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Mentors and Milestones
~FSHT PRESIDENTIAL ADDRESS) Mentors and Milestones* Evelyn J. Mackin, PT IFSHT President (1986-7992) Executive Director, Hand Rehabilitation Foundation, Philadelphia, Pennsylvania Editor, Journal of Hand Therapy
he dictionary defines milestone as "a signifi-
T cant or important event in the history or career of a person." For those who witnessed the First American Society of Hand Therapists (ASHT) International Meeting in Rotterdam in 1980 and the beginning of our federation of hand therapy societies in France just a decade ago and all that has come since then, the Second Congress of the International Federation of Societies of Hand Therapists (IFSHT), held in Paris in May 1992, stands as a milestone. As we look into the future with great enthusiasm to an ever-growing membership of hand therapy societies around the world, we should open the windows of our past and pay honor to some of the surgeons and therapists among us who have been mentors and friends, and who have lifted us to this wondrous international level. It was Sterling Bunnell whose forward vision and remarkable energies during World War II led to the establishment of specific hand surgery centers in selected military hospitals across the United States. The "Bunnell Era" showed the way to a small group of surgeons who, as they worked with complex reconstructive surgery, learned to depend on the support offered by the close proximity of physical and occupational therapists. It was Paul Brand in India who used his extraordinary skills and devotion to God to establish the world's first hand rehabilitation center where patients with Hansen's disease received reconstructive surgery and postoperative therapy and were taught new skills to become self-sufficient and live with dignity. Paralleling the work of Bunnell in the United States and Brand in India, Wing Commander Wynn 'Excerpts from the Presidential Address of the 2nd Congress of the International Federation of Societies of Hand Therapists, Paris, France, May 29-30, 1992. Correspondence to Evelyn]. Mackin, PT, Executive Director, Hand Rehabilitation Foundation, 901 Walnut Street, Philadelphia, PA 19107.
Parry in England created a special hand unit within the famed Rehabilitation Service of the Royal Air Force in Chessington. Parry's concepts of sensory reeducation, splinting, and goal-oriented competitive activities provided much of the impetus for hand rehabilitation today. It became very evident to those working in the hand units that a plan for continuity of treatment from injury to maximum recovery was essential if ideal standards were to be achieved in surgery, hand therapy, work therapy, and return to work. Dr. Bunnell organized the American Society for Surgery of the Hand in 1946, and became the first President. Hand therapy as a specialty in the United States followed 30 years later. In 1975 six therapists working closely with surgeons met in San Francisco, Judith Bell-Krotoski (Louisiana), Margaret CarterWilson (Arizona), Mary Kasch (California), Evelyn Mackin (Pennsylvania), Bonnie Olivett (Colorado), and Karen Prendergast-Lauckhardt (New York). The meeting culminated in the founding of the American Society of Hand Therapists with Bonnie Olivett as the first President. Therapists by this time had begun to write and speak extensively regarding hand therapy and educational meetings were attracting hundreds of therapists. This was the beginning ... and it provided the springboard to our international growth and the seeds of the Journal of Hand Therapy. Today we can celebrate together the clinical growth of hand therapy on an international level. We shall always be indebted to D:. Alfred Swanson (United States), Dr. Robert McFarlane (Canada), and Dr. Van der Mueilen (The Netherlands), who in 1980 made possible the American Society of Hand Therapists First International Meeting held during the first Congress of the International Federation of Societies for Surgery of the Hand (IFSSH) in The Netherlands. Approximately 200 therapists and surgeons crowded into a meeting room at the Erasmus University in Rotterdam to attend the "Therapists' Day." It July-September 1992
129
was exciting to share the emerging discipline of hand therapy with our international peers for the first time. In 1983, the hand therapists traveled to historic Boston to participate in the Second Congress. Cindy Phillips and the late Dr. Richard Smith were our hosts. In 1986 Japan invited the hand therapists to participate in the Third Congress. The hospitality extended to us in Japan was exceeded only by Dr. Tajima's kindness and support of the goals of hand therapists. It was shortly after the Congress in Japan that a group of therapists from several countries met during the Congress of La Societe Fran~aise de Chirurgie de la Main (GEM) in Paris. With encouragement from Drs. Raoul Tubiana and Yves Allieu (France) and R. Georgio Brunelli (Italy), the International Federation of Societies of Hand Therapists was founded. In 1989 when we went to Israel to