Relative motion extension management of zones V and VI extensor tendon repairs: Does international practice align with the current evidence?

Journal of Hand Therapy xxx (2020) 1e13

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Relative motion extension management of zones V and VI extensor tendon repairs: Does international practice align with the current evidence? Melissa J. Hirth B (OT), MSc (Hand & Upper Limb Rehab) a, b, c, *, Julianne W. Howell PT, MS, CHT d, Ted Brown PhD, MSc, MPA, BScOT(Hons), GCHPE, OT(C), OTR, MRCOT, FOTARA, FAOTA c, Lisa O'Brien PhD, B App Sci (OT), M Clin Sci (Hand & Upper Limb Rehab), Grad Dip Ergonomics, Grad Cert Clinical Research Methods c a

Occupational Therapy Department, Austin Health, Heidelberg, Australia Malvern Hand Therapy, Malvern, Australia c Department of Occupational Therapy, Faculty of Medicine, Nursing and Health Sciences, Monash University, Peninsula Campus, Frankston, Australia d St Joseph, MI, USA b

a r t i c l e i n f o

a b s t r a c t

Article history: Received 17 October 2019 Received in revised form 3 December 2019 Accepted 31 December 2019 Available online xxx

Study Design: Electronic Web-based survey. Introduction: Therapists participating in an international survey selected relative motion extension (RME) as the “most used” approach for the postoperative management of zones V and VI extensor tendon repairs. A subgroup of respondents identified RME as their preferred approach and were asked about their routine RME practices. Purpose of the Study: The purpose of this study was to capture data from routine RME users about their practices and compare this with the RME evidence. Methods: An English-language survey was distributed to 36 International Federation of Societies for Hand Therapy full-member countries. Participation required therapists to have postsurgically managed at least one extensor tendon repair within the previous year. Those who selected RME as their “most used” approach were asked to identify which variation of the RME approach they favored: RME plus (with wrist orthosis), RME only, or “both” RME plus and RME only, and then were directed to additional questions related to their choice. Results: Respondents from 28 International Federation of Societies for Hand Therapy full-member countries completed the survey. RME users (N ¼ 368; 41.5% of sample) contributed to this secondary data. Respondents favored the RME variation “RME plus” (47%), followed by “both” (44%), then “RME only” (9%) with most managing single digit/simple injuries (n ¼ 287, 81%) versus multiple digit/complex injuries (n ¼ 96, 27%), and partial repairs (n ¼ 278, 79%). Discussion: Practices not aligning with limited level II-IV evidence includes half of RME only users not adding/substituting an overnight orthosis; use of RME plus versus RME only for both repairs of independent extensor tendons and repairs proximal to the juncturae tendinum; fabrication of three not fourfinger orthotic design; and restricting use to only repairs of one or two fingers. Conclusions: RME plus and RME only are used interchangeably depending on surgeon preferences and patient/tendon factors. Compared with RME plus, from this survey, it appears that the RME only approach yields similar uncomplicated, early return of motion and hand function. Ó 2020 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.

Keywords: Extensor tendon Hand therapy Relative motion Orthosis Splint Survey

Introduction and purpose

Conflicts of interest: None. * Corresponding author. Occupational Therapy Department, Austin Health, 145 Studley Rd, Heidelberg VIC 3084, Australia. E-mail address: [email protected] (M.J. Hirth).

Approaches available to hand therapists for management of zones V and VI extensor tendon repairs include early active motion (EAM) using a relative motion orthosis, a resting hand orthosis or a resting hand orthosis with the interphalangeal (IP) joints free, early

0894-1130/$ e see front matter Ó 2020 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jht.2019.12.016

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passive motion (EPM) with a dynamic orthosis, or immobilization with a resting hand orthosis.1-3 Early motion programs provide better outcomes than immobilization4 with evidence suggesting the relative motion extension (RME) approach has some benefits over other EAM approaches including sooner recovery of hand function, total active motion, and orthotic satisfaction.5 Although the RME finger orthosis combined with a wrist orthosis (RME plus) for management of extensor tendon repairs with EAM has been in the literature for nearly 40 years,6 controlled studies over the past 10 years used only the RME finger orthosis (RME only) for zone V-VI reporting comparable outcomes.5,7,8 Before this survey being completed, the extent of RME approach use was unknown, as were the use of (and reasons for) variations of RME. To pursue answers to these questions, an international survey of therapists belonging to 28 International Federation of Societies for Hand Therapy (IFSHT) full-member countries identified early active motion (EAM) delivered by RME orthoses as their “most used” approach in the previous 12 months after repair of zones V and VI finger extensor tendons.9 Our intent in this article is to take a closer look at the RME orthosis/EAM approach practice patterns that emerged from this survey as secondary data which have not been previously presented. Of particular interest is the way in which RME plus (with a wrist orthosis) and RME only are being successfully integrated into practice by therapists and consider how these practices align with the evidence. Methods After ethical review and approval (Monash University Human Research Ethics Committee, Victoria, Australia, approval number 13583), a closed self-reported electronic survey (Qualtrics, Provo, UT) was distributed to the participating full-member countries of the IFSHT.9 Functionality and field testing for content relevance and utility of the survey was tested before dissemination. Twenty-three experienced hand therapy colleagues (occupational therapists and physical therapists) in Australia (n ¼ 12) and the United States of America (n ¼ 11) provided feedback resulting in minor word and phrase revisions to clarify questions. The final survey consisted of both closed (force choice) and open-ended (free text) questions.10 The IFSHT representative for each country was contacted via email up to three times by the primary author (MH) to invite membership participation in the survey. A copy of the survey for review and a permission to participate form was provided to each contact requesting a reply of consent and the number of therapists on their email database. Contact details for unanswered emails were checked with the Secretary General of the IFSHT. The organizations that accepted our invitation emailed members of their database to request their participation in the survey of postoperative management of extensor tendons in finger zones V and VI, with a second reminder email a few weeks later.9 Outlined in the email to potential participants was the purpose of the study, consent details relating to voluntary participation, and the survey link. To meet survey inclusion criteria, the therapist had to have managed at least one extensor tendon repair in the previous 12 months. After completion of demographic questions, therapists were asked to select their “most used” approach in the previous year. Available choices were five combinations of orthosis and motion: resting hand orthosis, interphalangeal joints (IPJs) included [immobilization]; resting hand orthosis, IPJs included [early active motion]; palmar resting orthosis, IPJs-free [early active motion]; dynamic orthosis [early controlled or early passive motion]; and relative motion extension (RME) orthosis [early active motion].1-3 After selection of an approach (orthosis/motion program), respondents were directed via use of adaptive questioning with

