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Bamford E, Berntsson H, Beale S, Desoysa L, Dias J, Hamer-Kiwacz S, Hind D, Johnson N, Loban A, Molloy K, Morvan E, Rombach I, Selby A, Thokala P, Turtle C, Walters S, Drummond A. Flexor Injury Rehabilitation Splint Trial (FIRST): protocol for a pragmatic randomised controlled trial comparing three splints for finger flexor tendon repairs. Trials 2024; 25:193. [PMID: 38493121 PMCID: PMC10943783 DOI: 10.1186/s13063-024-08013-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/23/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Without surgical repair, flexor tendon injuries do not heal and patients' ability to bend fingers and grip objects is impaired. However, flexor tendon repair surgery also requires optimal rehabilitation. There are currently three custom-made splints used in the rehabilitation of zone I/II flexor tendon repairs, each with different assumed harm/benefit profiles: the dorsal forearm and hand-based splint (long), the Manchester short splint (short), and the relative motion flexion splint (mini). There is, however, no robust evidence as to which splint, if any, is most clinical or cost effective. The Flexor Injury Rehabilitation Splint Trial (FIRST) was designed to address this evidence gap. METHODS FIRST is a parallel group, superiority, analyst-blind, multi-centre, individual participant-randomised controlled trial. Participants will be assigned 1:1:1 to receive either the long, short, or mini splint. We aim to recruit 429 participants undergoing rehabilitation following zone I/II flexor tendon repair surgery. Potential participants will initially be identified prior to surgery, in NHS hand clinics across the UK, and consented and randomised at their splint fitting appointment post-surgery. The primary outcome will be the mean post-randomisation score on the patient-reported wrist and hand evaluation measure (PRWHE), assessed at 6, 12, 26, and 52 weeks post randomisation. Secondary outcome measures include blinded grip strength and active range of movement (AROM) assessments, adverse events, adherence to the splinting protocol (measured via temperature sensors inserted into the splints), quality of life assessment, and further patient-reported outcomes. An economic evaluation will assess the cost-effectiveness of each splint, and a qualitative sub-study will evaluate participants' preferences for, and experiences of wearing, the splints. Furthermore, a mediation analysis will determine the relationship between patient preferences, splint adherence, and splint effectiveness. DISCUSSION FIRST will compare the three splints with respect to clinical efficacy, complications, quality of life and cost-effectiveness. FIRST is a pragmatic trial which will recruit from 26 NHS sites to allow findings to be generalisable to current clinical practice in the UK. It will also provide significant insights into patient experiences of splint wear and how adherence to splinting may impact outcomes. TRIAL REGISTRATION ISRCTN: 10236011.
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Affiliation(s)
- Emma Bamford
- Pulvertaft Hand Centre, Royal Derby Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, DE22 3NE, UK
| | - Hannah Berntsson
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, S1 4DA, Sheffield, UK.
| | - Suzanne Beale
- Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, B15 2GW, Birmingham, UK
| | - Lauren Desoysa
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, S1 4DA, Sheffield, UK
| | - Joseph Dias
- University Hospitals of Leicester NHS Foundation Trust, LE1, 7RH, Leicester, UK
| | - Sienna Hamer-Kiwacz
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, S1 4DA, Sheffield, UK
| | - Daniel Hind
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, S1 4DA, Sheffield, UK
| | - Nick Johnson
- Pulvertaft Hand Centre, Royal Derby Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, DE22 3NE, UK
| | - Amanda Loban
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, S1 4DA, Sheffield, UK
| | | | - Emma Morvan
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, S1 4DA, Sheffield, UK
| | - Ines Rombach
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, S1 4DA, Sheffield, UK
| | - Anna Selby
- Pulvertaft Hand Centre, Royal Derby Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, DE22 3NE, UK
| | - Praveen Thokala
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, S1 4DA, Sheffield, UK
| | - Chris Turtle
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, S1 4DA, Sheffield, UK
| | - Stephen Walters
- SCHARR, Division of Population Health, School of Medicine and Population Health, University of Sheffield, S1 4DA, Sheffield, UK
| | - Avril Drummond
- School of Health Sciences, University of Nottingham, Nottingham, NG7 2QL, UK
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Ayhan E, Arslan OB, Cevik K, Oksuz C. Relative Motion Extension Splint after Extensor Tendon Reconstruction. J Hand Microsurg 2024; 16:100020. [PMID: 38854382 PMCID: PMC11127533 DOI: 10.1055/s-0043-1761222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Recently, the wide-awake local anesthesia no tourniquet (WALANT) technique and relative motion extension (RME) splint changed practice in extensor tendon reconstruction and therapy. We wanted to share our approach for zones 5 to 8 extensor tendon management following the up-to-date developments. The impacts of surgery under WALANT and early active motion therapy with RME splinting were explained frankly and shown in several videos throughout the article.
