Postoperative hand therapy management of zones V and VI extensor tendon repairs of the fingers: An international inquiry of current practice

Journal of Hand Therapy xxx (2020) 1e17

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Journal of Hand Therapy journal homepage: www.jhandtherapy.org

Postoperative hand therapy management of zones V and VI extensor tendon repairs of the fingers: An international inquiry of current practice Melissa J. Hirth B (OT), MSc (Hand & Upper Limb Rehab) a, b, c, *, Julianne W. Howell PT, MS, CHT d, Lynne M. Feehan BScPT, MSc, PhD e, Ted Brown PhD, MSc, MPA, BScOT(Hons), GCHPE, OT(C), OTR, MRCOT, FOTARA, FAOTA c, Lisa O’Brien PhD, B App Sci (OT), M Clin Sci (Hand & Upper Limb Rehab), Grad Dip Ergonomics, Grad Cert Clinical Research Methods c a

Occupational Therapy Department, Austin Health, Heidelberg, Victoria, Australia Malvern Hand Therapy, Malvern, Victoria, Australia c Department of Occupational Therapy, Faculty of Medicine, Nursing and Health Sciences, Monash University e Peninsula Campus, Frankston, Victoria, Australia d Saint Joseph (Self-employed), MI, USA e Faculty of Medicine, Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada b

a r t i c l e i n f o

a b s t r a c t

Article history: Received 30 August 2019 Received in revised form 27 November 2019 Accepted 31 December 2019 Available online xxx

Study Design: Electronic Web-based survey. Introduction: Evidence supports early motion over immobilization for postoperative extensor tendon repair management. Various early motion programs and orthoses are used, with no single approach recognized as superior. It remains unknown if and how early motion is used by hand therapists worldwide. Purpose of the Study: The purpose of this study was to determine if there is a preferred approach and identify practice patterns for constituents of International Federation of Societies for Hand Therapy fullmember countries. Methods: Participation in this English-language survey required respondents to have postoperatively managed at least one extensor tendon repair within the previous year. Approaches surveyed included programs of immobilization, early passive (EPM), and early active (EAM) with motion delivered by resting hand, dynamic, palmar/interphalangeal joints (IPJs) free, or relative motion extension (RME) orthoses. Survey flow depended on the respondent’s answer to their “most used” approach in the previous year. Results: There were 992 individual responses from 28 International Federation of Societies for Hand Therapy member countries including 887 eligible responses with an 81% completion rate. The order of most used program was EAM (83%), EPM (8%), and immobilization (7%). The two most used orthoses for delivery of EAM were RME (43%) and palmar/IPJs free (25%). The RME orthosis was preferred for earlier recovery of hand function and motion. Barriers to therapists wanting to use the RME/EAM approach related to preference of surgeon (70%) and clinic (24%). Discussion: In practice, many therapists select from multiple approaches to manage zone V and VI extensor tendon repairs. Therapists believed TAM achieved with the RME/EAM approach was superior to the other approaches. Contrary to the literature, in practice, many therapists modify forearm-based palmar/IPJs free orthosis to exclude the wrist to manage this diagnosis. Conclusions: The RME/EAM approach was identified as the favored approach. Practice patterns and evidence did not always align. Ó 2020 Published by Elsevier Inc. on behalf of Hanley & Belfus, an imprint of Elsevier Inc.

Keywords: Extensor tendon Hand therapy Relative motion Orthosis Splint Survey

Introduction

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

Numerous approaches1-3 have been described for therapy management of postoperative extensor tendon repairs in zones V and VI as delineated by Kleinert and Verdan.4 All aim to optimize patient outcomes, accomplishing this with various orthoses and types of motion. Five systematic reviews have identified four

0894-1130/$ e see front matter Ó 2020 Published by Elsevier Inc. on behalf of Hanley & Belfus, an imprint of Elsevier Inc. https://doi.org/10.1016/j.jht.2019.12.019

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separate motion programs (immobilization, early controlled mobilization, early active mobilization, early passive motion) and two types of orthosis (static and dynamic).5-9 These motion programs, when combined with either type of orthosis become a specific “approach” to guide therapists’ postoperative management of tendon repair. The orthoses and type of motion used in the approaches are quite similar; however, the different names are confusing. To aid clarity, the approaches can be grouped into five main combinations of orthosis and motion: resting hand orthosis with interphalangeal joints (IPJs) included [immobilization]; resting hand orthosis with IPJs included [early active motion]; palmar resting orthosis with IPJs free [early active motion]; dynamic orthosis [early controlled or early passive motion]; and relative motion extension (RME) orthosis [early active motion].6-8 There is general consensus that early motion is likely to result in quicker recovery of mobility than immobilization,6-9 and that early active motion (EAM) is likely superior to all the other programs; however, which is the best orthosis to facilitate active motion is still unclear.9 Given the lack of a clearly superior EAM approach, it is likely that hand therapists are using factors other than high-quality evidence to guide their choice of therapy program and the type of motion delivered or permitted by the orthosis. To further improve our understanding of what choices therapists are making, we conducted an international survey. Our aim was to describe current practice patterns of therapists from IFSHT full-member countries who have managed postoperative finger extensor tendon repairs in zones V and VI (Fig. 1) in the previous 12 months. Specifically, we intended to
identify whether there is a preferred postoperative management approach (therapy program þ orthosis);
investigate how reported practices align with current evidence;
compare how the preferred orthosis design, perceived level of skill and amount of time to fabricate the orthosis, duration of








orthosis wear, and level of hand function and therapeutic exercises were recommended when the orthosis worn varies across different management approaches; compare therapist-reported outcomes for the different approaches used; explore therapist perceptions regarding the advantages and disadvantages of the various approaches; explore the factors that influence the selection of a postoperative approach; identify barriers to implementing therapists’ preferred approach; describe variations in the return to work process, such as who provides the return to work guidelines, usual timing for return to work, and common reasons for delayed return to work.

Methods Survey planning and administration was undertaken as per the guidelines by Jones et al10 and planned and reported as per the “Checklist for Reporting Results of Internet E-Surveys” (CHERRIES).11 Ethics approval was obtained from the Monash University Human Research Ethics Committee, Victoria, Australia (13583). We created a Web-based survey using the Qualtrics platform (Qualtrics, Provo, UT). Our aim was to include all therapist members from International Federation of Societies for Hand Therapy (IFSHT) fullmember countries. Each country’s IFSHT representative was contacted by email (up to three times) by the primary author (MH) to invite membership participation in the survey. Each representative was sent a copy of the survey for review and a consent to participate form and asked to provide the total number of therapist members in their organization. If the original invitation emails were not answered, the contact details were confirmed with the Secretary General of the IFSHT. It was the responsibility of each national organization to distribute the email invitation to their membership. Outlined in the invitation was the purpose of the study, information about consent and voluntary participation, and the online link to the survey. After the initial email was sent out by the national organizations, each representative was sent a second email to distribute to their membership as a reminder to complete the survey. To encourage participation, respondents were informed that a small donation for each survey completed would be made by the authors to the IFSHT Triennial Congress Travel grant fund. The informed consent process on the initial page of the survey consisted of an introduction to the investigating team, an estimate of the time required to complete the survey, assurance that all answers and data would be nonidentifiable, partial responses may be included in the analysis, and completion of the survey implied consent to participate. To qualify for participation in the survey, each therapist had to answer “yes” to the initial screening question in the survey stating they had postoperatively managed at least one zone V-VI extensor tendon repair within the previous 12 months. Survey instrument

Fig. 1. Extensor tendon zones (Rights retained by the illustrator, Craig Hirth).

The survey (see Appendix 1) was designed by the authors of this study. Authors MH, JH, LF, and LO’B each having over 20 years of practical experience in hand therapy and authors LF, TB, and LO’B have extensive experience in survey design and implementation. The survey items were constructed to obtain information about current preferences and practice in the postoperative management of extensor tendons in finger zones V and VI based on the approaches shown in Figures 2A-2F, along with an option to select “other”. Survey flow varied depending on the respondent’s answer to their most used postoperative therapy approach in the previous 12 months. As the relative motion extension (RME)/EAM approach

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Fig. 2. A-F. Orthosis/program examplesd(A) resting hand orthosis [immobilization], (B) resting hand orthosis [EAM], (C) palmar resting orthosis with IPJs free [EAM], (D) dynamic orthosis [EPM], (E) RME plus [EAM], and (F) RME only [EAM].

has been described with a wrist orthosis as ‘RME plus’ and without a wrist orthosis as ‘RME only’, data for each was collected separately. Before survey dissemination, technical functionality was tested by authors MH, JH, and LF, each moving through the survey several times, changing their responses to fit the various possible combinations. Additional technical functionality and field testing for content relevancy and utility was undertaken with experienced hand therapy colleagues (Occupational Therapists and Physical Therapists) in Australia (n ¼ 12) and the United States of America (n ¼ 11).10 Minor word and phrase revisions were made to clarify questions and “time” intervals were added to time-based questions. The final survey questions included closed (forced choice) and open-ended (free text) answer options.10 While there were 262 questions in the final survey, participants answered between 39 and 60 questions because adaptive questioning with branches, skip logics, and display logics were used (see Appendix 2).11 The survey was also designed to group-related questions, such as details of orthosis fabrication, separately from questions surrounding return to work details. Consequently, the number of items per page varied and, with adaptive questions, the number of survey pages varied for each participant. Whenever the survey branched, answers to the questions were mandatory to ensure appropriate survey flow. If there was no branching, answers to questions were optional. Hence, not all questions were answered by all participants. A “back” button was available for the purpose of returning to review previous questions and responses; however, a check for completeness was not an option provided before the final survey submission. The use of the word “usual” was added to many questions to be sensitive to the fact that various factors impact clinical reasoning, and hence therapy interventions can and do vary between patients. Similarly, therapists were asked questions related to their “most used approach during the previous 12 months” to acknowledge that many respondents use more than one approach. The term “splint” was selected over “orthosis” for survey questions, as currently “splint” is more widely used globally than “orthosis”. Responses to closed questions were analyzed descriptively while thematic analysis was utilized for open-ended questions and was completed by authors MH. and JH. To establish trustworthiness and rigor of the thematic analysis, several phases were involved in

the analyses.12 This included MH and JH becoming familiar with the raw data in the Excel spreadsheet, peer debriefing on initial codes, diagramming to make sense of theme connections, reaching a consensus on themes, and debriefing and review by therapy colleagues.12 Given the large amount of information collected in this survey, we have chosen to report selected descriptive quantitative and summary thematic analyses for the main findings of this survey.

