- Email: [email protected]
Hand Therapy Modalities Following Extensor Mechanism Surgery
IN BRIEF
Hand Therapy Modalities Following Extensor Mechanism Surgery Garet C. Comer, MD,* Carolyn Gordon, BS,† Jeffrey Yao, MD*
T
HE EXTENSOR MECHANISM IS A complex structure that receives contributions from both the extrinsic and intrinsic musculature of the hand. A precise balancing of the numerous forces working across each joint is necessary for optimal function. Surgical management of extensor mechanism pathology seeks to restore this complex anatomic balance, and postsurgical hand therapy is indispensable when focusing on maximizing the function of the entire mechanism. Several general concepts should be followed to optimize hand function and avoid complications such as lost motion, extensor lag, and decreased strength after extensor mechanism surgery. The first consideration is the surgeon’s assessment of the integrity of the surgical repair or reconstruction, which is essential in determining the proper therapy protocol.1 Early immobilization, immediate passive motion,2 and immediate active motion3 protocols may be employed. Furthermore, typical functional hand use rarely incorporates resisted extension; as such, patients may return to functional use of the hand earlier in the postoperative period than patients undergoing flexor tendon surgery.1 Other concepts include edema control, which is essential to decrease the work of tendon excursion3; judicious orthotic use; and appreciation of the ligamentous and tendinous structures that link the motion of the joints of each digit.
ORTHOSES The judicious use of orthotics is an essential part of the rehabilitative process. Orthoses are useful to both From the *Department of Orthopaedic Surgery, †Stanford University Medical Center, Redwood City, CA. Received for publication December 4, 2014; accepted in revised form April 27, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Jeffrey Yao, MD, Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway Avenue, Pavilion C, Redwood City, CA 94063; e-mail: [email protected]. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.04.043
protect the surgical site and isolate motion to those structures that may continue moving as healing of the injured structures progresses. Although full immobilization was historically the mainstay of postsurgical protocols, newer immediate passive motion and immediate active motion protocols have gained popularity.2e4 Selecting the proper orthosis depends on the level of tendon injury and postoperative protocol set forth by the surgeon and therapist. Tendon repairs in zones I through IV are typically managed with early immobilization to prevent extensor lag, swan neck deformity, or boutonniere deformity.5 Orthoses for zone I and II tendon surgery immobilize the distal interphalangeal joint in extension, whereas orthoses for zone III and IV tendon surgery immobilize the proximal interphalangeal joint in extension. For zone V through VII extensor tendon surgery, more variability exists with regard to orthotic design. This is because of the importance of early motion in these zones where the tendons are intrasynovial and motion allows for nutrient diffusion and adhesion prevention.5 A recent systematic review demonstrated improved outcomes with the use of dynamic orthoses compared with early immobilization for these tendon injuries.4 Commonly used orthoses include hand- or forearm-based outrigger orthoses, which are indicated for immediate passive extension protocols (Fig. 1). These orthoses permit a short arc of active flexion with an elastic pulley system passively returning the digit to full extension. They may be removed for active motion exercises, or a separate orthosis may be fabricated for active motion. An example of such an orthosis is the immediate controlled active motion orthosis, which was described for zone IV through VII tendon repair. This orthosis positions the wrist in 25 to 30 extension and limits the involved metacarpophalangeal joint to 25 to 30 less flexion than those of non-injured digits, effectively eliminating extremes of motion and decreasing stress across the repair site.5 The duration of orthotic wear depends on the strength of the repair, associated injuries, and surgeon and therapist preference; however, orthotics are typically used
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
HAND THERAPY FOR EXTENSOR MECHANISM
FIGURE 1: Forearm-based outrigger orthotic that allows for active digital flexion and passive extension.
FIGURE 3: Scar release maneuver in which the therapist attempts to pull the soft tissues adjacent to the extensor tendon distally while the patient actively extends. This creates a shearing force between the tendon and adjacent tissue, preventing adhesions.
