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Rehabilitation Following Extensor Tendon Repair
Rehabilitation Following Extensor Tendon Repair Colin D. Canham, MD, Warren C. Hammert, MD THE PATIENT A 29-year-old right-handed man sustained a laceration over the dorsum of the middle finger metacarpal of his right hand with a box cutter at work. On examination, he is unable to extend his middle finger. A radiograph of the hand demonstrated no skeletal injury or foreign body. The wound was irrigated and sutured in the emergency department. Three days later, the patient underwent tendon repair with a braided core suture. THE QUESTION What rehabilitation protocol is best after extensor tendon repair? CURRENT OPINION Extensor tendon lacerations are often splinted for a month before initiating motion exercises. Alternatively, the wrist and metacarpophalangeal (MCP) joints may be immobilized (in neutral) and the proximal interphalangeal (PIP) joints allowed to move. There are also several exercise protocols for dynamic or active motion after extensor tendon repair, including dynamic extension splinting (DES; the dorsal equivalent of Kleinert splinting), controlled early active motion (active motion with the wrist splinted in slight extension and the MCP joints in slight flexion), and relative motion splinting (active motion with the wrist splinted in 30° extension, and the affected digit in 10°–15° more MCP extension than the uninvolved digits).1 Typically, all splinting is discontinued at 6 to 8 weeks and activity progresses with few restrictions. THE EVIDENCE Historically, patients undergoing repair of extensor tendons in zones 5 to 7 have been placed in a static splint From the Department of Orthopaedic Surgery, University of Rochester Medical Center, Rochester, NY. Received for publication March 9, 2013; accepted in revised form March 28, 2013. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Warren C. Hammert, MD, Department of Orthopaedic Surgery, University of Rochester Medical Center, 601 Elmwood Ave., Rochester, NY 14642; e-mail: [email protected]. 0363-5023/13/38A08-0029$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2013.03.060
for 3 to 4 weeks in order to protect the repair. Purcell et al2 obtained 95% excellent or good results in 33 patients treated with static splinting based on StricklandGlogovac criteria at 6 months of follow-up evaluation. However, others have reported poorer results. At a mean follow-up of 5 years, Newport et al3 reported excellent/good results according to Miller’s criteria in only 64% of 33 simple extensor tendon lacerations treated with static splinting. Chow et al4 also experienced disappointing results with only 40% of 35 fingers with simple lacerations achieving excellent/good results at a minimum of 12 months according to Dargan’s criteria. With improvements in outcomes seen with flexor tendon repair treated with early active motion protocols,5–7 there has been increased interest in applying similar regimens after extensor tendon repair. Dynamic extension splinting In a prospective study of 82 extensor tendon repairs in zones 4 to 7 treated with DES, Browne and Ribik8 used a protocol consisting of a dynamic outrigger splint, allowing active flexion and passive extension for 5 weeks. They noted good to excellent extension and flexion in 93% of digits an average of 2.5 months after surgery. There were no ruptures, and no subsequent procedures.8 Chow et al4 conducted a prospective, nonrandomized trial comparing 54 patients treated with DES with 32 patients treated with static splinting after repair of simple lacerations of extensor tendons in zones 4 to 7. They found markedly better results with the DES protocol. Based on Dargan’s criteria, 100% of patients treated with DES achieved excellent results by 6 weeks, whereas only 40% achieved excellent results with static splinting at a mean follow-up of 13 weeks. Grip strength was also significantly greater in the DES group.4 Neuhaus et al9 prospectively followed 12 patients treated with DES after extensor tendon repair in zones 4 and 5 and noted excellent or good results in 92% at 6 weeks’ follow-up according to Miller’s criteria. In a retrospective analysis of 58 patients with extensor tendon repairs in zones 5 to 7 treated with DES, Bruner et al10 reported excellent or good results in 94% based on Geldmacher’s grading.
© ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 1615
Evidence-Based Medicine
EVIDENCE-BASED MEDICINE
1616
EXTENSOR TENDON REHABILITATION
Evidence-Based Medicine
Ip and Chow11 prospectively evaluated 84 patients with extensor tendon repairs in zones 4 to 8 treated with DES. At a follow-up of at least 8 weeks, they found 93% excellent or good results based on Dargan’s criteria. Active motion with volar blocking splint Sylaidis et al12 prospectively followed up 24 simple extensor tendon repairs in zones 4 to 7 treated with a volar splint that held the wrist in 30° extension and allowed MCP flexion to 45° with the PIP joints at neutral (the Norwich regimen). They found 92% excellent or good results at 6 weeks based on Dargan’s criteria. Comparative randomized clinical trials Mowlavi et al13 conducted a prospective randomized trial comparing DES to static splinting and found significantly better total active motion (TAM) and grip strength in the DES group at 8 weeks. However, by 6 months, no differences were seen between groups. Kitis et al14 conducted a prospective, randomized trial comparing DES with static splinting and found improved TAM and overall function with DES at 6 months. Khandwala et al15 conducted a prospective randomized trial of 100 patients in which they compared a volar blocking splint with DES. At 8 weeks, they evaluated their patients with Miller and TAM assessments and found excellent or good results in 95% and 98% with DES and 93% and 95% with the blocking splint, respectively. Chester et al16 also conducted a randomized trial comparing controlled early active motion with DES in 36 patients with simple lacerations in zones 4 to 8 and found no differences in TAM at 3 months. All patients in both groups achieved an excellent or a good result. Bulstrode et al17 performed a randomized trial comparing 3 rehabilitation protocols following repair of simple zones 5 and 6 lacerations: static splinting, controlled motion with the wrist and MCP joints in extension and the PIP joints free, and the Norwich regimen. They found significantly reduced TAM in the static group at 4 weeks but not at 12 weeks. There was no difference in the amount of hand therapy utilized by the 3 groups. Grip strength at 12 weeks was significantly reduced compared with the uninjured hand in the static splinting group.17 Relative motion splinting Howell et al1 described their experience with 140 patients over 20 years treated with a relative motion
splinting protocol after repair of extensor tendons in zones 4 to 7. At an average of 49 days, 96% of patients had excellent or good results based on Miller’s criteria. Average time to return to work was 18 days. There have been no comparative studies between relative motion splinting and DES or early active motion with a volar blocking splint. Return to activities/work Limited data are available on average time to return to work after extensor tendon repair. However, there is evidence that relative motion splinting may facilitate the most rapid return to work, which was reported as an average of 18 days.1 Sylaidis et al12 reported an average return to work at 6 weeks with the Norwich regimen. Bruner et al10 reported return to work at 10 weeks, and Browne and Ribik8 reported a range of 8 to 11 weeks with DES. SHORTCOMINGS OF THE EVIDENCE Extensor tendon injuries are relatively uncommon and, therefore, difficult to study. There are no standards for assessing outcomes after extensor tendon repair. A myriad of clinician-based assessments have been used, including Miller’s assessment, Dargan’s criteria, Geldmacher’s grade, Strickland-Glogovac criteria, TAM, and grip strength. To our knowledge, no study has employed a patient-based outcome measure such as the Michigan Hand Outcomes Questionnaire (MHQ), Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure, or other hand/upper extremity–specific subjective outcomes measure. Current outcomes data are, therefore, limited to clinician-based assessments, which are often biased and may not truly reflect accurate outcomes. Return to activities is important but difficult to assess owing to the variability in patients’ jobs and their ability to perform light work. There have been no studies in which relative motion splinting is compared with DES or early active motion with a volar blocking splint. It has been observed that prognosis after repair of tendon lacerations is associated with the zone of injury, with more distal lacerations typically having poorer prognoses.3 There are limited data examining outcomes after extensor tendon repair based on zone of injury. This is likely due to the difficulty of obtaining large enough samples from which meaningful conclusions can be drawn. Most studies of early active motion after extensor tendon repair can only demonstrate a benefit in the short term and the results are somewhat inconsistent. It is not clear that the differences are clinically meaningful or
JHS 䉬 Vol A, August
that the cost and effort of more sophisticated protocols are justified.
