Certified Hand Therapist Research Articles

45 A Three Year Analysis of a Multi-tiered Orthotic Protocol

Abstract Introduction A variety of factors affect the fit of custom orthoses in those with burn injuries. A resting hand orthosis (RHO) is a common device within burn care, yet fabrication and fitting of this custom orthosis requires precision and expert assessment. However, burn therapists have varying degrees of education and credentials and previously we had noted preventable complications. Our center implemented a multi-tiered protocol focused on custom RHOs and found a marked decrease in complications immediately following implementation. The purpose of this QI project was to evaluate whether these improvements had been sustained over the following three-year period. Methods This was a retrospective chart review. Per protocol an RHO could be fabricated by a single certified hand therapist (CHT) or co-fabricated by two (non-CHT) therapists. Incidence of orthosis complications, defined as erythema and/or an orthotic induced partial-thickness injury to the volar second metacarpal head (index finger) was the primary outcome measure. Other data collected were average time to fabricate & modify devices and average refabrication(s) required between CHT vs non-CHT devices. Patients with missing data points was excluded. Results Eighty-five patient hands were examined from 2019-2022. Prior to implementation, total erythema occurrences were reported in 23.4% of orthoses (n=18) and total orthotic induced partial thickness injury occurred in 11.7% (n=9) of cases. Post protocol implementation erythema occurred in 5% of cases (n=5), and partial thickness injury in 0% of cases (n=0). This represents a decrease of 95% and 100%, respectively. On average CHTs fabricated RHOs in 59 minutes vs 48 minutes for non CHTs. CHTs had a complication rate of 0.0% vs 10.98% for non-CHTs. Potential complication was also limited to 0.0% for CHTS and 27% of non-CHTs. Modification rates were limited to 18.75% for CHTS vs 47.56% of non-CHTs. Conclusions Data from this QI project showed a clinically significant decrease in erythema and decrease in breakdown and number of modifications needed from utilization of either a CHT or two therapists when managing hand orthoses. Since instituting our protocol focusing on RHOs, our center has decreased complications and potential complications to improve patient outcomes. Although, most therapists receive standard education, it can be inferred that CHTs may approach orthotic fabrication through a different lens. The required studying and education required to maintain an advanced practice certification may benefit burn therapy departments. Therapists without this specialty certification can enhance skill and outcomes via co-fabrication and assessment. Applicability of Research to Practice Orthotic induced erythema may be decreased by utilizing CHTs or two non-CHTs to manage RHOs. This protocol can be expanded to include other orthoses or with other advanced certifications.

Abductor Pollicis Longus Tendon Abnormalities and Release in Children With Congenital Clasped Thumb.

Congenital clasped thumb is associated with deficient thumb extensor tendons. Reconstruction includes tendon transfer. Here, we describe a variant of the abductor pollicis longus (APL) tendon, not previously reported, contributing to the flexion deformity. The purpose of this study is to report examples of and offer surgical repair techniques for APL variants identified in patients with clasped thumb. We reviewed records of 11 consecutive patients undergoing reconstruction for clasped thumb. Surgical anatomy of the APL tendon was evaluated in all patients, followed by release of aberrant APL attachments. Participants were invited to return for an in-person assessment with a certified hand therapist. Data were collected regarding intraoperative findings, surgical techniques for reconstruction, postoperative thumb motion, and patient and caregiver satisfaction. Eleven children (12 thumbs) underwent aberrant APL release and rerouting between 2019 and 2021. Preoperatively, all thumbs were passively correctible to 0° of extension. In all patients, the APL was found to terminate palmar to the metacarpophalangeal (MCP) joint, creating an MCP flexion moment when tensioned. The average age at surgery was 7 years (range: 1-15 years), and the average follow-up was 14.2 months (range: 1-21 months). The mean postoperative thumb radial abduction was 55° (range: 20°-75°). When reconstructing clasped thumbs, surgeons should explore the presence of APL abnormalities. Release and centralization of the APL can improve thumb position and function. This technique may avoid the need for extra-anatomical tendon transfer in patients with clasped thumb.

