An evaluation of early motion management following primary flexor tendon repair: Zones 1–3

C__S_C_'E_N_T_'F_'C_I_C_Ll_N_'C_A_L_A_R_T_'_CL_E_S_) An Evaluation of Early Motion Management Following Primary Flexor Tendon Repair: Zones 1-3 Ronald G. Stone, MS, OTRIl

Associate Professor, School of Occupationa1 and Physical Therapy, University of Puget Sound, Tacoma, Washington

Elizabeth L. Spencer, BS, OTR/l Director, Seattle Hand Rehabilitation Clinic, Seattle, Washington

Edward E. Almquist, MD

Seattle Hand Surgery Group; Clinical Professor of Orthopedic Surgery, University of Washington, Seattle, Washington

INTRODUCTION Advances in knowledge, surgical technique, and therapeutic intervention strategies during this century have resulted in improved functional outcomes for individuals with injury to the flexor tendons of the hand. As knowledge and clinical technique have advanced, many questions have been answered, but many more have been raised. For the hand therapi.st, it is still unclear (1) what type and how much exerCIse or activity is indicated for the patient with primary repair of the flexor tendons, (2) at precisely what point exercise and activity should be initiated or modified, (3) how frequently the patient should be seen during the rehabilitation phase, and (4) how factors related to the patient, the wound, or the surgical procedure affect the therapy program. This Adapted from a presentation at the Eleventh Annual Meeting of the American Society of Hand Therapists, September, 1988. The authors gratefully acknowledge the assistance of Allegra Andersen, MOT, Lori Lingle, BS, and Sherri Toft, BS, in data collection, and Thomas C. Aldrich, MS, Margo B. Holm, PhD, and George Tomlin, MA, MS, for statistical analysis. Reprint requests to Ronald G. Stone, MS, OTRlL, School of Occupational and Physical Therapy, University of Puget Sound, 1500 North Warner, Tacoma, WA 98416-0510

ABSTRACT: This study examined consecutive clinic charts for 95 patients with primary or delayed primary repair of traumatically severed flexor superficialis or profundus tendons without concomitant fractures or joint trauma, in digits 2-5, zones 1-3. Patient traits, wound characteristics, surgical variables, therapeutic programs, and intervention outcomes including rupture, need for tenolysis, and total active motion (TAM) were examined. The study included 117 injured fingers and 174 lacerated tendons. The average number of therapy visits was 8.6. The dorsal blocking splint was almost universally used in conjunction with a modified Duran approach. Outcomes of intervention included the following: 7% of patients required follow-up tenolysis; 4% of repaired tendons ruptured; mean TAM at discharge was 217°. MannWhitney U and one-way analysis of variance tests indicated that discharge TAM for injuries involving both tendons in a finger and injuries occurring in zone 2 were significantly lower than TAM for injuries involving only the profundus or occurring in zone 1. Pearson correlation identified independent variables that correlated with TAM. Further investigation of the effects of wound and intervention variables on outcome is warranted.

study was undertaken as part of an effort to establish functional results realized by patients of the Seattle Hand Rehabilitation Clinic (SHRC) who have undergone primary or delayed primary repair of flexor tendons to digits 2-5 in zones 1-3. A companion study examining the long-term outcomes of surgery and therapy will also be conducted. In recent years, demand has increased for health care providers to establish systems which will insure that the highest quality care feasible be provided in the most cost-effective manner. Professional organizations, such as the American Occupational Therapy Association and the American Physical Therapy Association, have supported this public mandate by establishing policies that require members to "periodically and systematically review the quality and appropriateness of total services delivered. "1 Quality assurance programs examine to what degree goals for both patients and programs are achieved. To date, neither the hand therapy literature nor the quality assurance literature contains a full report of a quality assurance study conducted in a hand therapy program.

FUNCTIONAL OUTCOMES A general goal of hand surgery and rehabilitation is to restore maximum function to the individual with dysfunction of the hand. Determining the extent of October-December 1989