1617
greater involvement with hand therapists,15,16 but more formal analysis is needed. REFERENCES
DIRECTIONS FOR FUTURE RESEARCH Agreement among researchers on standard objective and subjective outcomes measures for evaluating extensor tendon repairs would facilitate more accurate comparison of data between studies. A multicenter database could provide adequate power to determine the prognosis for specific zones of injury. It might be possible to determine whether specific postoperative exercise programs are helpful for certain zones of injury. Additional research comparing the cost and value of various exercise protocols after extensor tendon repair is desirable. Further research examining whether different rehabilitation protocols are associated with different times to return to work would be helpful. OUR CURRENT CONCEPTS FOR THIS PATIENT For simple zone 6 extensor tendon lacerations, the literature indicates that, compared with static splinting, early active motion regimens provide improved outcomes in the early postoperative period and possibly later. The method of obtaining early motion, whether through DES, controlled motion with a volar splint, or relative motion splinting, does not appear to alter outcomes. Therefore, because of the relative ease, simplicity, and functionality of the relative motion splint, we prefer it in reliable patients with 1 to 3 fingers that have zones 5 and 6 extensor tendon lacerations. Patients are allowed to begin range of motion immediately within the confines of the splint. They can participate in light activities, such as office work, but refrain from heavy work/manual labor until the time of splint discontinuation at 6 weeks. Relative motion splinting cannot be used when more than 3 tendons are involved, so in these cases we employ an early active motion protocol with a volar blocking splint. In pediatric patients and unreliable adults, consideration must be given to static splinting to decrease the risk of tendon rupture, followed by a therapy program to restore motion at 3 weeks. It has been theorized by some authors that DES is likely more expensive than other protocols owing to the need for a more complex, expensive splint and
1. Howell JW, Merritt WH, Robinson SJ. Immediate controlled active motion following zone 4-7 extensor tendon repair. J Hand Ther. 2005;18(2):182–190. 2. Purcell T, Eadie PA, Murugan S, O’Donnell M, Lawless M. Static splinting of extensor tendon repairs. J Hand Surg Br. 2000;25(2): 180 –182. 3. Newport ML, Blair WF, Steyers CM Jr. Long-term results of extensor tendon repair. J Hand Surg Am. 1990;15(6):961–966. 4. Chow JA, Dovelle S, Thomes LJ, Ho PK, Saldana J. A comparison of results of extensor tendon repair followed by early controlled mobilisation versus static immobilisation. J Hand Surg Br. 1989; 14(1):18 –20. 5. Silfverskiold KL, May EJ. Flexor tendon repair in zone II with a new suture technique and an early mobilization program combining passive and active flexion. J Hand Surg Am. 1994;19(1):53– 60. 6. Small JO, Brennen MD, Colville J. Early active mobilisation following flexor tendon repair in zone 2. J Hand Surg Br. 1989;14(4): 383–391. 7. Trumble TE, Vedder NB, Seiler JG III, Hanel DP, Diao E, Pettrone S. Zone-II flexor tendon repair: a randomized prospective trial of active place-and-hold therapy compared with passive motion therapy. J Bone Joint Surg Am. 2010;92(6):1381–1389. 8. Browne EZ Jr, Ribik CA. Early dynamic splinting for extensor tendon injuries. J Hand Surg Am. 1989;14(1):72–76. 9. Neuhaus V, Wong G, Russo KE, Mudgal CS. Dynamic splinting with early motion following zone IV/V and TI to TIII extensor tendon repairs. J Hand Surg Am. 2012;37(5):933–937. 10. Bruner S, Wittemann M, Jester A, Blumenthal K, Germann G. Dynamic splinting after extensor tendon repair in zones V to VII. J Hand Surg Br. 2003;28(3):224 –227. 11. Ip WY, Chow SP. Results of dynamic splintage following extensor tendon repair. J Hand Surg Br. 1997;22(2):283–287. 12. Sylaidis P, Youatt M, Logan A. Early active mobilization for extensor tendon injuries. the Norwich regime. J Hand Surg Br. 1997; 22(5):594 –596. 13. Mowlavi A, Burns M, Brown RE. Dynamic versus static splinting of simple zone V and zone VI extensor tendon repairs: a prospective, randomized, controlled study. Plast Reconstr Surg. 2005;115(2): 482– 487. 14. 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(3– 4):267–271. 15. 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 Br. 2000;25(2):140 –146. 16. 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 Br. 2002; 27(3):283–288. 17. Bulstrode NW, Burr N, Pratt AL, Grobbelaar AO. Extensor tendon rehabilitation: a prospective trial comparing three rehabilitation regimes. J Hand Surg Br. 2005;30(2):175–179.