Results Survey response The same survey was used across all participating national hand therapy organizations, opening on the 3rd of July 2018 and closing on the 11th February 2019. All 36 IFSHT full-member countries were invited to participate and 28 participated. Reasons for nonparticipation included inability to use the organization’s database for nonsociety matters, limited English comprehension by their members, and failure to return a willingness to participate form. No response was received from four organizations, and two organizations chose to send the survey only to selected members.

Fig. 3. Number of adult extensor tendon zone V-VI repairs managed in the past year.

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Table 1 Participating countries and eligible respondents

Participating countries (Hand Therapy Association/Society membership) grouped into 8 global regionsa Eligible respondents/number of email requests sent to participate in the survey Asia Hong Kong

Middle East, North Africa, Greater Arabia Turkey

4/50

4/65

Europe Austria Belgium Denmark France Germany Ireland The Netherlands Norway Portugal Slovenia Spain Sweden Switzerland The United Kingdom 272/3643

North America Canada The United States

Central America, Caribbean Guatemala

South America Argentina Brazil Chile Columbia Uruguay

Sub-Sahara Africa Kenya South Africa

Australia, Oceania Australia New Zealand

136/3598

1/16

44/336

11/110

184/1074

Bold is responses received from those who were send the survey for each region. The 8 global regions are in italics. a One therapist from a non-participating national hand therapy organization completed the survey, for a total of 29 represented countries.

The survey was sent to a total of 8892 therapists across the 28 participating organizations. The overall survey response rate was 11% with 997 therapists responding and 887 satisfying the eligibility criteria of managing one or more zone V-VI extensor tendon repairs in the past year. Of those who commenced the survey, the completion rate was 81% (n ¼ 722).

Respondent demographics Figure 3 details the number of ETs managed over the previous year by the respondents and Table 1 identifies countries and number of participating therapists. English was chosen by 71% as their primary language. The occupational to physical therapy ratio was 3:1, which included 762 females, 12 males, and two other. The number of respondents distributed across each age category was 20 to 29 years, 68; 30 to 39 years, 269; 40 to 49 years, 240; 50 to 59

years, 208; and 60þ years, 88. Table 2 describes specific professional qualifications and experience of the respondents. Extensor tendon orthosis/program approaches used in the previous 12 months (select 1 or more) Many respondents indicated they had used more than one approach in the previous 12 months, for a total of 1793 responses (see Fig. 4). The most commonly reported approach was RME/EAM (65%), followed by the palmar resting orthosis with IPJs free/EAM approach (50%). Extensor tendon orthosis/program “most used” approach in the previous 12 months (select 1 only) There were 853 responses to the questions. The most used approach (Fig. 5) was the RME/EAM (43%), followed in descending

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Table 2 Professional qualifications and clinical experience of respondents (n ¼ 887b) Post-secondary rehabilitation or research qualification(s) (select ALL that apply) Entry levela diploma/bachelors/ masters/clinical doctorate

Postgrad. Diploma (hand therapy focus)

Postgrad. Diploma (other)

788

138

43

Postgrad. Masters: Coursework or research (hand therapy focus) 82

Postgrad. Masters: Coursework or research (other) 74

Postgrada Clinical Doctorate 26

Postgrad. PhD: research

Other

14

54

Number of years practicing in hand therapy specialty <1 7 (<1%)

1-4 114 (13%)

1-4 114 (13%)

10-14 157 (18%)

15-19 145 (17%)

20þ 264 (30%)

Number of years working as a rehabilitation professional <1 1 (0.2%)

1-4 57 (6.5%)

5-9 129 (15%)

10-14 139 (16%)

15-19 147 (17%)

20þ 395 (45.5%)

Do you have added specific credentials in hand therapy? Yes 497 (58%)

No 361 (42%)

If yes, hand therapy credentials (select ALL that apply) Accredited hand therapist 112 (23%)

Certified hand therapist 364 (73%)

Other 62 (12%)

Postgrad ¼ Postgraduate. a In occupational therapy or physical therapy. b Total does not always add to 887 as responses to many questions were not mandatory.

order by the palmar resting orthosis with IPJs free/EAM (25%), resting hand orthosis/EAM (15%), dynamic orthosis/EPM (8%), resting hand orthosis/immobilization (7%), and “other” (2%). Table 3 details the most commonly used approach by country. Skill level to fabricate the orthosis/es There were 725 responses to this question. The dynamic orthosis was rated as needing the most skill to fabricate (mean difficulty: 7.3/10), followed by RME plus (mean difficulty: 6.0/10), with the remaining options reported as having a similar level of skill needed for fabrication (mean difficulty: 4.9-5.6/10) (see Table 4).

Time required to fabricate the orthosis/es There were 730 responses to this question. Of these responses, it was reported that a dynamic orthosis took the longest to fabricate (45-60 min) with the RME only orthosis taking the least amount of time, 38% of RME only users reporting less than 10 min for fabrication, and 50% reporting 10 to 19 min for fabrication (see Table 4). Therapeutic exercise prescription Most therapists (n ¼ 681 of 702 responses) routinely prescribe exercises (see Table 4) except the resting hand orthosis/immobilization approach which avoids motion during the postoperative

Fig. 4. Approaches used in the previous 12 months [more than one option could be selected] (n ¼ 1796).

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Fig. 5. Most used approach during the previous 12 months [one option only selected] (n ¼ 853, no response n ¼ 34).

phase of orthosis wear. Exercises were mostly performed while wearing the orthosis (61%-83%). Depending on the orthosis/program used, most of the 753 respondents (varying from 39% to 75%) waited to commence “out of orthosis” composite active finger flexion (MCP þ PIP þ DIP joints) until 4-6 weeks after repair (see Table 4). Orthosis design preferencedPalmar resting orthosis with IPJs free [early active motion] Of 202 therapists who selected the palmar resting orthosis with IPJs free/EAM as their preferred approach, 61% reported they did

not use an attachment overnight to extend the IPJs and 31% stated they usually did add an attachment. Orthosis design preferenceddynamic orthosis [early passive motion] Of 60 therapists using a dynamic orthosis, 69% restricted MCP joint flexion either using a palmar block attachment (47%), or a stop bead (22%). When asked how many fingers were included in the dynamics of the orthosis, 26 indicated all four fingers, 23 only the injured and adjacent fingers, and 19 the injured finger only. Thirtythree of the dynamic orthosis/EPM approach users issued a second overnight resting hand orthosis, 22 advised patients to wear the

Table 3 Most used approach by country Country

Number of therapists responding to this question

Resting hand orthosis, IPJs included [IMMOBILE]

Resting orthosis, IPJs included [EAM]

Palmar orthosis, IPJs free [EAM]

Dynamic orthosis [EPM]

Relative motion extension orthosis [EAM]

“Other” An alternative approach selected

Argentina Australia Austria Belgium Brazil Canada Chile Columbia Denmark Germany Guatemala Hong Kong Ireland Kenya The Netherlands New Zealand Norway Portugal Slovenia South Africa South Korea Spain Sweden Switzerland Turkey The United Kingdom The United States Uruguay Total

23 139 11 2 11 46 2 3 20 20 1 4 19 9 43 44 5 1 3 12 1 6 40 18 4 88 275 3 853

4 5 1 2 4 3 1 1 1 1 1 1 15 1 1 2 14 3 61

23 1 2 1 2 1 12 3 4 14 2 1 5 1 42 14 128

8 18 2 1 2 17 1 7 1 3 2 3 3 6 1 17 1 1 6 110 210

6 2 6 1 1 1 13 3 2 1 3 1 2 1 1 2 19 65

3 90 2 1 5 22 1 2 1 1 6 1 36 25 2 3 1 1 14 37 114 368

2 1 4 1 5 2 1 1 4 21

IMMOBILE ¼ immobilization; EAM ¼ early active motion; EPM ¼ early passive motion; IPJs ¼ interphalangeal joints.