223

functional restoration and identifying factors that affect restoration is complex because of the variety of diagnostic categories treated in most hand programs. Chai, Dimick, and Kasch2 identified 13 distinct diagnostic categories which are treated by hand therapists in the United States. Within the diagnostic category, "tendon disorders," identified by Chai et aI., additional classification is needed to improve the validity of outcome studies. Recent research 3 -5 supports the classification of tendon injuries based on the following factors: (1) whether the laceration site is within or lies outside a tendon sheath; (2) whether extrinsic blood supply has been disturbed; (3) the degree to which the tendon and other surrounding structures has been disrupted, and further, the extent to which such structures have been repaired; (4) the duration of time from injury to repair; and (5) the specific surgical procedure performed, such as primary repair, delayed primary repair, secondary repair, or graft. Other factors that are believed to affect functional outcomes include the following: 3 - 7 1. Wound characteristics encompassing (a) nature of the injury, including position of the hand at the time of injury, (b) cleanliness of the wound, and (c) tendon condition. 2. Surgical factors including (a) training and experience of the surgeon, (b) choice of materials and suture technique, (c) decision to repair or excise associated structures, and (d) choice of postoperative dressing and protocol. 3. Therapy factors including (a) training and experience of the therapist, (b) choice and timing of splints, (c) choice and timing of exercise and activity, (d) frequency and duration of treatment sessions, and (e) amount of patient education provided. 4. Patient traits including age, sex, occupation, compliance, and factors related to payment for services. In their extensive review of the literature, Rosenblum and Robinson 3 cite numerous tendon healing studies which indicate that differences in vascular anatomy, healing mechanism, and healing time exist between digital hand flexor tendons and digital hand extensor tendons. Further, evidence is presented that those portions of digital hand flexor tendons which lie within synovial sheath receive nutrients from synovial fluid. Factors that are directly linked to adhesion formation and tendon gliding limitations include (1) the preoperative condition of the tendon; (2) whether one or both tendons are injured, particularly in zone 2; and (3) the condition of structures which support or surround the tendon. Amadio, et al. 4 reporting on animal studies conducted by McDowell and others, note that adhesion-free healing consistently occurs when vincula to a lacerated flexor tendon remain intact, synovial sheath surrounding the tendon is intact, and motion is permitted during the postoperative stage. When freedom to move is withdrawn, or when structures such as vincula, sheath, or pulleys are not intact, limiting adhesions abound. Recent 224

JOURNAL OF HAND THERAPY

research 3 - 9 points to improved outcome expectations when meticulous, atraumatic surgical technique is used to repair the tendon and all accessory structures rather than ignoring or excising them. Literatu re Reports

The hand therapy literature contains many reports of research studies and papers discussing the rationale and techniques of postoperative management for individuals with flexor tendon injuries. 3 -14 Early controlled motion, which has become the accepted form of management, is directed at reducing adverse adhesion formation and hastening tendon tensile strength gains. Most early controlled motion programs are variations of the controlled active motion program (named for active extension of the digits) associated with Kleinert,5,6 or the controlled passive motion program (named for passive extension and flexion of the digits) associated with Duran. 6,12 Descriptions of these programs include recommendations for type of splint, duration of splint use, type of exercise, and timing of exercise changes. The need to instruct patients in self-exercise is noted, as both programs require exercise more than once daily. One report stated that one treatment session weekly should be adequate for the instructed, noncomplicated patient. 7 Of patient traits identified as potential contributors to treatment outcome, perhaps the least explored is gender. In a review of literature that covered 66 studies of patient compliance, Mayo15 found three studies which supported the hypothesis that women are more compliant with treatment programs than men. The hand therapy literature does not report the impact of gender on outcomes. Although not well studied in hand therapy programs, compliance has long been identified in other settings as a factor contributing to patient outcomes.I6 Ekes,17 in a survey of burn centers, found that therapists believed patients to be least compliant with range of motion exercises, splint use, and debridement. According to Chai et al. 2 these same three treatments are performed by 39-93% of hand therapists several times daily, and are considered by them to be "very important." BrandIS states that patients are most compliant when they believe that they hold the key to successful rehabilitation. His gentle admonition to surgeons and therapists is to foster that belief on the part of patients and to be humble. Many therapists believe that patient education is a prerequisite for patient compliance. BrandIS provides a rationale for patient education, and many authors make brief mention of the need for patient instruction. Schneider and McEntee 7 state that "educating the patient is a key part of the therapy process," attributing to the therapist the responsibility for informing the patient about the nature of the injury, the precautions that must be taken, and methods for preventing complications and achieving goals.

_For more than a century, it has been recognized that age plays a role in wound healing via its effects on connective tissue. 19 From Pickles'2o review of the effects of aging on connective tissue, it appears that age has the potential to affect tendon healing both directly and indirectly. The direct effect is related to differences between aged and youthful tendon composition. The indirect effect is related to changes in connective tissue of the vascular walls, which produce changes in tendon nutrition. Pickles also notes that with advancing age, fibrinogen exudation into tissue space increases. The increase in tissue fibrin may account in part for a greater problem with adhesions following flexor tendon repair in elderly individuals. Studies .reporting outcomes of primary flexor tendon repair and subsequent therapy9-11,21,22 differ in design and in method of reporting outcomes. Patient selection criteria vary widely or are not fully reported. Most outcomes are inconsistently reported, and those that are reported with some consistency often use incompatible measures. Rupture of a repaired tendon and adhesions that limit motion are generally considered to be unsatisfactory outcomes of primary tendon repair. Limited information about wound characteristics, surgical technique, the postoperative management employed, and patient characteristics, coupled with the lack of a standardized outcome reporting format, limit the usefulness of existing reports as bases for comparison.