JHS 䉬 Vol A, August
Evidence-Based Medicine
EXTENSOR TENDON REHABILITATION
for 3 to 4 weeks in order to protect the repair. Purcell et al2 obtained 95% excellent or good results in 33 patients treated with static splinting based on StricklandGlogovac criteria at 6 months of follow-up evaluation. However, others have reported poorer results. At a mean follow-up of 5 years, Newport et al3 reported excellent/good results according to Miller’s criteria in only 64% of 33 simple extensor tendon lacerations treated with static splinting. Chow et al4 also experienced disappointing results with only 40% of 35 fingers with simple lacerations achieving excellent/good results at a minimum of 12 months according to Dargan’s criteria. With improvements in outcomes seen with flexor tendon repair treated with early active motion protocols,5–7 there has been increased interest in applying similar regimens after extensor tendon repair. Dynamic extension splinting In a prospective study of 82 extensor tendon repairs in zones 4 to 7 treated with DES, Browne and Ribik8 used a protocol consisting of a dynamic outrigger splint, allowing active flexion and passive extension for 5 weeks. They noted good to excellent extension and flexion in 93% of digits an average of 2.5 months after surgery. There were no ruptures, and no subsequent procedures.8 Chow et al4 conducted a prospective, nonrandomized trial comparing 54 patients treated with DES with 32 patients treated with static splinting after repair of simple lacerations of extensor tendons in zones 4 to 7. They found markedly better results with the DES protocol. Based on Dargan’s criteria, 100% of patients treated with DES achieved excellent results by 6 weeks, whereas only 40% achieved excellent results with static splinting at a mean follow-up of 13 weeks. Grip strength was also significantly greater in the DES group.4 Neuhaus et al9 prospectively followed 12 patients treated with DES after extensor tendon repair in zones 4 and 5 and noted excellent or good results in 92% at 6 weeks’ follow-up according to Miller’s criteria. In a retrospective analysis of 58 patients with extensor tendon repairs in zones 5 to 7 treated with DES, Bruner et al10 reported excellent or good results in 94% based on Geldmacher’s grading.
© ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 1615
Evidence-Based Medicine
EVIDENCE-BASED MEDICINE
1616
EXTENSOR TENDON REHABILITATION
Evidence-Based Medicine
Ip and Chow11 prospectively evaluated 84 patients with extensor tendon repairs in zones 4 to 8 treated with DES. At a follow-up of at least 8 weeks, they found 93% excellent or good results based on Dargan’s criteria. Active motion with volar blocking splint Sylaidis et al12 prospectively followed up 24 simple extensor tendon repairs in zones 4 to 7 treated with a volar splint that held the wrist in 30° extension and allowed MCP flexion to 45° with the PIP joints at neutral (the Norwich regimen). They found 92% excellent or good results at 6 weeks based on Dargan’s criteria. Comparative randomized clinical trials Mowlavi et al13 conducted a prospective randomized trial comparing DES to static splinting and found significantly better total active motion (TAM) and grip strength in the DES group at 8 weeks. However, by 6 months, no differences were seen between groups. Kitis et al14 conducted a prospective, randomized trial comparing DES with static splinting and found improved TAM and overall function with DES at 6 months. Khandwala et al15 conducted a prospective randomized trial of 100 patients in which they compared a volar blocking splint with DES. At 8 weeks, they evaluated their patients with Miller and TAM assessments and found excellent or good results in 95% and 98% with DES and 93% and 95% with the blocking splint, respectively. Chester et al16 also conducted a randomized trial comparing controlled early active motion with DES in 36 patients with simple lacerations in zones 4 to 8 and found no differences in TAM at 3 months. All patients in both groups achieved an excellent or a good result. Bulstrode et al17 performed a randomized trial comparing 3 rehabilitation protocols following repair of simple zones 5 and 6 lacerations: static splinting, controlled motion with the wrist and MCP joints in extension and the PIP joints free, and the Norwich regimen. They found significantly reduced TAM in the static group at 4 weeks but not at 12 weeks. There was no difference in the amount of hand therapy utilized by the 3 groups. Grip strength at 12 weeks was significantly reduced compared with the uninjured hand in the static splinting group.17 Relative motion splinting Howell et al1 described their experience with 140 patients over 20 years treated with a relative motion
splinting protocol after repair of extensor tendons in zones 4 to 7. At an average of 49 days, 96% of patients had excellent or good results based on Miller’s criteria. Average time to return to work was 18 days. There have been no comparative studies between relative motion splinting and DES or early active motion with a volar blocking splint. Return to activities/work Limited data are available on average time to return to work after extensor tendon repair. However, there is evidence that relative motion splinting may facilitate the most rapid return to work, which was reported as an average of 18 days.1 Sylaidis et al12 reported an average return to work at 6 weeks with the Norwich regimen. Bruner et al10 reported return to work at 10 weeks, and Browne and Ribik8 reported a range of 8 to 11 weeks with DES. SHORTCOMINGS OF THE EVIDENCE Extensor tendon injuries are relatively uncommon and, therefore, difficult to study. There are no standards for assessing outcomes after extensor tendon repair. A myriad of clinician-based assessments have been used, including Miller’s assessment, Dargan’s criteria, Geldmacher’s grade, Strickland-Glogovac criteria, TAM, and grip strength. To our knowledge, no study has employed a patient-based outcome measure such as the Michigan Hand Outcomes Questionnaire (MHQ), Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure, or other hand/upper extremity–specific subjective outcomes measure. Current outcomes data are, therefore, limited to clinician-based assessments, which are often biased and may not truly reflect accurate outcomes. Return to activities is important but difficult to assess owing to the variability in patients’ jobs and their ability to perform light work. There have been no studies in which relative motion splinting is compared with DES or early active motion with a volar blocking splint. It has been observed that prognosis after repair of tendon lacerations is associated with the zone of injury, with more distal lacerations typically having poorer prognoses.3 There are limited data examining outcomes after extensor tendon repair based on zone of injury. This is likely due to the difficulty of obtaining large enough samples from which meaningful conclusions can be drawn. Most studies of early active motion after extensor tendon repair can only demonstrate a benefit in the short term and the results are somewhat inconsistent. It is not clear that the differences are clinically meaningful or
JHS 䉬 Vol A, August
that the cost and effort of more sophisticated protocols are justified.