Fig. 1. RME plus orthosis/EAM approach. RME ¼ relative motion extension; EAM ¼ early active motion.

branches, skip logics, and display logics to questions on their “most used” approach in clinical practice for comparison with alternate approaches.9 Whenever RME orthoses/EAM was selected as the “most used” approach, additional questions about the two different RME orthoses, RME plus (Fig. 1) and RME only (Fig. 2) used to deliver EAM were asked and are presented in this article (see Appendix 1).9 We used guidelines by Jones et al10 to plan and administer the survey which included consideration of 12 identified principles, such as using short unambiguous questions and allowing space for voluntary additional comments, along with field testing of the developed survey. “The Checklist for Reporting Results of Internet E-Surveys” (CHERRIES) document was used as a guide to report relevant and pertinent information in this article including recruitment and survey administration, response rates, and analysis.11 To compare survey practice results with the literature, a systematic database search was conducted using MEDLINE, Embase, EmCare, PubMed, CINAHL Plus, and the Cochrane Library, which included the search terms: hand inju*, tendon injur*, splint, splints, relative motion, yoke, bridge splint, Merritt, immediate controlled active motion, orthotic device, orthotic, and orthosis/es. The primary criterion for inclusion was published zones V and/or VI extensor tendon repair studies with measured outcomes that utilized the RME approach. To elicit best practice from the available literature, we examined final patient outcomes, including how the RME plus or RME only orthoses were applied, the RME orthotic

Fig. 2. RME only orthosis/EAM approach. RME ¼ relative motion extension; EAM ¼ early active motion.

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Table 1 RME-user demographics, professional experience, and credentials (n ¼ 368a) Gender Female

Male

Prefer not to say

Other

326 (89%)

42 (11%)

0

0

Age (y) 20-29

30-39

40-49

50-59

60+

34 (9%)

123 (34%)

99 (27%)

78 (21%)

34 (9%)

Number of years practicing in hand therapy specialty <1

1-4

5-9

10-14

15-19

20+

7 (<1%)

114 (13%)

181 (21%)

157 (18%)

145 (17%)

264 (30%)

5-9

10-14

15-19

Number of years working as a rehabilitation professional <1 1 (<1%)

1-4 24 (7%)

56 (15%)

66 (18%)

62 (17%)

20+ 155 (43%)

Rehabilitation discipline (select ALL that apply) Occupational therapy

Physical therapy

Other

264 (72%)

99 (27%)

3 (1%)

Do you have added specific credentials in hand therapy? Yes

No

214 (59%)

146 (41%)

If yes, hand therapy credentials (select ALL that apply) (n ¼ 214) Accredited hand therapist

Certified hand therapist

Other

57 (27%)

167 (77%)

19 (9%)

a

Total does not always add to 368 as responses to these questions were not mandatory.

design used, the number of injured digits versus tendons repaired, and the zone of injury managed. Results Survey results Participants For this article, only the secondary data (obtained from the larger one Web-based survey) from a subgroup of identified RME orthosis/EAM approach users were analyzed.9 Data were collected starting on the 3rd of July 2018 and closed on the 11th February 2019.9 The survey was sent to 8892 therapists by 28 IFSHT fullmember national organizations with a total of 997 therapists responding and 887 therapists satisfying the requirement of managing one or more zone V-VI extensor tendon repairs in the previous year.9 The survey was completed by 722 therapist for an 81% completion and 11% response rates. This response rate was similar to a flexor tendon study12 conducted with the American Society for Surgery of the Hand members that recorded 15%, and lower than the 25% response rate of the American Society of Hand Therapists members surveyed on their practice patterns for carpal tunnel syndrome.13 The subgroup group who selected RME orthosis/EAM as their “most used” approach in the previous year consisted of 368/887 therapists from the full survey. As shown in Table 1, 80% were English-speaking, mostly female (89%), and 264 were occupational therapists, 99 physical therapists, and 3 “other”. Therapists from 21 countries selected RME as their most used approach in the past year (see Table 2), with most (84%) managing more than three patients with extensor tendon repairs in the previous year (see Fig. 3). Nearly all were experienced hand therapy clinicians with at least five or more years of experience and 60% of these had 10 or more years of hand therapy experience (see Fig. 4). Sixty percent of this subgroup had added hand therapy credentials such as accreditation or

certification (see Fig. 5). The demographics of this RME-user subgroup was identified to be representative of both the demographics found in the larger survey data set9 and the IFSHT 2014 membership survey report https://www.ifsht.org/page/ifsht-reports. Findings from the full survey: A summary of the RME orthosis/EAM approach responses Skill level ratings by respondents indicated that a RME finger orthosis can be custom fabricated using readily available low-cost thermoplastic material by therapists with a skill level of 5.5/10 RME only and 6/10 RME plus (0 ¼ entry level skill, 10 ¼ advanced skills) in 20 min or less. The perceived advantages of the RME orthosis/EAM approach over the other choices (EAM, early passive (EPM) and immobilization) were that RME can be used for most patients, allows earlier functional hand use, and opens the possibility of earlier return to work secondary to the orthosis' small size and low-profile design. Reported outcomes for recovery of total active motion (TAM) aligned with estimates for other EAM/EPM/immobilization approaches, with most reporting “good” and “excellent” results; however, those managed by either RME orthosis/EAM approaches were perceived to achieve motion and function earlier and yield more “excellent” TAM outcomes. In keeping with other EAM approaches, most premorbidly employed patients eventually returned to work; however, respondents estimated that those managed with RME orthoses returned earlier and had little need for secondary surgeries.9 Practice patterns of therapists who predominantly use the RME orthosis/EAM approach RME/EAM approach selection. When 353 therapist users of the RME orthosis/EAM approaches were asked to select which approach they had used most in the previous year for extensor tendon zones V and VI, results were about equal for RME plus (47%, n ¼ 166) and “both” RME plus and only (44%, n ¼ 154); a minority used RME only

