make follow-up appointments for adjustments. Case Study of Shoulder Slings. C.W. Stegink Jansen, M.E. Bui, J.A. Miller, M.R. Villamin, B. Abreu Purpose: Treatment of the upper extremity of hemiplegic patients is not always provided in a holistic manner. Often, referrals are directed to occupational or physical therapy depending on whether the affected body part requiring treatment is physically located above or below the waist line! The purpose of this case study was to test the need for holistic treatment in patients with hemiplegia from a physical perspective. The hypothesis was that application of two types of shoulder supports, taping, or no support at all affected gait parameters of hemiplegic patients with shoulder subluxation. Subjects: Three hemiplegic patients with shoulder subluxation, aged 33, 29, and 18 years old, at least five months after sustaining brain injury participated in the study. Two patients used an ankle–foot orthosis and a quad cane; subject 2 did not use any assistive or corrective lowerextremity devices. Methods and materials: A multiple single-subject repeated-measures research design was used. In random order, the Harris Hemi sling, the North Coast sling, and taping, or no sling were applied to subjects. Subjects ambulated 7 meters over a 3meter gait-recording mat in the center of this path. Gait velocity, cadence, stride length, step length, and foot angles were recorded. Subjects performed three trials, repeated over

three days, resulting in nine data points per condition. Data were evaluated graphically and by splitmiddle line technique (alpha of 0.05). Results: Across all subjects, use of a corrective device affected all gait parameters of the affected and unaffected side significantly. In subjects 1 and 3, slowing of the gait and a decrease in gait symmetry was observed. Subject 2 also showed a slowing of gait, but demonstrated an improved toe angle indicative of a better gait symmetry. Statistically significant changes were found in all parameters using the Harris Hemi sling and the North Coast sling as compared with not wearing a sling. Conclusion: Application of shoulder slings affected gait parameters in three cases. Relevance to hand therapy: It is important that therapists realize that treatments of the upper extremity may affect other aspects of physical function in brain-injured patients with hemiplegia. This study suggests the need for a holistic view of treatment for these patients. A Randomized Trial on the Use of Astaxanthin as an Adjunct in the Treatment of Carpal Tunnel Syndrome. Joy C. MacDermid, Bing Siang Gan, MD, PhD, FRCSC, PhD, Douglas C. Ross, MD, FRCSC, James H. Roth, MD, FRCSC, FACS, Robert S. Richards, MD, FRCSC, Kenneth Faber, MD, FRCSC, Graham King, MD, FRCSC, Tom Miller, MD, FRCPC, Jeffrey C. Howard, PhD, Conrad Earnest, PhD, Anthony Almada, MSc Purpose: Nutritional supplementation is a potential adjunct in the conservative management of carpal tunnel syndrome (CTS). This study investigated whether a beta-carotenoid (astaxanthin) increased the effectiveness of a splinting in managing CTS. Study design: A randomized controlled (placebo) trial. Patients: A total of 73 patients were enrolled (60 completed) this study. The groups were similar on the basis of age (average 49 6 10 years) and sex distributions (astaxathin 1 splinting: 26 females/11 males; splinting 1 placebo: 27 females/9 males). All patients had CTS confirmed by clinical diagnosis from a hand surgeons and electrodiagnosis.

Intervention: All patients were provided a prefabricated splint that was adjusted to a neutral position. Patients were instructed to splint at night and when doing activities they knew aggravated their symptoms. The astaxanthin group were given 4 mg of astaxanthin in capsules and instructed to take the capsules with their evening meal. The splinting/ placebo group were given pills that were identical in form to the astaxanthin and given the same instructions. Medications were taken for nine week followed by a three-week washout. The physician, patient, and research assistant were all blinded to the allocation to astaxanthin or placebo. Compliance was encouraged in biweekly phone calls to all patients. Outcome measures: The primary outcome measure was the carpal tunnel symptom severity scale. Secondary outcome measures included: blood levels of triglycerides, cholesterol, grip strength, sensory threshold using the PSSD, The NK dexterity test, electrodiagnostic testing, vibration threshold using the Jtech Medical vibrometer (prototype), adverse effects, the DASH, and the Sf-36 General Health Scale. The electrodiagnostic testing was performed before entry into the study and again at 12 weeks. All other outcome measures were taken at baseline, six weeks, and 12 weeks. Results: There was a small reduction in symptoms as measured by the Symptom Severity Scale over the course of treatment in both groups (p 5 0.002), but no differences between the two treatment groups (p 5 0.18). Functional self-report scales and the Sf-36 showed no effects over time or between treatment groups. There were some baseline differences between the groups on level of total and LDL cholesterol, but values remained constant over the course of the study. Impairment measures demonstrated no significant changes in grip, dexterity, or sensation. To date, 50% of the patients have had surgical release. Discussion: Patients studied represent those seen in Canadian hand centers who tend to have prolonged symptoms and at least moderate severity of CTS. Astaxanthin is not an effective adjunct in this population. Preventative or early intervention studies would need to be