Intra-rater reliability of goniometry to measure scapular protraction and retraction

Study DesignObservational, descriptive design. BackgroundDespite scapular mobility being essential for the completion of activities of daily living (ADLs), there is currently no established, a reliable goniometric technique to measure scapular protraction and retraction. A proposed method has shown clinically significant inter-rater reliability for a goniometric technique for these measurements. PurposeThis observational descriptive study examined the intra-rater reliability of a goniometric technique to assess scapular protraction and retraction among a sample of healthy adults. MethodsAn occupational therapist who is a certified hand therapist (CHT) and an occupational therapy student used goniometry to measure the neutral (resting), protracted, and retracted positions of the right and left scapula for a sample of healthy young adults (n = 54; a total of 108 data points for each measurement). These measurements were compared to analyze intra-rater and inter-rater reliability. ResultsFor measurements of the scapula in neutral, protraction, and retraction, the standard error of measure (SEM) for repeat measures by the expert and novice raters was < 4.5° and < 3.9° respectively and ICC values ranged from poor to moderate (0.37-0.63). The SEM for measures between evaluators was < 5.0° and the ICC was poor (0.16-0.35). Minimum detectable change (MDC) values as a percentage of the mean (% MDC) ranged between 15.9 and 43.7% for intra-rater reliability and 21.9-52.8% for inter-rater reliability. DiscussionThe results of the study were mixed; variance of less than 5° for repeat measures by the same rater and measures between raters suggest clinically acceptable reliability. However, variance as a proportion of available motion (%MDC) demonstrates a broader range both above and below the threshold of 30% suggested for rehabilitation assessments. ConclusionThere are few efficient, reliable techniques to measure scapular mobility in clinical practice. The absolute reliability of goniometry to measure scapular protraction and retraction is similar to measurements of other joints. However, additional research and possible refinement of the technique is recommended to further address relative reliability and validity.

Factors Which Influence Patient Choice When Choosing a Hand Therapist

Background: Orthopedic surgeons often refer patients to hand therapy following orthopedic injury or surgery to facilitate recovery and maximize outcomes. Patients should be a key part of the shared decision-making process when it comes to their rehabilitation. While there is existing literature investigating factors considered by patients when choosing other medical providers, there are currently no studies investigating factors considered by patients when choosing a hand therapist. Purpose: The purpose of the study is to investigate public perception of factors which are important when choosing a hand therapist. Methods: A convenience sample (N = 220) of adults over the age of 18 completed an anonymous online survey using an internet crowdsourcing platform. Respondents were asked to quantitatively rank the importance of 10 predetermined factors related to selecting a hand therapist. Results: Respondents ranked insurance coverage and credentialing as a certified hand therapist as highest in terms of importance. Conclusion: We found that the factors people consider important when selecting a hand therapist are similar to the factors described in the medical literature that are important when selecting a physician or other healthcare provider. The results have implications for physicians when ensuring continuity of care for their patients.