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Table 2 Countries (Hand Therapy Association/Society membership) with respondents using the RME orthosis / EAM approach

Countries (Hand Therapy Association/Society membership) with respondents using the RME orthosis / EAM approach Asia Hong Kongd1 Europe Austriad2 Belgiumd1 Denmarkd2 Germanyd1 Irelandd6 The Netherlandsd36 Norwayd2 Spaind1 Swedend1 Switzerlandd14 United Kingdomd37

North America Canadad22 United Statesd114 South America Argentinad3 Brazild5 Columbiad1 Sub-Sahara Africa Kenyad1 South Africad3 Australia, Oceania Australiad90 New Zealandd25

RME ¼ relative motion extension; EAM ¼ early active motion

(9%, n ¼ 33) (see Fig. 6). Those using “both” RME approaches interchangeably were then asked to select the orthosis they used most over the previous six months, with more than two-thirds selecting RME plus (67%, n ¼ 96), and one-third selecting RME only (33%, n ¼ 47).

The most common reasons given of the 146 therapist responses for interchangeably using the RME approaches were to be able to accommodate hand surgeon requests (36%) and to support their practice of patient-centered management. In selecting “both”, therapists gave themselves the option to selectively add the wrist component to protect repairs located proximal to the juncturae tendinum (40%), or in distal zone VI (20%), or when extensor indicis

Fig. 3. RME users: Number of zones V and VI extensor tendon repairs managed in the previous 12 mo (N ¼ 368). RME ¼ relative motion extension.

Fig. 4. Number of years practicing in hand therapy (N ¼ 366).

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Fig. 5. Added credentials in hand therapy (N ¼ 360). AHT ¼ accredited hand therapist; CHT ¼ certified hand therapist.

proprius (EIP) (17%) or extensor digiti minimi (EDM) (16%) repairs were involved, or to provide additional protection at work (62%), or for patients who were less likely to adhere to advice (56%), and address patient comfort requirements (32%) (see Table 3). When RME plus users were asked if they would consider using the RME only approach, one-half of the 165 responders said “maybe”, approximately one-third said “yes”, and one-sixth said “no” (see Table 4). The primary reasons given by the RME plus users for not using RME only were preference for RME plus (59%) by the hand surgeon or other medical staff, preference of the therapy department for RME plus (36%), lack of evidence supporting RME only (33%), preference of the individual (therapist) for RME plus (22%), and not knowing about the RME only approach (17%).

followed by zone VI (n ¼ 290, 82%), zone IV (n ¼ 194, 55%), and zone VII (n ¼ 164, 46%) (see Table 5). RME orthosis/EAM approaches were used most for single finger repairs (n ¼ 287, 81%) with fewer therapists using the RME orthosis when up to 3 fingers were involved (n ¼ 96, 27%). When asked about use with the independent finger extensors, more than half of the users managed EIP (n ¼ 202, 57%) and EDM (n ¼ 190, 54%) with RME orthoses. Therapists also reported using RME orthoses with partial and complete tendon lacerations with equal distribution between partial (n ¼ 278, 79%) and complete (n ¼ 279, 79%). The least frequent use of the RME orthosis/EAM approach was for complex injuries (n ¼ 71, 20%) or when all four fingers were involved (n ¼ 352, 5%) (see Table 5).

Tendon-related factors. For the 353 respondents who postoperatively used any variation of the RME orthosis/EAM approach, management of zone V was the most common (n ¼ 344, 97%),

Patient-related factors. A minority of respondents (13%) reported using an RME orthosis/EAM approach for all patients, whereas others were hesitant to use this approach for patients believed to be

Fig. 6. Current use of RME during the phase of orthosis wear (For questions asked see Appendix 1).

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Table 3 Use both RME only and RME plus approaches (for question asked see Appendix 1). I select either the “RME finger orthosis plus wrist orthosis” or “RME finger orthosis only” approach because of the following reasons: (n ¼ 146) Transitioning to RME only 17 (12%) Distal zone VI, I use RME + wrist 29 (20%)

Therapy department is transitioning to RME only 9 (6%) Proximal to juncturae tendinum, I use RME + wrist 59 (40%)

Surgeon makes the decision

EIP repairs, I use RME + wrist

53 (36%) For more protection at work I may use RME + wrist 90 (62%)

25 (17%) For patient comfort, I may use RME + wrist 47 (32%)

EDM repairs, I use RME + wrist 24 (16%) For less adherent patients, I may use RME + wrist 82 (56%)

Zone VI, I use RME + wrist 43 (29%) Other 16 (11%)

When you use the “RME finger plus wrist orthosis” approach do you routinely add any other orthoses? (n ¼ 138) I do not add any other orthoses 76 (55%)

A resting hand orthosis with IP joints included, overnight 33 (24%)

A resting hand orthosis with IP joints included, if lag develops 43 (31%)

A resting hand orthosis with IP joints included, for comfort 14 (10%)

Other 4 (3%)

When you use the “RME finger orthosis only” approach do you routinely add any other orthoses? (n ¼ 141) I do not add any other orthoses 43 (30%)

Wrist orthosis overnight 30 (9%)

Wrist orthosis if a lag develops 23 (16%)

Wrist orthosis for comfort 22 (16%)

Resting hand orthosis overnight 43 (30%)

Resting hand orthosis if lag develops 41 (29%)

Other 6 (4%)

RME only ¼ relative motion extension orthosis; RME plus ¼ RME orthosis plus wrist orthosis; IP joints ¼ Interphalangeal joints; EIP ¼ extensor indicis proprius; EDM ¼ extensor digiti minimi.

less adherent (27%, n ¼ 94), younger than 18 years of age (8%, n ¼ 28), or with accompanying connective tissue diseases (13%, n ¼ 45) (see Table 5).

Orthosis details Degree of relative motion extension and wrist position. Most respondents indicated that the relative difference in extension of the involved metacarpophalangeal joints (MCPJs) was 15 to 20 (RME plus 79% of n ¼ 259, RME only 70% of n ¼ 80) (see Figs. 7A and 7B). For 259 respondents, the position of the wrist when using RME plus was nearly evenly split between 30 extension (47%) and 15 extension (43%), with some therapists electing to substitute a prefabricated brace for a custom wrist orthosis (see Fig. 8).