Table 4 Orthosis/program comparison based on percentage of total responses (for questions see Appendix 1) Variable

Resting hand orthosis, IPJs included (IMMOBILE)

Resting hand orthosis, IPJs included (EAM)

Palmar resting orthosis, IPJs free [EAM]

Dynamic orthosis [EPM]

RME plus wrist orthoses [EAM]

RME only orthosis [EAM]

5.63 2.32/5.39 59 <10 10-19 20-29 30-44 45-60 60þ 59 Not applicable

4.92 2.33/5.42 106 <10 10-19 20-29 30-44 45-60 60þ 106 Yes

5.30 2.16/4.65 202 <10 10-19 20-29 30-44 45-60 60þ 201 Yes No 201 0-13 14-27 28-41 42-55 56-69 70þ 198 In Out Both 200 Yes No 198 2-4 4-6 6-8 8-10 173 4-6 6-8 8-10 10þ 174 2-4 4-6 6-8 8-10 24

7.34 2.11/4.65 61 <10 10-19 20-29 30-44 45-60 60þ 59 Yes No 61 0-13 14-27 28-41 42-55 56-69 70þ 58 In Out Both 56 Yes No 58 2-4 4-6 6-8 8-10 32 4-6 6-8 8-10 10þ 32 2-4 4-6 6-8 8-10: 0 25

6.02 1.89/3.55 220 <10 10-19 20-29 30-44 45-60 60þ 225 Yes No 256 0-13 14-27 28-41 42-55 56-69 70þ 258 In either Out either Both 249 Yes No 258 0-2: 1% 4-6 6-8 8-10 196 4-6 6-8 8-10 10þ 196 2-4 4-6 6-8 8-10 54

5.45 2.15/4.61 77 <10 10-19 20-29 30-44 45-60 60þ 80 Yes No 78 0-13 14-27 28-41 42-55 56-69 70þ 79 In Out Both 89 Yes No 79 2-4 4-6 6-8 8-10 67 4-6 6-8 8-10 10þ 67 2-4 4-6 6-8 8-10 10

Orthosis examples

Skill 0-10 mean SD/Var. Number of responses Time to fabricate (minutes)

Number of responses Exercises during full-time phase of orthotic wear (in/out or both of the orthosis) Number of responses Full to part-time step-down phase of orthotic wear Number of responses Change from full to part-time orthotic wear (weeks)

Number of responses Stop orthosis completely [after stepdown phase of orthotic wear] (weeks) Number of responses Stop orthosis completely [no stepdown phase of orthotic wear] (weeks) Number of responses

0-13 14-27 28-41 42-55 56-69 70þ 54 Not applicable

7% 26% 39% 24% 0 4%

Yes No 52 2-4 4-6 6-8 8-10 43 4-6 6-8 8-10 10þ 42 2-4 4-6 6-8 8-10 8

85% 15% 24% 44% 30% 2% 19% 38% 33% 10% 25% 38% 25% 12%

106 0-13 14-27 28-41 42-55 56-69 70þ 106 In Out Both 106 Yes No 106 2-4 4-6 6-8 8-10 96 4-6 6-8 8-10 10þ 95 2-4 4-6 6-8 8-10 10

19% 57% 21% 3% <1% 0 100%

6% 3% 68% 23% <1% 0 83% 9% 8% 91% 9% 2% 72% 24% 2% 4% 63% 30% 3% 0 40% 60% 0

4% 35% 39% 21% 1% 0 99.5% n ¼ 1 0.5% 1% 16.5% 64% 17.5% 1% 0 68% 6% 27% 88% 12% 7% 60% 32% 1% 10% 56% 28% 6% 0 46% 54% 0

0 7% 17% 24% 41% 11% 95% n ¼ 3 5% 0 14% 55% 28% 1.5% 1.5% 61% 14% 25% 57% 43% 16% 56% 25% 3% 16% 59% 19% 6% 8% 20% 68% 10þ: 4%

2% 25% 41% 26% 5% <1% 96.5% n ¼ 9 3.5% 1% 9.5% 56% 31.5% 2% 0 83% 2% 15% 79% 21% 2-4: 5% 52% 25% 3% 11% 49% 37% 3% 2% 20% 72% 6%

38% 50% 10% 2% 0 0 90% n ¼ 8 10% 0 9% 76% 13% 1% 1% 76% 15% 9% 87% 13% 7.5% 67% 2% 4.5%

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Number of responses Exercises during the phase of full-time orthotic wear Number of responses Composite finger flexion out of orthosis (days)

7% 35% 39% 14% 2% 3%

18% 54% 22% 6% 0 60% 40% 0

IMMOBILE ¼ immobilization; EAM ¼ early active motion; EPM ¼ early passive motion; RME ¼ relative motion extension; SD ¼ standard deviation; Var. ¼ variance.

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dynamic orthosis full-time, and six reported a variety of alternatives including removing the dynamics at night and use of an overnight palmar resting orthosis with the IPJs free. The arc of MCP joint motion permitted during the postoperative phase of orthosis wear was between 30 and 45 in most patients (n ¼ 29), followed by an arc of motion between 46 and 60 (n ¼ 12), then an arc of less than 30 (n ¼ 5). A single respondent allowed a 61 to 75 arc of motion. Orthosis design preferencedRelative motion orthoses [early active motion] Of the 353 respondents who used the RME approach, most chose RME plus (47%) or a combination of RME plus and RME only (44%). Only 9% exclusively chose RME only. When users of “both” were asked to select their single most used RME approach over the past 6 months, most (67%) used RME plus. Orthotic wear time Independent of the type of orthosis used, a large percentage (82% of 751 responses) of therapists reported a “weaning” or “step-down” phase from full to part-time orthosis wear. Those more likely to not wean orthosis wear were the dynamic orthosis users (43% of 58 responses) (see Table 4). The timing for transition from full- to part-time wear most commonly occurred during the 4 to 6 weeks postoperative period, varying from 44% to 72% depending on the orthosis used. However, transition from parttime to nonwear occurred between 6 and 8 weeks with the percentage varying between 38% and 63% depending on orthosis used. For those that did not use a step-down phase (n ¼ 131), the orthosis was stopped slightly earlier, between 4 and 6 weeks (20%75%) (see Table 4). Hand functional usedDuring orthotic wear Ratings of patient ability to use the hand when wearing the orthosis varied widely between the mean ability of 1.54 and

6.77/10 (see Table 5). Therapists who used RME orthoses gave the highest means for functional ability while wearing the orthosis (RME plus mean ability: 6.6/10, RME only mean ability: 6.77/10) in contrast to therapists who used a resting hand orthosis (immobilization mean ability: 2.63/10, EAM mean ability: 1.54/10) (see Table 5). Of the 735 responses assessing the level of safe hand use while wearing the orthosis, 91% to 100% reported light-level tasks were safe in any of the orthotic choices offered. Fewer felt it was safe to perform medium-level tasks (varying from 3% to 17%) and heavylevel tasks (varying from <1%-4%) when wearing the orthosis. Those more likely to advise it was safe to use the hand during orthosis wear for medium-level tasks were the RME plus users (11%) and RME only (17%). More than one answer could be chosen about showering/ bathing orthosis recommendations, which included “keep it dry”, “remove it for washing”, and “ok to get it wet”, consequently there were 731 responses (see Table 5). For all approaches, removal of the orthosis for washing was chosen the most, varying between 57% and 71%, with 229 RME/EAM approach users endorsing removal. Keep it dry was selected most when dynamic (47%) and palmar resting IPJs free (42%) orthoses were used. Removal of the orthosis for hand hygiene was reported by more RME orthosis users, RME only (38% of n ¼ 78) and RME plus (36% of n ¼ 248) and least likely by those using immobilization (10% of n ¼ 48) and dynamic/EPM (12% of n ¼ 57) approaches. Hand functional usedAfter orthosis wear Therapists were asked to select one answer to the question, “once the orthosis has been stopped what is the heaviest 2-handed activity you would recommend to at least ninety percent of your patients?” There were 735 of responses to this question (see Table 4). The most common response was medium 2-handed activity (up to 25 pounds/11 kg) with percentages varying between 48.5% and 79% across all approaches. Next selected was light 2hand activity (up to 10 pounds/4.5 kg), varying between 13 and

Table 5 Orthosis/program functional hand use (for questions see Appendix 1) Variable

Resting hand orthosis, IPJs included (IMMOBILE)

Resting hand orthosis, IPJs included (EAM)

Palmar resting orthosis, IPJs free [EAM]

Dynamic orthosis [EPM]

RME plus wrist orthoses [EAM]

RME only orthosis [EAM]

Hand use in orthosis 0-10a mean SD/Var. Number of responses Showering/bathing recommendations Keep dry, Safe washing, OK wet Can select >1 response Number of responses Safe tasks with orthosis on

2.63

1.54

3.73

3.63

6.25

6.77

2.36/5.57 48 KD: 18 SW: 30 OK: 5 48

1.63/2.67 105 KD: 37 SW: 69 OK: 27 105

1.59/2.54 199 KD: 63 SW: 135 OK: 56 195

2.31/5.52 57 KD: 27 47% SW: 34 60% OK: 7 12% 57

1.54/2.38 246 KD: 59 24% SW: 177 71% OK: 89 36% 248

1.41/1.99 75 KD: 17 22% SW: 52 67% OK: 30 38% 78

L: 41 M: 4 Light, Medium, Heavy H: 0 Can select >1 response Number 45 of responses Heaviest tasks when orthosis L: 22 stopped M: 25 Light, Medium, Heavy H: 1 Number of responses 48 Return to unrestricted hand use 4-6 without orthosis (weeks) 6-8 8-10 10-12 12þ Number of responses 48