conducted to see if efficacy can be demonstrated with milder disease. As no adverse effects can be attributed to astaxanthin, these studies are justifiable. Conclusion: At present, a role for astaxanthin in treatment of CTS has not been established. The Human Trapeziometacarpal Joint: Osteoarthritic Degeneration and 3-Dimensional Modeling. Maksim Kovler, BSc (PT), Katie Lundon, PhD, Nancy McKee, MD, Anne Agur, PhD Purposes: 1. To characterize the normal human trapeziometacarpal joint (TMCJ) using 3-D modeling of the trapezial and metacarpal articular surfaces. 2. To determine the locus of degeneration in minimally degenerated and osteoarthritic specimens. Design methods: The articular surfaces of 25 embalmed cadaveric TMCJs were graded for degree of degenerative osteoarthritis (OA) using a modified Byers scale. The location of cartilage damage was mapped using a dissection microscope. The specimens were classified as either mildly (grade 0–2) or severely (grades 3, 4) degenerated. The trapezial and metacarpal articular facets in 14 minimally damaged joints were digitized using the Microscribe 3D-X Digitizer. The Rhinoceros 1.1 NURBS Modeling Software was then used to fit a surface curve to the data creating manipulatable 3-dimensional (3-D) models of the joint surfaces. Topographical parameters were determined for the normal and osteoarthritic articular surfaces. Types of data analyses: The means and the standard errors of the mean for measures of area and joint contour of the normal and osteoarthritic specimens were determined. Results: The complex topography of the TMCJ was reconstructed and viewed as a manipulatable 3-D model. Surfaces of female specimens were found to be significantly smaller than those of males; the metacarpal articular surface was found to be consistently larger than that of the trapezium in both males and females. The dorsoradial facet of the trapezium was found to be the most degenerated in joints categorized as both mildly and severely degenerated. The presence of three main

bony joint recesses (ventral, ulnar, and radial) was confirmed in both minimally and severely degenerated specimens. Qualitative analysis indicated that advanced OA results in marked alteration of trapezial and metacarpal joint surface topography. Conclusions: 3-D digitization and reconstruction provides a novel approach to the study of human diarthrodial joints. The trapezium in males is shallower than in females. TMCJs of females are smaller than those of males. Topographical localization of cartilage damage in this study is consistent with a mechanical etiology of TMCJ-OA. Osteoarthritic degeneration of the TMCJ begins in the dorsoradial area of the joint and is associated with marked alteration in joint topography. Relevance to hand therapy: In the upper extremity, the TMCJ is the site most frequently affected by OA. Variations in TMCJ topography have been linked to an increased risk of degeneration. The smaller area and steeper topography of the TMCJ in females may be a factor in females’ higher risk of developing TMCJ-OA. 3-D digitization and reconstruction may facilitate a better understanding of the topography of the TMCJ as well as of the changes in joint topography accompanying OA. The benefits of this technique lie in its ability to create accurate, high-resolution 3-D models of diarthrodial joints. Acceleration Tendon Program: A Nonoperative Technique to Maximize Active Range of Motion. Marisol Monasterio, OTR, Kathy E. Brou, OTR, CHT, Fernando Levaro, MD, Mark Henry, MD Purpose: To present an invaluable technique that addresses tendon adhesion by changing the force and velocity of the tendon at the point of maximum adherence, resulting in improved tendon excursion. Method and clinical applications: Tendon acceleration incorporates isometric muscular contraction in a submaxium range followed by a sudden isotonic concentric muscular contraction that abruptly changes the tendon velocity. When performed repetitively, it remodels the scar tissue at the area of increased concentration of tendon adherence

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without compromising the musculotendinous physiological integrity. The goal of tendon acceleration is to load and concentrate the forces that act directly on the involved tendon and minimize the dissipation of energy into adjacent tissues, thus maximizing the energy at the direct location of the adherence. The method proposed for tendon acceleration starts by localizing the area of greatest adhesion and its closest distal joint. The motion unit should be isolated by blocking the affected area’s proximal joint, so that the force and abrupt change in velocity can be directly applied to this specific location. Essential criteria should be met within certain diagnoses before utilizing this method, for example: flexor and extensor tendons should be healed; fractures should be stable; 75% of the joint passive range of motion should be achieved with a soft end feel; edema should be minimized. Various diagnoses benefit from this protocol inclucing: P1/P2 stable fractures, extensor or flexor tendon repairs, tendocapsulolysis, complicated nerve injuries, crush injuries, and numerous others. Observations: This technique has been used successfully in patients ranging from complex injuries to isolated flexor and extensor tendon injuries, but most commonly utilized with patients with extension lags at the MP and PIP joints. The technique is most beneficial when utilized early in the rehabilitation program when the active/passive discrepancy is approximately less or equal to 25%. Tendon acceleration is a technique that should be incorporated into current protocols that address tendon adhesions. Conclusions: Traditional therapeutic modalities have been moderately successful in increasing patients’ functional motion without directly managing the primary source of the problem, the tendon adhesion. This protocol has been shown to promote further tendon gliding and to decrease adhesions. Relevance to hand therapy: Tendon adhesions can be caused by posttraumatic or post-surgical edema, direct trauma to the natural gliding layers that surround and protect the tendons, or trauma to adjacent skeletal structures. Tendon acceleration is

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a technique that improves therapeutic outcomes by remodeling scar tissue and allowing further tendon excursion, thus benefiting patients in their hand rehabilitation. Responsiveness of the DASH and PRWHE in Evaluating Response to Hand Therapy. Joy C. MacDermid, BScPT, PhD, Virginia Tottenham, BSCPT, CHT Purpose: To assess the responsiveness of two questionnaires in evaluation of patients with wrist or hand pathology and therapist preference for routine usage upon completion of the study. Subjects: Patients with a either wrist (n 5 24) or hand (n 5 36) pathology referred for rehabilitation at a hand therapy clinic initiating implementation of patient self-report measures. Methods and materials: Patients completed both a modified version of the Patient-rated wrist evaluation (PRWE), which named wrist/hand in place of wrist (PRWHE) and included a supplemental question on aesthetics and a DASH on admission and three months later. Questionnaires were copied and forwarded to the first author when all subjects had completed data collection. Study results were fed back to the clinic, who then chose an instrument for routine usage. Analysis: Effect sizes and standardized response means were calculated. Results: Responsiveness statistics for the DASH or PRWHE indicated that either scale was equally responsive in hand and wrist patients (SRMs ranging 1.57–1.60 and effect sizes 1.47–1.70). The aesthetics question was less responsive (SRMs: 1.08– 1.20) and was left as a supplemental question not to be included in the overall PRWHE score. Clinicians preferred the PRWHE based on its ease of use. Conclusions: Both questionnaires demonstrated similar responsiveness in evaluating the hand or wrist in this patient population. Relevance to hand therapy: Either the DASH or the PRWE/PRWHE can be expected to measure clinical change in patients with wrist or hand problems that present to a hand therapy clinic. Where instruments have similar measurement properties, instru-