Additional orthoses used with the RME approaches RME plus users. When asked if RME plus orthosis/EAM approach was supplemented with another orthosis, most respondents said 'no' (n ¼ 108/155, 70%). Less than twenty percent of RME plus users added an overnight resting hand orthosis (n ¼ 21, 14%) or a resting hand orthosis to manage extensor lag (n ¼ 30, 19%) (see Table 4). RME only users. Nearly half of the 32 RME only responders (n ¼ 15, 47%) did not add an orthosis. Therapists who questioned the patient's adherence used an overnight resting hand orthosis (n ¼ 10, 31%) or a wrist orthosis (n ¼ 9, 28%) (see Table 6). A few RME only users added a wrist orthosis overnight (n ¼ 3, 9%), or for injuries proximal to the juncturae tendinum (n ¼ 3, 9%). RME plus and RME only dual users. One hundred and forty-six respondents used “both” RME plus and RME only approaches. When the dual users chose RME plus, over half (n ¼ 76, 55%) did not supplement with another orthosis. Some added a resting hand orthosis if a lag developed (n ¼ 43, 31%) or for overnight (n ¼ 33, 24%). When this group implemented RME only, 30% (n ¼ 43) did not add another orthosis, 30% (n ¼ 43) added a resting hand orthosis overnight, and 29% (n ¼ 41) if a lag developed (see Table 3).

Orthosis design: 3- versus 4-finger design. There was a slight disparity between those who designed the RME orthosis to include three (61%, n ¼ 216) or four fingers (53%, n ¼ 188) (see Table 5). Fingers included in the design. When either border digit (index or small finger) was repaired, preference was nearly equal for a “balanced” (52%, n ¼ 181) or “unbalanced” design (49%, n ¼ 172). Most positioned only the involved fingers in relative MCPJ extension, with 11% (n ¼ 40) also including a finger adjacent to the injured finger in relative MCPJ extension (see Table 5 and Figs. 9A and 9B). Orthotic materials used. Thermoplastic materials (68%, n ¼ 239) were used over soft materials (<1%, n ¼ 1) to fabricate the RME orthosis, and 22% of respondents (n ¼ 76) used both materials (see Table 5). Most RME plus users custom fabricated the wrist orthosis (87% of n ¼ 259) rather than using a prefabricated wrist orthosis.

Composite wrist and finger motion in the orthosis. Most RME only approach users (77% of n ¼ 79) advised patients to avoid composite wrist and finger flexion during the phase of full-time orthosis wear.

Table 4 RME orthosis plus wrist orthosis (RME plus) program (for questions asked, see Appendix 1) Do you add any orthoses to the RME plus wrist orthoses approach? (n ¼ 155) I do not add any other orthoses 108 (70%)

A resting hand orthosis with IP joints included, overnight 21 (14%)

A resting hand orthosis with IP joints included, if lag develops 30 (19%)

A resting hand orthosis with IP joints included, for comfort 8 (5%)

Other 4 (3%)

Would you consider an RME only approach? (n ¼ 165) YES 52 (32%)

NO 30 (18%)

MAYBE 83 (50%)

Reasons not using an RME only approach: (n ¼ 165) Surgeon or medical staff prefer another approach 97 (59%)

Therapy department prefers another approach 36 (22%)

Lack of evidence 55 (33%)

Prefer the RME + wrist orthosis program/approach 59 (36%)

Did not know about the RME finger orthosis only approach 82 (17%)

RME only ¼ relative motion extension orthosis; RME plus ¼ RME orthosis plus wrist orthosis; IP joints ¼ interphalangeal joints.

Other 23 (14%)

Table 5 RME approach usage (for questions asked, see Appendix 1) When do therapists use a RME/EAM approach? (select all that apply): (n ¼ 353) Zone Zone Zone Zone

IV repairs V repairs VI repairs VII repairs

194 344 290 164

55% 97% 82% 46%

Single tendon repairs Repairs in up to 3 digits Partial lacerations Complete lacerations

287 96 278 279

81% 27% 79% 79%

Complex injuries EIP repairs EDM repairs All patients

71 202 190 46

20% 57% 54% 13%

All except <18 years All except connective tissue Only with adherent patients Othera

28 45 94 26

8% 13% 27% 7%

ALL choices that reflect usual usage of RME: (n ¼ 351) 4-Finger orthosis design 3-Finger orthosis design

188 53% 216 61%

Balanced design Unbalanced design

181 52% 172 49%

Injured plus adjacent in ext. I only use thermoplastics

40 11% 239 68%

1 <1% 76 22%

I only use soft materials I use both hard & soft materials

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Balanced design: for index or small finger injuries, both are included in extension in the orthosis to protect either the injured index or small finger. Unbalanced design: for index or small finger injuries, only the injured finger is in extension in the orthosis. RME ¼ relative motion extension orthosis; EIP ¼ extensor indicis proprius; EDM ¼ extensor digiti minimi; ext ¼ extension. a Other: 26 responses, 8 of which were tendon repairs of up to 2 tendons.

Table 6 RME only program (For questions asked see Appendix 1) Do you add any orthoses to the RME only/EAM approach? (n ¼ 32) I do not add any other orthoses A resting hand orthosis with IP joints included, overnight 15 (47%) Wrist orthosis for EIP repairs 0

10 (31%) Wrist orthosis for EDM repairs

A resting hand orthosis with IP joints included, if lag develops 0 Wrist orthosis for zone VI

0

0

A resting hand orthosis with IP joints included, for comfort 1 (3%) Wrist orthosis for proximal zone VI 0

Wrist orthosis overnight

Wrist orthosis if a lag develops

Wrist orthosis for comfort

3 (9%) Wrist orthosis for proximal to the juncturae tendinum 3 (9%)

1 (3%) Wrist orthosis if patient adherence is questionable 9 (28%)

0 Other 2 (6%)

RME only ¼ relative motion extension orthosis; IP joints ¼ interphalangeal joints; EIP ¼ extensor indicis proprius; EDM ¼ extensor digiti minimi.

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Fig. 7. The amount of relative difference in MCP joint extension between the involved and uninvolved adjacent fingers. (A) RME plus n ¼ 259, (B) RME only n ¼ 80. MCPJ ¼ metacarpophalangeal joint; RME ¼ relative motion extension.