37.5% 2.5% 10%

35% 66% 26%

42% 69% 29%

91% 9%

L: 82 M: 2 H: 0 84

98% 2%

L: 182 M: 5 H: 0 184

99% 3%

L: 51 M: 5 H: 0 52

98% 3%

L: 243 M: 28 H: 1 244

100% 11% <1%

L: 75 M: 13 H: 3 78

96% 17% 3%

46% 52% 2%

L: 51 M: 51 H: 3 105 4-6 6-8 8-10 10-12 12þ 105

48.5% 48.5% 3%

L: 65 M: 121 H: 3 199 4-6 6-8 8-10 10-12 12þ 198

32.5% 61% 6.5%

L: 28 M: 28 H: 1 57 2-4: 2% 6-8 8-10 10-12 12þ 57

49% 49% 2%

L: 64 M: 165 H: 19 248 4-6 6-8 8-10 10-12 12þ 249

26% 66% 8%

L: 10 M: 62 H: 6 78 <2: 1% 6-8 8-10 10-12 12þ 78

13% 79% 8%

8% 13% 32% 25% 23%

1% 11% 22% 32% 34%

1% 9% 33% 31% 26%

4-6: 3% 11% 24% 30% 30%

<1% 13% 30% 32% 24%

4-6: 1% 7% 33% 37% 21%

IMMOBILE ¼ immobilization; EAM ¼ early active motion; EPM ¼ early passive motion; RME ¼ relative motion extension; IPJs ¼ interphalangeal joints; KD ¼ keep dry; SW ¼ safe washing; OK ¼ okay to wet; L ¼ light; M ¼ medium; H ¼ heavy. a 0 ¼ Unable to use hand in the orthosis; 10 ¼ Full use of hand in the orthosis.

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Table 6 Orthosis/program outcomes based on percentage of total responses (for questions see Appendix 1) Variable

Resting hand orthosis, IPJs included (IMMOBILE)

Resting hand orthosis, IPJs included (EAM)

Palmar resting orthosis, IPJs free (EAM)

Dynamic orthosis (EPM)

RME plus wrist orthoses (EAM)

RME only orthosis (EAM)

Yes: n ¼ 2 No 47

4% 96%

Yes: n ¼ 8 No 104

8% 92%

Yes: n ¼ 9 No 197

5% 95%

Yes: n ¼ 8 No 55

15% 85%

Yes: n ¼ 14 6% No 94% 246

Yes: n ¼ 2 No 77

3% 97%

2% 4% 6% 47% 41%

<4 4-6 6-8 8-12 >12 105

0 0 3% 57% 40%

<4 4-6 6-8 8-12 >12 197

<1% 0 7% 60% 32%

<4 4-6 6-8 8-12 >12 56

0 4% 11% 46% 39%

<4 4-6 6-8 8-12 >12 248

<1% 0 13% 60% 27%

<4 4-6 6-8 8-12 >12 77

1% 3% 22% 60% 14%

Number of responses

<4 4-6 6-8 8-12 >12 47

TAM on discharge Exc: equal or 100% Good: 75%-99% Fair: 50%-74% Poor: <50% Number of responses

Exc Good Fair Poor 47

6.5% 85% 6.5% 2%

Exc Good Fair Poor 103

21% 77% 2% 0%

Exc Good Fair Poor 196

19% 80% 1% 0%

Exc Good Fair Poor 57

12% 79% 9% 0%

Exc Good Fair Poor 248

23.5% 75.5% 1% 0%

Exc Good Fair Poor 74

22% 78% 0% 0%

Orthosis examples

Tendon rupture Number of responses Usual discharge from therapy (weeks)

Satisfaction on discharge Yes: my opinion Yes: patient opinion Yes: satisfaction survey No: my opinion No: patient opinion No: satisfaction survey Unsure Number of responsesa

28% 68% 13%

47% 82% 19%

51% 79% 27%

32% 72% 32%

66% 81% 18%

65% 79% 29%

2% 6% 0

<1% 2% 2%

1.5% 1% 1%

5% 5% 3.5%

0 <1% <1%

0 0 0

4% 47

2% 105

3.5% 197

9% 57

1% 247

0 78

RTW pre-injury capacity Number of responses

Yes No 47

94% 6%

Yes No 105

98% 2%

Yes No 197

96% 4%

Yes No 55

93% 7%

Yes No 248

98% 2%

Yes No 77

97% 3%

RTW in any capacity

50% 50%

Yes No 2

50% 50%

Yes No 7

85% 15%

Yes No 4

50% 50%

Yes No 5

100% 0

Yes No 2

50% 50%

Number of responses

Yes No 2

RTW guidelines set by No one Surgeon Surgical team Therapist Combination Other Number of responses

2% 38% 0 22% 31% 7% 45

2% 20% 2% 28% 48% <1% 105

1% 49% 2% 10% 35% 3% 194

0 40% 0 8% 50% 2% 52

1% 30% 2% 19% 46% 2% 247

0 25% 1% 25% 46% 3% 75

IMMOBILE ¼ immobilization; EAM ¼ early active motion; EPM ¼ early passive motion; RME ¼ relative motion extension; IPJs ¼ interphalangeal joints; TAM ¼ total active motion; Exc ¼ excellent; RTW ¼ return to work. a Percentage amounts add to >100% as more than one option could be selected.

49%, and least often selected heavy 2-hand activities (up to 50 pounds/22.5 kg) varying between 2% and 8%. Those that used immobilization, resting hand/EAM, and dynamic/EPM approaches selected light and medium 2-handed activity nearly equally, with medium 2-handed activity selected by more respondents using the palmar resting orthosis with IPJs free/EAM and both RME/EAM approaches. There was great variability in the 735 responses to “at what week post-repair do you usually recommend patients can return to unrestricted hand use without the orthosis?” The breakdown by week before unrestricted use was allowed: >12 weeks (26%), 10 to 12 weeks (32%), 8 to 10 weeks (29%), 4 to 6 weeks (11%), and 2 to 4 weeks (2%) (see Table 5).

Therapist-reported outcomes Tendon ruptures Of the 726 responses to this question, most reported no ruptures (varying from 85 to 100%) (see Table 6). For the 43 respondents who reported ruptures, the highest rates (15%) where when dynamic orthoses/EPM were used, followed by 8% for resting hand/EAM approach. Remaining approaches reported rates of 6% or less. Usual timeframe for discharge from therapy Of the 730 responses to this question, most therapists discharged their patients between 8 and 12 weeks after surgery (57%), followed by 31% beyond 12 weeks (see Table 6). The RME only/EAM

10

M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e17

approach had the smallest percentage (14% of n ¼ 77) of patients discharged after 12 weeks compared with all other approaches. Total active motion (TAM) on discharge Of the 725 responses estimating total active motion on discharge from therapy, most therapists selected “good” TAM (75.5%-85%) at discharge, followed by “excellent” (6.5%-23.5%), “fair” (1%-9%) and “poor” (0%-2%). The greatest percentage of “excellent” TAM were reported by users of RME only/EAM (78% of n ¼ 74) and RME plus/EAM (75.5% of n ¼ 248) approaches (see Table 6). Satisfaction on discharge Respondents (n ¼ 731) were asked whether more than 90% of patients were satisfied with their hand function at the time of therapy discharge; choices included therapist opinion, patient report, or a satisfaction survey (see Table 6). Therapists generally deemed patients to be satisfied, derived mostly from therapist’s opinion (54%) and patient report (79%), as few therapists used a formal survey to determine satisfaction (22%). Returning to work Of the 729 responses, percentages varied from 93% to 98% for the question “on therapy discharge do almost all (>90%) patients who have paid employment return to their PRE-INJURY work capacity?” across all approaches (see Table 6). If the answer was “no” to this question (n ¼ 23), respondents were asked if the worker could return to work in any capacity, with the percentages for a “yes” answer varying from 50% to 100% and percentages for “no” varying from 17% to 50%. Of the 718 responses to the inquiry on who usually provides the return to work guidelines/restrictions, similar percentages were reported across approaches with the answer “surgeon” varying from 20% to 49%, an answer of a “combination” varying from 31% to 50%, and the answer “therapist” varying from 8% to 28% (see Table 6). The same top three reasons for delayed return to work were reported for all approaches: the workplace does not have any light or modified duties, the worker cannot return to full duty until there are no restrictions, and the worker cannot return to work wearing an orthosis. Advantages of usual approach Therapists could select from a list of advantages related to orthotic design, therapy program, function, return to work, and outcomes. Specific response percentages of the 708 respondents to this question are detailed in Table 7. Orthosis design RME plus and RME only had the highest percentages of respondents who believed that these orthoses had a small and lowprofile design (>92% of n ¼ 321). However, the RME only also had a high percentage of users reporting it is quick to make (84% of n ¼ 75), and that materials cost less (75%). Forty percent of respondents (n ¼ 104) using a resting hand orthosis/EAM felt that the orthosis could be made by a junior therapist, followed by RME only orthosis users (32% of n ¼ 75), and palmar resting orthosis with IPJs free users (22% of n ¼ 193). Only 8% of those using a dynamic orthosis believed it could be made by a junior therapist. Therapy program/approach Program instruction was considered “quick” by most respondents of RME only/EAM (60% of n ¼ 75), RME plus/EAM (59% of