642 Orthotic Fabrication of the Upper Extremity Survey

Abstract Introduction Designing and fitting orthoses is an essential component of burn care. Burn therapists fabricate and fit orthoses at a high rate due to continuous changes in patient presentation. The purpose of this survey was to assess the current level of comfort with orthosis fabrication of burn therapists, identify trends about management and quality assurance regarding orthoses, and determine areas that may be improved through a directed educational initiative. Methods An anonymous, internet-based, 31-item survey was developed to evaluate training and comfort level of practicing therapists. The survey was distributed to burn therapists at North American burn centers. Descriptive statistics were performed. Results There were 44 respondents to the survey. Most were occupational therapists (75%), followed by physical therapists (25%). The majority of respondents had more than 15 years of burn experience (61%). Most respondents reported education at a master’s degree level or higher (59%), 18% reported being a certified hand therapist, and 13% a burn certified therapist. A large majority of respondents indicated they received orthotic instruction as part of their academic curriculum (91%), and 80% indicate instruction lasted a semester or less. Since graduation, 89% respond that they have had further orthotic instruction, with most training occurring on the job (92%). One hundred percent of respondents indicated therapists were involved in fitting orthoses. Most indicated they were very comfortable with fabricating both static (90%) and static progressive (69%) upper extremity orthoses. Elbow extension orthotics received the highest very comfortable rating at 92%, while shoulder abduction splints received the lowest relative rating at 56% reporting very comfortable. Despite these confident scores, 51% of respondents reported complications due to orthoses at least sometimes or more often, and these are seldom or never (55%) reviewed through a formal process. Conclusions Unanimously, therapists are involved with fitting orthoses. The majority of respondents do not have advanced certifications and receive limited post-graduate orthotic training. Complications occur at least sometimes according to most respondents and appear only modestly integrated into peer review. Given the potential consequences of orthotic induced complications and the high reported comfort levels fabricating orthotics by primarily veteran burn therapists, there is concern that these issues are under-examined through formal processes.

The hand therapist's role in the prevention and management of upper extemity injuries in the modern mass production industrial setting

BackgroundThis case study presents the role of an onsite hand therapist (Certified Hand Therapist, Occupational Therapist, Physical Therapist) in an industrial setting and the services that can be provided in this comprehensive care model. Onsite hand therapists can impact on Occupational Safety and Health Administration (OSHA) first aid programs and can provide state of the art treatment for the injured worker in both a direct and indirect capacity. PurposeThe purpose of this case study article is to review the many potential services the hand therapist can offer to facilitate the return-to-work of injured employees and provide employers with a proactive case management and state-of-the-art ergonomic prevention, improving profit margins and facilitating safe work environments. Study DesignA Case Study design demonstrating the diverse and positive impact of hand therapy on the mass production industrial setting. MethodsNovel to this approach is a description of outcome instruments (QuickDASH) administered in a periodic manner to understand the trajectory of change in patient-level disability throughout the rehabilitation process. The Optimal Screening for Prediction of Referral and Outcome (OSPRO-YF) is utilized to help predict the functional outcome for the injured worker. Case studies on common upper extremity pathologies will be discussed, demonstrating the benefits of onsite hand therapy with enhanced treatment and case management. ResultsThe utilization of the QuickDASH and the OSPRO-YF creates a process to determine the progression of injured workers in therapy, the trajectory of change in patient-level disability and to observe when changes occurred. An example of the periodic assessment approach is described in a case study to identify when the most significant change occurred and creating a mechanism to determine if patients were progressing as expected. ConclusionsInherent in this case study process is a fluidity in which the therapist can monitor patient progress and adjust the rehabilitation process that benefits both the patient and the industrial setting. A hierarchical functional level system is presented to describe an appropriate intervention strategy to coincide with a patient's progression of wound healing which can be provided by a hand therapist with specialized knowledge.

Collaborative Curriculum - Advancing Ergonomics Education by Incorporating the Expertise of a Certified Hand Therapist

Dental professions are at a high risk of experiencing musculoskeletal disorders (MSDs), with estimates indicating that between 60% and 96% of the workplace is impacted. 1 The dental hygiene studies (DHS) program at Pacific University previously included standardized ergonomics education in their curriculum, however these principles were reinforced predominantly through passive techniques (posters and brochures). In 2017, Pacific adopted a plan for ergonomics curricular revision that incorporated the expertise of a faculty member in Pacific’s Physical Therapy (PT) program; this involved introducing the Core Four activity set to incoming DHS student cohorts by a PT who is a Certified Hand Therapist.