participate in the Fourth Congress, we went as the IFSHT with 12 member societies throughout the world, Australia, Belgium, Brazil, France, Great Britain, Israel, Italy, Japan, New Zealand, Poland, Republic of South Africa, and the United States. Societies continued to arise from the enthusiasm of a few therapists in each country, and we now have 18 member societies that include Canada, Finland, Greece, The Netherlands, Sweden, and Switzerland. In addition, we have corresponding members in Austria, Germany, Lithuania, Malaysia, Norway, Spain, and Taiwan. During these past years since the First Congress held in Rotterdam, therapists have continued to learn from the sciences of biology, biomechanics, anatomy, and neurophysiology, and this quest to learn has not been just in anyone country-it's worldwide and our collective knowledge is reflected in growth and change in many clinical areas, including management of healing wounds, splinting, management of the healing tendon, sensibility, evaluation, and returnto-work programs. As we move forward into the future, it serves us well to recognize a few of those colleagues of ours who laid down in fact, and in spirit, the foundations upon which we are now building. Roslyn Evans (United States) introduced us to a universal classification system for open wounds developed by Marion Laboratories that simplifies wound description as it relates to each phase of wound healing. Thus, while we necessarily speak in terms of number of days or weeks post injury or surgery, we do so by an approach that uses color to describe wound status. The red wound is uninfected, properly healing with definite borders, granulation tissue and collagen synthesis occurring. The yellow wound is draining, purulent, characterized by slough that is semi-liquid to liqUid in texture. The black wound is covered with eschar or thick necrotic tissue. Corrianne van Velze (South Africa) and her colleagues demonstrated that there is a difference in the volumes of the dominant and nondominant hands, and that, on average, the left hand is 3.43% smaller than the right hand. It is therefore possible to use the measurement of the uninvolved hand to predict the volume of the involved hand, enabling us to set realistic goals for our patients. 130
JOURNAL OF HAND THERAPY
Nathalie Barr (Great Britain) has been one of our earlier teachers in the principles and techniques of splinting. Her career spanned wars and continents. Professor Yves Allieu and Jean-Claude Rouzaud (France) provided a consistent and controlled force to dynamic splinting when they developed in France the Scomac springs. The premeasured steel springs were the first commercially available springs developed especially for splinting and were a response to the need for quantification and objective treatment technique when applying forces in dynamic splinting. Lisa Dennys, Lawrence Hurst, and Jane Cox (Canada) reported their good results and patient compliance in the management of PIP joint fractures using a lateral-hinge dynamic traction splint, combined with early active motion. Esther May and Kris Silfverskiold (Sweden) have added to the field, too, by their research on a new power source in dynamic splinting that addresses flexor tendon mobilization in the early postoperative period. Dr. Jean Pillet (France) listened to the functional needs as well as the psychological needs of the amputee and provided an aesthetic prosthesis that can lengthen a person's shortened index finger, enabling him or her to play the piano, and prostheses for so many other amputees, to better integrate these people into the complex socioeconomic environment of today's society. Tendon management, especially for zone II flexor tendon injuries, is another area of tremendous growth. The research and teaching of many dedicated surgeons, such as Harold Kleinert (United States) and Goran Lundberg (Sweden), have vastly improved our knowledge of tendon nutrition through vincular and synovial sheath pathways, of intrinsic vs. extrinsic tendon healing, and of anatomy of the pulley system and its importance to digital function. We have learned that pulley reconstruction is as sensitive as tendon repair and that repaired pulleys must be protected, with special attention to the Al pulley. The Al pulley fair leads and protects the A2 pulley by reducing the angular power drive at the proximal end of the construction. Firm pressure on a repaired Al pulley during rehabilitative training is important. It has been a great honor for me to have been associated with Dr. James Hunter for over 25 years and been a witness to the leading edge of advances in tendon surgery. The results are that early motion with elastic band protection has become the most favored form of aftercare tendon repair. Strickland (United States) reports results with early passive motion better than with 3 1/2 weeks of immobilization . Meals (United States) reports recovery of repaired digital nerves not compromised by protective early motion. Gelberman (United States) reports that early motion stimulates maturation and remodeling of scar tissue. We learned from McGrouther and Ahmed (Scotland) in 1981 that complete excursion of the FOP and differential excursion between the FOP and FDS could be accomplished only through flexion-of the DIP jOint. In other words, they report it is necessary to flex the