Literature search results The search strategy identified 4241 nonduplicate references as presented in the PRISMA flowchart in Figure 10. After screening, 34 articles were reviewed, with six meeting our inclusion criteria. The Oxford 2011 Levels of Evidence ratings14 revealed no level I, one level II, one level III, and four level IV studies, and included 201 zone V, 34 zone VI, and 2 zone V/VI repairs. Data extracted (see Table 7) to form the basis for current best practice included the RME plus approach in three studies6,8,16 and the RME only approach in four studies.5,7,8,17 Three studies implemented an overnight wrist-handfinger orthosis,5,7,16 whereas one study added a wrist-hand orthosis for repairs proximal to the juncturae tendinum and for extensor digiti minimi (EDM repairs).8 No tendon ruptures were reported in any study, and authors reported “excellent” and “good” range of motion outcomes for most patients.5-8,16,17 Discussion Findings from the full survey demonstrated similarity in the RME plus and RME only approaches with very little difference in reported TAM on discharge, satisfaction, or the patient's ability to return to preinjury work capacity, and tendon rupture.9 Perceived advantages of the RME only approach were the need for less materials and time to fabricate, and slightly better functional hand use

than RME plus.9 The following discussion pertains to analysis of the secondary data obtained from RME users' answers to our specific questions regarding their use of RME orthoses/EAM approaches. Alignment of practice patterns and evidence Although gray literature has been identified,18 we elected to include only peer-reviewed published data to ensure rigorous detail to the methodology, along with complete quantitative outcome data, to elicit best practice and provide a comparison for survey responses. The early published studies using RME/EAM approaches for extensor tendon zones V and VI included a wrist component (RME plus);6,19,20 however, recent studies have eliminated the wrist component (RME only).5,7,8 In practice, for those who used “both” RME orthoses/EAM approaches interchangeably, tendon and patient factors were taken into consideration when deciding whether to use the wrist component, whereas half of RME only users chose not to supplement with any other orthoses. The evidence5,7,8,17 and therapists' responses to this survey suggest that the wrist component may not be necessary. In other words, survey responses suggest that it is quite possible that all zone V and VI injuries could be safely managed using the RME only orthosis. Four studies have investigated the use of RME only orthoses for zones V and VI extensor tendon repair all reporting no tendon

Fig. 8. The amount of wrist extension for users of RME plus (n ¼ 259). RME ¼ relative motion extension.

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Fig. 9. (A) “Balanced” RME design, both index and small finger in relative MCP joint extension to protect an injured index or small finger (B) “Unbalanced” RME design, only the injured index or small finger in relative extension.

ruptures and good/excellent range of motion outcomes.4,5,7,8 Hirth et al,7 a retrospective study in Australia involving 23 participants, and Collocott et al,5 a prospective study in New Zealand involving 21 participants, both added a night resting hand orthosis and advised RME only participants to avoid composite wrist and finger flexion. Hirth compared the RME approach with immobilization7 and Collocott with EAM with a resting hand orthosis with IPJs free.5 A prospective Australian study by Svens et al8 (n ¼ 63), added a wrist orthosis for repairs proximal to the juncturae tendinum for both of their RME intervention groups, with the variant between treatment groups the duration of orthosis wear. In the United States, Burns et al17 reported retrospective data on two zone V case studies managed by the RME only approach without additions or restrictions. After looking more closely at these four studies with a total of 109 participants, there are only 14 zone V cases (Svens et al,8 n ¼ 12; Burns et al,17 n ¼ 2) managed with RME only orthoses without imposed limitations or additions such as an overnight resting hand orthosis.

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Practice patterns found in this survey show that the wrist orthosis (RME plus) for EIP and EDM zone V-VI repairs is used by less than 20% of the RME users with most electing to use the RME only approach for these repairs. The literature reveals limited evidence, however, for this practice. Two studies demonstrated no complications with use of RME only for five EIP repairs in the study by Hirth et al,7 and in the study by Collocott et al,5 eight index and six small finger repairs, although exactly which tendons (EDC and/ or EDM) were involved in the latter study is unknown. By contrast, the study by Sven's et al8 utilizing the RME only approach was more cautious, adding a wrist component for EDM repairs. When a zone VI repair was proximal to the juncturae tendinum Svens et al's8 protocol required the addition of the wrist component to the RME orthosis, and this practice was observed in some of those surveyed. We suspect the reasoning for this is based on the opinion of Thomas et al21 who suggested that repairs proximal to juncturae tendinum in zone VI would be tensioned with finger flexion, so these authors recommended incorporation of Frere's three-finger rule into a forearm based wrist-hand-finger orthosis to limit the possibility of repair attenuation or rupture. Bottom line: Use a wrist orthosis or not? Survey practices suggest that RME only is being used for zones V and VI repairs with modifications. There is very limited clinical trial evidence for RME only in zone VI without these modifications, or for EIP and EDM repairs, so the rationale for the wrist orthosis when zone VI repairs are proximal to JT, or involve the EIP or EDM is likely to be precautionary.5,7,8,17 To date, two clinical studies have shown RME plus safely protects zone VI, and repairs of the independent extensors.6,8 Howell et al,6 in the United States, reported retrospective data of an RME plus cohort of 140 patients in zones IV-VII, including nine patients with repairs in zone VI and repairs to the index and small fingers accounted for 35% and 10%, respectively, of their population. Svens et al8 included a wrist orthosis for their zone VI (n ¼ 17) and EDM tendon repairs (n ¼ 11 for small finger

Fig. 10. PRISMA flowchart of search results.

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Table 7 Relative motion extension programs best practice as presented in the literature for zones V and/or VI extensor tendon repair Injuries included

RME approach sample populations in zones V-VI

Research approach/Level of evidence

Program details

Orthoses used

Orthotic design

Outcomes

Howell et al, 20056

Zones IV-VII ET

Zone V: 112 Zone VI: 9 89 simple & 51, complex injuries Unable to determine fingers injured for zones V-VI

Retrospective cohort Level IV evidence

3 wk RME plus (full-time); then RME only (full-time) an additional 2 wk, adding WHO for heavy tasks; Cease RME only between 5 and 7 wk.