Barriers and Solutions to Fieldwork Education in Hand Therapy

Study DesignSurvey. IntroductionFieldwork education is a vital component of training the next generation of CHTs. Barriers and solutions to fieldwork rotations in hand therapy are examined, as well as proposed solutions, including recommendations for student preparation. Purpose of the StudyThis descriptive study examined barriers for certified hand therapist clinicians to accept students for clinical rotations and clinicians' preferences for student preparation before a rotation in a hand setting. MethodsA survey was developed, peer reviewed, and distributed using the electronic mailing list of the Hand Therapy Certification Commission via SurveyMonkey. Aggregate responses were analyzed to identify trends including barriers to student clinical rotations and recommendations for students to prepare for hand rotations. ResultsA total of 2080 participants responded to the survey, representing a 37% response rate. Common logistical barriers were identified for accepting students such as limited clinical time and space. Many clinicians (32% agree and 8% strongly agree) also felt that the students lack the clinical knowledge to be successful. Areas of knowledge, skill set, and experience were surveyed for development before a clinical rotation in a hand setting. Most respondents (74%) reported increased likelihood of accepting a student with the recommended preparation. Novel qualitative responses to improve clinical experiences are presented as well. DiscussionStudent preparation before a clinical rotation in a hand setting appears to be a significant barrier based on the survey results. Areas of recommended knowledge, skill set, and experience may serve to guide both formal and informal methods of student preparation before a hand-specific clinical rotation to facilitate knowledge translation from experienced certified hand therapists to the next generation. ConclusionAlthough logistical barriers may be difficult to overcome, hand-specific preparation based on clinician' recommendations may facilitate student acceptance and success in hand specialty clinical rotations. Level of EvidenceN/A.

Efficacy of a radial-based thumb metacarpophalangeal-stabilizing orthosis for protecting the thumb metacarpophalangeal joint ulnar collateral ligament

Study DesignBasic research (biomechanics). IntroductionThe high degree of motion that occurs at the thumb metacarpophalangeal (MCP) joint must be taken into account when immobilizing a partially torn or repaired thumb ulnar collateral ligament. Purpose of the StudyTo determine the efficacy of a radial-based thumb MCP-stabilizing orthosis in resisting abduction across the thumb ulnar collateral ligament. MethodsTen fresh cadaveric hands were mounted to a custom board. An anteroposterior radiograph of the thumb was obtained with a 2 N preload valgus force applied to the thumb, and the angle between the Kirschner wires was measured as a baseline. Subsequently, 20, 40, 60, 80, and 100 N valgus forces were applied 15 mm distal to the MCP joint. Anteroposterior radiographs of the thumb were obtained after each force was applied. The angle of displacement between the wires was measured and compared with the baseline angle. The angles were measured with an imaging processing tool. A custom radial-based thumb MCP-stabilizing orthosis was fashioned for each cadaveric thumb by a certified hand therapist. The aforementioned loading protocol was then repeated. ResultsThe radial-based thumb MCP-stabilizing orthosis significantly reduced mean abduction angles at each applied load. DiscussionWe found that our orthosis, despite being hand-based and leaving the thumb IP and CMC joints free, significantly reduced mean abduction angles at each applied load. ConclusionsThis investigation provides objective evidence that our radial-based thumb MCP-stabilizing orthosis effectively reduces the degree of abduction that occurs at the thumb MCP joint up to at least 100 N. Level of Evidencen/a (cadaveric).