joints distal to the repair to achieve glide of a tendon. This study has obvious and profound implications for all passive mobilization programs . New splinting protocols emphasize this concept. The development of the staged tendon graft surgery by Hunter opened the way to restoration of function in a digit unfit for single-stage grafting. The Hunter active tendon implant is leading to new applications. The core of the implant is a porous Dacron weave designed by textile engineers to simulate the weave of collagen fibers. Currently, Dr. Hunter is using the core in ligament reconstruction in the MP and PIP joints and in the flail distal radial/ulnar joint. This work is in laboratory and clinical study stages. The end result is to help the patient achieve a comfortable balance between mobility and stability of the reconstructed joint and build strength within that range. Roslyn Evans and the late Dr. William Burkhalter (United States) applied the concepts of tendon healing, tendon excursion, and methods of flexor tendon care to the extensor system based on the KleinertDuran method, and thereby improved our management of complex extensor tendon injuries in zones 5, 6, and 7 with early controlled motion. Dominique Thomas (France) demonstrated the value of functional electrical stimulation as an adjunct to patient care to augment or enhance tendon excursion at the appropriate stage of wound healing following tendon surgery, i.e., tenolysis. Sensibility evaluation is yet another area of clinical growth . The word sensibility is synonymous with Erik Moberg, for it has been the teachings of Dr. Moberg (Sweden) that have led the way in one of the most challenging aspects of nerve injury and regeneration. Great respect is due Judy Bell-Krotoski (United States), who is the therapist most responsible for increasing our knowledge in this area. From Judy and her team we have learned that no hand-held instrument that we use in the clinic today is capable of testing specifically for one type of sensory receptor. Of the hand-held instruments in current use, the Semmes-Weinstein monofilaments are the most reliable, and Judy has demonstrated that when the monofilaments are calibrated to ensure correct length and diameter and given that these two dimensions are correct, "the application forces of the filaments are repeatable within a predictable range." Thus, they are "controlled, objective, reproducible force stimulus" for testing peripheral nerve function. The complete kit of monofilaments in its present form can be cumbersome to use and expensive. A smaller kit was made, however. Judy has gone on to develop the "pocket filaments. " Telescoping rods allow extension and collapse of the filaments. Prof. Raoul Tubiana and Philippe Chamagne (France) have made us pay attention to the medical difficulties of the musician and remind us that causative factors for instrument-related injuries can be analyzed with much the same reasoning one applies to sports and workplace injuries. The rehabilitation of a patient with a brachial plexus injury is a difficult and prolonged process.
The implications of the injury are considerable as the majority of the patients are young men with many years of life ahead. Vicky Frampton (Great Britain) has increased our knowledge as clinician, teacher, and author. Evaluation has been another area of clinical growth. Elaine Fess (United States) has been our greatest advocate of the need for reliability and validity in hand evaluation and has directed her efforts toward that end. Time does not allow me to mention all of the many others among us who continue to assess their performance as clinicians, such as Wilma Walsh (Australia), Wim Brandsma (The Netherlands), Maude Malick (United States), and Judy Colditz (United States). It is impossible to imagine our specialty without their contributions. They are the trailblazers who lead the way, like Mayumi Nakada Gapan), tireless pioneer in the field of sensory investigation. Now, what are the dreams and future goals of our Society with this impressive past? Roz Evans reminds us that we must still question why? when? how much? what for? how often? ... what if? Our role is an exacting one. To maintain our status as a federation of societies highly qualified in the care and treatment of the disabled hand, we must individually and collectively continue to refine our skills. We can be proud of our approximately 1,500 members in the IFSHT on continents throughout the world. But we must look to regional membership in the IFSHT, involving those countries that may be unable to form their own societies. As we map out the road we wish to travel, the goals we set for ourselves, it is most important, I believe, that we stay tuned to each other, hear and understand each other, give to each other, and take from each other.
