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The American Society of Hand Therapists
PROCEEDINGS The American Society of Hand Therapists Marcia McCalla, R.P.T., Phoenix, Ariz.
The American Society of Hand Therapists Eighth Annual Meeting was held at the MGM Grand Hotel, January 23-25, 1985. Abstracts of the papers presented are published below.
The hand therapist in industry: How to establish your services. SUSAN EMERSON, O.T.R., presented a program that integrates hand therapy in industry. The goals of such a program can be clinically oriented to increase the referral base, to prepare workers for return to work, to prepare site visits, and to act as a liaison between the physician and industry. It can also be consultation oriented to provide personnel support, work station evaluation and design, exercise programs, and development of light duty stations. Marketing and follow-up were an essential part of this program. SARA WALKER, O.T.R., agreed that patient treatment and consultation are valuable because more information on jobs and job stresses is needed. She emphasized that therapists must be well trained and base their programs on research before serving as a consultant. Preemployment analysis must be non biased and follow legal guidelines. The mutilated hand: A new alternative. BARBARA GOODWIN, R.P.T., and WANDRA MILES, O.T.R., presented ideas for patient selection and for patient physical and psychologic preparation for the passive functional prosthesis fabricated by DR. JEAN PILLET. They also presented the results of a survey of 25 patients to correlate factors such as sex, age, occupation, and level of amputation with user satisfaction/dissatisfaction with the prosthesis. ROSLYN EVANS, O. T.R., suggested that expansion of the survey questionnaire to investigate what effect the prosthesis has on an earlier return to work of the patient would provide useful information for the clinician and for insurance companies.
An EMG analysis of five muscles with the use of tool attachments of the BTE (Baltimore Therapeutic Equipment) work simulator. SCOTT MCPHEE, O. T. R., studied the participation of five muscles in the forearm and hand during use of three tools on the BTE work simulator at three levels of resistance with use of EMG recordings on normal SUbjects. He concluded that at different levels of resistance the muscles participated in a different pattern, especially at zero resistance. This
method can be used to develop a chart of muscle use at different levels to assist the therapist in selecting the optimal tool and resistance for the therapeutic effect desired. He believed that the research supports the use of different tool attachments and assists therapists in documenting the effect of therapy. JUDY BELL, O.T.R., pointed out that skin resistance is critical in the use of surface EMG electrodes, and that forearm and wrist position must be controlled during such studies. She questioned if the abductor pollicis brevis is representative of thumb flexion and extension.
String wrapping versus massage for reducing digital volume. KENNETH FLOWERS, L.P.T., studied the effect of four techniques for reducing digital edema of four digits in 14 patients with edema secondary to proximal injury. Forty-four trials were run, alternating techniques to each digit, and each technique was applied for 5 minutes. Massage, string wrapping, and two combinations of those techniques were used, and circumference was measured before and after treatment. The two combined techniques were found to be significantly more effective than either of the pure techniques. No significant difference was found between massage and string wrapping alone. DONNA REIST, O.T.R.lL., complimented the author on this study that supports a clinical hunch that combined treatment is more effective. She criticized the research design because no reliability or validity measures were demonstrated, and there was no demographic information on subjects or indication of the duration that edema was present. She suggested that comparisons to the other hand be included.