Measurement Functional outcomes can be measured in a variety of ways. Occupational performance, the abilitY to perform usual tasks of daily living (self-maintenance, leisure, and work) to the patient's satisfaction, is perhaps the best measure of functional outcome from an occupational therapist's point of view. It is also the most difficult to determine in the current health delivery system because of the length of time required for proper assessment. The most commonly reported measure related to occupational performance is whether or when the patient is able to resume employment. Performance components, skills, and physical signs such as coordination, dexterity, strength, edema, sensation, and joint range of motion are commonly assessed in the hand therapy clinic. Coordination and dexterity can be measured with a variety of criterion-referenced or norm-referenced standardized tests such as the Purdue Pegboard, the Minnesota Rate of Manipulation Test, or the Crawford Small Parts Dexterity Test. 23 Strength in the hand is reliably tested with properly calibrated and properly used grip and pinch dynamometers. 24 Manual muscle testing is also used to measure strength. Edema of the hand is measured by volume displacement or circumferential measurement. 25 A variety of objective and subjective tests are used to assess sensory function, including sweat tests, Weber's two-point discrimination test, and Semmes-Weinstein monofilaments. 26

Joint range of motion has been functionally assessed by measuring the distance from finger pulp to distal palmar crease. Goniometric measures of individual joints that are taken by a single tester using a specific protocol have been found to be more reliable than measures taken by more than one tester or without specific protocol. 27 It is recommended that bilateral goniometric measures be taken so that the involved hand may be compared with the uninvolved hand. 28 It is also recommended that both active and passive measurement be made. 29 Total active motion (TAM) and total passive motion (TPM) measures are also suggested. 24,27,29 Another outcome of interest to the hand practitioner is the anatomical integrity of the injury site, for example, whether the repaired tendon ruptures or develops adhesions which limit function. The purpose of this study was to establish the degree to which functional outcomes have been realized by SHRC patients who had primary or delayed primary repair of traumatically lacerated flexor tendons in zones 1-3, digits 2-5, in the absence of concomitant fracture, joint trauma, or disease; and to establish which wound, surgery, therapy, and patient factors contributed to those outcomes.

METHOD All SHRC charts for patients treated 1980-1987 were examined in this retrospective chart review. Charts for 108 patients were found with the surgical diagnosis of primary or delayed primary flexor tendon repair to digits 2-5 without concomitant laceration of extensor tendons, laceration of thumb tendons, joint injury, fracture, partial laceration, rheumatic disease, or need for replantation. The - therapy chart and the surgery chart for each of the selected patients were simultaneously reviewed by an independent researcher. In order to improve validity, 13 charts were eliminated from the study because of insufficient surgical data. All surgery for the remaining 95 cases was performed by a member of the Seattle Hand Surgery Group (SHSG). The following data were collected using both the therapy and the surgery charts for each patient: 1. Patient data: (i!-} gender, (b) age, (c) occupation, (d) whether the injury was work-related, (e) dominant hand, and (f) therapist's assessment of patient compliance (to eliminate the possibility of therapist bias in cases where rupture occurred, only statements recorded prior to rupture date were recorded). 2. Wound data: (a) elapsed time, injury to surgery, (b) hand injured, (c) tendons injured by zone and digit, (d) tendon condition, (e) pulleys injured by digit, (f) sheath condition, (g) whether nerves were injured, and (h) whether the digital arteries were injured. 3. Surgical data: (a) year of surgery, (b) surgeon, (c) tendon suture technique, (d) whether the sheath was sutured, (e) whether injured pulleys were repaired, (f) whether injured nerve or artery was repaired, and (g) type of postoperative dressing applied. October-December 1989

225

21-28 days: Begin active flexion exercises with wrist blocked at 30°-60° flexion and Mep joints blocked at 60° flexion. 42 days: Modify splint to wrist block only, or discontinue. Begin active finger extension and abduction. 56-70 days: Begin light resistive and blocking exercises. Frequencies and measures of central tendency were examined for all wound, surgical, therapist, patient, and outcome variables. Because of the small number of patients for whom data on tendon rupture, need for tenolysis, and return to work were recorded, no further statistical analysis was performed for these outcome variables. For the same reason, several independent variables were also excluded from further analysis. Pearson correlation coefficients were computed to examine the nature and strength of the relationship between hand and finger TAM, and variables related to the patient, the wound, the surgery, and therapy.