RME plus (day and overnight)

4-Finger thermoplastic Relative MCP extension 15 -20 WHO wrist extension 20 -25

Data presented for zones IV-VII (140 patients): No tendon ruptures

Zone V: 21 Zone VI: 2 Single digit tendon repairs Index: 8 Long: 10 Ring: 3 Small: 2 EIP/EDC ¼ 5 EDM ¼ 0 Capsular repair ¼ 12 Zone V: 2 Single digit tendon repairs Long: 2

Retrospective cohort Level IV evidence

4 wk (full-time) RME only and overnight WHFO. RME only wear for heavy activities an added 2 wk. Advicedavoid composite wrist and finger flexion.

RME only (d), overnight WHFO

4-Finger thermoplastic Relative MCP extension 15 -20 Overnight WHFO wrist extension 30 ; MCPJs 30 flexion; IPJs neutral

Retrospective case reports Level IV evidence

RME only (day and overnight)

4-Finger thermoplastic Relative MCP extension 10 -15

Zone V: 5 Five tendon repairs in 4 patients Index: 1 Long: 2 Ring: 2

Retrospective cohort Level IV evidence

4 wk (full-time) RME only wear. Advicedno heavy lifting or heavy use with the injured hand. No passive stretch before 6 wk. 3 wk RME plus (full-time); then RME only (full-time) for an additional 2 wk, adding WHO for heavy tasks; cease RME only between 5 and 7 wk Overnight WHFO initial 6 wk

RME plus (d), overnight WHFO

4-Finger thermoplastic Relative MCP extension 15 Wrist extension 20 -25 Overnight WHFO wrist neutral; fingers extended

Burns et al, 201317

Zone V ET

Altobelli et al, 201316

Zone IV-V ET & thumb TI-TIV

No tendon ruptures TAM: 2 “excellent” Grip strength: 99% of contralateral case 1; no data case 2 No tendon ruptures No secondary surgeries Miller's15 extension and flexion criteria Index: 1 “excellent”; and 1 “good” Long: 1 “excellent”; and 1 “good” Ring: 2 “excellent” one result was for a zone IV repair, the other a zone V repair, details per zone was not provided

ˇ

Zones V-VI ET

ˇ

Hirth et al, 20117

Miller's15 criteria: Extension lossd114 “excellent”; 21 “good”; and 5 “fair” Flexion lossd111 “excellent”; 20 “good” and 9 “fair” Grip strength: 85% of contralateral Discharge: Average 49 d RTW: Average 18 d Therapy visits: Average 8.1 No tendon ruptures TAM % at 12 wk: 18 “excellent”; and 5 “good” RTW: mean 3.33 wk RTW full duty: mean 7.72 wk

M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e13

Author

Svens et al, 20158

Zones IV-VI

Zone V: 47 Zone VI: 17 Total patients#-Group 1:45 Group 2: 18 Three patients had two fingers injured, remaining patients single digit injuries Unable to determine fingers injured for zones V-VI# Index: 31 Long: 17 Ring: 8 Small: 11 #

includes 3 zone IV repairs

Zone V: 14 Zone VI: 6 Zones V þ VI:2 22 tendon repairs in 21 patients Index: 8 Long: 5 Ring: 3 Small: 6

Prospective RCT Level II evidence

Group 1: 3 wk RME plus; 3-4 wk wean from WHO Advicedavoid use of hand initial 3 wk Group 2: 3 wk RME only or RME plus. 3-4 wk RME plus wean from WHO. Advicedboth groups between 3 and 5 weeks- light hand use Group 1: 5-6 wk no WHO; wear RME only until full composite finger/wrist flexion attained Advicedokay to drive Group 1: 7-11 wk light to progressive hand use no orthosis 12þ wk no restrictions Group 2: 4-6 wk no extensor lag cease wearing any orthoses Advicedokay to drive 5 wkþ: no restrictions 4 wk RME only full-time; cease RME only for light tasks at 4 wk; wear RME only for progressive moderate to heavy tasks between 4 and 8 wk Cease RME only 8 wk 6 wk wear overnight WHFO Advicedavoid composite wrist and finger flexion initial 6 wk Begin composite wrist and finger flexion after 6 wk No driving initial 6 wk

RME only* (day and overnight) Or RME plus** (day and overnight) *Group 2 zones V-VI repairs distal to juncturae tendinum **Group 2 zone VI proximal and all EDM repairs and all group 1 zone V-VI repairs

4-Finger thermoplastic Relative MCP extension 15 -20 WHO wrist extension 20 -25

No tendon ruptures Group 1 and 2 data pooled for results^ Miller's15 extension lag n ¼ 44: 16 “excellent”; 17 “good”; 10 “fair”; 1 “poor” Miller's15 flexion deficit n ¼ 44: 21 “excellent”; 17 “good”; 4 “fair”; 2 “poor” Grip strength: 83% of contralateral RTW: Modified duty mean 3.7 wk (n ¼ 31); full duty mean 6.2 wk (n ¼ 26) Therapy visits: mean 4.8 (varying 1-14) n ¼ 60 ^includes 3 zone IV repairs

RME only (day), overnight WHFO

4-Finger thermoplastic Relative MCP extension 15 -20 Overnight WHFO wrist 30 extension; MCPJs 30 flexion; IPJs neutral

No tendon ruptures TAM 8 wk: 5 “excellent”; 13 “good”; 1 “fair” Miller's15 extension lag: mean 3.1 ; 17 “excellent”; 2 “fair” Miller's15 flexion deficit mean: 15.2 ; 4 “excellent”; 10 “good”; 2 “fair”; 3 “poor” Grip strength: mean 35.2 Kg Therapy discharge: mean 8.8 wk Therapy visits: mean 5.6; SD 4.4

ET ¼ extensor tendon; RME ¼ relative motion extension; RTW ¼ return to work; WHFO ¼ wrist-hand-finger orthosis; WHO ¼ wrist-hand orthosis; EDM ¼ extensor digiti minimi; TAM ¼ total active motion; MCPJs ¼ metacarpophalangeal joints; IPJs ¼ interphalangeal joints; wk ¼ week(s); SD ¼ standard deviation.