THERAPEUTIC HEAT Heat therapy may take many forms including paraffin baths, ultrasound, heating pads and wraps, and warm soaks. The application of heat is useful for increasing blood flow through vasodilation, increasing collagen extensibility, and decreasing pain and muscle spasms.10 Collectively, these mechanisms lead to decreased swelling and improve the suppleness of joints, which decreases the work of motion. We find heat therapy most beneficial once the patient’s therapy protocol allows for active motion. As such, we defer heat therapy modalities until this point and also defer if moderate to severe edema is present because of the possibility of exacerbating the swelling.
FIGURE 2: Neuromuscular electrical stimulation unit stimulating extension of index finger.
for the first 6 weeks after surgery while a repair is in the early stages of healing.1,5,6 Regardless of the orthotic used, the goals of early motion protocols are to decrease tendon adhesions and increase the strength of the tendon repair as the tissue remodels in line with the tension placed on it.1
CRYOTHERAPY Cold therapy is used to induce vasoconstriction, decrease the metabolic rate, and provide an analgesic effect.10 Vasoconstriction and decreased metabolic activity aid in decreasing edema formation and blunting the effect of inflammatory mediators.11 Cold therapy may be employed clinically through ice packs, contrast baths, immersion, wraps, and vapo-coolant sprays. Similar to heat therapy, cryotherapy is especially beneficial once active motion has been initiated. Contrast baths employ both heat and cold therapy together to reduce edema and increase blood flow. Anecdotal support of the use of contrast baths is abundant, although its impact on edema control and functional benefit remains questionable.12
ULTRASOUND Ultrasound treatment uses high-frequency sound waves that increase tissue extensibility, decrease pain, and augment tendon healing. Nonthermal ultrasound has been investigated as an adjunct to tendon healing7 whereas thermal ultrasound as a heating agent has been found useful in reducing joint pain, swelling, and stiffness.8,9 The efficacy of nonthermal ultrasound as an adjunct in tendon healing is debatable; some animal data has shown improved tendon healing.7 Because of the questionable efficacy with regard to tendon healing, we focus on thermal ultrasound used at 3 MHz, not before 6 weeks after surgery, and used to improve circulation and decrease swelling and adhesions.10 J Hand Surg Am.
ELECTRICAL STIMULATION Electrical stimulation may be applied through a myriad of forms, but the effects of pain control, neuromuscular r
Vol. -, - 2015
HAND THERAPY FOR EXTENSOR MECHANISM
REFERENCES
reeducation, and edema control are common goals of enhancing tendon excursion via electrical stimulation of muscle contraction. In addition, electrical stimulation may be useful in patients who are too apprehensive to attempt active motion. Electrical stimulation frequently takes the form of neuromuscular electrical stimulation in which the extensor tendon muscle bellies are stimulated to contract inducing tendon excursion.10 Neuromuscular electrical stimulation is most beneficial once the repair strength has matured enough to allow active motion, augmenting motion and tendon gliding (Fig. 2).