The effect of thumb interphalangeal joint position on strength of key pinch. EILEEN APFEL, O.T.R., presented a study to determine if thumb interphalangeal (IP) joint position affects the outcome of lateral pinch strength tests. Results demonstrated that 29 of 30 normal male and female subjects spontaneously flex their thumbs during lateral pinch. When thumb IP flexion was used, the female subjects demonstrated an increased strength of 30% for the right upper extremity and 28% for the left upper extremity compared to measurements with the use of thumb IP extension. The men demonstrated an increased strength of 36% for the right upper extremity and 38% for the left upper extremity THE JOURNAL OF HAND SURGERY
583
584 Proceedings
when thumb IP flexion versus extension was used. She concluded that thumb IP joint position significantly affects the result of lateral pinch strength tests. MARY KASCH, O.T.R., suggested that the position of the metacarpophalangeal joint be noted when the patient hyper6exes the IP joint. The use of continuous passive motion in the upper extremity: A preliminary report. MARY DIMICK, O. T. R. , described her preliminary experience with continuous passive motion devices (CPM) in the rehabilitation of flexor tendon injuries, intra-articular finger fractures, capsulectomies, and elbow injuries. She suggested that CPM may have wide application in upper extremity rehabilitation, especially in the prevention of pain, edema, and joint contractures. NANCY CANNON, O.T.R., emphasized that this is a preliminary study, but CPM may have implications to help reduce pain and edema. A systematic approach in the selection of elastic traction in dynamic splinting. LAURA MILDENBERGER, O.T.R., PETER AMADIO, M.D., and KAI N. AN, Ph.D., described a method of measurement of material properties of elastic traction with the use of the Instrom MTS testing machines. Results indicated (1) specific elastic constant values for rubber bands frequently used in the clinical setting range from 0.3 to 1.0 pounds per unit elongation, (2) the ability of each band to maintain its material properties with repeated use was similar from band to band and demonstrated a gradual diminution after several hundred repetitions, and (3) the consistency of bands labeled as identical by the manufacturer was generally very good. The authors then described a model for combining this data with theoretic construction of splint fabrication to enable easier identification by therapists inexperienced in splinting of the appropriate rubber band for splint application. ELAINE FESS, O.T.R., commended the authors for their studies but suggested that the use of a greater number of rubber bands, especially from different sources, could influence the statistical reliability of the results. Serial casting in the treatment of proximal interphalangeal joint flexion contractures. BARBARA PUDDICOMBE, O.T.R., KAREN MATHEWSON, O.T.R., and LEONARD HUBBARD, M.D., treated 30 digits with flexion contractures by serial casting. Those patients in the inflammatory arthritis group demonstrated a 59% improvement in range of motion, and those in the soft tissue injury group had 63% improvement. In the author's opinion, serial casting of proximal interphalan-
The Journal of HAND SURGERY
geal joint contractures appears to be a safe and effective method of gaining at least partial correction. JUDY BELL, O.T.R., noted that the study did not contain a control group without serial casting, nor was serial casting compared with other types of dynamic splints. Staged tendon grafts 1973-1981 at the Mayo Clinic. S. D. BOGARD, R.P.T., M. B. WOOD, M.D., W. P. COONEY, III, M.D., and P. C. AMADIO, M.D., reviewed 68 charts of patients who had a two-staged tendon graft. Results were evaluated statistically by use of the paired t and sign test p < 0.001. Results in correction of a flexion lag were significant; however, extension lag results were not significant. Forty-four percent of the patients believed improvement was sufficient to term the procedure a success. EVELYN MACKIN, R.P.T., suggested the results be expressed in range of motion measurements. She pointed out that the extent and level of the injury or if there were an intact flexor digitorum superficialis was not mentioned. The study does not demonstrate that this procedure has merit. Rehabilitation protocol for free dynamic gracilis muscle transfers to the upper extremity. THOMAS KOWALSKI, O.T.R., and ELLIOTT ROSE, M.D., presented two cases of free dynamic gracilis muscle transfers from the ipsilateral thigh to restore motion in a paralytic upper extremity. The rehabilitation protocol was presented. In both cases elbow flexion was restored, and one patient recovered wrist extension and digital extension. Surgical intervention helped these two patients when other conservative measures failed. JANET W AYLETT-RENDALL, O. T.R., commented that one cannot develop a protocol with two different cases. It was also asked why the pectoralis to biceps transfer was not used. Electrokinesiologic feedback: An adjunct in therapeutic restoration of hand function. DIANA WILLIAMS, O.T.R., reported that therapeutic implementation of feedback goniometers can be a simple and cost-effective adjunct in attaining restoration of hand function. This method was compared to results of active exercises only. Various goniometers were discussed. DAVID BIERWAGEN, R.P.T., noted that the patient has no way to assess improvement until he meets the end of the range. Loss does not mean less. SPRING HARKINS, O. T.R., and SHELLYE BITTINGER, O.T.R., reported on 12 male amputees' use of the TRS grip voluntary closing device. Five of the amputees had been wearing the traditional split hook voluntary opening terminal device, and seven