ment selection is based on other practical issues such as ease of application, scoring, or face validity. Symbolic Aspects of Hand Care. Cynthia Cooper, MFA, MA, OTR/L, CHT Purpose: To present examples of hand therapy treatment in which the symbolic dimensions of hand therapy intervention are identified and incorporated into the care. Method: A literature review will be presented on procedural reasoning, interactive reasoning, and themes of meaning. These concepts will be illustrated through hand therapy case examples. Principles: Hand therapists must understand the biomechanics of the hand in order to provide treatment that is structure-specific. Such a highly specific focus is necessary for accurate tissue care, but it may be an approach that looks so closely at components of the patient that it could overlook the whole person whose arm is being treated. When therapists assess a patient’s physical components and determine the appropriate treatment procedures, they are using procedural reasoning. When therapists collaborate with a patient to understand that person’s unique needs, they are using interactive reasoning. This clinical paper provides examples and steps to help therapists identify and apply the symbolic aspects of care to goalsetting and treatment decisions. Clinical application and rationale: A deconditioned, overweight female computer operator was referred for hand therapy with a diagnosis of bilateral upper extremity overuse syndrome. She was instructed in postural exercises but did not practice these as instructed. Through discussion, she revealed that she had been gaining weight and was self-conscious about this. She stated that she did not practice better posture because she felt that she would look ‘‘fatter’’ by doing so. Observations: A physical problem or limitation cannot be separated from a patient’s experiences that give that problem meaning. The meaning that a physical problem holds for a patient is personal and idiosyncratic. This meaning is conveyed symbolically through a patient’s

choices to engage in activity. It is different for each person, and it affects each patient’s decision to comply with treatment. Conclusions: The medical model advocates professional distance and objectivity. While it is important to be able to make decisions objectively, it is also important to make decisions that acknowledge the more subjective aspects of a patient’s experience. Recognizing the symbolic dimensions of hand therapy treatment leads to more personal and individualized treatment programs and facilitates patient participation and compliance. Relevance to hand therapy: Patients who seem non-compliant may actually be reacting to the symbolic meaning of a treatment or activity, and that meaning may be unknown to the therapist. This clinical paper presents cases illustrating how the symbolic dimensions of treatment can be identified and used to promote patient participation and compliance. Does a Uni-directional Dynamic Splint Affect Bi-directional Wrist ROM? Jerry Coverdale, OTR, CHT, Paul La Stayo, PhD, PT, CHT, Linda Meynarez, MOT Purpose: This retrospective study reports range of motion (ROM) outcomes in two directions, both wrist flexion and extension (following traumatic wrist injuries), after using a dynamic splint designed to address a ROM limitation in only one direction, e.g., ROM changes in both extension and flexion after using dynamic extension splint. Description: Nine patients with wrist stiffness (both in flexion and extension) following traumatic wrist injuries (seven distal radius fractures, one scaphoid fracture, and one scapholunate tear) were issued a Dynasplint, a commercially available splint that applies a low-load prolonged force in a uni-directional plane, once ROM measurements were at a plateau (four to six weeks after initiation of therapy). The type of splint (extension or flexion) was issued for the motion that was most limited. Two patients were issued flexion units and the remaining seven patients extension units. Patients utilized the splint at least eight hours per day on

a gentle tension (between 1/2 and 3). Traditional hand therapy treatments were continued after initiating the Dynasplint. Pre-splint active range of motion (AROM) measurements were compared with AROM measurements taken one month later (mean 5 32 days). Observations: In nine out of nine (100%) patients, AROM improved in the direction of splint application by an average of 35% (mean ROM 5 208). In eight out of nine (89%) patients, AROM improved in the opposite direction of splint application by an average of 22% (mean ROM 5 128). These ROM improvements are thought to be due to both the splint and the traditional in-clinic methods of treatment. The one patient who did not exhibit an increase in the opposite direction of the splint application did not, however, show a decrease in AROM. It is possible that the Dynasplint helped lengthen the restrictive peri-articular soft tissues in one direction, hence the peri-articular soft tissue volume surrounding the joint was decreased, thus enhancing the ability to achieve greater AROM in the opposite direction of the splint. Conclusion: This retrospective study reports how a uni-directional low-load prolonged dynamic tension splint can be utilized (following traumatic wrist injuries) in conjunction with a traditional in-clinic rehabilitation program to improve wrist AROM. The increase in ROM in the direction of the splint has been reported previously; however, the lack of a loss of AROM in the opposite direction (and in most cases there was an increase in AROM) is reported for the first time. Relevance to hand therapy: When used in the early stages of hand rehabilitation (four to six weeks), a splint applied in a uni-directional manner did not appear to result in a decrease AROM in the opposite direction in these nine patients. In most cases, this uni-directional splint application enhanced ROM in both directions.