4. Therapy data: (a) elapsed time, surgery to therapy evaluation; (b) elapsed time, surgery to first exercise; (c) elapsed time, therapy evaluation to last therapy. session (when follow-up surgery was required, last therapy session was considered to be the last session prior to the follow-up surgery); (d) total number of therapy visits (when follow-up surgery was required, visits were counted to last therapy session prior to the follow-up surgery); (e) elapsed time, surgery to removal of postoperative dressing: (f) elapsed time, surgery to each splint fabricated, purchased, or modified (up to five splints); (g) type of splint fabricated or purchased, or nature of splint modification; (h) elapsed time, surgery to initiation of exercise, and type of exercise prescribed; and (i) elapsed time, surgery to each change in exercise, and type of exercise prescribed (up to five changes). 5. Outcome data: (a) whether follow-up tenolysis was performed, and, if so, elapsed time, initial surgery to tenolysis (data collection for this study terminated as of the last visit prior to tenolysis); (b) whe~her the repaired tendon ruptured, and, if so, elapsed time, initial surgery to rupture date (data collection for this study terminated on the date rupture was discovered); (c) initial postoperative TAM in each digit repaired (recorded from therapist's note when first reported; finger TAM is the total active motion of an individual injured finger; hand TAM is the average total active motion of all injured fingers on a hand); (d) discharge TAM in each digit repaired (recorded from therapist's note on last date reported); (e) elapsed time surgery to return to light-duty work; and (f) elapsed time, surgery to return to usual work. A modified Duran therapy protocol was used for all patients but permitted variations based on patient, wound, or surgical considerations. The patient education program was augmented in 1984 with written materials on scar tissue, edema, splint use, and specific exercises. The protocol provided the following timelines from date of surgery: 7-10 days: Replace postoperative dressing with forearm-based static dorsal block splint; all joints in 30° flexion; no strap on fingers. Begin passive flexion and passive extension exercises in splint, 3 to 6 sessions daily, 10 repetitions per session holding each repetition for count of 10.

TABLE 1.

1

2

3

1

FDSt only FDPt only

2

FDS and FDP Total fingers

2

Ninety-five hands were included in this study involving 117 fingers, with a total of 174 lacerated tendons in zones 1-3. Fifty-one right hands and 44 left hands were injured. Table 1 provides a detailed breakdown of flexor digitorum superficialis (FOS) and flexor digitorum profundus (FOP) tendons injured by zone of injury and by digit. Fifty-seven fingers incurred laceration of both FOS and FDP tendons. In six such instances, all in zone 2, the FOS was not repaired; however, in each the FOP was repaired. Sixty fingers incurred laceration to a single tendon (54 FOP and 6 FOS). In no case was bilateral injury reported. Of 174 lacerated tendons, 159 were listed as cut (60 FOS, 99 FOP), 10 as avulsed (all FOP), and 5 as frayed (3 FOS, 2 FOP). Table 2 details the number of tendons injured by case and by finger. . Seventy-one patients (75%) were male; 24 were female. Age ranged from 1 year to 75 years, with a mean age of 28.1 years. Nineteen patients (20%) were under 18 years, and two (2%) were 65 years or more. Of 54 patients whose occupations were reported, 18 were students, nine were members of a construction

Injured Fingers by Tendon and Zone Digit III

Digit II Zone

RESULTS

7

1

11"

2

18

3

6 6

Digit IV

2

3

1

1

6

1 10

11"

5

18

6

10

tFDS = Flexor digitorum superficials; FDP = Flexor digitorum profundus "One FDS was not surgically repaired §Four FDS were not surgically repaired 226

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Digit V

2

3

2

1

4

1

1

19

2

3

1 6

13

2

6

6

12 13§ 26

TOTAL

1 1

54 .57 117

TABLE 2. NUMBER OF TENDONS INJURED PER CASE

NUMBER OF CASES

1 2 3 4 6 7

44

TOTAL

95

41 3 2 4 1

Number of Tendons Injured By Case and 'Finger NUMBER OF FINGERS NUMBER OF FINGERS WIlli ONE INJURED WIlli BOlli TENDONS TENDON INJURED