Vol lOA, No.4 July 1985
were fitted primarily with the GRIP. The authors concluded that the voluntary closing action of the GRIP that resembles natural grasp patterns coupled with the versatility of the GRIP in force/strength of grip and pinch make it the choice of their amputees and therapists. WANDRA MILES, O.T.R., agreed that the GRIP is a major breakthrough for upper extremity prosthetics and suggested that additional knowledge of the negative aspects of the GRIP (weak cable system and coil spring, problems with sustained grip, and cost) would have been beneficial to the therapists working with amputees. Early active flexion after flexor tendon repair. DEBORAH SEIBLY, O.T.R. , presented an early active flexion program used after injury to flexor tendons and digital nerves in zone II. Thirty-one cases were reviewed. Time spent in active therapy, functional results , number of ruptures, and number of tenolyses were reviewed. Time spent in therapy averaged 6Yz to 8 weeks from date of injury. Results were as follows: 26%, excellent; 16%, good; 45%, fair; and 13%, poor. Results were assessed at the end of active therapy. Rupture rate was 13%. Rate of tenolysis was 3%. The authors concluded that even though rupture rate was higher than desired, functional results were good, particularly when results were reviewed at 6 months after injury and after a second repair. CHRIS BURKE, O.T.R., complimented the authors for investigating what has long been a fear to practicing hand therapists. Even though rupture rate was high, the authors had presented an alternative to treatment of zone II flexor tendon injuries. Early protective motion (EPM I and II)-A hand therapy protocol for management of digital replantation. VIRGINIA WILLETIE-GREEN, O.T.R., PAMELA SILVERMAN, O.T.R., JOAN PETRILLI, O .T.R., and JOHN CASSELL, M.D ., presented the rationale for a protocol with the use of early motion after digital replantation. The first stage, early protection motion I (EPM I) involved dorsally splinting the hand in an intrinsic plus position with the wrist in neutral. As early as 5 days postoperatively, active flexion of the wrist is started to allow a tenodesis effect for extension of the metacarpophalangeal joints (MP), followed by wrist extension to neutral with simultaneous passive MP joint flexion. The second stage, EPM II, involved interphalangeal joint motion with the MP joints in the opposite position. Cadaver and diagrammatic slides were used to confirm the author's rationale. Two cases were reviewed for demonstration purposes. The authors concluded that the
Proceedings
585
protocol has proved useful for controlled management of digital replantations in a large replantation center and may provide basis for further study. ROBIN MILLER, O.T.R., commended the authors in presenting an organized outline for management of digital replantation and on their attention to biomechanics, wound healing, and therapeutic relationship. An overview of the extensor mechanism in zone II replants. PAMELA SILVERMAN, O.T.R., VIRGINIA WILLETIE-GREEN, O.T.R., JOAN PETRILLI, O.T.R., and JOHN CASSELL, M.D., reviewed the anatomy of the extensor mechanism and stated that a finger amputated in palmar zone II may be replanted with or without repair of the extensor mechanism. Common complications observed are extensor lag at the proximal interphalangeal and distal interphalangeal joints and paradoxical extensor habitus. A retrospective study was conducted on 25 of their patients to observe if an early protective motion program (EPM) resulted in less extensor lag. There was no statistically significant difference in active extensor lag, but the EPM group had improved passive motion compared to the non-EPM group. The authors recommended repair of dorsal structures, early motion, protective splinting, and a need to establish consistency in reporting results of replantation by severity of injuries. BETH NICHOLSON, O.T.R., noted that variations in damage, surgeons, and the experience and judgment of the therapist will influence results . She questioned the effect of technique used on the multiple structures involved and asked if other structures were considered in the study. She pointed out that extensor lag may be a problem of flexion and function of the digits and encouraged the authors to design a prospective study. Relationship of grip strength measurements between the JAMAR dynamometer and BTE work simulator. MAUREEN GILCHRIST, O.T.R., JUDI COULTHARD, O .T.R., and RUTH ZEMKE, O.T.R., tested a hypothesized correlation between the dynamometer and selected BTE work simulator tools in normal subjects. BTE tools used were power grip tool, large grip screwdriver, and large knob in the static mode. Correlation coefficients demonstrated a relationship between dynamometer and work simulator tool number 161, power grip (right and left hand), and between dynamometer and forearm circumference (left and right), r > 0.70. The authors concluded that BTE scores could provide a check for dynamometer readings recorded by the practitioner. ANN GALBRAITH, O.T.R., commented that little, if any, data have been published on the BTE work sim-