Management of the Massive Rotator Cuff Tear: A Review of Current Treatment Philosophy in Surgery and Therapy. Michael Hopkins, MOT, OTR, Anil K. Dutta, MD, Marcos Masson, MD

Purpose: The patient with a massive rotator cuff tear presents a challenging clinical problem. The authors present a review of the management algorithm of the patient with a massive cuff tear including the indications for non-surgical and surgical treatments. In addition, a model for the rehabilitation of the patient who has had a direct repair of the massive rotator cuff tear is presented. Methods and clinical applications: Massive rotator cuff tears are defined as greater than 5 cm or involving two or more of the four cuff tendons. The treatment algorithm for these patients was constructed from a review of the current literature as well as the authors’ practices. Patients are selected based on age, physical demands, activity level, radiographic parameters, and patient preferences for the various treatment options. Non-surgical patients are treated with a specific therapy program as well as NSAIDs, rest, activity modification, and steroid injections in selected cases. Those who fail or are selected for surgery are treated with the outlined surgical options including: A. arthroscopic debridement (+/2 biceps tenotomy), B. direct repair (open or arthroscopic), C. musculotendinous transfers, C. alternative tissue augmentations, D. arthroplasty. The rehabilitation of the direct repairs was based on protection and passive/ active assisted motion. Abduction braces in 30–45 degrees of abduction are used initially with immediate motion above the level of the pillow. After six to eight weeks internal and external rotation actively is allowed at the side. Additionally, all planes passive motion is allowed at this time. After ten to 12 weeks all planes active motion is allowed. After 14 to 16 weeks strenghtening and functional exercises are commenced. Observations: The progressive management of patients with massive cuff tears can lead to acceptable clinical results. Following a treatment algorithm allows patients to understand their options at each step of their treatment. For patients with repairs of a massive cuff tear, protective motion and early active assisted motion may provide biological tensioning and muscle re-balancing to permit optimal results. Conclusions: The proper therapy and surgical treatment algorithm

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allows therapists and surgeons to provide individualized treatment and maximal success. An understanding of the variations in presentation, pathoanatomy, and options in the treatment arsenal is critical for the upper extremity therapist to understand. Distal Radius Fractures as the First Sign of Other Health Problems: Examination and Treatment Considerations for Osteoporosis. Elissa Cardoni, MPT, ATC, Jane Fedorczyk, MS, PT, CHT, ATC Purpose: To present clinical guidelines for the examination and treatment of patients who are initially referred to hand therapy with a distal radius fracture, which may be the first clinical sign of osteoporosis. Description of method, materials, principles, clinical application, and rationale: This clinical paper will present a review of the literature pertinent to the condition of osteoporosis, including epidemiology, risk factors, predictive variables, and recommendations for treating patients with upper extremity disorders that have a high suspicion of osteoporosis. The World Health Organization defines osteoporosis as a progressive, systemic, skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue with a consequent increase in bone fragility and susceptibility to fracture. Bone loss begins as early as the third decade of life. Bone density is measured through specialized radiological techniques. The clinician must rely on a review of the risk factors associated with osteoporosis after an incidence of fracture to raise suspicion. Statistics indicate that about 18 million Americans have low bone mass, 80% of whom are females. There are approximately 250,000 wrist fractures each year in which the underlying cause of the fracture is osteoporosis. Hand therapists can have a positive impact on patients they suspect may have osteoporosis by 1) identifying risk factors, 2) making recommendations for referral to other health care specialists, 3) selecting appropriate therapeutic exercises to manage current impairments as well as promote bone growth, 4) emphasizing posture education and scapular strengthening,

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and 5) educating the patient in joint protection, safe lifting, and falls prevention. Observations: Hand therapists are strong patient advocates and will benefit from the information presented in this clinical paper to identify potential undiagnosed cases of osteoporosis as well as enhance the plan of care for the rehabilitation of upper extremity fractures in postmenopausal women. Conclusions: An increasing number of females in the U.S. population are now postmenopausal. Therefore, more patients are at risk for developing osteoporosis. Hand therapists treating upper extremity fractures have a unique opportunity to help identify undiagnosed patients and to possibly decrease the devastating consequences of untreated osteoporosis, especially future debilitating fractures. Relevance to hand therapy: Osteoporosis is likely an undiagnosed comorbidity associated with an upper extremity fracture. Distal radius fractures are a common first fracture. A presentation that includes examination and treatment considerations for osteoporosis will improve the quality of the rehabilitation plan provided by hand therapists. Contrasting Perspectives on Pain Following Hand Injury. Josephine Chan, PhD, OTR, Jean Spencer, PhD, OTR, FAOTA Purposes: To compare contrasting ways of documenting pain and to identify the usefulness of information each method provides. Data from an ongoing study will compare use of (1) a visual analog scale to document global intensity of pain, (2) the DASH questionnaire to document pain during functional tasks, and (3) qualitative interviews to document ways individuals experience and adapt to pain. Subjects: Participants in the ongoing study are adults with acute hand injuries who are receiving therapy two to three times a week for at least eight weeks. Purposive sampling is used to recruit participants who are diverse in age, ethnicity, and major occupations. Five to six participants are recruited during two cycles a year of a hand therapy fellowship pro-

gram. Usual treatment protocols are followed for each client. Methods: Data are collected by hand fellows and graduate students monthly while the client is receiving therapy and quarterly thereafter for a year. Data sources include quantitative measures of physical recovery (range, strength, sensation, function, and pain); quantitative measures of psychosocial recovery and perceived outcomes using the DASH (Disabilities of Arm, Shoulder, and Hand) questionnaire; and qualitative interviews to document impact of the injury on occupations and relationships, adaptive challenges and strategies, and hopes for the future. Data are recorded and analyzed through an online data management system. Data analysis: Quantitative and qualitative data are tracked graphically over time for individual clients. Additional analysis involves comparison across clients within each fellowship program cycle, and cumulatively across program cycles. Methods to increase trustworthiness based on the qualitative research tradition include interpretation of findings from multiple perspectives by hand therapy fellows, graduate students, and outside peer reviewers. For this presentation, data on documentation of pain will be drawn from the ongoing study database. Results: Correlations examine relationships between quantitative measures of global intensity of pain from a visual analog scale, and pain during functional tasks from the DASH questionnaire. Moderate correlations indicate that both kinds of measures provide distinctive information. Qualitative interviews provide an ‘‘insiders’ perspective’’ on how individuals describe pain and its consequences in their lives and about contrasting ways clients adapt to pain. Conclusions: Each method of documentation provides important information about pain, a major issue that powerfully affects recovery from hand injury. Qualitative interviews add an important perspective to quantitative methods of assessing pain that are commonly used in hand therapy including the visual analog scale and structured questionnaires with fixed response alternatives. Relevance to hand therapy: Discussion with clients about their pain