n ¼ 246), palmar resting orthosis with IPJs free/EAM (56% of n ¼ 193), and resting hand orthosis/EAM (55% of n ¼ 609). When asked whether the usual approach was suitable for less adherent patients, the most likely to agree were users of the resting hand orthosis/immobilization (50% of n ¼ 40), and the least likely were the dynamic orthosis/EPM (20% of n ¼ 50) users. Sixty percent or more of all users felt any of the approaches could be used for almost all (>90%) of patients. Function Eighty-six percent of therapists using RME/EAM approaches (of n ¼ 321) reported the ability to use the hand while in the orthosis as an advantage compared with less than 3% (of n ¼ 104) or 8% (of n ¼ 40) of therapists using a resting hand orthosis for EAM or immobilization, respectively. Return to work Eighty-one percent of therapists (of n ¼ 75) using RME only/ EAM reported this approach allowed earlier return to work, followed by RME plus/EAM (63% of n ¼ 246). Conversely, 15% (of n ¼ 193) therapists using a palmar resting with IPJs free/EAM felt this approach allowed earlier return to work, followed by resting hand orthosis/immobilization (10% of n ¼ 40), and resting hand orthosis/EAM (6% of n ¼ 104). Outcomes Eighty-eight percent of therapists (of n ¼ 75) using the RME only/EAM reported this approach yields better outcomes than other approaches, followed in descending order by RME plus/EAM (82% of n ¼ 246), dynamic/EPM (56% of n ¼ 50), palmar resting IPJs free/ EAM (55% of n ¼ 193), immobilization (48% of n ¼ 40), and resting hand/EAM (38% of n ¼ 104).

Disadvantages of usual approach Therapists could select from a list of disadvantages related to orthotic design, therapy program, function, return to work, and outcomes, as well as the choice to say there were no disadvantages. Specific response percentages for the 691 respondents are detailed in Table 7. More than a third of RME/EAM users responded that there were no disadvantages (36% of 312 responses). Orthosis design From the 691 responses, the most common disadvantage identified was the perception of the orthosis design being “cumbersome”, varying from 4% (of n ¼ 238) for the RME plus orthosis reporting this as a disadvantage compared with 69% (of n ¼ 102) resting hand orthosis/EAM users. Forty-one percent of n ¼ 49 fabricators of the dynamic orthosis reporting it as “taking too much time to make”. While 20% (of n ¼ 49) dynamic orthosis users and 16% (of n ¼ 102) resting hand orthosis/EAM users identified “material costs too much” as a disadvantage. Therapy program and approach Six therapists (12% of n ¼ 49) using the dynamic/EPM approach identified “instructions taking too much time” as a disadvantage, which was the highest rating for all approaches. As well, 18% of therapists using this approach also reported the program as unsuitable for a junior therapist. The approaches, more likely to be identified as “not suitable for nonadherent patients”, were by users of the RME/EAM approaches (RME plus 42% of n ¼ 238, RME only 39% of n ¼ 74) and dynamic/EPM approach (33%). Very few therapists identified “cannot be used for 90% of patients” as a potential disadvantage for any approach.

M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e17

11

Table 7 Orthosis/program advantages and disadvantages (for questions see Appendix 1) Advantages and disadvantages

Resting hand orthosis, IPJs included (IMMOBILE)

Resting hand orthosis, IPJs included (EAM)

Palmar resting orthosis, IPJs free (EAM)

Dynamic orthosis (EPM)

RME plus wrist orthoses (EAM)

RME only orthosis (EAM)

Orthosis examples

Advantages (Percentage of total respondents) Orthotic design Small & low profile 13 Larger & more 28 limiting Quick to make 53 Junior therapist can 20 make Materials cost less 5 Materials are 35 available Therapy program Instruction is quick 30 Instruction junior 20 therapist Use less adherent 50 patients Used for >90% of 68 patients Function in orthosis 8 Able to use hand for usual ADLs in orthosis Cannot use hand in 35 orthosis Return to work Allows for earlier 10 RTW Outcomes Fewer 50 complications Fewer 2 surgeries 28 Better clinical 48 outcomes Number of 40 responses Disadvantages (Percentage of total respondents) Orthotic design Cumbersome 40 Too small & less 0 limiting Too much time to 5 make Junior therapist 3 cannot make Materials cost too 5 much Materials are 5 unavailable Therapy program Instruction too 3 much time 5 Instruction cannot be done by junior therapist Not suitable for less 5 adherent patients Cannot be used 5 >90% of patients Function in orthosis Not able to use 58 hand for usual ADLs Allows too much 3 hand use Return to work Not allowed until 33 >6 weeks

16 25

42 9

14 6

92 <1

100 0

69 40

56 22

14 8

53 19

84 32

12 44

14 34

6 32

33 44

75 60

55 35

56 16

28 14

59 21

60 25

42

44

20

26

31

81

77

70

68

63

3

36

18

85

91

41

11

4

2

0

6

15

10

63

81

49

57

64

62

68

29 38

26 55

44 56

36 82

45 88

104

193

50

246

75

69 0

29 3

65 0

4 8

7 18

3

3

41

3

0

0

1

0

1

0

16

6

20

3

3

1

1

4

1

1

5

2

12

<1

1

3

4

18

8

9

23

23

33

42

39

0

<1

0

3

0

78

41

41

3

1

4

19

8

33

43

48

28

37

3

3 (continued on next page)

12

M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e17

Table 7 (continued ) Advantages and disadvantages Outcomes Higher risk of complications Higher risk secondary surgery Poor clinical outcomes No disadvantages Number of responses

Resting hand orthosis, IPJs included (IMMOBILE)

Resting hand orthosis, IPJs included (EAM)

Palmar resting orthosis, IPJs free (EAM)

Dynamic orthosis (EPM)

RME plus wrist orthoses (EAM)

RME only orthosis (EAM)

5

4

3

6

2

4

8

8

6

8

0

0

8

3

3

4

<1

1

15 40

9 102

19 188

2 49

36 238

36 74

IMMOBILE ¼ immobilization; EAM ¼ early active motion; EPM ¼ early passive motion; RME ¼ relative motion extension; IPJs ¼ interphalangeal joints.

Function Eighty therapist users of resting hand orthosis/EAM (78% of n ¼ 102) and 23 therapists (58% of n ¼ 40) of resting hand orthosis/ immobilization users identified “not able to perform ADLs with orthosis on” as a disadvantage. Conversely, users of RME only/EAM approach (43% of n ¼ 74), followed by RME plus/EAM approach (33% of n ¼ 238) identified “able to use the hand too much” as a potential disadvantage to these approaches. Return to work When asked which approach “does not allow return to work until after 6 weeks” response percentagesvaried from a high of 48% (of n ¼ 102) for users of the resting hand orthosis/EAM to a low of 3% for each RME approach (of n ¼ 238 RME plus; n ¼ 74 RME only). Outcomes Across all approaches, therapists generally reported low rates (<10% of n ¼ 691) of complications, need for secondary surgery, and

poor clinical outcomes. Users of both RME/EAM approaches were least likely (36% each of n ¼ 238 RME plus; n ¼ 74 RME only) to report any of these complications. Continue approach or use another All therapists who used the RME only/EAM (n ¼ 76) approach reported they would continue with their approach (see Table 7). Of those RME users who added a wrist orthosis (n ¼ 245), only seven indicated they would like to start using another approach; these included two who selected RME only/EAM, two users a resting hand orthosis with IPJs included/EAM, and three who selected “other” with details of the preferred approach unspecified. By contrast, 55% of the 401 therapists not using an RME/EAM approach wanted to continue with their current approach, whereas the remaining 45% said they would like to start using another approach. Notably, 85% of 184 these respondents wanting to use another approach selected “relative motion extension” (see Table 8 and Fig. 6). The reasons

Table 8 Continue using preferred approach or use another approach: Percentage of total responses (for questions see Appendix 1) Continue using or use another approach

Resting hand Resting hand orthosis, IPJs orthosis, IPJs included (IMMOBILE) included (EAM)

Palmar resting orthosis, IPJs free (EPM)

Dynamic orthosis (EAM)

RME plus wrist orthoses (EAM)

“Other”

RME only orthosis (EAM)

An alternative approach was selected by respondent

Orthosis examples

Continue or use another

Continue Another

56% 44%

Continue Another

53% 47%

Continue Another

56% 44%

Continue Another

51% 49%

Continue Another

97% 3%

Continue

100%

Continue 71% Another 19%

Number of responses 41 Would like to start using Resting hand orthosis, IPJs included (IMMOBILE) Resting hand orthosis, IPJs included (EAM) Palmar resting orthosis, IPJs free (EAM)

104

193

49

245

76

14

0

1 1%

0

0

0

0

3 4% -

2 9%

2 28.5%

0

0

1 4%

0

0

1 25%

-

2 11% 5 28%

3 4%

0

2 4%

0

1 4%

0

0

0

11 61%

45 92%

76 94%

19 79%

2 28.5%

-

3 75%

0

0

1 1%

1 4%

3 43%

0

0

18

49

81

24

7

0

4

Dynamic orthosis (EPM)

RME (EAM)

Other

Number of responses IMMOBILE ¼ immobilization; EAM ¼ early active motion; EPM ¼ early passive motion; RME ¼ relative motion extension; IPJs ¼ interphalangeal joints.