586
Proceedings
ulator. She believed that the fact that correlations were found was commendable but suggested that a larger sampling (separating male and female patients) for testing was needed. Vascular testing for the practitioner. CHERRY KOONTZ, R.P. T., addressed the diagnostic functions of the Doppler ultrasound and volume plethysmography in localizing/quantifying measures in digital artery occlusions, in defining arterial components of thoracic outlet syndrome, and in confirming/quantifying vasospastic cold and tobacco intolerance . The role of hemodynamic information in predicting outcome of clinical and surgical treatment was discussed. She concluded that vascular knowledge is a necessary component of the hand practitioner's repertoire. LAURA CHAPMAN, R.P.T., commended the author on demonstrating the value of noninvasive vascular procedures and the simplicity with which they can be used in the clinic, emergency room, or operating room . She supported these techniques over the arteriogram, particularly for the distal extremity. The suggestion was made to stress the importance of selective temporary vascular occlusion, since the Doppler cannot evaluate direction of flow.
The Journal of HAND SURGERY
The pros and cons of upper extremity externally powered prostheses. SUSAN CLARKE, O.T.R., discussed the functional advantages ofthe Otto-Bock myoelectric, below-elbow prosthesis. Advantages of the system include (1) increased work area, (2) increased pinch/grip strength, and (3) improved comfort as a result of freedom from the harness and body-powered system. It was described as being durable, reasonably trouble free, and easily maintained. Disadvantages are cost and weight of the device , especially for children. She also presented information on myoelectric units in development including the Utah for higher level amputees. KAREN SCHULTZ, O. T.R., appreciated the author's effort to tie in the meager literature available with her own clinical experiences. She commented that functional needs of stump length and future reconstruction must be considered before amputation is performed. She questioned if the case studies included congenital or acquired amputations and the length of time postoperative before fitting .
The American Society of Hand Therapists Eighth Annual Meeting was held at the MGM Grand Hotel, January 23-25, 1985. Abstracts of the papers presented are published below.
The hand therapist in industry: How to establish your services. SUSAN EMERSON, O.T.R., presented a program that integrates hand therapy in industry. The goals of such a program can be clinically oriented to increase the referral base, to prepare workers for return to work, to prepare site visits, and to act as a liaison between the physician and industry. It can also be consultation oriented to provide personnel support, work station evaluation and design, exercise programs, and development of light duty stations. Marketing and follow-up were an essential part of this program. SARA WALKER, O.T.R., agreed that patient treatment and consultation are valuable because more information on jobs and job stresses is needed. She emphasized that therapists must be well trained and base their programs on research before serving as a consultant. Preemployment analysis must be non biased and follow legal guidelines. The mutilated hand: A new alternative. BARBARA GOODWIN, R.P.T., and WANDRA MILES, O.T.R., presented ideas for patient selection and for patient physical and psychologic preparation for the passive functional prosthesis fabricated by DR. JEAN PILLET. They also presented the results of a survey of 25 patients to correlate factors such as sex, age, occupation, and level of amputation with user satisfaction/dissatisfaction with the prosthesis. ROSLYN EVANS, O. T.R., suggested that expansion of the survey questionnaire to investigate what effect the prosthesis has on an earlier return to work of the patient would provide useful information for the clinician and for insurance companies.
An EMG analysis of five muscles with the use of tool attachments of the BTE (Baltimore Therapeutic Equipment) work simulator. SCOTT MCPHEE, O. T. R., studied the participation of five muscles in the forearm and hand during use of three tools on the BTE work simulator at three levels of resistance with use of EMG recordings on normal SUbjects. He concluded that at different levels of resistance the muscles participated in a different pattern, especially at zero resistance. This
method can be used to develop a chart of muscle use at different levels to assist the therapist in selecting the optimal tool and resistance for the therapeutic effect desired. He believed that the research supports the use of different tool attachments and assists therapists in documenting the effect of therapy. JUDY BELL, O.T.R., pointed out that skin resistance is critical in the use of surface EMG electrodes, and that forearm and wrist position must be controlled during such studies. She questioned if the abductor pollicis brevis is representative of thumb flexion and extension.