experience conveys an empathetic approach, which is an important factor in psychosocial recovery. Therapists can help clients learn to monitor pain as a useful indicator as they attempt new activities, while avoiding paralyzing overattention to this aspect of hand injury. Alternative perspectives on pain including both quantitative and qualitative approaches allow therapists to incorporate individual differences in therapy and thus maximize client outcomes and ways to document for clinical and reimbursement purposes. Distal Radius Fractures as the First Sign of Other Health Problems: A Clinical Guideline for Falls Risk. Kimberly Kalaher, DPT, Jane Fedorczyk, MS, PT, CHT, ATC Purpose: To present a clinical guideline for the examination and treatment of community-dwelling elderly patients who are initially referred to hand therapy with upper extremity trauma, such as a distal radius fracture, associated with a fall. This guideline provides the structure required for screening, examination, and treatment of patients who are at risk for falls. Description of method, materials, principles, clinical application, and rationale: This clinical paper will present a review of the literature pertinent to identifying risk factors for individuals at risk for falls. Thirty two percent of individuals over age 65 and 50% of individuals over age 85 experience a fall. Ten to fifteen percent of falls result in injury, frequently involving upper extremity musculoskeletal trauma. These patients are commonly referred to hand therapy for management of their injury, but likely have not been assessed for falls risk. Using a decision tree format that correlates to the systematic process of examination, a clinical guideline to determine and manage patients at risk for falls has been developed. Patients are classified into one of four groups according to risk factors and perceived risk for fall. Objective fall screening tests such as the Functional Reach Test or the Timed-Up-and-Go Test can be readily administered in the hand therapy clinic to determine the perceived risk for fall. Recommendations for treatment and patient

education are presented within the guideline for each classification. This guideline offers additional examination and treatment considerations for managing patients with upper extremity trauma associated with a fall that allows the hand therapist to offer a ‘‘whole patient’’ plan of care. Observations: Therapists who specialize in hand therapy are usually unaware of the risk factors associated with falls, yet they commonly treat the injuries associated with falls. Hand therapists are strong advocates for reducing the incidence of future injuries. Conclusions: By presenting this clinical guideline, hand therapists will gain valuable information on how to screen a patient to determine risk for falls, prognosis, and a rehabilitation plan to prevent future falls. If appropriate and within the scope of their practice, the hand therapist should be able to provide more effective treatment for reducing the risk of falls in community-dwelling elderly patients by using this guideline. If it is not within the scope of practice, such as for certified hand therapist/occupational therapist, then an appropriate recommendation can be made to the referring physician or primary care physician to seek referrals to other HCPs. If nothing else, this guideline should at least increase awareness that risk factor modification cannot be accomplished with random tests and exercises, but rather requires a systematic process of examination, assessment, and treatment for this patient population. Relevance to hand therapy: Hand therapists treat patients with distal radius fractures or other upper extremity trauma associated with falls. They may likely be the first health care professional to determine that the patient is at risk for falls. Risk assessment and appropriate management should help reduce future falls, musculoskeletal injuries, and medical costs. A Canadian Survey of Postoperative Management Techniques for Carpal Tunnel Release. Kara Ludlow, BScOT, CHT, Leann Merla MSc, Jane Cox, BScOT, CHT Purpose: Although carpal tunnel release (CTR) is an extremely com-

mon procedure, there is a paucity of literature regarding postoperative management protocols. This presentation will highlight commonalities and differences in therapy practices related to CTR patients across Canada. This information is beneficial to therapists wishing to review current practice, develop or revise treatment protocols, or carry out research in this area. Description of method, materials, principles, clinical application, and rationale: Using a snowball recruitment technique, occupational and physical therapists working in the area of hand therapy in Canadian academic teaching hospitals were contacted and asked to complete a survey regarding their postoperative management of CTR patients. This population was chosen to allow a comparison with the authors’ facility. Surveys were mailed to the identified individuals with a two-week return date requested. Questions, which were developed following a review of the available literature, addressed referral patterns, splinting, therapeutic modalities, restrictions placed on patients, and timing and duration of treatment. The majority of questions were forced-answer responses with provision for additional comments or responses. Responses were tabulated using descriptive statistics. Trends and areas of variation were identified by the authors. Observations: Survey responses indicated that considerable variations in practice exist for this population. This variation was noted in nearly every area investigated from whether CTR patients were even referred for therapy to the types of intervention and duration of therapy. Even within individual facilities, variations in practice were noted. Conclusion: Therapists involved in the treatment of CTR patients appear to base their intervention on a combination of clinical judgment and historical practice. Individual client needs were commonly identified factors in determination of interventions. Relevance to hand therapy: The lack of consensus in treatment protocols for CTR patients creates a challenge for evaluation of outcomes. Research literature specific to postoperative management is lacking, which further exacerbates the difficulties for