1617
greater involvement with hand therapists,15,16 but more formal analysis is needed. REFERENCES
DIRECTIONS FOR FUTURE RESEARCH Agreement among researchers on standard objective and subjective outcomes measures for evaluating extensor tendon repairs would facilitate more accurate comparison of data between studies. A multicenter database could provide adequate power to determine the prognosis for specific zones of injury. It might be possible to determine whether specific postoperative exercise programs are helpful for certain zones of injury. Additional research comparing the cost and value of various exercise protocols after extensor tendon repair is desirable. Further research examining whether different rehabilitation protocols are associated with different times to return to work would be helpful. OUR CURRENT CONCEPTS FOR THIS PATIENT For simple zone 6 extensor tendon lacerations, the literature indicates that, compared with static splinting, early active motion regimens provide improved outcomes in the early postoperative period and possibly later. The method of obtaining early motion, whether through DES, controlled motion with a volar splint, or relative motion splinting, does not appear to alter outcomes. Therefore, because of the relative ease, simplicity, and functionality of the relative motion splint, we prefer it in reliable patients with 1 to 3 fingers that have zones 5 and 6 extensor tendon lacerations. Patients are allowed to begin range of motion immediately within the confines of the splint. They can participate in light activities, such as office work, but refrain from heavy work/manual labor until the time of splint discontinuation at 6 weeks. Relative motion splinting cannot be used when more than 3 tendons are involved, so in these cases we employ an early active motion protocol with a volar blocking splint. In pediatric patients and unreliable adults, consideration must be given to static splinting to decrease the risk of tendon rupture, followed by a therapy program to restore motion at 3 weeks. It has been theorized by some authors that DES is likely more expensive than other protocols owing to the need for a more complex, expensive splint and
1. Howell JW, Merritt WH, Robinson SJ. Immediate controlled active motion following zone 4-7 extensor tendon repair. J Hand Ther. 2005;18(2):182–190. 2. Purcell T, Eadie PA, Murugan S, O’Donnell M, Lawless M. Static splinting of extensor tendon repairs. J Hand Surg Br. 2000;25(2): 180 –182. 3. Newport ML, Blair WF, Steyers CM Jr. Long-term results of extensor tendon repair. J Hand Surg Am. 1990;15(6):961–966. 4. Chow JA, Dovelle S, Thomes LJ, Ho PK, Saldana J. A comparison of results of extensor tendon repair followed by early controlled mobilisation versus static immobilisation. J Hand Surg Br. 1989; 14(1):18 –20. 5. Silfverskiold KL, May EJ. Flexor tendon repair in zone II with a new suture technique and an early mobilization program combining passive and active flexion. J Hand Surg Am. 1994;19(1):53– 60. 6. Small JO, Brennen MD, Colville J. Early active mobilisation following flexor tendon repair in zone 2. J Hand Surg Br. 1989;14(4): 383–391. 7. Trumble TE, Vedder NB, Seiler JG III, Hanel DP, Diao E, Pettrone S. Zone-II flexor tendon repair: a randomized prospective trial of active place-and-hold therapy compared with passive motion therapy. J Bone Joint Surg Am. 2010;92(6):1381–1389. 8. Browne EZ Jr, Ribik CA. Early dynamic splinting for extensor tendon injuries. J Hand Surg Am. 1989;14(1):72–76. 9. Neuhaus V, Wong G, Russo KE, Mudgal CS. Dynamic splinting with early motion following zone IV/V and TI to TIII extensor tendon repairs. J Hand Surg Am. 2012;37(5):933–937. 10. Bruner S, Wittemann M, Jester A, Blumenthal K, Germann G. Dynamic splinting after extensor tendon repair in zones V to VII. J Hand Surg Br. 2003;28(3):224 –227. 11. Ip WY, Chow SP. Results of dynamic splintage following extensor tendon repair. J Hand Surg Br. 1997;22(2):283–287. 12. Sylaidis P, Youatt M, Logan A. Early active mobilization for extensor tendon injuries. the Norwich regime. J Hand Surg Br. 1997; 22(5):594 –596. 13. Mowlavi A, Burns M, Brown RE. Dynamic versus static splinting of simple zone V and zone VI extensor tendon repairs: a prospective, randomized, controlled study. Plast Reconstr Surg. 2005;115(2): 482– 487. 14. 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(3– 4):267–271. 15. 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 Br. 2000;25(2):140 –146. 16. 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 Br. 2002; 27(3):283–288. 17. Bulstrode NW, Burr N, Pratt AL, Grobbelaar AO. Extensor tendon rehabilitation: a prospective trial comparing three rehabilitation regimes. J Hand Surg Br. 2005;30(2):175–179.
JHS 䉬 Vol A, August
Evidence-Based Medicine
EXTENSOR TENDON REHABILITATION