• RETROSPECTIVE NOTES The Second Congress of the IFSHT, so eagerly looked forward to, is now over . .. however, the memory of Paris in May '92 will never be forgotten! It was a superb educational experience exceeded only by the opportunity to meet 561 colleagues from countries (Argentina, Australia, Austria, Belgium, Brazil, Canada, Finland, France, Germany, Great Britain, Greece, China, India, Israel, Italy, Japan , Luxembourg, Malaysia, The Netherlands, New Zealand, Norway, Portugal, Republic of South Africa, Spain, Sweden, Switzerland, Taiwan, Tunisia, Turkey, the United States) throughout the world. We exchanged ideas . . . shared knowledge . . . and laughed together. It was fantastic! We owe a special debt of thanks to the GEMMSOR, French Society of Hand Therapists, especially thanking Philippe Chamagne and his Organizing Committee, Philippe Durafourg, Auguste Lericolais, Henri Tourniaire, Paul Redondo, and Antoine Baiada, as well as Jean-Claude Rouzaud (France) and Judith Leonard (United States), Chairmen of the Scientific Committee that included Dominique Thomas (France), Jacques Otthiers (Belgium), Annett~ Leveridge (Great Britain), Alain Berthe (France), and Victoria Frampton (Great Britain). July-September 1992
131
Our new officers, Jean-Claude Rouzaud (France), President, Victoria Frampton (Great Britain), SecretaryGeneral, Sue Sewell (New Zealand), Treasurer, and Corrianne van Velze (Republic of South Africa), Historian, bring continuity and experience to our young Federation. With the additional strength of Annette Leveridge (Great Britain), Membership Director Committee, and Judy Colditz (United States), By-laws Committee, we can look forward with great enthusiasm to our Third Congress in Helsinki, Finland, in 1995. Ritta Helin-Fay, President, and the Organizing Committee of the Finnish Hand Therapy Society will host the therapists Congress. Plan to be with us in '95/ I have been deeply honored to have been President of the IFSHT; however, I wish to acknowledge the efforts of those therapists in our member societies who are truly responsible for the progress we have made. I wish to give special recognition to Jean-Claude Rouzaud with whom I have had the privilege of working during these past years. I have great respect and admiration for him. I encourage each of you to become involved in the IFSHT, to support the specialty of hand therapy it serves, and to stretch its expanding horizons. Help shape our future directions as we reach out to each other across all international boundaries in learning, friendship, and peace. BIBLIOGRAPHY 1. Barr N: The Hand: Principles and Techniques of Simple Splintmaking in Rehabilitation. London, Butterworth, 1975. 2. Bell-Krotoski J: "Pocket filaments" and specifications for the Semmes-Weinstein monofilaments. J Hand Ther 3:26-31, 1990. 3. Bell-Krotoski JA, Buford WL Jr: The force/time relationship of clinically used sensory testing instruments. J Hand Ther :7685, 1988. 4. Brandsma JW: Secondary defects of the hand with intrinsic paralysiS: Prevention, assessment and treatment. J Hand Ther 3:14-19, 1990.
132
JOURNAL OF HAND THERAPY
5. Brockman R, Tubiana R, Chamagne P: Anatomic and kinesiologic considerations of posture for instrumental musicians. J. Hand Ther 5:61-64, 1992. 6. Callahan AD: Hand rehabilitation and the American Society of Hand Therapists: A decade of progress. J Hand Ther 1:5357, 1988. 7. Colditz, JC: Low profile dynamic splinting of the injured hand. Am J Occup Ther 37:182-188, 1983. 8. Dennys, LJ, Hurst LN, Cox J: Management of proximal interphalangeal joint fractures using a new dynamic traction splint and early active motion, J Hand Ther 5:16-24, 1992. 9, Evans RB: An update on wound management. Hand Clin 7:409-432, 1992, 10, Evans, RB, Burkhalter WE: A study of the dynamic anatomy of extensor tendons and implications for treatment. J Hand Surg llA: 774-779, 1986. 11. Fess EE: The need for reliability and validity in hand assessment instruments. J Hand Surg 11A: 621-623, 1986, 12, Frampton VM: Management of brachial plexus lesions. J Hand Ther 1:115-120, 1988. 13. Hunter JM, Sattel AB, Belkin J, Masada K: Collateral ligament reconstruction of metacarpophalangeal and proximal interphalangeal joints using porous Dacron tendon. Hand Clin 7:557-568, 1992, 14, Hunter JM, Singer DI, Mackin EJ: Staged flexor tendon reconstruction, In Hunter JM, Schneider LH, Mackin EJ, Calahan AD (eds): Rehabilitation of the Hand: Surgery and Therapy, 3rd Ed, St. Louis, C.V, Mosby, 1989, 15. Malick, MH: Manual on Dynamic Hand Splinting with Thermoplastic Materials, 2nd ed., Pittsburgh, Harmarville Rehabilitation Center, 1978, 16, Malick, MH: Manual on Static Hand Splinting, 4th ed, Pittsburgh, Harmarville Rehabilitation Center, 1978, 17, May EJ, Silfverskiold KL: A new power source in dynamic splinting: Experimental studies. J Hand Ther 2:164-168,1989, 18, May EJ, Silfverskiold KL: A new power source in dynamic splinting: Clinical experience and results. J Hand Ther 2:169174, 1989. 19, McGrouther DA, Ahmed MR: Flexor tendon excursions in "no man's land," The Hand 13:129-141, 1981. 20, Pillet J, Mackin EJ: Aesthetic Restoration, Atlas of Limb Prosthetics: American Academy of Orthopaedic Surgeons, 2nd ed. St. Louis, C. V, Mosby, 1992, 21. van Velze CA, Kluever, I, van der Merwe CA, Mennen U: The difference in volume of dominant and nondominant hands. J Hand Ther 4:6-9, 1991.