0 37 2 3 12 3 57

44

8 5 2 0 1

60

TOTAL NUMBER OF TENDONS

44

44

45 7 5 12 4 117

82 9 8 24 7 174

cise program. Table 3 provides detail regarding elapsed times from surgery to evaluation, to first passive flexion exercise, to first active flexion exercise, to first resistive exercise, to first blocking exercise, to fabrication of splints, and to discontinuation of the dorsal blocking splint. The data confirmed that the modified Duran protocol was generally followed in the therapy program, except that blocking and resistive exercises were typically begun 9 to 11 days earlier than recommended in the protocol. Data for patients being treated surgically by year are as follows: 1980, 4; 1981, 11; 1982, 20; 1983, 12; 1984, 8; 1985, 17; 1986, 14; and 1987, 9. Throughout the 8year time span, SHSG maintained the same three hand surgeons continuously on staff. A fourth surgeon was added to the staff in 1983. During the same time period, the hand therapy program expanded from two full-time positions to three, while maintaining high continuity in staff and program protocol. Discharge TAM data were available for 72 fingers with FOP-only or FDP-FDS injuries. The average discharge finger TAM was 217'. The average discharge TAM for each finger in which both tendons were lacerated was 201 0 ; TAM was 226 0 for fingers in which only the FOP was severed. A Mann-Whitney U test was applied to the ranked data for FOP-only injuries (n = 35). The difference in ranks was statistically significant (z = - 2.06, r g = .29, P < 0,05), indicating that TAM at discharge was higher for fingers in which only the FOP was injured than for fingers in which both. tendons were injured. The difference between i!litial and discharge finger TAM for FOP-only andFDP-FDS injuries was not statistically significant. In patients for whom both initial and discharge TAM measures were recorded, no statistically significant difference existed between

trade, five worked in food service settings, three performed bench work, and three were warehousemen. Twenty-two patients (23%) received treatment through a state workers' compensation plan. Thirty-six patients (38%) lived more than 30 miles from SHRC; six of these patients lived out of state. Of 42 individuals reporting hand dominance, four were left-dominant and 38 were right-dominant. Of 14 patients who were reported to be noncompliant, nine patients were classified as exceeding treatment recommendations or exercising poor judgment in activities; five patients were classified as not performing up to expectations. Twelve noncompliant patients were male; two were female. The mean age for noncompliant patients was 32 years. Of 92 patients whose injury dates were recorded, elapsed time from injury to primary repair ranged from days to 25 days. The average number of days from injury to surgery was 5.3. Twenty-nine patients (31%) were treated surgically on the day of injury. Forty-two tendon pulleys were reported injured (35 arcuate, 7 cruciate); 22 pulleys were repaired (17 arcuate,S cruciate); in addition, 11 uninjured pulleys were sacrificed. In 14 patients, the tendon sheath was reported to have been injured; in four instances the sheath was repaired. Digital nerve supply was reportedly interrupted by injury in 55 digits; in each case repair was made. Digital artery injury and repair were reported in 16 digits. For the 161 tendon repairs for which suture technique was reported, three techniques were most commonly used: Mason-Allen, 53 (22 FDS, 31 FOP) (33%); Kessler, 42 (13 FDS, 29 FOP) (26%); and Modified Kessler, 39 (FDS 10, FOP 29)

°

(24%).

.Repprted hand therapist intervention focused on splinting and a modified Duran postoperative exerTABLE 3.

TOTAL NUMBER OF FINGERS

Elapsed Times for Therapy Intervention Following Primary Repair of Hand Flexor Tendons, Zones 1-3

INTERVENTION

Elapsed times from surgery to Evaluation First passive flexion exercise First active flexion exercise First blocking exercise First resistive exercise Fabrication dorsal blocking splint Discontinue dorsal blocking splint Elapsed time from therapy evaluation to Discharge from therapy

N

RANGE

MEAN

93 45 55 93 38

0-37 days 1-32 days 8-44 days 29-75 days 29-68 days 2-28 days 18-53 days

14 days 11 days 27 days 47 days 45 days 11 days 37 days

93

0-243 days

56 days

72 71

October-December 1989

227

gains for individuals with FDP-only injuries and gains for individuals with FDP-FDS injuries. A one-way analysis of variance was performed comparing TAM means of individuals with zone I, zone 2, and zone 3 injuries. The F was statistically significant (F = 4.8, df = 2,70, P < 0.01). The Scheffe procedure indicated that the mean discharge finger TAM for zone 1 injuries (244°) was statistically significantly greater than the mean discharge finger TAM for zone 2 injuries (203°). The mean TAM for zone 3 injuries (21~) did not differ significantly from the TAM for either zone 1 or zone 2 injuries. In patients for whom both initial and discharge TAM measures were recorded, the average increase in TAM from first recording to last was 63°, with no statistically significant difference between gains for individuals with injuries in zones I, 2, or 3. For the five patients whose return to light-duty work was recorded, average elapsed time from injury to return to work was 11 days; for 15 patients whose return to usual work was recorded, average elapsed time from injury to work was 54 days. Seven of 95 patients (7%) required tenolysis to improve functional motion. Elapsed time from tendon repair to tenolysis ranged from 130 days to 248 days; the average was 170 days. Of 168 tendons repaired, seven (4%) subsequently ruptured. Elapsed time from primary repair to rupture averaged 27 days and ranged from 2 days to 58 days. Analysis of the nature and strength of the relationships between discharge hand TAM and each independent variable, considered separately, yielded four variables with statistical significance < 0.05. For these four variables, the Pearson correlation coefficient ranged from 0.20 to 0.32 (Table 4). Elapsed time from injury to surgery was negatively correlated with hand TAM. Variables that were positively correlated with discharge hand TAM were frequency of visits, number of visits, and elapsed time from surgery to first blocking exercise. Table 5 provides Pearson correlation coefficients for five independent variables with (a) mean discharge hand TAM, (b) mean discharge finger TAM for fingers with FDP-FDS injuries, and (c) mean discharge finger TAM for fingers with FDP-only injury. For each independent variable, a difference is TABLE 4.