1. Klein LJ. Extensor tendon injury. In: Cooper C, ed. Fundamentals of Hand Therapy. 2nd ed. St Louis, MO: Mosby; 2014:426e437. 2. Walsh MT, Rinehimer W, Muntzer E, Patel J, Sitler MR. Early controlled motion with dynamic splinting versus static splinting for zones III and IV extensor tendon lacerations: a preliminary report. J Hand Ther. 1994;7(4):232e236. 3. Cao Y, Tang JB. Investigation of resistance of digital subcutaneous edema to gliding of the flexor tendon: an in vitro study. J Hand Surg. 2005;30(6):1248e1254. 4. 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(4): 365e372. 5. Evans RB. Managing the injured tendon: current concepts. J Hand Ther. 2012;25(2):173e189. 6. Howell JW, Merritt WH, Robinson SJ. Immediate controlled active motion following zone 4-7 extensor tendon repair. J Hand Ther. 2005;18(2):182e190. 7. Ng CO, Ng GY, See EK, Leung MC. Therapeutic ultrasound improves strength of Achilles tendon repair in rats. Ultrasound Med Biol. 2003;29(10):1501e1506. 8. Robinson V, Brosseau L, Casimiro L, et al. Thermotherapy for treating rheumatoid arthritis. Cochrane Database Syst Rev. 2002;(2): CD002826. 9. Wessling KC, DeVane DA, Hylton CR. Effects of static stretch versus static stretch and ultrasound combined on triceps surae muscle extensibility in healthy women. Phys Ther. 1987;67(5): 674e679. 10. Hartzell TL, Rubinstein R, Herman M. Therapeutic modalities—an updated review for the hand surgeon. J Hand Surg. 2012;37(3): 597e621. 11. Deal DN, Tipton J, Rosencrance E, Curl WW, Smith TL. Ice reduces edema: a study of microvascular permeability in rats. J Bone Joint Surg Am. 2002;84(9):1573e1578. 12. Breger Stanton DE, Lazaro R, MacDermid JC. A systematic review of the effectiveness of contrast baths. J Hand Ther. 2009;22(1): 57e70. 13. Kasch MC. Clinical management of scar tissue. Occup Ther Health Care. 1988;4(3-4):37e52.
SCAR MOBILIZATION As a scar remodels and matures, some degree of tissue contracture is inevitable. Scar mobilization through various forms of massage attempts to restore suppleness to the wound and decrease tendon adhesions. Cross-friction massage is typically performed with the assistance of a thick lubricating cream (vitamin E lotion, cocoa butter, etc) and a slow, deep circular motion performed several times daily. Furthermore, prudently employed scar release techniques (Fig. 3) may help prevent and eliminate tendon adhesions.13 A close working relationship between the surgeon and hand therapist is essential after extensor mechanism surgery. A rehabilitative protocol that is individualized to fit each patient’s tendon pathology and surgery is essential. Several therapeutic modalities may be employed during the postoperative rehabilitation period to optimize the patient’s functional outcome.
J Hand Surg Am.
3
r
Vol. -, - 2015
Hand Therapy Modalities Following Extensor Mechanism Surgery Garet C. Comer, MD,* Carolyn Gordon, BS,† Jeffrey Yao, MD*
T
HE EXTENSOR MECHANISM IS A complex structure that receives contributions from both the extrinsic and intrinsic musculature of the hand. A precise balancing of the numerous forces working across each joint is necessary for optimal function. Surgical management of extensor mechanism pathology seeks to restore this complex anatomic balance, and postsurgical hand therapy is indispensable when focusing on maximizing the function of the entire mechanism. Several general concepts should be followed to optimize hand function and avoid complications such as lost motion, extensor lag, and decreased strength after extensor mechanism surgery. The first consideration is the surgeon’s assessment of the integrity of the surgical repair or reconstruction, which is essential in determining the proper therapy protocol.1 Early immobilization, immediate passive motion,2 and immediate active motion3 protocols may be employed. Furthermore, typical functional hand use rarely incorporates resisted extension; as such, patients may return to functional use of the hand earlier in the postoperative period than patients undergoing flexor tendon surgery.1 Other concepts include edema control, which is essential to decrease the work of tendon excursion3; judicious orthotic use; and appreciation of the ligamentous and tendinous structures that link the motion of the joints of each digit.