he dictionary defines milestone as "a signifi-
T cant or important event in the history or career of a person." For those who witnessed the First American Society of Hand Therapists (ASHT) International Meeting in Rotterdam in 1980 and the beginning of our federation of hand therapy societies in France just a decade ago and all that has come since then, the Second Congress of the International Federation of Societies of Hand Therapists (IFSHT), held in Paris in May 1992, stands as a milestone. As we look into the future with great enthusiasm to an ever-growing membership of hand therapy societies around the world, we should open the windows of our past and pay honor to some of the surgeons and therapists among us who have been mentors and friends, and who have lifted us to this wondrous international level. It was Sterling Bunnell whose forward vision and remarkable energies during World War II led to the establishment of specific hand surgery centers in selected military hospitals across the United States. The "Bunnell Era" showed the way to a small group of surgeons who, as they worked with complex reconstructive surgery, learned to depend on the support offered by the close proximity of physical and occupational therapists. It was Paul Brand in India who used his extraordinary skills and devotion to God to establish the world's first hand rehabilitation center where patients with Hansen's disease received reconstructive surgery and postoperative therapy and were taught new skills to become self-sufficient and live with dignity. Paralleling the work of Bunnell in the United States and Brand in India, Wing Commander Wynn 'Excerpts from the Presidential Address of the 2nd Congress of the International Federation of Societies of Hand Therapists, Paris, France, May 29-30, 1992. Correspondence to Evelyn]. Mackin, PT, Executive Director, Hand Rehabilitation Foundation, 901 Walnut Street, Philadelphia, PA 19107.
Parry in England created a special hand unit within the famed Rehabilitation Service of the Royal Air Force in Chessington. Parry's concepts of sensory reeducation, splinting, and goal-oriented competitive activities provided much of the impetus for hand rehabilitation today. It became very evident to those working in the hand units that a plan for continuity of treatment from injury to maximum recovery was essential if ideal standards were to be achieved in surgery, hand therapy, work therapy, and return to work. Dr. Bunnell organized the American Society for Surgery of the Hand in 1946, and became the first President. Hand therapy as a specialty in the United States followed 30 years later. In 1975 six therapists working closely with surgeons met in San Francisco, Judith Bell-Krotoski (Louisiana), Margaret CarterWilson (Arizona), Mary Kasch (California), Evelyn Mackin (Pennsylvania), Bonnie Olivett (Colorado), and Karen Prendergast-Lauckhardt (New York). The meeting culminated in the founding of the American Society of Hand Therapists with Bonnie Olivett as the first President. Therapists by this time had begun to write and speak extensively regarding hand therapy and educational meetings were attracting hundreds of therapists. This was the beginning ... and it provided the springboard to our international growth and the seeds of the Journal of Hand Therapy. Today we can celebrate together the clinical growth of hand therapy on an international level. We shall always be indebted to D:. Alfred Swanson (United States), Dr. Robert McFarlane (Canada), and Dr. Van der Mueilen (The Netherlands), who in 1980 made possible the American Society of Hand Therapists First International Meeting held during the first Congress of the International Federation of Societies for Surgery of the Hand (IFSSH) in The Netherlands. Approximately 200 therapists and surgeons crowded into a meeting room at the Erasmus University in Rotterdam to attend the "Therapists' Day." It July-September 1992
129
was exciting to share the emerging discipline of hand therapy with our international peers for the first time. In 1983, the hand therapists traveled to historic Boston to participate in the Second Congress. Cindy Phillips and the late Dr. Richard Smith were our hosts. In 1986 Japan invited the hand therapists to participate in the Third Congress. The hospitality extended to us in Japan was exceeded only by Dr. Tajima's kindness and support of the goals of hand therapists. It was shortly after the Congress in Japan that a group of therapists from several countries met during the Congress of La Societe Fran~aise de Chirurgie de la Main (GEM) in Paris. With encouragement from Drs. Raoul Tubiana and Yves Allieu (France) and R. Georgio Brunelli (Italy), the International Federation of Societies of Hand Therapists was founded. In 1989 when we went to Israel to participate in the Fourth Congress, we went as the IFSHT with 12 member societies throughout the world, Australia, Belgium, Brazil, France, Great Britain, Israel, Italy, Japan, New Zealand, Poland, Republic