noted in the statistical significance and the nature or strength of the correlation when discharge finger TAM recordings are compared with each other, or when each is compared with discharge hand TAM. For example, the Pearson correlation between discharge hand TAM and number of therapy visits was .23 (p < 0.05), indicating that as number of therapy visits increased, so did hand TAM. When both tendons in a single finger were injured, the correlation between finger TAM and number of visits was 0.37 (p < 0.01). When only the profundus was injured the -0.15 correlation between finger TAM and number of visits was no longer statistically significant (p = 0.22), however the direction of correlation shifted from positive to negative. Similar differences are noted in discharge TAM for other therapy variables (Table 5). Correlations between surgical and outcome variables could not be computed due to insufficient population size.

DISCUSSION Descriptive data obtained in this study depicted the typical SHRC patient who required primary or delayed primary flexor tendon repair, including patient traits, nature of wound, intervention, and outcome. Correlations provided indications of the nature and strength of relationship between certain independent variables and discharge TAM. Because this was a retrospective study, some data were not sufficiently available to fully describe the population or to establish certain relationships of interest. A prospective study of a larger population has the potential to overCome some of the limitations experienced in this study and to increase generalizability. The clinical observation that functional outcome is better for zone 1 injuries than for zone 2 injuries was supported by findings of this study. This study also supports the belief that within zone 2, discharge TAM is greater when a single tendon is severed than when both tendons are severed. The positive correlation between discharge TAM and elapsed time from surgery to first blocking exercise (Table 5) indicates that early initiation of blocking exercises may impede gains in TAM. The negative correlation between discharge TAM for FOP-only

Pearson Correlation Matrix for Hand Total Active Motion (TAM) with Selected Independent Variables

VARIABLE

Hand TAM ET" injury to surgery

ET'INJURY TO SURGERY

NUMBER OF mERAPY VISITS

FREQUENCY OF VISITS

ITS-" TO BLOCKING EXERaSE

-0.21 (p < 0.04)

0.23 (p < 0.03)

0.20 (p < 0.04)

0.32 (p < 0.02)

-0.18 (p < 0.05)

-0.24 (p < 0.01)

0.10 (p < 0.26)

0.12

0.11 (p < 0.25)

Number of therapy visits (p

Frequency of therapy visits "ET = Elapsed time from nETS = Elapsed time from surgery 228

JOURNAL OF HAND THERAPY

< 0.14)

0.11 (p < 0.26)

TABLE 5.

Pearson Correlation Coefficients for (A) Hand Total Active Motion (TAM), (B) FDP-FDS Finger TAM, and (C) FDP-only finger TAM with Selected Independent Variables INDEPENDENT VARIABLES

E1" INJURY TO SURGERY

NUMBER OF THERAPY VISITS

ETS" TO 1ST PASSIVE _ EXERCISE

ETS" TO 1ST BLOCKING EXERCISE

ETS" TO SPLINT DIC

A, Hand TAM

-0.21 (n=71) p < 0.04

0.23 (n=72) P < 0.03

-0.14 (n=58) P < 0.16

0.32 (n=41) P < 0.02

0.19 (n=33) P < 0.15

B, FDP-FDS Finger TAM

-0.26 (n=34) p < 0.06

0.37 (n = 35) P < 0.01

0.10 (n=25) P < 0.31

0.27 (n= 18) P < 0.13

0.47 (n= 16) P < 0.03

C, FDP-only Finger TAM

-0.36 (n=28) p < 0.03

-0.15 (n = 28) P < 0.22

-0.41 (n = 25) P < 0.02

0.38 (n=17) P < 0.07

-0.07 (n=l1) P < 0.42

DEPENDENT VARIABLES

*ET = Elapsed time from **ETS = Elapsed time from surgery Hand TAM = Average total active motion of all injured fingers on a hand Finger TAM = Total active motion of an individual injured finger FDP-FDS = Laceration of both profundus and superficialis tendons in a finger FDP-only = Only profundus tendon lacerated in a finger