M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e13

Collocott et al, 20195

Prospective cohort Level III evidence

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12

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injuries). It is possible in the future that hand surgeons could use active finger and wrist motion while using the Relative Motion Pencil Test during “Wide-Awake Local Anaesthesia No Tourniquet” (WALANT) surgery to directly observe tension on the tenorrhaphy to decide on a case-by-case basis when zone VI, EIP, or EDM repairs do or do not require a wrist orthosis.22,23 The RME only clinical trials reported by Hirth et al7 and Collocott et al5 included the use of a night resting orthosis, with the rationale of preventing accidental composite wrist and finger flexion during sleep, which might result in tendon gapping or rupture.5,7 By contrast, our survey results indicate that only a small percentage of therapists who used any RME orthosis/EAM approach added an overnight resting hand orthosis. Although, if an extensor lag developed, users of RME plus and “both” RME approaches were more likely to add a resting hand orthosis, than therapists using RME only. To protect zones V and VI extensor tendon repairs, the literature advises avoidance of active simultaneous composite wrist and finger flexion during the phase of full-time RME only orthotic wear.5,7 In keeping with this, survey respondents have largely passed this advice to patients, although it is unknown if the advice has prevented any tendon ruptures or attenuations. RME survey responders were more likely to implement the RME orthosis/EAM approach for simple or single digit injuries and less likely to use it for complex or up to three finger injuries, some suggesting that RME should only be used for injuries involving one or two fingers. The evidence has demonstrated that single finger zones V andVI extensor tendon repairs can be effectively managed with EAM delivered with RME plus or RME only.5-8,16,17 Only one study6 had three finger injuries included in their RME plus cohort, although the actual number of patients with three finger tendon repairs was not revealed. In this same study, the 51/140 complex injuries included those with more than one tendon repair, joint involvement, crush injury, repair delayed by five or more days, or injuries not repaired.6 Others have identified complex injuries to include a breach of the joint capsule7,8 and repairs to two finger.5,8,16 Because less than 10% of survey respondents use RME orthoses for patients younger than 18 years of age, it can be inferred to be a cautionary practice. On the other hand, children are not often included in clinical trials with adults; hence, a lack of representation in the RME literature may be influencing this practice pattern. There is, however, no evidence to suggest that adolescents and children who can dependably wear the orthosis should be excluded from this approach. Approximately one-third of the RME users did not use the RME orthosis/EAM approach when adherence may be in question. Adherence has not been specifically studied after extensor tenorrhaphy; however, the evidence informs us that adherence to wearing an orthosis can be influenced when the orthosis has a favorable appearance, is comfortable, does not contribute to pain, supports safe function, and allows for hand hygiene.24 Respondents in this survey suggest these are the qualities inherent in the RME orthoses which are simple low-profile designs which allow for earlier hand function and hand hygiene. Bottom line: Simple or complex? Supplement with other orthoses? RME in all variations is used in practice for EAM of single or simple repairs more than multiple digits and complex injuries, although all applications are supported by the limited evidence available. There is no evidence supporting the following practices: addition of a resting hand orthosis overnight or for extensor lags, and advice not to simultaneously make a fist and flex the wrist. In the future, investigation into the practice of supplementing with a resting hand orthosis overnight or for early extensor lags is warranted.

Alignment of orthotic details and evidence The amount of relative MCPJ extension used by RME plus and RME only users was similar with most using 15 to 20 difference between the repaired and adjacent MCPJs. There was no report that the effectiveness of this practice changed whether or not the wrist was immobile or moved freely, or if the injury was in zone V or VI; although the possibility of any relationship between wrist and MCPJ position has not been formally investigated as it specifically relates to RME.18 A small percentage of therapists reported including an adjacent finger with the injured finger(s) in the MCPJ relatively extended orthotic position. We are not aware of this being formally tested in clinical trials, but Thomas et al21 recommended the Frere's three-finger rule whereby the adjacent finger was either included in the orthosis or buddy taped to the repaired finger for repairs proximal to the juncturae tendinum in tandem with wrist immobilization.21 The practice of survey participants using a three-finger RME orthosis slightly more often than a four-finger RME orthosis is new, and differs from the RME evidence which used four-finger RME orthoses.18 Only two authors have detailed use of a “balanced”6 or “unbalanced” orthotic design,7 with survey respondents using these designs almost evenly. When asked about the use of “soft” or thermoplastic materials for fabrication of RME orthoses, given that there have been no clinical studies that have used “soft” materials, current practices differed with a quarter of participants indicating they use both “soft” and rigid thermoplastic materials.5-8,16,17 Bottom line: Best orthotic design? Current practice aligns with clinical studies in that 15 to 20 of relative MCPJ extension difference in RME orthoses fabricated from rigid thermoplastic material is the standard. There is no evidence describing how the use of a three- or four-finger RME orthosis design or inclusion of the repaired and adjacent digit in the RME orthosis affects the mechanics of relative motion. In the future, zone VI investigations in particular may determine if a change in orthotic design or the addition of the adjacent finger is important. Limitations The limitations cited in the full survey publication also can be applied to the subset of data presented in this article.9 Limitations previously cited and worth highlighting include availability of the survey in English only, respondents were constituents of only those IFSHT full-member countries who agreed to participate, and participation was somewhat limited although comparable with other hand therapy/surgery surveys.12,13 Because the additional RME questions were asked only of those who said they preferred the RME approach, the information obtained is secondary data, and may not be representative of all therapists who use RME to manage zones V and VI extensor tendon repairs. On review of the secondary data, we found that phrasing of the survey questions/available responses could be improved to provide us with more complete information regarding the RME approach practices. Namely, the phrase “extensor lag” did not specify either the MCP or IP joints. When asked to select uses of the RME approach, respondents were given only two repair optionsd“single finger repairs” or “repairs in up to three fingers”. To better define use, we could have provided the option “repairs involving two fingers”, with some respondents mentioning this in open-text comments. Although the length of the survey was of concern, had we asked more about the zone of injury as well as how were these injuries managed with RME plus or RME only, these answers would have told us more about partial laceration practices as use of RME for