of South Africa, and the United States. Societies continued to arise from the enthusiasm of a few therapists in each country, and we now have 18 member societies that include Canada, Finland, Greece, The Netherlands, Sweden, and Switzerland. In addition, we have corresponding members in Austria, Germany, Lithuania, Malaysia, Norway, Spain, and Taiwan. During these past years since the First Congress held in Rotterdam, therapists have continued to learn from the sciences of biology, biomechanics, anatomy, and neurophysiology, and this quest to learn has not been just in anyone country-it's worldwide and our collective knowledge is reflected in growth and change in many clinical areas, including management of healing wounds, splinting, management of the healing tendon, sensibility, evaluation, and returnto-work programs. As we move forward into the future, it serves us well to recognize a few of those colleagues of ours who laid down in fact, and in spirit, the foundations upon which we are now building. Roslyn Evans (United States) introduced us to a universal classification system for open wounds developed by Marion Laboratories that simplifies wound description as it relates to each phase of wound healing. Thus, while we necessarily speak in terms of number of days or weeks post injury or surgery, we do so by an approach that uses color to describe wound status. The red wound is uninfected, properly healing with definite borders, granulation tissue and collagen synthesis occurring. The yellow wound is draining, purulent, characterized by slough that is semi-liquid to liqUid in texture. The black wound is covered with eschar or thick necrotic tissue. Corrianne van Velze (South Africa) and her colleagues demonstrated that there is a difference in the volumes of the dominant and nondominant hands, and that, on average, the left hand is 3.43% smaller than the right hand. It is therefore possible to use the measurement of the uninvolved hand to predict the volume of the involved hand, enabling us to set realistic goals for our patients. 130
JOURNAL OF HAND THERAPY
Nathalie Barr (Great Britain) has been one of our earlier teachers in the principles and techniques of splinting. Her career spanned wars and continents. Professor Yves Allieu and Jean-Claude Rouzaud (France) provided a consistent and controlled force to dynamic splinting when they developed in France the Scomac springs. The premeasured steel springs were the first commercially available springs developed especially for splinting and were a response to the need for quantification and objective treatment technique when applying forces in dynamic splinting. Lisa Dennys, Lawrence Hurst, and Jane Cox (Canada) reported their good results and patient compliance in the management of PIP joint fractures using a lateral-hinge dynamic traction splint, combined with early active motion. Esther May and Kris Silfverskiold (Sweden) have added to the field, too, by their research on a new power source in dynamic splinting that addresses flexor tendon mobilization in the early postoperative period. Dr. Jean Pillet (France) listened to the functional needs as well as the psychological needs of the amputee and provided an aesthetic prosthesis that can lengthen a person's shortened index finger, enabling him or her to play the piano, and prostheses for so many other amputees, to better integrate these people into the complex socioeconomic environment of today's society. Tendon management, especially for zone II flexor tendon injuries, is another area of tremendous growth. The research and teaching of many dedicated surgeons, such as Harold Kleinert (United States) and Goran Lundberg (Sweden), have vastly improved our knowledge of tendon nutrition through vincular and synovial sheath pathways, of intrinsic vs. extrinsic tendon healing, and of anatomy of the pulley system and its importance to digital function. We have learned that pulley reconstruction is as sensitive as tendon repair and that repaired pulleys must be protected, with special attention to the Al pulley. The Al pulley fair leads and protects the A2 pulley by reducing the angular power drive at the proximal end of the construction. Firm pressure on a repaired Al pulley during rehabilitative training is important. It has been a great honor for me to have been associated with Dr. James Hunter for over 25 years and been a witness to the leading edge of advances in tendon surgery. The results are that early motion with elastic band protection has become the most favored form of aftercare tendon repair. Strickland (United States) reports results with early passive motion better than with 3 1/2 weeks of immobilization . Meals (United States) reports recovery of repaired digital nerves not compromised by protective early motion. Gelberman (United States) reports that early motion stimulates maturation and remodeling of scar tissue. We learned from McGrouther and Ahmed (Scotland) in 1981 that complete excursion of the FOP and differential excursion between the FOP and FDS could be accomplished only through flexion-of the DIP jOint. In other words, they report it is necessary to flex the