ORTHOSES The judicious use of orthotics is an essential part of the rehabilitative process. Orthoses are useful to both From the *Department of Orthopaedic Surgery, †Stanford University Medical Center, Redwood City, CA. Received for publication December 4, 2014; accepted in revised form April 27, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Jeffrey Yao, MD, Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway Avenue, Pavilion C, Redwood City, CA 94063; e-mail: [email protected]. 0363-5023/15/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.04.043
protect the surgical site and isolate motion to those structures that may continue moving as healing of the injured structures progresses. Although full immobilization was historically the mainstay of postsurgical protocols, newer immediate passive motion and immediate active motion protocols have gained popularity.2e4 Selecting the proper orthosis depends on the level of tendon injury and postoperative protocol set forth by the surgeon and therapist. Tendon repairs in zones I through IV are typically managed with early immobilization to prevent extensor lag, swan neck deformity, or boutonniere deformity.5 Orthoses for zone I and II tendon surgery immobilize the distal interphalangeal joint in extension, whereas orthoses for zone III and IV tendon surgery immobilize the proximal interphalangeal joint in extension. For zone V through VII extensor tendon surgery, more variability exists with regard to orthotic design. This is because of the importance of early motion in these zones where the tendons are intrasynovial and motion allows for nutrient diffusion and adhesion prevention.5 A recent systematic review demonstrated improved outcomes with the use of dynamic orthoses compared with early immobilization for these tendon injuries.4 Commonly used orthoses include hand- or forearm-based outrigger orthoses, which are indicated for immediate passive extension protocols (Fig. 1). These orthoses permit a short arc of active flexion with an elastic pulley system passively returning the digit to full extension. They may be removed for active motion exercises, or a separate orthosis may be fabricated for active motion. An example of such an orthosis is the immediate controlled active motion orthosis, which was described for zone IV through VII tendon repair. This orthosis positions the wrist in 25 to 30 extension and limits the involved metacarpophalangeal joint to 25 to 30 less flexion than those of non-injured digits, effectively eliminating extremes of motion and decreasing stress across the repair site.5 The duration of orthotic wear depends on the strength of the repair, associated injuries, and surgeon and therapist preference; however, orthotics are typically used
Ó 2015 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
HAND THERAPY FOR EXTENSOR MECHANISM
FIGURE 1: Forearm-based outrigger orthotic that allows for active digital flexion and passive extension.
FIGURE 3: Scar release maneuver in which the therapist attempts to pull the soft tissues adjacent to the extensor tendon distally while the patient actively extends. This creates a shearing force between the tendon and adjacent tissue, preventing adhesions.
THERAPEUTIC HEAT Heat therapy may take many forms including paraffin baths, ultrasound, heating pads and wraps, and warm soaks. The application of heat is useful for increasing blood flow through vasodilation, increasing collagen extensibility, and decreasing pain and muscle spasms.10 Collectively, these mechanisms lead to decreased swelling and improve the suppleness of joints, which decreases the work of motion. We find heat therapy most beneficial once the patient’s therapy protocol allows for active motion. As such, we defer heat therapy modalities until this point and also defer if moderate to severe edema is present because of the possibility of exacerbating the swelling.
FIGURE 2: Neuromuscular electrical stimulation unit stimulating extension of index finger.
for the first 6 weeks after surgery while a repair is in the early stages of healing.1,5,6 Regardless of the orthotic used, the goals of early motion protocols are to decrease tendon adhesions and increase the strength of the tendon repair as the tissue remodels in line with the tension placed on it.1
CRYOTHERAPY Cold therapy is used to induce vasoconstriction, decrease the metabolic rate, and provide an analgesic effect.10 Vasoconstriction and decreased metabolic activity aid in decreasing edema formation and blunting the effect of inflammatory mediators.11 Cold therapy may be employed clinically through ice packs, contrast baths, immersion, wraps, and vapo-coolant sprays. Similar to heat therapy, cryotherapy is especially beneficial once active motion has been initiated. Contrast baths employ both heat and cold therapy together to reduce edema and increase blood flow. Anecdotal support of the use of contrast baths is abundant, although its impact on edema control and functional benefit remains questionable.12
ULTRASOUND Ultrasound treatment uses high-frequency sound waves that increase tissue extensibility, decrease pain, and augment tendon healing. Nonthermal ultrasound has been investigated as an adjunct to tendon healing7 whereas thermal ultrasound as a heating agent has been found useful in reducing joint pain, swelling, and stiffness.8,9 The efficacy of nonthermal ultrasound as an adjunct in tendon healing is debatable; some animal data has shown improved tendon healing.7 Because of the questionable efficacy with regard to tendon healing, we focus on thermal ultrasound used at 3 MHz, not before 6 weeks after surgery, and used to improve circulation and decrease swelling and adhesions.10 J Hand Surg Am.