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incomplete tendon injuries is not in the literature. Another choice for describing their use of the RME approach was “complex injury”, which required each respondent to self-interpret. Had we provided a brief definition more precise practice information may have been obtained, as the RME literature varies in its use of the phrase “complex injury”.5-8,16 Finally, although the full survey was directed at the management of zones V and VI extensor tendon repairs, RMErelated secondary data found that RME users also use this approach for repairs mostly in zone IV and some zone VII. We were conscious of not making the survey too long, so missed the opportunity to gain further insight into global practices using the RME approach for these more proximal and distal extensor tendon zones. Conclusions Postoperatively, the RME orthosis/EAM approach is widely used in the management of extensor tendon repairs in zones V and VI. Two versions, RME plus and RME only, have been identified; apart from including or excluding the wrist component, survey results suggest that therapists are modifying the orthotic design and applications. While much was learned through an extensive relative motion scoping review, recent literature and this practice survey enlightens us further regarding the RME orthosis/EAM approach. This includes mounting evidence for the use of RME only after zones V and VI repairs and without the need for additional orthoses.18 Certainly the practice patterns from this survey have uncovered additional areas worthy of investigation. Acknowledgments The authors express their thanks to Lynne Feehan, BScPT, MSC, PhD, who contributed to the survey development and provided invaluable direction for manuscript preparation. The authors appreciated the therapists who took time to respond to the survey, through their insights, others will benefit. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.jht.2019.12.016. References 1. Ng CY, Chalmer J, Macdonald DJ, Mehta SS, Nuttall D, Watts AC. Rehabilitation regimens following surgical repair of extensor tendon injuries of the hand-a systematic review of controlled trials. J Hand Microsurg. 2012;4:65e73. 2. Sameem M, Wood T, Ignacy T, Thoma A, Strumas N. A systematic review of rehabilitation protocols after surgical repair of the extensor tendons in zones V-VIII of the hand. J Hand Ther. 2011;24:365e372. quiz 373. 3. Talsma E, de Haart M, Beelen A, Nollet F. The effect of mobilization on repaired extensor tendon injuries of the hand: a systematic review. Arch Phys Med Rehabil. 2008;89:2366e2372.

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4. Collocott SJ, Kelly E, Ellis RF. Optimal early active mobilisation protocol after extensor tendon repairs in zones V and VI: a systematic review of literature. Hand Ther. 2018;23:3e18. 5. Collocott SJF, Kelly E, Foster M, Myhr H, Wang A, Ellis RF. A randomized clinical trial comparing early active motion programs: earlier hand function, TAM, and orthotic satisfaction with a relative motion extension program for zones V and VI extensor tendon repairs. J Hand Ther. 2019. In press. 6. Howell JW, Merritt WH, Robinson SJ. Immediate controlled active motion following zone 4-7 extensor tendon repair. J Hand Ther. 2005;18:182e190. 7. Hirth MJ, Bennett K, Mah E, et al. Early return to work and improved range of motion with modified relative motion splinting: a retrospective comparison with immobilization splinting for zones V and VI extensor tendon repairs. Hand Ther. 2011;16:86e94. 8. Svens B, Ames E, Burford K, Caplash Y. Relative active motion programs following extensor tendon repair: a pilot study using a prospective cohort and evaluating outcomes following orthotic interventions. J Hand Ther. 2015;1:11e 19. 9. Hirth MJ, Howell JW, Feehan LM, Brown T, O’Brien L. Postoperative hand therapy management of zones V and VI extensor tendon repairs of the fingers: an international inquiry of current practice “Under Review”. J Hand Ther. 2019. In press. 10. Jones D, Story D, Clavisi O, Jones R, Peyton P. An introductory guide to survey research in anaesthesia. Anaesth Intensive Care. 2006;34:245e253. 11. Eysenbach G. Improving the quality of web surveys: the checklist for reporting results of internet E-surveys (CHERRIES). J Med Internet Res. 2004;6:e34. 12. Gibson PD, Sobol GL, Ahmed IH. Zone II flexor tendon repairs in the United States: trends in current management. J Hand Surg. 2017;42:e99ee108. 13. Parish R, Morgan C, Burnett CA, et al. Practice patterns in the conservative treatment of carpal tunnel syndrome: survey results from members of the American Society of Hand Therapy. J Hand Ther. 2019. In press. 14. Howick J, Chalmers I, Glasziou P, et al. The 2011 Oxford CEBM levels of evidence (Introductory Document). Oxford Centre for Evidence-Based Medicine. Available at: http://www.cebm.net/index.aspx?o¼5653. Accessed December 31, 2014. 15. Miller H. Repair of severed tendons of the hand and wrist; stastical analysis of 300 cases. Surg Gynecol Obstet. 1942;75:693e698. 16. Altobelli GG, Conneely S, Haufler C, Walsh M, Ruchel, Sman DE. Outcomes of digital zone IV and V and thumb zone TI to TIV extensor tendon repairs using a running interlocking horizontal mattress technique. J Hand Surg. 2013;38: 1079e1083. 17. Burns MC, Derby B, Neumeister MW. Wyndell merritt immediate controlled active motion (ICAM) protocol following extensor tendon repairs in zone IVVII: review of literature, orthosis design, and case study-a multimedia article. Hand. 2013;8:17e22. 18. Hirth MJ, Howell JW, O'Brien L. Relative motion orthoses in the management of various hand conditions: a scoping review. J Hand Ther. 2016;29: 405e432. 19. Merritt WH, Howell JW, Tune R, Saunders S, Hardy M. Achieving immediate active motion by using relative motion splinting after long extensor repair and sagittal band ruptures with tendon subluxation. Operat Tech Plastic Reconstr Surg. 2000;7:31e37. 20. Robinson SJ, Rosenblum NI, Merritt WH. A new splint design for immediate active motion following extensor tendon repair. In: Abstract presented at the Ninth Annual Meeting American Society of Hand Therapists. New Orleans, LA: American Society of Hand Therapists; 1986. 21. Thomas D, Moutet F, Guinard D. Postoperative management of extensor tendon repairs in zones V, VI, and VII. J Hand Ther. 1996;9:309e314. 22. Howell JW. Therapist's Corner - Relative Motion Flexion. American Association for Hand Surgery, Hand Association News; 2016. 23. Lalonde DH, Flewelling LA. Solving hand/finger pain Problems with the Pencil test and relative motion splinting. Plast Reconstr Surg Glob Open. 2017;5: e1537. 24. Sandford F, Barlow N, Lewis J. A study to examine patient adherence to wearing 24-hour forearm thermoplastic splints after tendon repairs. J Hand Ther. 2008;21:44e52. quiz 53.