Measuring intrinsic hand strength in healthy adults: The accuracy intrarater and inter-rater reliability of the Rotterdam Intrinsic Hand Myometer

Study DesignClinical measurement study. IntroductionMeasuring the isometric strength generated during isolated hand joint motions is a challenging feat. The Rotterdam Intrinsic Hand Myometer (RIHM; med.engineers, Rotterdam, Netherlands) permits measurement of isolated movements of the hand. To date, there is limited evidence on the inter-rater reliability and limited adult normative data of RIHM. Given that multiple raters, often with varying degrees of experience, are needed to collect normative data, inter-rater reliability testing and a comparison of novice and experienced raters are needed. Purposes of the StudyThe purposes of this study were to test the accuracy, intrarater reliability, and inter-rater reliability of the RIHM in healthy-handed adults. MethodsRIHM accuracy was tested through use of precision class F weights. Adults 18 years or older without upper limb dysfunction were recruited. Each participant was tested by 4 raters, 3 occupational therapy graduate students, and an experienced certified hand therapist, through use of a calibrated RIHM. Five strength measures were tested bilaterally (ie, thumb carpometacarpal palmar abduction, index finger metacarpophalangeal [MP] abduction, index finger MP flexion, thumb MP flexion, and small finger MP abduction) 3 times per a standardized protocol. Statistical methods were used to test accuracy, inter-rater reliability, and intrarater/response stability. ResultsThe accuracy of RIHM device error was 5% or less. Reliability testing included the participation of 19 women and 10 men (n = 29). All raters were in excellent agreement across all muscles (intraclass correlation coefficient, ≥0.81). Low standard error of measurement values of ≤8.3 N (1.9 lb) across raters were found. The response stability and/or intrarater reliability of the novice and certified hand therapist raters were not statistically different. DiscussionThe RIHM has an acceptable instrument error; the RIHM and its standardized procedure have excellent inter-rater reliability and response stability when testing those without hand limitations; and the response stability and/or intrarater reliability of expert and novice raters were consistent. ConclusionsThe use of the RIHM is justified when multiple raters of varying expertise collect normative data or conduct cohort studies on persons with healthy hands. Future research is warranted. Level of EvidenceNot applicable.

Thirty years of hand therapy: The 2014 practice analysis

Study DesignQuantitative and descriptive study. IntroductionIn 2014, the Hand Therapy Certification Commission (HTCC), in consultation with Professional Examination Service, performed a practice analysis study of hand therapy, the fifth in a series of similar studies performed by HTCC over a 30-year period. PurposeThe purpose of the study was to gather data on current hand therapy practice to ensure the content of the Certified Hand Therapist (CHT) examination and credentialing program requirements match current practice. MethodsSubject-matter experts from the United States and Canada, representing a broad range of experiences and perspectives, developed an updated delineation of the domains, tasks, knowledge, and techniques and tools used in hand therapy practice. Practicing hand therapists from the United States, Canada, Australia, and 13 other countries reviewed the delineation in a large-scale online survey. ResultsThe survey overwhelmingly validated the updated profile. Additionally, the survey explored trends in hand therapy practice and compared findings with previous studies. The results were analyzed and compared with findings from previous studies. ConclusionThis analysis led to the revision of the test specifications for the HTCC; the affirmation of the definition of hand therapy; the refinement of the scope of hand therapy practice; and guidance for HTCC policy decisions. Level of evidenceNot applicable.

Collagenase Dupuytren Contracture: Achieving Single Treatment Success with a Hand Therapist-Based Protocol.

Background:Surgery remains the gold standard in the treatment of Dupuytren contracture but is technically demanding, carries significant risk of complications, and requires prolonged recovery time. Collagenase injection is an efficacious alternative to surgery; however, contracture release often requires multiple treatments spaced a month apart. We report our experience with a new collagenase treatment protocol aimed to minimize the total treatment time per joint contracture.Methods:We performed a single institution retrospective review of patients with Dupuytren contracture treated with collagenase using our protocol from 2011 to 2013. Patients returned 24 hours after collagenase injection for cord manipulation by a certified hand therapist while under digital block. Treatment success was defined as reduction in contracture to 5 degrees or less. Successfully treated joints were evaluated for recurrence (>10 degrees contracture) at 30-day and 6-month follow-up appointments. Serious adverse events, including skin tears, were recorded.Results:Success was achieved in 36 of 47 treated joints (76.6%) after a single injection. There were 2 recurrences in 32 joints at 30-day follow-up (6.2%) and no recurrences in 17 joints available at 6-month follow-up. Skin tears were the only serious adverse event occurring in 18 of 47 cord ruptures (38.3%). All healed secondarily without complication.Conclusions:Our protocol preserves treatment efficacy while maximizing efficiency. Achieving successful cord rupture with a single injection allows earlier return of function, reduced cost of treatment, and increased convenience for the patient. Patients, particularly those with greater contractures, should be counseled regarding the risk of skin tear during cord manipulation.