String wrapping versus massage for reducing digital volume. KENNETH FLOWERS, L.P.T., studied the effect of four techniques for reducing digital edema of four digits in 14 patients with edema secondary to proximal injury. Forty-four trials were run, alternating techniques to each digit, and each technique was applied for 5 minutes. Massage, string wrapping, and two combinations of those techniques were used, and circumference was measured before and after treatment. The two combined techniques were found to be significantly more effective than either of the pure techniques. No significant difference was found between massage and string wrapping alone. DONNA REIST, O.T.R.lL., complimented the author on this study that supports a clinical hunch that combined treatment is more effective. She criticized the research design because no reliability or validity measures were demonstrated, and there was no demographic information on subjects or indication of the duration that edema was present. She suggested that comparisons to the other hand be included.
The effect of thumb interphalangeal joint position on strength of key pinch. EILEEN APFEL, O.T.R., presented a study to determine if thumb interphalangeal (IP) joint position affects the outcome of lateral pinch strength tests. Results demonstrated that 29 of 30 normal male and female subjects spontaneously flex their thumbs during lateral pinch. When thumb IP flexion was used, the female subjects demonstrated an increased strength of 30% for the right upper extremity and 28% for the left upper extremity compared to measurements with the use of thumb IP extension. The men demonstrated an increased strength of 36% for the right upper extremity and 38% for the left upper extremity THE JOURNAL OF HAND SURGERY
583
584 Proceedings
when thumb IP flexion versus extension was used. She concluded that thumb IP joint position significantly affects the result of lateral pinch strength tests. MARY KASCH, O.T.R., suggested that the position of the metacarpophalangeal joint be noted when the patient hyper6exes the IP joint. The use of continuous passive motion in the upper extremity: A preliminary report. MARY DIMICK, O. T. R. , described her preliminary experience with continuous passive motion devices (CPM) in the rehabilitation of flexor tendon injuries, intra-articular finger fractures, capsulectomies, and elbow injuries. She suggested that CPM may have wide application in upper extremity rehabilitation, especially in the prevention of pain, edema, and joint contractures. NANCY CANNON, O.T.R., emphasized that this is a preliminary study, but CPM may have implications to help reduce pain and edema. A systematic approach in the selection of elastic traction in dynamic splinting. LAURA MILDENBERGER, O.T.R., PETER AMADIO, M.D., and KAI N. AN, Ph.D., described a method of measurement of material properties of elastic traction with the use of the Instrom MTS testing machines. Results indicated (1) specific elastic constant values for rubber bands frequently used in the clinical setting range from 0.3 to 1.0 pounds per unit elongation, (2) the ability of each band to maintain its material properties with repeated use was similar from band to band and demonstrated a gradual diminution after several hundred repetitions, and (3) the consistency of bands labeled as identical by the manufacturer was generally very good. The authors then described a model for combining this data with theoretic construction of splint fabrication to enable easier identification by therapists inexperienced in splinting of the appropriate rubber band for splint application. ELAINE FESS, O.T.R., commended the authors for their studies but suggested that the use of a greater number of rubber bands, especially from different sources, could influence the statistical reliability of the results. Serial casting in the treatment of proximal interphalangeal joint flexion contractures. BARBARA PUDDICOMBE, O.T.R., KAREN MATHEWSON, O.T.R., and LEONARD HUBBARD, M.D., treated 30 digits with flexion contractures by serial casting. Those patients in the inflammatory arthritis group demonstrated a 59% improvement in range of motion, and those in the soft tissue injury group had 63% improvement. In the author's opinion, serial casting of proximal interphalan-
The Journal of HAND SURGERY