injuries and elapsed time from surgery to first passive exercise indicates that early passive motion was associated with higher discharge TAM for FOP-only injuries. However, a similar correlation did not exist for individuals with FOP-FOS injuries, raising the question whether timelines for beginning passive exercise for fingers with single-tendon injuries should differ from timelines for fingers with both tendons injured. Table 5 also provides correlation coefficients for discharge TAM, with number of therapy visits and elapsed time from surgery to splint discontinuation. These data raise further questions about protocols that do not differentiate between fingers with singletendon injuries and fingers with both tendons injured. Whether separate protocols should be developed for fingers based on the number of tendons injured in the finger warrants further exploration. Some variables that were identified as potentially useful for this study were not suitable for statistical analysis, owing either to insufficient documentation or to the small number of cases to which they applied. Outcome variables for which correlations with independent variables could not be computed due to population size include rupture, need for tenolysis, and finger. TAM by zone and by number of tendons injured. Outcome variables that required additional documentation to be used in this study include, strength, dexterity, occupational performance, return-to-work dates, and additional joint range of motion measures (including TPM, independent joint measures, distance of finger pulp to distal palmar crease, and joint measures for the uninvolved side). Potentially useful independent variables that evaded statistical analysis because of small numbers or insufficient reporting include (1) details regarding the wound, for example more specific data about accessory structures injured such as pulleys, vincula,

sheath; (2) more detail about surgical procedure, structures repaired, surgical method, and materials; (3) occupation; and (4) patient compliance. Problems related to insufficient data and population size can be ameliorated with a well-designed, prospective study involving a larger sample. This study has provided SHRC with valuable information and a wealth of data about its program for treatment of patients with primary or delayed primary repair of flexor tendon lacerations. The companion study to assess long-term outcomes achieved by these patients will add greater clarity and depth to the analysis of accumulated data. The value of this retrospective chart review to SHRC is in its description of program components and outcomes. It provides the clinic with a picture of the types of patients and the types of wounds that have been encountered, and the specific surgical and treatment approaches that have been undertaken. The study has also provided SHRC with a description of the outcomes achieved by patients. Although p()pulation size and limitations in available data do not permit findings of this study to be generalized to other programs, the study does provide an analysis of the clinical experience of an established hand therapy program that other hand therapy programs may find useful as a basis for comparison or as a model for their own quality assurance studies. A well-designed instrument for data collection, used on a nationwide basis, has the potential to provide additional benefits to both the profession and patients. A uniform national database can serve as a source of comparison for clinics, assisting them to identify which aspects of their programs are strong and which require additional development; it could also serve as a primary resource for theory-building and developing new treatment approaches and techniques. October-December 1989

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REFERENCES 1. American Occupational Therapy Association: Standards of practice for occupational therapy. Am J Occup Ther 37:802-804, 1983. 2. Chai SH, Dimick MP, Kasch MC: A role delineation study of hand therapy. J Hand Ther 1:7-16, 1987. 3. Rosenblum NI, Robinson SJ: Advances in flexor and extensor tendon management. In Moran CA (ed): Hand Rehabilitation. New York, Churchill Livingstone, 1986, pp 17-44. 4. Amadio PC, Jaeger SH, Hunter JM: Nutritional aspects of tendon healing. In Hunter JM, Schneider LH, Mackin EJ, Callahan AD (eds): Rehabilitation of the Hand, 2nd ed. St. Louis, C. V. Mosby, 1984, pp 255-260. 5.' Jaeger SH, Mackin EJ: Primary care of flexor tendon injuries. In Hunter JM, Schneider LH, Mackin EJ,Callahan AD (eds): Rehabilitation of the Hand, 2nd ed. St. Louis, C. V. Mosby, 1984, pp 261-272. 6. Cannon NM, Strickland JW: Therapy following flexor surgery. Hand Clin 1:147-165, 1985. 7. Schneider LH, McEntee P: Flexor tendon injuries: Treatment of the acute problem. Hand Clin 2:119-147, 1986. 8. Kleinert HE, Schepel S, Gill T: Flexor tendon injuries. Surg Clin North Am 61:267-286,1981. 9. Lister GD, Kleinert HE, Kutz JE, Atasoy E: Primary flexor tendon repair followed by immediate controlled mobilization. J Hand Surg 2:441-451, 1981. 10. Coenen L, Boeckx W, Gruwez JA: The treatment of flexor tendon lesions in the fingers. Acta Chir Belg 4:195-204, 1981. 11. Verdan CE: Half a century of flexor tendon surgery: Current status and changing philosophies. J Bone Joint Surg 54A:472-491, 1972. 12. Duran RJ, Houser RG, Coleman CR, Stover MG: Management of flexor tendon lacerations in zone 2 using controlled passive motion postoperatively. In Hunter JM, Schneider LH, Mackin EJ, Callahan AD (eds): Rehabilitation of the Hand, 2nd ed. St. Louis, C. V. Mosby, 1984, pp 273-279. 13. Fess EE, Philips CA: Hand Splinting: Principles and Methods, 2nd ~d. St Louis, C. V. Mosby, 1987, P 360. 14. Wynn-Parry CB: Rehabilitation of tne Hand, 4th ed. London, Butterworths, 1981, pp 36-64. 15. Mayo NE: Patient compliance: Practical implications for physical therapists. Phys Ther 58:1083-1090, 1978.