M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e17

13

Fig. 6. Preference for approach therapists would like to start using (n ¼ 183).

these 156 therapists desired use of RME included achievement of functional hand use (83%), sooner recovery of motion (82%), smaller and lower profile of the orthosis (76%), earlier functional hand use reported by the literature (62%), and earlier return to work (58%). Importantly, these same therapists (n ¼ 156) reported the single largest barrier to using another approach was surgeon preference (70%), followed by therapy department preference (24%) (see Table 9). Surgeon preference was also reported as the single largest barrier for the 27 therapists who did not select RME but would like to start using another approach. Two other barriers to implementing an

RME/EAM approach was the concern that the orthosis does not provide enough protection (22%, n ¼ 35) and concerns about lack of adherence by the therapist’s patient population (19%, n ¼ 29). Summary of respondent open-text comments Therapists were invited to comment within the open-text fields about select therapy approaches, extensor tendon postoperative management, and the survey structure. Overall, 318 open-text comments were received from 260 therapists or 29% of

Table 9 Barriers for therapists in implementing their preferred approach (see Appendix 1, question 50) Barriers for implementing another approach

Resting hand orthosis, IPJs included (IMMOBILE)

Resting hand orthosis, IPJs included (EAM)

Palmar resting orthosis, IPJs free (EPM)

Dynamic orthosis (EAM)

RME (with or without wrist orthosis) (EAM)

An alternative approach was selected by respondent

Orthosis examples

Orthotic design Time to make the orthosis is too much Cost of orthosis is too much Orthotic materials are not available Does not provide enough protection Preference Surgeon preference Therapy department preference Other Lack of evidence for orthosis/program Lack of confidence to make the orthosis Lack of confidence to progress program Lack of adherence by my pt. population Other Number of responses

“Other”

1

100%

1

11%

2

67%

7

4%

1

20%

1

<1%

1

20%

35

22%

1

20%

109 37

70% 24%

4

80%

17

11%

2

40%

2

22%

1

11%

1

33%

2

22%

2

22%

1

33%

1

11%

6 5

67% 56%

6 3

67% 33%

2

22%

1

11%

1 1

1

100%

1

11%

3 9

33%

1 9

11%

1 1

33% 33%

1

33%

23

15%

1

33%

23

15%

1

20%

29

19%

1

20%

14 156

9%

11% 3

IMMOBILE ¼ immobilization; EAM ¼ early active motion; EPM ¼ early passive motion; RME ¼ relative motion extension; IPJs ¼ interphalangeal joints.

5

14

M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e17

Table 10 Coding of therapists (n ¼ 318) open-text comments Theme Subtheme

RME discussion
Prefer RME
Reasons for not doing RME
Advantages of RME

Comments on approach
Adaptation to approach

Patient-centered therapist management required

Surgeon preference
The surgeon decides the postoperative approach
Therapist preferred approach is limited by surgeon preference

Compliments and complaints

Number of comments

155

138

49

40

33

RME ¼ relative motion extension.

all respondents. Responses have been blended for thematic analysis as many responses crossed over between two open-text fields. For these analyses, comments were first coded into five themes as outlined in Table 10 and then similar threads were categorized into subthemes. When possible, themes and subthemes are supported by direct quotes. Theme 1: Relative motion extension discussion Discussion on relative motion was the most prevalent topic, with 155 comments (49% of all respondents) in the open-text fields with several subthemes emerging. The subthemes identified were a preference for the RME orthosis/EAM approach although not supported by the practice setting, reasons for not implementing an RME approach, and reasons why patients and therapists liked the approach. Subtheme: “Prefer RME”. Several therapists wrote that their preference would be to use RME; however, their practice setting did not allow for implementation of an RME/EAM approach. An example comment was “I prefer the I-CAM (RME) regime as patients return to full work and ADLs much quicker, however the new department I work in state [another] regimen is their protocol and not open to adopting an alternative.” Subtheme: “Reasons for not using RME”. There were 55 comments (17%) by therapists citing reasons for not using RME/EAM approaches, these largely related to not being able to use RME orthoses for all patients. Some noted the RME/EAM approach could not be used when all four fingers were injured, or restricted use to when the injury involved only one finger, or two fingers, whereas others did not believe RME/EAM approaches could be used if two adjacent fingers were injured. This comment offered by a therapist who identified preference for use of a resting hand orthosis/EAM used the following rationale: “Can be used for multiple tendon repairs whereas the Relative Motion protocol is suitable for 1-2 tendons only” Others stated that RME orthoses/EAM approaches could not be used with patients referred late to therapy. Subtheme: “Advantages of RME”. Both therapist users and nonusers highlighted advantages of the RME program in 42 comments, frequently citing, ease of use, adherence to instructions, improved clinical outcomes, and early return to work. The most often cited advantages of RME orthoses/EAM approaches are reflected in these quotes: “I love this program! Patients have much fewer issues with scar adherence and incorporate regular activity more quickly versus the dynamic programs we’ve previously used.”

“The patients love the freedom of movement that this splint and protocol allow as well as the prospect of earlier return to work.” Theme 2: Comments on selected approach Therapists made 138 comments (43%) regarding the program selected as their most used approach in the previous 12 months. These comments varied greatly with one emergent subtheme: orthosis/program adaption. Other comments included specific merits of their most used approach, how to manage adhesions, the level of skill needed to fabricate the orthosis, and a few on thirdparty pay or insurance issues. Subtheme: “Adaptation to orthosis/approach program”. Comments related to adapting their most used orthosis/approach came mostly from (28/40) therapists who used the palmar orthosis with IPJs free/EAM approach. Several therapists wrote that they made a patient-centered change for example adding an orthosis if the patient developed an active PIP joint extension lag or modified the orthosis design from forearm to a hand-based orthosis. Theme 3: Patient-centered management required Factors related specifically to the patient were cited by 49 therapists to effect selection of the approaches. Ideally, many suggested having a variety of approaches from which to select is better, as supported by the following comment: “I think it is better for a hand therapy service to have all the methods at their disposal and choose based on sound clinical reasoning, such as anticipation of serious adhesion, as described, or based on surgeon feedback concerning the integrity of the repair. It is the therapist’s responsibility to weigh up the risks and benefits of the chosen regimen and also ensure that it fits with the capacity of the patient to comply. I don’t think we will ever have ‘one size fits all’ clinical guidelines for this injury.” Theme 4: Surgeon preference Subtheme: “The surgeon decides the postoperative therapy approach”. Interestingly, 40 therapists said that the surgeon decided which postoperative approach was to be used, further commenting “The hand surgeons in my area almost all specify the type of splint they want, usually the palmar/IPs free style, so the decision is theirs not mine.” “Unfortunately, I have almost no participation in the decision process about which splint the patient is going to get. It is always decided by the surgeon.” Subtheme: “My preferred approach is limited by surgeon preference”. Over half of the comments indicated a preference for the RME orthoses/EAM approach, with surgeon preference the limitation or barrier. Comments such as

M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e17

“Personally, I like the relative motion orthosis more. It has a better outcome. BUT the doctors that refer want me to follow this protocol.” “I would choose to use relative motion splinting more if surgeons were on board. We have several referral sources who refuse to try it with their patients.” Theme 5: Compliments and complaints Congratulations and well wishes were extended by 21 therapists to the researchers with many interested in the survey results. A few therapists commented that the survey fell short in collecting information about confounding factors that may influence the therapist’s choice of approach as noted in the following comment: “Survey does not account for straight forward laceration vs complex fracture/crush. Surgeon repair timing/technique. Patient comprehension/compliance factors. All of these play into decision of postoperative management strategy.” Discussion To our knowledge, this study is the first to globally investigate current practice patterns in hand therapy and specifically for the postoperative management of finger zones V and VI extensor tendon repairs. We received responses from 28 of 36 IFSHT fullmember countries and our sample was mostly female occupational therapists who had 10 or more years of hand therapy experience, with >50% holding additional credentials in hand therapy. Our sample closely matches the typical demographics of therapist members from IFSHT full-member countries reported in a 2015 IFSHT survey https://www.ifsht.org/page/ifsht-reports. As such, we have confidence that the findings from our survey are likely representative of postoperative practice patterns in the management of extensor tendon zones V and VI of the fingers by Englishspeaking hand therapists working in countries that have a national hand therapy organization with full-membership in the IFSHT. Survey responses inform us that therapists worldwide use or have used a variety of postoperative approaches after extensor tendon zone V-VI repair. While many were familiar with all five of the best-known approaches, the data suggests that RME orthoses with EAM is the most used or “preferred” approach. Moreover, in this survey, the RME orthosis/EAM approach was chosen by most therapists who are not currently using it but wanted to use it. Regarding the “most used approach in the previous 12 months” regional influence was evident, with high uptake of the RME/EAM approach in Australia, the Netherlands, New Zealand, and Switzerland. High usage of the resting orthosis IPJs included/EAM, also known as the “Norwich regimen”,13 was in Ireland and in nearly half of all United Kingdom respondents (the origin of the Norwich regimen program), with the RME/EAM approach a close second. The United States and Canada almost equally used the RME and palmar orthosis with IPJs free EAM approaches. Sweden’s usage was almost equal between immobilization and a palmar orthosis with IPJs free/EAM, while German therapists primarily used a dynamic/EPM approach. The remaining participating countries had a more equal spread of approaches selected or had too few survey participants to identify a trend. Early motion rehabilitation programs are known to yield earlier and better TAM than immobilization after extensor tendon repair.79 Although there have been many studies that have not found appreciable difference between early active and early passive motion approaches,1,3,14-16 there are recognized disadvantages of dynamic orthoses including poor patient acceptance and orthosis