“Hand Surgeons Probably don't Starve”: Patient's Perceptions of Physician Reimbursements for Performing an Open Carpal Tunnel Release

The purpose of this study is to evaluate patient's perceptions of physician reimbursement for the most commonly performed surgery on the hand, a carpal tunnel release (CTR). Anonymous physician reimbursement surveys were given to patients and non-patients in the waiting rooms of orthopaedic hand physicians' offices and certified hand therapist's offices. The survey consisted of 13 questions. Respondents were asked (1) what they thought a surgeon should be paid to perform a carpal tunnel release, (2) to estimate how much Medicare reimburses the surgeon, and (3) about how health care dollars should be divided among the surgeon, the anesthesiologist, and the hospital or surgery center. Descriptive subject data included age, gender, income, educational background, and insurance type. Patients thought that hand surgeons should receive $5030 for performing a CTR and the percentage of health care funds should be distributed primarily to the hand surgeon (56%), followed by the anesthesiologist (23%) and then the hospital/surgery center (21%). They estimated that Medicare reimburses the hand surgeon $2685 for a CTR. Most patients (86%) stated that Medicare reimbursement was "lower" or "much lower" than what it should be. Respondents believed that hand surgeons should be reimbursed greater than 12 times the Medicare reimbursement rate of approximately $412 and that the physicians (surgeons and anesthesiologist) should command most of the health care funds allocated to this treatment. This study highlights the discrepancy between patient's perceptions and actual physician reimbursement as it relates to federal health care. Efforts should be made to educate patients on this discrepancy.

Therapist-Supervised Hand Therapy Versus Home Therapy With Therapist Instruction Following Distal Radius Fracture

To investigate whether there was a difference in Patient-Rated Wrist Hand Evaluation (PRWHE) scores between patients with and without comorbidities who receive regular supervised therapy provided by a certified hand therapist (CHT) compared with patients who were provided with a home exercise program and were regularly monitored. Fifty patients with a diagnosis of distal radius fractures and volar plate fixation were enrolled in a prospective, randomized clinical trial comparing those who received therapy under the supervision of a CHT with those enrolled in a home exercise program that was instructed and monitored by a CHT. The primary outcome measure (PRWHE) and secondary outcome measures, total arc of motion for wrist flexion and extension, supination and pronation, and grip strength, were assessed at 12 weeks. The primary outcome measure for both groups was also gathered at 6 months. There were no statistically significant differences between the final scores of the PRWHE, wrist or forearm motion, pain, or grip strength between groups. Effect size calculations revealed that both groups experienced a large effect size for all outcomes. Supervised clinic-based therapy is equally beneficial for patients without complications. Clinic-based therapy may be preferable for patients with noteworthy complications after a distal radius fracture with volar plate fixation. Patients with decreased finger motion and various comorbidities may benefit from therapy provided in a clinic under the supervision of a certified hand therapist. Therapeutic II.