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therapists who strive to be evidencebased practitioners. The results of this survey provide a stepping stone for further research. Outcome evaluation of different therapeutic interventions is needed to provide guidance regarding the most effective methods of assisting patients to gain the maximum benefit from CTR surgery. Clinical Implications of Differential Testing and Stretching of the Interosseous versus the Lumbrical Muscles of the Hand. Judy C. Colditz, OTR/L, CHT, FAOTA, Detlev Erdmann, MD, L. Scott Levin, MD, FRCS Purpose: Tightness of the intrinsic muscles is a frequent cause of limited digital motion following injury and/ or surgery. Many assume that the passive ‘‘intrinsic tightness’’ test is evaluating tightness of both the lumbrical and the interosseous muscles. To accurately resolve stiffness in the hand, therapists should be able to differentially test tightness of the lumbrical and the interosseous muscles, as well as know what maneuver maximally stretches each of these muscles. Isolated lumbrical tightness primarily diminishes active DIP joint flexion in the position of concurrent active MP and IP flexion while interosseous tightness primarily limits passive PIP flexion when the MP joint is in a position of full extension. Unlike the interosseous muscle, the lumbrical muscle tightness testing position and stretching position are different. Also unlike the interosseous muscle, the lumbrical muscle can only be elongated with active, not passive, motion. The purpose of this paper is to clarify the correct testing and stretching positions for each of these muscles and relate these findings to current clinical practice. Description of method, materials, principles, clinical application, and rationale: The recommendations in this paper result from a literature review and a cadaveric study of nine fresh cadaveric index finger lumbrical muscles that were marked with sutures at the origin and insertion. Digital joint angles and lumbrical length from origin to insertion were recorded in the passive hook position (400 gr. force) and the active hook position (MP joint stabilized in ex-

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tension and 600 grams force applied to the proximal FDP tendon). Afterward, each lumbrical muscle was restrained to its resting length with a suture and measurements repeated. These two sets of measurements were taken with the wrist in 45 degrees of extension, at 0 degrees, and in 45 degrees of flexion. Observations: Based on the findings of this study and a review of the literature, the following conclusions are relevant to the current practice of hand therapy: (1) Testing of interosseous muscle tightness is a passive test, achieved by positioning the MP joint in full extension (hyperextension) and passively flexing the PIP joint, comparing this with the resistance to passive PIP flexion when the MP joint is allowed to flex. (2) Stretching the interosseous muscle is therefore achieved by either applying an active or passive force to flex the PIP joint/s while the MP joint is held in hyperextension. (3) Testing for lumbrical muscle tightness is dependent on active proximal excursion of the profundus tendon and the lumbrical origin and therefore must be an active test. To observe lumbrical tightness, interosseous tightness and joint tightness must be resolved, as this observational test demonstrates an inability to actively flex the DIP joints at the end range of finger flexion. A slight paradoxical extension of the DIP joints can be seen when the patient exerts force for full flexion, because the tightness of the lumbrical muscle is transmitted to the lateral band insertion on the dorsum of the DIP joint. Conclusions: Based on the findings of this study and a review of the literature, the following conclusions are relevant to the current practice of hand therapy: Testing of interosseous muscle tightness is a passive test, achieved by positioning the MP joint in full extension (often hyperextension) and passively flexing the PIP joint, comparing this with the resistance to passive PIP flexion when the MP joint is allowed to flex.

Stretching the interosseous muscle is therefore achieved by either applying an active or passive force to flex the PIP joint/s while the MP joint is held in hyperextension. Testing for lumbrical muscle tightness is dependent on active proximal excursion of the profundus tendon origin and the lumbrical and therefore must be an active test. To observe lumbrical tightness, interosseous tightness and joint tightness must be resolved, as this observational test demonstrates an inability to actively flex the DIP joints at the end range of finger flexion. A slight paradoxical extension of the DIP joints can be seen when the patient exerts force for full flexion, because the tightness of the lumbrical is transmitted to the lateral band insertion on the dorsum of the DIP joint. Although one might assume that the wrist position could alter the amount of proximal FDP excursion and thereby alter the elongation of the lumbrical muscle, there was no significant difference in the lumbrical length in the three wrist positions. Relevance to hand therapy: Therapists should refrain from the terminology of intrinsic tightness and should specifically describe interosseous tightness or lumbrical tightness. Specific testing for interosseous tightness must provide passive flexion to the PIP joint only and the MP joint must be in maximum hyperextension for the test to be precise. The force must not be applied to flex the DIP joint. When applying a mobilization splint to reduce interosseous tightness, the MP joints must be held in hyperextension and the force applied to gain PIP flexion only. Splints that provide concurrent PIP and DIP flexion for this purpose should be abandoned. When the interphalangeal joints have been mobilized and the interosseous tightness resolved, the inability to fully flex the IP joints is usually a result of isolated lumbrical tightness. Splinting all joints into flexion does not resolve this tightness, as effective stretching can be achieved only by positioning the MP joints in hyperextension and actively flexing the IP joints. Since active IP flexion with the MP joints held in hyperextension can stretch both the interosseous and lumbrical muscles, therapists should

consider exercise splints that precisely position the MP joints in hyperextension and allow the patient full active IP flexion (and extension). Wrist position is not important during the active elongation of the lumbrical muscle, thereby assuring therapists that a splint that excludes the wrist while positioning the MP joints in maximum extension is all that is required. MP Joint Flexion: Should It Be the Priority in Mobilizing the Stiff Hand? Judy C. Colditz, OTR/L, CHT, FAOTA Purpose: Classic teaching has impressed on therapists the need to maintain metacarpophalangeal (MP) joint flexion because of the collateral ligament configuration. This paper questions the assumption that MP joint flexion should be the first priority when working to regain mobility of the stiff hand. Description of rationale: A literature review of the anatomy and biomechanics of digital motion indicates that finger flexion is initiated with the flexor digitorum profundus (FDP) muscles while the extensor digitorum muscles maintain the MP joint in extension until a hook position is achieved in the interphalangeal (IP) joints. Only then do the interosseous muscles assist with MP joint flexion. The injured edematous hand develops interosseous tightness, creating a pattern where MP joint flexion initiates finger flexion and interphalangeal joint flexion is limited. Contradictory to previous teaching that would never advocate immobilizing MP joints in extension in the stiff hand; the author has developed a rationale for this to be desirable. Observations: Based on the author’s experience of casting motion to mobilize stiffness (CMMS) in chronically stiff hands, patients have regained full finger flexion by first immobilizing the MP joints to allow isolation and strengthening of the FDP. First, active motion with the MP joints blocked in some extension allows active motion to mobilize the stiff IP joints, changes the cortical mapping of active finger flexion to the normal extrinsic dominance, and stimulates lymphatic flow in the fingers. Secondly, the active hook position regains excursion of the interosseous