15

malfunction,9 and more skill and time is required to fabricate a dynamic orthosis compared with a resting hand orthosis.14 The practical disadvantages, specifically skill level and fabrication time were identified by survey respondents, and may be why dynamic orthosis/EPM was ranked as the approach least used, and perceived to have the lowest patient satisfaction. Survey respondents elected to use the RME and palmar IPJs free orthoses as their number one and two, respectively, “most used” orthoses to deliver EAM, aligning with the conclusions from several systematic reviews which cautiously recommended the RME approach despite the lack of high-level evidence.5,9 The opinions of the review authors have since been supported by a recent randomized controlled trial that compared EAM with palmar orthosis/ IPJs free to EAM with RME only orthosis/EAM.17 This trial also reported similar advantages to those reported by respondents in our study, in that RME orthoses achieved earlier functional hand use and TAM, and greater patient satisfaction than the palmar orthosis with IPJs free/EAM.17 Given respondents reported similar recovery timelines across approaches, with most reporting good to excellent TAM and return to work outcomes, we wondered why the RME/EAM was the “most used” approach as well as the approach the vast majority of nonRME users would like to use. Literature published to date lists the advantages of the RME orthosis such as its small size, low profile, and low cost2,17-21 all of which align with the survey findings. Survey responses suggest another advantage might be the difference in the degree of difficulty to fabricate and, therefore, time to fabricate, especially when compared with dynamic orthoses. Our survey was constructed in such a way that it did not take into consideration the time required to instruct the patient or if the amount of time available to the therapists for fabrication of the orthosis affected orthotic choice. Our results, however, suggest a hierarchy to skill level required for orthosis fabrication, further supported by responses to a separate question asking if a “junior therapist” could fabricate the orthosis. If this is true, then the easiest to fabricate orthoses is more likely be selected by therapists with less skill, unless influenced by implementation barriers recognized in this survey. Although there is some evidence that earlier recovery of TAM and hand function occurs when an RME only orthosis/EAM is used compared with use of a palmar orthosis with IPJs free/EAM,17 there are no published trials comparing different EAM approaches. We recommend studies with EAM in both groups but comparing either RME only with RME plus or either RME orthosis/EAM approach to the Norwich/EAM Regimen (resting hand orthosis). Survey responses indicate therapists believe that TAM outcomes are superior with either RME orthosis/EAM approaches compared with all other approaches surveyed, but there is no level 1 or 2 evidence to support this. Responses to the question regarding approaches allowing the greatest/earliest hand function resulted in selection of the RME orthosis with and without the wrist component with EAM. This is supported by the functional hand use (Sollerman test) results of Collocott et al17 and the observations of others.2,18,20,21 An interesting observation is that although the palmar IPJs free and dynamic orthoses allow for IP joint motion, the respondents perceived the RME plus orthoses to be more functional for hand use; the only difference being that the RME plus orthoses permits both IP and MCP joint active motion. Another finding of interest is that survey respondents report modifying the palmar orthosis IPJs free to permit wrist motion, which differs from the orthosis description in the literature.22 The question about patient satisfaction after extensor tendon repair has only recently been explored in the literature by Svens et al21 and Collocott et al,17 who used questions from some sections

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of the Patient Evaluation Measure. Collocott17 also added their own orthosis satisfaction questions to compare EAM using RME only orthoses to EAM with a palmar orthoses/IPJs free. In brief, at 8 weeks postoperatively orthosis satisfaction questions were found to be significantly different, as well as better for those who wore RME only orthoses.17 Clinical practice after extensor tendon repair from this survey reflects the literature in that few respondents measure outcome with a validated patient satisfaction questionnaire (see Table 6). However, therapist’s perceived satisfaction for both themselves and their patients by far exceeded respondents who perceived dissatisfaction with any approach. Furthermore, perceived and measured satisfaction was greater for EAM and EPM approaches than immobilization. Tendon rupture is often used as an indicator for successful repair and postoperative management. While no tendon ruptures have been reported in RME clinical or cohort studies,2,17,18,20,21,23 survey respondents reported experience with ruptures for all approaches, including RME/EAM. Those with the greatest rupture experience used dynamic orthosis/EPM and tendons were reported to ruptured least with use of RME only orthosis/EAM. In addition, the need for secondary surgical procedures was identified to be a greater “risk” by respondents for all approaches except the RME/EAM approaches. RME users for the most part want to continue to use this approach, whereas nearly half of those using other approaches would like to use another. Of those wanting to make a change, 85% would like to use RME but faced barriers to use. The top four barriers to therapist use of RME are surgeon preference, clinic policies/ procedures, and a belief that RME orthoses afford less protection, and RME orthoses are not indicated for nonadherent patients. Regarding the first two barriers, to our knowledge, until this survey, there has been no documentation to suggest that hand therapists may be limited in their capacity to make patient-centered choices after extensor tendon repair due to surgeon or clinic preferences. If this is so, strategies to provide the necessary information to the surgeon or those responsible for a clinic’s policy and procedure should be considered. The last two barriers mentioned were also singled out as disadvantages alongside some saying RME orthoses allowed too much use of the injured hand. The idea that the RME/ EAM approach is not indicated for nonadherent patients and the impression that the RME orthoses do not provide enough protection has not been substantiated. Given that users in this survey of RME did experience tendon repair ruptures, this was less when compared with the alternate approaches in this survey, and there have been no ruptures with the RME orthosis/EAM approach reported in the literature. Exactly which approach (orthosis/program) best protects extensor tendon repairs of the nonadherent patients has not been established. There is no evidence, other than opinion circulated throughout the literature that suggests immobilization as the best approach for nonadherent patients.6,24 However, there is evidence to recommend patient adherence after tendon repair can be improved when the patient likes the appearance of the orthosis, is comfortable, has no pain wearing the orthosis, can function safely in the orthosis, and is able to perform hand hygiene.25 Correspondingly, many of these factors are supported by RME orthoses, as demonstrated by Collocott et al17 and recognized by survey respondents. Hirth et al20 also commented that the simplicity of the RME orthotic design, along with early functional hand use, may yield improved adherence. For all approaches, respondents reported nearly all patients returned to their preinjury work capacity before therapy discharge, and if not, most injured workers returned to work in some capacity. Four of the five extensor tendon systematic reviews investigated return to work time frames. The return to work for dynamic/EPM and resting hand/EAM varied between 9 and 12 weeks.1,14,26-28 One

study separated return to light (4 weeks) and heavy (12 weeks) duties for dynamic/EPM and resting hand/EAM,3 whereas another separated simple (6.5 weeks) and complex (8.5 weeks) injuries for those managed with a resting hand/EAM approach.13 RME has the earliest report of return to work (18 days) after tendon repair.2 However, Collocott et al17 reported return to work time frames were often limited by a driving restriction until 6 weeks after surgery. As such, timeliness of return to work may not be a valid measure of tendon repair outcome due to these extraneous variables. This was supported by the survey which explored various barriers for return to work, and regardless of the approach used and who provided the return to work guidelines (surgeon, therapist, combination), the top three reasons for a delayed return to work were variables controlled by the workplace. Limitations Respondents to this electronic survey came from a convenience sample, which included only therapist members from IFSHT fullmember countries, and therefore may not be representative of all hand therapists worldwide. While a large proportion of full-member countries did participate, we acknowledge it was unknown if the email lists of the national organizations were complete or accurate, four full-member countries failed to respond, others did not follow the participation protocol, two organizations did not send the survey to their full membership, and there is limited data for several regions surveyed. Translating the survey into multiple languages was not feasible, so it was developed for those who read English, which could have influenced participation because 70% of respondents affirmed that English was their first language. Overall survey participation rate was 11%; while low, this was similar to a flexor tendon study29 conducted with American Society for Surgery of the Hand members that recorded 15%, and less than the 25% response rate recorded by Parish et al30 who surveyed American Society of Hand Therapists members on practice patterns for carpal tunnel syndrome. We suspect that targeting a larger global population including countries for which English was not their first language likely contributed to a lowered response rate. We also acknowledge that a survey design that ultimately required participants to answer anywhere from 39 to 69 questions may have been a limitation. In support of our efforts to design the instrument, an extensive English-language review was done, approval of the ethics committee was given, and a pilot trial for content review was done with 23 therapists from Australia and the United States. Furthermore, while strong consideration was given to the fact that not all respondents have English as a first language, we cannot project to know if the content of all questions was fully understood, even by the English first language respondents. The authors fully appreciate that hand therapy intervention and clinical reasoning is patient-centered and may vary more among injuries of various complexity. Because the aim of the survey was to learn about management after extensor tenorrhaphy, we did not explore cases with concomitant fractures or multiple injuries such as described in zone III-V case reports.31 To undertake this study and gain a wider understanding of practice patterns, the term “usually” was applied to many questions to manage these potential variations of injury and therapeutic management to reduce survey length. This may have resulted in presentation of data in a more simplistic manner than what occurs in clinical practice. It was consensus of the authors that our interest was to learn of the practice patterns of hand therapists regardless of the number of extensor tendon repairs managed over the past year. Some may view the fact that therapists were made to choose and respond regarding a single approach, their “most used” in the previous 12 months and respond accordingly as a limitation. We understand