Surface Replacement Arthroplasty of the Proximal Interphalangeal Joint Using the SR PIP Implant: Long-Term Results

To evaluate the long-term results of proximal interphalangeal (PIP) joint surface replacement arthroplasty for arthritis using the SR PIP implant (Small Bone Innovations, NewYork, NY). This is a long-term retrospective analysis of results in 39 of 43 joints first reported in 2008. Subjective results were based upon a mailed questionnaire. Active range of motion was measured by a certified hand therapist, and x-rays were obtained to analyze changes occurring since the first study. The average follow-up time was 9.3 years. The average active PIP joint arc of motion in the present cohort of patients went from 64° at the first report (2008) to 56° at this time. Radiographic comparisons revealed no major changes since the first study. Ten of 11 revisions were done for pain due to loosening and were performed at an average of 20 months after the primary procedure. No further revisions were necessary in the interim. Overall, subjective measures of satisfaction and symptomatic and functional improvement remained unchanged. Surface replacement arthroplasty using the SR PIP implant continues to be an option for patients with osteoarthritis of the PIP joint. Long-term subjective and objective outcomes are comparable to those reported using other implants. This and other studies suggest that this procedure is not appropriate for most rheumatoid joints. In the interim between studies, we saw a reduction in the average PIP joint arc of motion, although this change did not reach statistical significance. Our original revision incidence of 26% has not changed. Subjective evaluation and radiologic findings did not change between studies. Therapeutic IV.

The Effect of a Therapy Protocol for Increasing Correction of Severely Contracted Proximal Interphalangeal Joints Caused by Dupuytren Disease and Treated With Collagenase Injection

To determine the effect of a specific orthotic intervention and therapy protocol on proximal interphalangeal (PIP) joint contractures of greater than 40° caused by Dupuytren disease and treated with collagenase injections. All patients with PIP joints contracted at least 40° by Dupuytren disease were prospectively invited to participate in the study. Following standard collagenase injection and cord rupture by a hand surgeon, a certified hand therapist evaluated and treated each patient based on a defined treatment protocol that consisted of orthotic intervention to address residual PIP joint contracture. In addition, exercises were initiated emphasizing reverse blocking for PIP joint extension and distal interphalangeal joint flexion exercises with the PIP joint held in extension to lengthen a frequently shortened oblique retinacular ligament. Patients were assessed before injection, immediately after injection, and 1 and 4 weeks later. There were 22 fingers in 21 patients. The mean age at treatment was 63 years (range, 37-80 y). The mean baseline passive PIP joint contracture was 56° (range, 40° to 80°). At cord rupture, the mean PIP joint contracture became 22° (range, 0° to 55°). One week after cord rupture and therapy, the contracture decreased further to a mean of 12° (range, 0° to 36°). By 4 weeks, the mean contracture was 7° (range, 0° to 35°). The differences in PIP joint contracture were statistically significant at all time points except when comparing the means at 1 week and 4 weeks. The results represent an 88% improvement of the PIP joint contracture. In the short term, it appears that severe PIP joint contractures benefit from specific, postinjection orthotic intervention and targeted exercises. Therapeutic IV.

Static Versus Dynamic Splinting for Proximal Interphalangeal Joint Pyrocarbon Implant Arthroplasty: A Comparison of Current and Historical Cohorts

Study Design Nonrandomized mixed current and historical cohort follow-up study. The purpose of the study was to test the effectiveness of static splinting after arthroplasty in patients with osteoarthritis. Dynamic splinting is recommended after proximal interphalangeal joint pyrocarbon implant arthroplasty; however, static splinting may be more feasible to deliver. Nine consecutive patients received static splinting in this study. These patients were compared with those of a historical control group ( n = 10) who received dynamic splinting. Function and performance variables were measured preoperatively and 3 months after surgery. All patients underwent surgery by the same hand surgeon, and most of the patients were treated by the same certified hand therapist. Both static and dynamic groups showed improvement on several function and performance measures. Compared with the dynamic group, the static group showed greater improvements in the Michigan. Hand Outcomes Questionnaire subset of work performance (21.00 ± 14.75 vs 3.13 ± 14.13, p < 0.05) and Jebsen-Taylor Test (−11.58 ± 5.44 vs −2.81 ± 3.23, p < 0.03). Patients who received static splinting had similar outcomes to those who received the dynamic splinting. Static splinting requires less therapist training and offers greater patient convenience and is a promising protocol that should be evaluated in a larger study.