geal joint contractures appears to be a safe and effective method of gaining at least partial correction. JUDY BELL, O.T.R., noted that the study did not contain a control group without serial casting, nor was serial casting compared with other types of dynamic splints. Staged tendon grafts 1973-1981 at the Mayo Clinic. S. D. BOGARD, R.P.T., M. B. WOOD, M.D., W. P. COONEY, III, M.D., and P. C. AMADIO, M.D., reviewed 68 charts of patients who had a two-staged tendon graft. Results were evaluated statistically by use of the paired t and sign test p < 0.001. Results in correction of a flexion lag were significant; however, extension lag results were not significant. Forty-four percent of the patients believed improvement was sufficient to term the procedure a success. EVELYN MACKIN, R.P.T., suggested the results be expressed in range of motion measurements. She pointed out that the extent and level of the injury or if there were an intact flexor digitorum superficialis was not mentioned. The study does not demonstrate that this procedure has merit. Rehabilitation protocol for free dynamic gracilis muscle transfers to the upper extremity. THOMAS KOWALSKI, O.T.R., and ELLIOTT ROSE, M.D., presented two cases of free dynamic gracilis muscle transfers from the ipsilateral thigh to restore motion in a paralytic upper extremity. The rehabilitation protocol was presented. In both cases elbow flexion was restored, and one patient recovered wrist extension and digital extension. Surgical intervention helped these two patients when other conservative measures failed. JANET W AYLETT-RENDALL, O. T.R., commented that one cannot develop a protocol with two different cases. It was also asked why the pectoralis to biceps transfer was not used. Electrokinesiologic feedback: An adjunct in therapeutic restoration of hand function. DIANA WILLIAMS, O.T.R., reported that therapeutic implementation of feedback goniometers can be a simple and cost-effective adjunct in attaining restoration of hand function. This method was compared to results of active exercises only. Various goniometers were discussed. DAVID BIERWAGEN, R.P.T., noted that the patient has no way to assess improvement until he meets the end of the range. Loss does not mean less. SPRING HARKINS, O. T.R., and SHELLYE BITTINGER, O.T.R., reported on 12 male amputees' use of the TRS grip voluntary closing device. Five of the amputees had been wearing the traditional split hook voluntary opening terminal device, and seven
Vol lOA, No.4 July 1985
were fitted primarily with the GRIP. The authors concluded that the voluntary closing action of the GRIP that resembles natural grasp patterns coupled with the versatility of the GRIP in force/strength of grip and pinch make it the choice of their amputees and therapists. WANDRA MILES, O.T.R., agreed that the GRIP is a major breakthrough for upper extremity prosthetics and suggested that additional knowledge of the negative aspects of the GRIP (weak cable system and coil spring, problems with sustained grip, and cost) would have been beneficial to the therapists working with amputees. Early active flexion after flexor tendon repair. DEBORAH SEIBLY, O.T.R. , presented an early active flexion program used after injury to flexor tendons and digital nerves in zone II. Thirty-one cases were reviewed. Time spent in active therapy, functional results , number of ruptures, and number of tenolyses were reviewed. Time spent in therapy averaged 6Yz to 8 weeks from date of injury. Results were as follows: 26%, excellent; 16%, good; 45%, fair; and 13%, poor. Results were assessed at the end of active therapy. Rupture rate was 13%. Rate of tenolysis was 3%. The authors concluded that even though rupture rate was higher than desired, functional results were good, particularly when results were reviewed at 6 months after injury and after a second repair. CHRIS BURKE, O.T.R., complimented the authors for investigating what has long been a fear to practicing hand therapists. Even though rupture rate was high, the authors had presented an alternative to treatment of zone II flexor tendon injuries. Early protective motion (EPM I and II)-A hand therapy protocol for management of digital replantation. VIRGINIA WILLETIE-GREEN, O.T.R., PAMELA SILVERMAN, O.T.R., JOAN PETRILLI, O .T.R., and JOHN CASSELL, M.D ., presented the rationale for a protocol with the use of early motion after digital replantation. The first stage, early protection motion I (EPM I) involved dorsally splinting the hand in an intrinsic plus position with the wrist in neutral. As early as 5 days postoperatively, active flexion of the wrist is started to allow a tenodesis effect for extension of the metacarpophalangeal joints (MP), followed by wrist extension to neutral with simultaneous passive MP joint flexion. The second stage, EPM II, involved interphalangeal joint motion with the MP joints in the opposite position. Cadaver and diagrammatic slides were used to confirm the author's rationale. Two cases were reviewed for demonstration purposes. The authors concluded that the
Proceedings
585