and lumbrical tendons across the MP joint capsule while the muscles regain tone and elasticity. Concurrently the pressure of the cast and active IP joint flexion reduces MP joint edema, considered by the author to be the most frequent reason for lack of full MP joint flexion. This theory has been validated by the author’s experience with the CMMS technique where MP joint flexion mobilization has only been necessary when there is a dorsal adherence of the extensors or a direct MP joint injury. Conclusions: Initiating digital flexion with MP joint flexion allows the interosseous and lumbrical muscles to remain shorten and dominate the pattern of finger flexion. Less emphasis should be placed on maintaining the maximum length of the collateral ligaments of the MP joint and more emphasis should be placed on early reestablishment of the normal pattern of digital flexion. Relevance to hand therapy: Knowing that the normal pattern of digital flexion is initiated with the FDP muscles, mobilization of any digital stiffness should focus on regaining this normal pattern as early as possible. Splints that hold the MP joints in flexion while asking the patient to flex the fingers prevent this extrinsic contribution and reinforce the continued tightness of the intrinsic muscles. Therapists should consider blocking the MP joint in extension to better mobilize the IP joints, reduce digital edema, and mobilize the intrinsic muscles. This observation is relevant to any mobilization of the digits, but especially the stiff hand and flexor tendon injuries where it is mandatory for the extrinsic flexors to regain full excursion. Application of the Double Reverse Kleinert Technique in Extensor Tendon Repairs in Zones Surrounding Extensor Retinaculum. Shrikant J. Chinchalkar, BScOT, OTR, CHT, Douglas C. Ross, MD, FRCSC Extensor tendon repairs surrounding the extensor retinaculum in zone VI, zone VII, and proximal zone VIII are commonly treated with an immobilization method or using a controlled motion in a reverse Kleinert technique. The complications associated with this management vary depending on the level of repair. An

inter-tendinous adhesion, subcutaneous adhesion of tendons, and tendinous adhesions within the synovial sheath limits the excursion of the extensor tendons affecting the combined wrist and digital function. Inter-tendinous adhesions proximal to the synovial sheath in zone VIII limit composite digital flexion along with the flexion of the wrist. Whereas a composite extension of the wrist and digits (combined) is lost in the proximal zone VI, a combination of limitations seen in zones VI and VIII is observed in zone VII repairs. In order to achieve wrist and digital motion as well as function, isolated controlled motion of the wrist, and isolated controlled motion of the digits, Kleinert principle is used post-operatively. Achieving early tendinous gliding using a controlled arc of motion during the post-operative periods and gradually increasing the arc of motion with double reverse Kleinert splinting reduces/minimizes tendon adhesions. Classification of Dorsal Lip Proximal Interphalangeal Joint Fractures and Dislocations. Shrikant J. Chinchalkar, BScOT, OTR, CHT, Bing Siang Gan, MD, PhD, FRCSC, FACS Existing classifications for PIP joint fracture-dislocations address only those involving the volar lip. No universally accepted classification of dorsal lip fracture dislocations exists. To guide treatment of these fractures, we propose the following classification: Grade I: Dorsal lip fractures of less than 25% of the articular surface, with no subluxation of base of the middle phalanx. Grade II: Fractures of less than 50%, with minimal subluxation of the of the base of the middle phalanx; may have a frank boutonniere deformity. Grade III: Any size fracture, with complete palmar dislocation of the middle phalanx. In Grade III dorsal lip fracture dislocations, there is often a physical separation of the collateral and accessory collateral ligaments causing volar translation of the middle phalanx and absence of a classical boutonniere deformity because of the redundancy of the conjoined lateral bands. Grade I fractures can be successfully treated with splinting and early DIP joint mobilization. Grade II fractures often require traction

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with volar block splinting but, if this does not reduce subluxation, may require ORIF followed by early mobilization in a traction splint. Management of Grade III fractures require open articular reduction and/or internal fixation followed by early active ROM intermittently during the day with periodic PIP joint day splinting in extension and fulltime splinting at night. And if attaining active ROM is difficult, then mobilization of the joint in traction splinting is used. This classification of dorsal lip fracture-dislocations guides reduction methods and postoperative management. Syndrome of Extensor Quadrigia. Shrikant J. Chinchalkar, BScOT, OTR, CHT, Bing Siang Gan, MD, PhD, FRCSC, FACSC, Robert M. McFarlane, MD, FRCSC, Graham J. King, MD, FRCSC, James H. Roth, MD, FRCSC The shared functional performance of the individual digital extensor tendons is limited because of a common extensor digitorum communis muscle body. A corollary muscle body can act effectively only if the gliding amplitude of each of its four extensor tendons is normal. If one of the tendons is adherent at a fracture or tendon repair site, has a decreased excursion secondary to a flexion contracture at the MCP joint, or rupture, attenuation or laceration of a sagittal band or juncturae tendinum, its reduced gliding amplitude will limit the excursion of the adjacent extensor tendons. In analogy of the principles of the flexor tendon syndrome, this has been termed the ‘‘syndrome of extensor quadrigia.’’ Improper management of this clinical entity may lead to an abnormal patho-mechanical kinematic chain imbalance. Thus, based on the biomechanical analysis of this phenomenon, early identification and treatment are critical. Competencies in Hand Therapy. Practice Analysis Task Force: Mary Kasch, OTR, CHT, Dorit Aaron, MA, OTR, CHT, FAOTA, Mary Dimick, OTR, CHT, Lynnlee Fullenwider, OTR/ L, CHT, Terri Hansford, PT, CHT, Brenda Hilfrank, PT, CHT, Georgiann Laseter, OTR, FAOTA, CHT, Bonnie Lucio, LOTR, CHT, Joy MacDermid, PhD, PT, Christine Moran, MS, PT, CHT, Bonnie Olivett, OTR, CHT, Karen