Zone-II Flexor Tendon Repair: A Randomized Prospective Trial of Active Place-and-Hold Therapy Compared with Passive Motion Therapy

In order to improve digit motion after zone-II flexor tendon repair, rehabilitation programs have promoted either passive motion or active motion therapy. To our knowledge, no prospective randomized trial has compared the two techniques. Our objective was to compare the results of patients treated with an active therapy program and those treated with a passive motion protocol following zone-II flexor tendon repair. Between January 1996 and December 2002, 103 patients (119 digits) with zone-II flexor tendon repairs were randomized to either early active motion with place and hold or a passive motion protocol. Range of motion was measured at six, twelve, twenty-six, and fifty-two weeks following repair. Dexterity tests were performed, and the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome questionnaire and a satisfaction score were completed at fifty-two weeks by ninety-three patients (106 injured digits). At all time points, patients treated with the active motion program had greater interphalangeal joint motion. At the time of the final follow-up, the interphalangeal joint motion in the active place-and-hold group was a mean (and standard deviation) of 156 degrees +/- 25 degrees compared with 128 degrees +/- 22 degrees (p < 0.05) in the passive motion group. The active motion group had both significantly smaller flexion contractures and greater satisfaction scores (p < 0.05). We could identify no difference between the groups in terms of the DASH scores or dexterity tests. When the groups were stratified, those who were smokers or had a concomitant nerve injury or multiple digit injuries had less range of motion, larger flexion contractures, and decreased satisfaction scores compared with patients without these comorbidities. Treatment by a certified hand therapist resulted in better range of motion with smaller flexion contractures. Two digits in each group had tendon ruptures following repair. Active motion therapy provides greater active finger motion than passive motion therapy after zone-II flexor tendon repair without increasing the risk of tendon rupture. Concomitant nerve injuries, multiple digit injuries, and a history of smoking negatively impact the final outcome of tendon repairs.

Multidisciplinary team evaluation of upper extremity injuries in a single visit: the UPPER Program.

Musculoskeletal disorders are the leading cause of disability among people between 18 and 64 years of age. Patients with musculoskeletal injuries of the upper extremities are usually evaluated and treated by an individual physician and therapist. However, for patients who have problems, especially after being treated by a hand surgeon and a certified hand therapist, there are few other management options. A multidisciplinary assessment program for patients with chronic upper limb pain has not been described in the literature. As part of The University of Michigan RERC (Rehabilitation Engineering Research Center), the UPPER Program (UPper extremity Protocol Evaluation in Rehabilitation) was developed to evaluate patients who have disabling upper limb musculoskeletal disorders. At the center of the program is a multidisciplinary team composed of a physiatrist (physical medicine and rehabilitation specialist), occupational therapist, physical therapist, exercise physiologist, vocational counselor and pain psychologist. The UPPER Program elements include a pre-evaluation questionnaire, individual team member assessments and a team meeting. It is followed by a patient appointment with the team physician to review the results and recommendations. The essential details of the program are presented in this article so it can be reproduced elsewhere.

Digital neurorrhaphy after the age of 60 years.

Fifteen patients over the age of 60 years (average age: 65 years), with 19 digital nerve lacerations, were evaluated more than 1 year after injury. Two-point discrimination, Semmes-Weinstein evaluation, and subjective return of sensibility were examined by a certified hand therapist before and after local anesthetic block of the uninjured digital nerve. Sixty-three percent of the patients regained moving two-point discrimination less than 15 mm; 100 percent regained Semmes-Weinstein values of less than 4.56; and 84 percent of the patients subjectively noted greater than half of their normal sensation. Crossover innervation was a factor in four of 14 repairs. Based on the data, useful sensation can be regained by repairing a digital nerve in the majority of patients older than 60 years of age.