16. Becker M, Mailman, L: Sociobehavioral determinants of compliance and medical care recommendations. Med Care 24:55-56, 1975. 17. Ekes A, Marvin JA: Bum patient cooperation in physical and occupational therapy. J Bum Care Rehabil 6:246-249, 1985. 18. Brand PW: Hand rehabilitation-management by objective. In , Hunter lM, Schneider LH, Mackin EJ, Callahan AD (eds): Rehabilitation of the Hand, 2nd ed. St. Louis, C. V. Mosby, 1984, pp 3-5. 19. Roy CS: The elastic properties of the arterial wall. J Physiol (Lond) 3:125, 1880. 20. Pickles B: Biological aspects of aging. In Jackson 0 (ed): Physical Therapy of the Geriatric Patient. New York, Churchill Livingstone, 1983, pp 27-63. 21. Emery FE: Immediate mobilization following flexor tendon repair: A preliminary report. J Trauma 17:1-7, 1977. 22. Vahvanen V, Gripenberg L, Nuutinen P: Flexor tendon injury of the hand in children: A long-term follow-up study of 84 patients. Scand J Plast Reconstr Surg 15:43-48, 1981. 23. Pedretti LW: Occupational Therapy: Practice Skills for Physical Dysfunction, 2nd ed. St. Louis, C. V. Mosby, 1985, P 93. 24. American Society for Surgery of the Hand: The Hand: Examination and Diagnosis, 2nd ed. New York, Churchill Livingstone, 1983, p 107-110. 25. Hunter JM, Mackin EJ: Edema and bandaging. In Hunter JM, Schneider LH, Mackin EJ, Callahan AD (eds): Rehabilitation of the Hand, 2nd ed. St. Louis, C. V. Mosby, 1984, pp 146-153. 26. Tubiana R, Thomine J-M, Mackin EJ: Examination of the Hand and Upper Limb. Philadelphia, W.B. Saunders, 1984, pp 168-191.

27. Cambridge CA: Range of motion measurements of the hand. In Hunter JM, Schneider LH, Mackin EJ, Callahan AD (eds): Rehabilitation of the Hand, 2nd ed. St. Louis, C. V. Mosby, 1984, pp 79-90. 28. Aulicino PL, DuPuy TE: Clinical examination of the hand. In Hunter JM, Schneider LH, Mackin EJ, Callahan AD (eds): Rehabilitation of the Hand, 2nd ed. St. Louis, C. V. Mosby, 1984, pp 25-48. 29. Fess EE: Documentation: Essential elements of an upper extremity assessment battery. In Hunter JM, Schneider LH, Mackin EJ, Callahan AD (eds): Rehabilitation of the Hand, 2nd ed. St. Louis, C. V. Mosby, 1984, pp 49-78.

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FACULTY-CLINICIAN POSITION Hand Management Program

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Have the best of both worlds. The Department of Surgery at the Medical College of Virginia/ Virginia Commonwealth University, Richmond, Virginia, is seeking a registered occupational or physical therapist to perform both clinical and academic duties related to the hand management master's program. Responsibilities for the master's program include teaching and directing student research, plus coordinating arrangements for courses, clinical placements, and student liaison to the departments of occupational and physical therapy and surgery, which cooperatively offer the program. In addition, the therapist will spend 50 percent of the time working with hand management center patients under supervision of the center's director. Applicants should possess at least a master's degree, three years of t;Xperience as a h~nd therapist, and experience in clinical teaching and in conducting research. Comnutment to professlO~al . development, including taking an active role in a society related to treatment of hand patients, IS expected. A doctorate and experience in academic teaching and supervising student research are desirable. MCV-VCU is an AAlEO employer. Women and minorities are encouraged to apply. Please contact Larry Maddy at (804) 786-0247.

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JOURNAL OF HAND THERAPY