joints distal to the repair to achieve glide of a tendon. This study has obvious and profound implications for all passive mobilization programs . New splinting protocols emphasize this concept. The development of the staged tendon graft surgery by Hunter opened the way to restoration of function in a digit unfit for single-stage grafting. The Hunter active tendon implant is leading to new applications. The core of the implant is a porous Dacron weave designed by textile engineers to simulate the weave of collagen fibers. Currently, Dr. Hunter is using the core in ligament reconstruction in the MP and PIP joints and in the flail distal radial/ulnar joint. This work is in laboratory and clinical study stages. The end result is to help the patient achieve a comfortable balance between mobility and stability of the reconstructed joint and build strength within that range. Roslyn Evans and the late Dr. William Burkhalter (United States) applied the concepts of tendon healing, tendon excursion, and methods of flexor tendon care to the extensor system based on the KleinertDuran method, and thereby improved our management of complex extensor tendon injuries in zones 5, 6, and 7 with early controlled motion. Dominique Thomas (France) demonstrated the value of functional electrical stimulation as an adjunct to patient care to augment or enhance tendon excursion at the appropriate stage of wound healing following tendon surgery, i.e., tenolysis. Sensibility evaluation is yet another area of clinical growth . The word sensibility is synonymous with Erik Moberg, for it has been the teachings of Dr. Moberg (Sweden) that have led the way in one of the most challenging aspects of nerve injury and regeneration. Great respect is due Judy Bell-Krotoski (United States), who is the therapist most responsible for increasing our knowledge in this area. From Judy and her team we have learned that no hand-held instrument that we use in the clinic today is capable of testing specifically for one type of sensory receptor. Of the hand-held instruments in current use, the Semmes-Weinstein monofilaments are the most reliable, and Judy has demonstrated that when the monofilaments are calibrated to ensure correct length and diameter and given that these two dimensions are correct, "the application forces of the filaments are repeatable within a predictable range." Thus, they are "controlled, objective, reproducible force stimulus" for testing peripheral nerve function. The complete kit of monofilaments in its present form can be cumbersome to use and expensive. A smaller kit was made, however. Judy has gone on to develop the "pocket filaments. " Telescoping rods allow extension and collapse of the filaments. Prof. Raoul Tubiana and Philippe Chamagne (France) have made us pay attention to the medical difficulties of the musician and remind us that causative factors for instrument-related injuries can be analyzed with much the same reasoning one applies to sports and workplace injuries. The rehabilitation of a patient with a brachial plexus injury is a difficult and prolonged process.
The implications of the injury are considerable as the majority of the patients are young men with many years of life ahead. Vicky Frampton (Great Britain) has increased our knowledge as clinician, teacher, and author. Evaluation has been another area of clinical growth. Elaine Fess (United States) has been our greatest advocate of the need for reliability and validity in hand evaluation and has directed her efforts toward that end. Time does not allow me to mention all of the many others among us who continue to assess their performance as clinicians, such as Wilma Walsh (Australia), Wim Brandsma (The Netherlands), Maude Malick (United States), and Judy Colditz (United States). It is impossible to imagine our specialty without their contributions. They are the trailblazers who lead the way, like Mayumi Nakada Gapan), tireless pioneer in the field of sensory investigation. Now, what are the dreams and future goals of our Society with this impressive past? Roz Evans reminds us that we must still question why? when? how much? what for? how often? ... what if? Our role is an exacting one. To maintain our status as a federation of societies highly qualified in the care and treatment of the disabled hand, we must individually and collectively continue to refine our skills. We can be proud of our approximately 1,500 members in the IFSHT on continents throughout the world. But we must look to regional membership in the IFSHT, involving those countries that may be unable to form their own societies. As we map out the road we wish to travel, the goals we set for ourselves, it is most important, I believe, that we stay tuned to each other, hear and understand each other, give to each other, and take from each other.