protocol has proved useful for controlled management of digital replantations in a large replantation center and may provide basis for further study. ROBIN MILLER, O.T.R., commended the authors in presenting an organized outline for management of digital replantation and on their attention to biomechanics, wound healing, and therapeutic relationship. An overview of the extensor mechanism in zone II replants. PAMELA SILVERMAN, O.T.R., VIRGINIA WILLETIE-GREEN, O.T.R., JOAN PETRILLI, O.T.R., and JOHN CASSELL, M.D., reviewed the anatomy of the extensor mechanism and stated that a finger amputated in palmar zone II may be replanted with or without repair of the extensor mechanism. Common complications observed are extensor lag at the proximal interphalangeal and distal interphalangeal joints and paradoxical extensor habitus. A retrospective study was conducted on 25 of their patients to observe if an early protective motion program (EPM) resulted in less extensor lag. There was no statistically significant difference in active extensor lag, but the EPM group had improved passive motion compared to the non-EPM group. The authors recommended repair of dorsal structures, early motion, protective splinting, and a need to establish consistency in reporting results of replantation by severity of injuries. BETH NICHOLSON, O.T.R., noted that variations in damage, surgeons, and the experience and judgment of the therapist will influence results . She questioned the effect of technique used on the multiple structures involved and asked if other structures were considered in the study. She pointed out that extensor lag may be a problem of flexion and function of the digits and encouraged the authors to design a prospective study. Relationship of grip strength measurements between the JAMAR dynamometer and BTE work simulator. MAUREEN GILCHRIST, O.T.R., JUDI COULTHARD, O .T.R., and RUTH ZEMKE, O.T.R., tested a hypothesized correlation between the dynamometer and selected BTE work simulator tools in normal subjects. BTE tools used were power grip tool, large grip screwdriver, and large knob in the static mode. Correlation coefficients demonstrated a relationship between dynamometer and work simulator tool number 161, power grip (right and left hand), and between dynamometer and forearm circumference (left and right), r > 0.70. The authors concluded that BTE scores could provide a check for dynamometer readings recorded by the practitioner. ANN GALBRAITH, O.T.R., commented that little, if any, data have been published on the BTE work sim-
586
Proceedings
ulator. She believed that the fact that correlations were found was commendable but suggested that a larger sampling (separating male and female patients) for testing was needed. Vascular testing for the practitioner. CHERRY KOONTZ, R.P. T., addressed the diagnostic functions of the Doppler ultrasound and volume plethysmography in localizing/quantifying measures in digital artery occlusions, in defining arterial components of thoracic outlet syndrome, and in confirming/quantifying vasospastic cold and tobacco intolerance . The role of hemodynamic information in predicting outcome of clinical and surgical treatment was discussed. She concluded that vascular knowledge is a necessary component of the hand practitioner's repertoire. LAURA CHAPMAN, R.P.T., commended the author on demonstrating the value of noninvasive vascular procedures and the simplicity with which they can be used in the clinic, emergency room, or operating room . She supported these techniques over the arteriogram, particularly for the distal extremity. The suggestion was made to stress the importance of selective temporary vascular occlusion, since the Doppler cannot evaluate direction of flow.
The Journal of HAND SURGERY
The pros and cons of upper extremity externally powered prostheses. SUSAN CLARKE, O.T.R., discussed the functional advantages ofthe Otto-Bock myoelectric, below-elbow prosthesis. Advantages of the system include (1) increased work area, (2) increased pinch/grip strength, and (3) improved comfort as a result of freedom from the harness and body-powered system. It was described as being durable, reasonably trouble free, and easily maintained. Disadvantages are cost and weight of the device , especially for children. She also presented information on myoelectric units in development including the Utah for higher level amputees. KAREN SCHULTZ, O. T.R., appreciated the author's effort to tie in the meager literature available with her own clinical experiences. She commented that functional needs of stump length and future reconstruction must be considered before amputation is performed. She questioned if the case studies included congenital or acquired amputations and the length of time postoperative before fitting .