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Stewart Pettengill, MS, OTR/L, CHT, Patricia A. Taylor, PT, CHT, Terri Wolfe, OTR/L, CHT, Sandra Greenburg, PhD, Patricia M. Muenzen, MA The Hand Therapy Certification Commission, Inc. (HTCC), in consultation with Professional Examination Service (PES), completed a practice analysis of hand therapy in 2001. One goal was to obtain information about the competencies demonstrated by therapists at specific points of experience. Six competency areas were identified and included in the final survey: Scientific Knowledge, Clinical Judgment/ Clinical Reasoning, Technical Skills, Interpersonal and Communication Skills, Professionalism, and Resource Management. Certified hand therapists in the United States and Canada participated in the survey. All six competencies were rated moderately or highly critical to professional effectiveness. Thirty hypothesized behavioral progressions (from novice to expert) were included; 27 were validated by the results indicating that hand therapists demonstrate competence that is unique and increases over time. Potential uses of these results by hand therapists and hand therapy organizations are proposed, especially in regard to candidate eligibility, self-assessment by CHTs, and planning for continuing education.

A New Method of Dynamic Supination Splinting: A Case-study, Radiographic, and Electrophysiological Analysis. Michael J. Lee, DPT, Paul LaStayo, PhD, PT, CHT, Ann E. vonKersburg MPT, CHT The purposes of this study were to: 1) Describe a dynamic supination splint that does not cross the humeroulnar and humeroradial joints, allowing flexion and extension of the elbow. 2) Provide retrospective data on effectiveness of this splint in patients with limited supination. 3) Provide radiographic and electromyographic (EMG) data that document this splint’s ability to provide a passive supination force. Eleven subjects treated for various elbow and/or wrist fractures leading to losses of forearm supination significantly increased their passive range

of motion (PROM) from 34.08 at the initial visit to 82.38 at discharge and active range of motion (AROM) from 27.08 to 72.38. Radiographic images of the radius and ulna were identical in maximal voluntary supination and resting in the splint. Surface EMG was utilized to measure supinator muscle activity at rest, passively supinated while wearing the splint, and during a maximal isometric supination effort (without splint). Average supinator EMG activity was: 7.9 mV at rest, 7.8 mV in the splint, and 68.0 mV with maximal isometric contraction. Results indicate the supination splint is clinically effective in increasing supination PROM. The EMG data and radiographic images indicate that the splint passively positions the forearm in supination even though the proximal margin of the splint does not cross the elbow. Postoperative Management of Zone V and VI Extensor Tendon Injuries. Diana O’Grady, MClSc(OT), Leann Merla, MSc(OT), Cathy Vandersluis, BSc(OT), CHT Purpose: To present evidence that the static immobilization protocol yields favorable outcomes compared with other documented protocols in the literature and thus is an excellent method of postoperative management of zone V and/or VI extensor tendon injuries. Description of method, materials, principles, clinical application, and rationale: A retrospective chart review of records from one facility, which utilizes a static immobilization protocol post extensor tendon injury, was conducted. Patients who sustained an extensor tendon injury in zones V and/or VI from May 1997 to December 2000 were selected. Outcome measures were compared with those reported in published studies for immobilization, early passive motion, and controlled active mobilization. Due to the wide variety of outcome measures, the most common measures were chosen for comparison: total active motion (TAM) scores, extensor lag (total number of digits), incidence of tendon rupture, secondary complications, number of therapy visits, and length of the rehabilitation program. The princi-

ples of intrinsic and extrinsic healing of tendons and the effect of mobilization were considered in analyzing the results. At this facility, the authors continually strive to incorporate evidencebased practice into the standard care protocols while being cost-effective in terms of therapist and patient time, cost to the patient, and the ease of wearing a static splint compared with a dynamic splint. Historically, the therapists have utilized static immobilization with subjectively good results. This study was undertaken to gain objective evidence to support or refute the static immobilization protocol. Observations: Please refer to Table 1. Conclusions: Overall, the results derived from this study are comparable to the results of studies reported in the literature that utilize similar and alternative treatment protocols. When these favorable results are combined with the cost– effectiveness of this protocol, static

TABLE 1. Breakdown of Results for Static Immobilization Protocol Finger Lacerations Outcome Measures

Partial Laceration

Number of tendons Average total active motion (TAM) Extension lag (total number of digits) Number of tendon ruptures Secondary complications Average number of therapy visits Average length of rehabilitation program (weeks)

13 2568 1 0 2 5.9 7.5

Full Laceration Complex* 18 2318 4 0 1 6.7 8.6

1 2568 0 0 0 5 9

*Complex ¼ full laceration 1 partial MCP joint capsule tear.

immobilization is an excellent method of postoperative management of zone V and/or VI extensor tendon injuries. Relevance to hand therapy: The increased attention in the literature to extensor tendon injuries and their management illustrates the complexity and uniqueness of extensor tendon injuries and emphasizes the importance of ‘‘best practice’’ for patients. Ongoing research regard-

ing the most effective means of treating extensor tendon injuries is consequently required. This study strives to document the fit between scientific literature, expert consensus, and professional experience to provide patients with an effective and cost-saving method to postoperative management of zone V and/or VI extensor tendon injuries with good to excellent results.

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