• RETROSPECTIVE NOTES The Second Congress of the IFSHT, so eagerly looked forward to, is now over . .. however, the memory of Paris in May '92 will never be forgotten! It was a superb educational experience exceeded only by the opportunity to meet 561 colleagues from countries (Argentina, Australia, Austria, Belgium, Brazil, Canada, Finland, France, Germany, Great Britain, Greece, China, India, Israel, Italy, Japan , Luxembourg, Malaysia, The Netherlands, New Zealand, Norway, Portugal, Republic of South Africa, Spain, Sweden, Switzerland, Taiwan, Tunisia, Turkey, the United States) throughout the world. We exchanged ideas . . . shared knowledge . . . and laughed together. It was fantastic! We owe a special debt of thanks to the GEMMSOR, French Society of Hand Therapists, especially thanking Philippe Chamagne and his Organizing Committee, Philippe Durafourg, Auguste Lericolais, Henri Tourniaire, Paul Redondo, and Antoine Baiada, as well as Jean-Claude Rouzaud (France) and Judith Leonard (United States), Chairmen of the Scientific Committee that included Dominique Thomas (France), Jacques Otthiers (Belgium), Annett~ Leveridge (Great Britain), Alain Berthe (France), and Victoria Frampton (Great Britain). July-September 1992
131
Our new officers, Jean-Claude Rouzaud (France), President, Victoria Frampton (Great Britain), SecretaryGeneral, Sue Sewell (New Zealand), Treasurer, and Corrianne van Velze (Republic of South Africa), Historian, bring continuity and experience to our young Federation. With the additional strength of Annette Leveridge (Great Britain), Membership Director Committee, and Judy Colditz (United States), By-laws Committee, we can look forward with great enthusiasm to our Third Congress in Helsinki, Finland, in 1995. Ritta Helin-Fay, President, and the Organizing Committee of the Finnish Hand Therapy Society will host the therapists Congress. Plan to be with us in '95/ I have been deeply honored to have been President of the IFSHT; however, I wish to acknowledge the efforts of those therapists in our member societies who are truly responsible for the progress we have made. I wish to give special recognition to Jean-Claude Rouzaud with whom I have had the privilege of working during these past years. I have great respect and admiration for him. I encourage each of you to become involved in the IFSHT, to support the specialty of hand therapy it serves, and to stretch its expanding horizons. Help shape our future directions as we reach out to each other across all international boundaries in learning, friendship, and peace. BIBLIOGRAPHY 1. Barr N: The Hand: Principles and Techniques of Simple Splintmaking in Rehabilitation. London, Butterworth, 1975. 2. Bell-Krotoski J: "Pocket filaments" and specifications for the Semmes-Weinstein monofilaments. J Hand Ther 3:26-31, 1990. 3. Bell-Krotoski JA, Buford WL Jr: The force/time relationship of clinically used sensory testing instruments. J Hand Ther :7685, 1988. 4. Brandsma JW: Secondary defects of the hand with intrinsic paralysiS: Prevention, assessment and treatment. J Hand Ther 3:14-19, 1990.
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5. Brockman R, Tubiana R, Chamagne P: Anatomic and kinesiologic considerations of posture for instrumental musicians. J. Hand Ther 5:61-64, 1992. 6. Callahan AD: Hand rehabilitation and the American Society of Hand Therapists: A decade of progress. J Hand Ther 1:5357, 1988. 7. Colditz, JC: Low profile dynamic splinting of the injured hand. Am J Occup Ther 37:182-188, 1983. 8. Dennys, LJ, Hurst LN, Cox J: Management of proximal interphalangeal joint fractures using a new dynamic traction splint and early active motion, J Hand Ther 5:16-24, 1992. 9, Evans RB: An update on wound management. Hand Clin 7:409-432, 1992, 10, Evans, RB, Burkhalter WE: A study of the dynamic anatomy of extensor tendons and implications for treatment. J Hand Surg llA: 774-779, 1986. 11. Fess EE: The need for reliability and validity in hand assessment instruments. J Hand Surg 11A: 621-623, 1986, 12, Frampton VM: Management of brachial plexus lesions. J Hand Ther 1:115-120, 1988. 13. Hunter JM, Sattel AB, Belkin J, Masada K: Collateral ligament reconstruction of metacarpophalangeal and proximal interphalangeal joints using porous Dacron tendon. Hand Clin 7:557-568, 1992, 14, Hunter JM, Singer DI, Mackin EJ: Staged flexor tendon reconstruction, In Hunter JM, Schneider LH, Mackin EJ, Calahan AD (eds): Rehabilitation of the Hand: Surgery and Therapy, 3rd Ed, St. Louis, C.V, Mosby, 1989, 15. Malick, MH: Manual on Dynamic Hand Splinting with Thermoplastic Materials, 2nd ed., Pittsburgh, Harmarville Rehabilitation Center, 1978, 16, Malick, MH: Manual on Static Hand Splinting, 4th ed, Pittsburgh, Harmarville Rehabilitation Center, 1978, 17, May EJ, Silfverskiold KL: A new power source in dynamic splinting: Experimental studies. J Hand Ther 2:164-168,1989, 18, May EJ, Silfverskiold KL: A new power source in dynamic splinting: Clinical experience and results. J Hand Ther 2:169174, 1989. 19, McGrouther DA, Ahmed MR: Flexor tendon excursions in "no man's land," The Hand 13:129-141, 1981. 20, Pillet J, Mackin EJ: Aesthetic Restoration, Atlas of Limb Prosthetics: American Academy of Orthopaedic Surgeons, 2nd ed. St. Louis, C. V, Mosby, 1992, 21. van Velze CA, Kluever, I, van der Merwe CA, Mennen U: The difference in volume of dominant and nondominant hands. J Hand Ther 4:6-9, 1991.