ELECTRICAL STIMULATION Electrical stimulation may be applied through a myriad of forms, but the effects of pain control, neuromuscular r
Vol. -, - 2015
HAND THERAPY FOR EXTENSOR MECHANISM
REFERENCES
reeducation, and edema control are common goals of enhancing tendon excursion via electrical stimulation of muscle contraction. In addition, electrical stimulation may be useful in patients who are too apprehensive to attempt active motion. Electrical stimulation frequently takes the form of neuromuscular electrical stimulation in which the extensor tendon muscle bellies are stimulated to contract inducing tendon excursion.10 Neuromuscular electrical stimulation is most beneficial once the repair strength has matured enough to allow active motion, augmenting motion and tendon gliding (Fig. 2).
1. Klein LJ. Extensor tendon injury. In: Cooper C, ed. Fundamentals of Hand Therapy. 2nd ed. St Louis, MO: Mosby; 2014:426e437. 2. Walsh MT, Rinehimer W, Muntzer E, Patel J, Sitler MR. Early controlled motion with dynamic splinting versus static splinting for zones III and IV extensor tendon lacerations: a preliminary report. J Hand Ther. 1994;7(4):232e236. 3. Cao Y, Tang JB. Investigation of resistance of digital subcutaneous edema to gliding of the flexor tendon: an in vitro study. J Hand Surg. 2005;30(6):1248e1254. 4. 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(4): 365e372. 5. Evans RB. Managing the injured tendon: current concepts. J Hand Ther. 2012;25(2):173e189. 6. Howell JW, Merritt WH, Robinson SJ. Immediate controlled active motion following zone 4-7 extensor tendon repair. J Hand Ther. 2005;18(2):182e190. 7. Ng CO, Ng GY, See EK, Leung MC. Therapeutic ultrasound improves strength of Achilles tendon repair in rats. Ultrasound Med Biol. 2003;29(10):1501e1506. 8. Robinson V, Brosseau L, Casimiro L, et al. Thermotherapy for treating rheumatoid arthritis. Cochrane Database Syst Rev. 2002;(2): CD002826. 9. Wessling KC, DeVane DA, Hylton CR. Effects of static stretch versus static stretch and ultrasound combined on triceps surae muscle extensibility in healthy women. Phys Ther. 1987;67(5): 674e679. 10. Hartzell TL, Rubinstein R, Herman M. Therapeutic modalities—an updated review for the hand surgeon. J Hand Surg. 2012;37(3): 597e621. 11. Deal DN, Tipton J, Rosencrance E, Curl WW, Smith TL. Ice reduces edema: a study of microvascular permeability in rats. J Bone Joint Surg Am. 2002;84(9):1573e1578. 12. Breger Stanton DE, Lazaro R, MacDermid JC. A systematic review of the effectiveness of contrast baths. J Hand Ther. 2009;22(1): 57e70. 13. Kasch MC. Clinical management of scar tissue. Occup Ther Health Care. 1988;4(3-4):37e52.
SCAR MOBILIZATION As a scar remodels and matures, some degree of tissue contracture is inevitable. Scar mobilization through various forms of massage attempts to restore suppleness to the wound and decrease tendon adhesions. Cross-friction massage is typically performed with the assistance of a thick lubricating cream (vitamin E lotion, cocoa butter, etc) and a slow, deep circular motion performed several times daily. Furthermore, prudently employed scar release techniques (Fig. 3) may help prevent and eliminate tendon adhesions.13 A close working relationship between the surgeon and hand therapist is essential after extensor mechanism surgery. A rehabilitative protocol that is individualized to fit each patient’s tendon pathology and surgery is essential. Several therapeutic modalities may be employed during the postoperative rehabilitation period to optimize the patient’s functional outcome.
J Hand Surg Am.
3
r
Vol. -, - 2015