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that many therapists have experienced and do use multiple approaches; however, the survey structure did not allow for comparisons. The reasons for this were to limit the length of the survey and minimize any possible bias respondents might have for or against approaches that are not their “most used” approach. Recommendations for the future To capture a more comprehensive understanding of practice patterns worldwide, future survey should also attempt to recruit therapists from non-IFSHT member countries and be translated and disbursed through IFSHT full-member countries to potential respondents whom English is not their primary language. Conclusions This survey affords a better understanding of the global practice patterns of therapists who manage zone V-VI extensor tendon repairs of the fingers. For the most part, survey respondents preferred early active motion approaches over EPM/immobilization, and these approaches are used based on the perceived advantages in terms of superior results and speed of recovery. It is notable, however, that emerging evidence supporting the benefits of early active motion and clinical practice did not always align. Although there are many commonalities among the different approaches, the most preferred method of early active motion delivery was with RME orthoses. Unforeseen were the reported barriers of surgeon and clinic preferences as a primary reason preventing therapists from using their preferred or desired approaches. Future randomized clinical trials are warranted, comparing the relative effectiveness of different early active motion approaches conducted in real-world clinical settings. Acknowledgments Special recognition to Angela Chu, OT, for the fabrication of the orthoses photographed for this survey, and to Luke Robinson, OT, who assisted in the early development of the survey. Our appreciation to the Australian and USA survey field testers who helped us refine the questions. Many thanks to the IFSHT Secretary General, Maureen Hardy, for providing participating country contact information as well as the IFSHT Hand Therapy national society/association liaisons who kindly forwarded the survey link to their membership. Most importantly, the authors thank each therapist who devoted time to answer our questions! Through this collaboration, the authors now have a better understanding of practice patterns for the management of zone V-VI extensor tendon repairs of the fingers. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.jht.2019.12.019. References 1. Bulstrode NW, Burr N, Pratt AL, Grobbelaar AO. Extensor tendon rehabilitation a prospective trial comparing three rehabilitation regimes. J Hand Surg. 2005;30:175e179. 2. Howell JW, Merritt WH, Robinson SJ. Immediate controlled active motion following zone 4-7 extensor tendon repair. J Hand Ther. 2005;18:182e190. 3. Khandwala AR, Webb J, Harris SB, Foster AJ, Elliot D. A comparison of dynamic extension splinting and controlled active mobilization of complete divisions of extensor tendons in zones 5 and 6. J Hand Surg. 2000;25:140e146.

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4. Kleinert HE, Verdan C. Report of the committee on tendon injuries (international Federation of Societies for surgery of the hand). J Hand Surg. 1983;8: 794e798. 5. Collocott SJ, Kelly E, Ellis RF. Optimal early active mobilisation protocol after extensor tendon repairs in zones V and VI: a systematic review of literature. Hand Ther. 2018;23:3e18. 6. Ng CY, Chalmer J, Macdonald DJ, Mehta SS, Nuttall D, Watts AC. Rehabilitation regimens following surgical repair of extensor tendon injuries of the hand-a systematic review of controlled trials. J Hand Microsurg. 2012;4:65e73. 7. Sameem M, Wood T, Ignacy T, Thoma A, Strumas N. A systematic review of rehabilitation protocols after surgical repair of the extensor tendons in zones V-VIII of the hand. J Hand Ther. 2011;24:365e372. quiz 373. 8. Talsma E, de Haart M, Beelen A, Nollet F. The effect of mobilization on repaired extensor tendon injuries of the hand: a systematic review. Arch Phys Med Rehabil. 2008;89:2366e2372. 9. Wong AL, Wilson M, Girnary S, Nojoomi M, Acharya S, Paul SM. The optimal orthosis and motion protocol for extensor tendon injury in zones IV-VIII: a systematic review. J Hand Ther. 2017;30:447e456. 10. Jones D, Story D, Clavisi O, Jones R, Peyton P. An introductory guide to survey research in anaesthesia. Anaesth Intensive Care. 2006;34:245e253. 11. Eysenbach G. Improving the quality of web surveys: the Checklist for reporting results of Internet E-surveys (CHERRIES). J Med Internet Res. 2004;6:e34. 12. Nowell LS, Norris JM, White DE, Moules NJ. Thematic analysis: striving to meet the trustworthiness criteria. Int J Qual Methods. 2017;16:1e13. 13. Sylaidis P, Youatt M, Logan A. Early active mobilization for extensor tendon injuries. The Norwich regime. J Hand Surg. 1997;22:594e596. 14. Chester DL, Beale S, Beveridge L, Nancarrow JD, Titley OG. A prospective, controlled, randomized trial comparing early active extension with passive extension using a dynamic splint in the rehabilitation of repaired extensor tendons. J Hand Surg. 2002;27:283e288. 15. Hall B, Lee H, Page R, Rosenwax L, Lee AH. Comparing three postoperative treatment protocols for extensor tendon repair in zones V and VI of the hand. Am J Occup Ther. 2010;64:682e688. 16. Kitis A, Ozcan RH, Bagdatli D, Buker N, Kara IG. Comparison of static and dynamic splinting regimens for extensor tendon repairs in zones V to VII. J Plast Surg Hand Surg. 2012;46:267e271. 17. Collocott SJF, Kelly E, Foster M, Myhr H, Wang A, Ellis RF. A randomized clinical trial comparing early active motion programs: earlier hand function, TAM, and orthotic satisfaction with a relative motion extension program for zones V and VI extensor tendon repairs. J Hand Ther. 2019. In press. 18. Altobelli GG, Conneely S, Haufler C, Walsh M, Ruchelsman DE. Outcomes of digital zone IV and V and thumb zone TI to TIV extensor tendon repairs using a running interlocking horizontal mattress technique. J Hand Surg. 2013;38: 1079e1083. 19. Burns MC, Derby B, Neumeister MW. Wyndell merritt immediate controlled active motion (ICAM) protocol following extensor tendon repairs in zone IVVII: review of literature, orthosis design, and case study-a multimedia article. Hand. 2013;8:17e22. 20. Hirth MJ, Bennett K, Mah E, et al. Early return to work and improved range of motion with modified relative motion splinting: a retrospective comparison with immobilization splinting for zones V and VI extensor tendon repairs. Hand Ther. 2011;16:86e94. 21. Svens B, Ames E, Burford K, Caplash Y. Relative active motion programs following extensor tendon repair: a pilot study using a prospective cohort and evaluating outcomes following orthotic interventions. J Hand Ther. 2015;1:11e 19. 22. Slater Jr RR, Bynum DK. Simplified functional splinting after extensor tenorrhaphy. J Hand Surg. 1997;22:445e451. 23. Hirth MJ, Howell JW, O’Brien L. Relative motion orthoses in the management of various hand conditions: a scoping review. J Hand Ther. 2016;29:405e432. 24. Russell RC, Jones M, Grobbelaar A. Extensor tendon repair: mobilise or splint? Chir Main. 2003;22:19e23. 25. Sandford F, Barlow N, Lewis J. A study to examine patient adherence to wearing 24-hour forearm thermoplastic splints after tendon repairs. J Hand Ther. 2008;21:44e52. quiz 53. 26. Browne Jr EZ, Ribik CA. Early dynamic splinting for extensor tendon injuries. J Hand Surg. 1989;14:72e76. 27. Marin-Braun F, Merle M, Sanz J, Foucher G, Voiry MH, Petry D. Primary repair of extensor tendons with assisted post-operative mobilisation. A series of 48 cases. Ann Chir Main. 1989;8:7e21. 28. Patil RK, Koul AR. Early active mobilisation versus immobilisation after extrinsic extensor tendon repair: a prospective randomised trial. Indian J Plast Surg. 2012;45:29e37. 29. Gibson PD, Sobol GL, Ahmed IH. Zone II flexor tendon repairs in the United States: trends in current management. J Hand Surg. 2017;42: e99ee108. 30. Parish R, Morgan C, Burnett CA, et al. Practice patterns in the conservative treatment of carpal tunnel syndrome: survey results from members of the American Society of Hand Therapy. J Hand Ther. 2019. In press. 31. Hirth MJ, Howell JW, O’Brien L. Two case reports-Use of relative motion orthoses to manage extensor tendon zones III and IV and sagittal band injuries in adjacent fingers. J Hand Ther. 2017;30:546e557.