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Affiliation(s)
- Egemen Ayhan
- Department of Orthopedics and Traumatology, Hand Surgery, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Ozge Buket Arslan
- Department of Occupational Therapy, Faculty of Health Sciences, Hacettepe University, Ankara, Turkey
| | - Kadir Cevik
- Department of Orthopedics and Traumatology, Hand Surgery, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Cigdem Oksuz
- Department of Occupational Therapy, Faculty of Health Sciences, Hacettepe University, Ankara, Turkey
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Hirth MJ, Hunt I, Briody K, Milner Z, Sleep K, Chu A, Donovan E, O'Brien L. Comparison of two relative motion extension approaches (RME with versus without an additional overnight orthosis) following zones V-VI extensor tendon repairs: A randomized equivalence trial. J Hand Ther 2023; 36:347-362. [PMID: 34400031 DOI: 10.1016/j.jht.2021.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 02/28/2021] [Accepted: 06/18/2021] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Multi--center randomized controlled trial with two intervention parallel groups. An equivalence trial. INTRODUCTION Relative motion extension (RME) orthoses are widely used in the postoperative management of finger extensor tendon repairs in zones V-VI. Variability in orthotic additions to the RME only (without a wrist orthosis) approach has not been verified in clinical studies. PURPOSE OF THE STUDY To examine if two RME only approaches (with or without an additional overnight wrist-hand-finger orthosis) yields clinically similar outcomes. METHODS Thirty-two adult (>18 years) participants (25 males, 7 females) were randomized to one of two intervention groups receiving either 1) a relative motion extension orthosis for day wear and an overnight wrist-hand-finger orthosis ('RME Day' group), or 2) a relative motion extension orthosis to be worn continuously ('RME 24-Hr' group); both groups for a period of four postoperative weeks. RESULTS Using a series of linear mixed models we found no differences between the intervention groups for the primary (ROM including TAM, TAM as a percentage of the contralateral side [%TAM], and Millers Criteria) and secondary outcome measures of grip strength, QuickDASH and PRWHE scores. The models did identify several covariates that are correlated with outcome measures. The covariate 'Age' influenced TAM (P = .006) and %TAM (P = .007), with increasing age correlating with less TAM and recovery of TAM compared to the contralateral digit. 'Sex' and 'Contralateral TAM' are also significant covariates for some outcomes. DISCUSSION With similar outcomes between both intervention groups, the decision to include an additional night orthosis should be individually tailored for patients rather than protocol-based. As the covariates of 'Age' and 'Sex' influenced outcomes, these should be considered in clinical practice. CONCLUSIONS A relative motion extension only approach with or without an additional overnight wrist-hand-finger orthosis yielded clinically similar results whilst allowing early functional hand use, without tendon rupture.
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Affiliation(s)
- Melissa J Hirth
- Occupational Therapy Department, Austin Health, Heidelberg, Victoria, Australia; Malvern Hand Therapy, Malvern, Victoria, Australia; Department of Occupational Therapy, Faculty of Medicine, Nursing and Health Sciences, Monash University, Peninsula Campus, Frankston, Victoria, Australia.
| | - Ian Hunt
- TIA, College of Sciences and Engineering, University of Tasmania, Tasmania, Australia
| | - Kelly Briody
- Occupational Therapy Department, Monash Health, Dandenong, Victoria, Australia
| | - Zoe Milner
- Occupational Therapy Department, Melbourne Health, Parkville, Victoria, Australia
| | - Kate Sleep
- Malvern Hand Therapy, Malvern, Victoria, Australia
| | - Angela Chu
- Occupational Therapy Department, Austin Health, Heidelberg, Victoria, Australia
| | - Emily Donovan
- Occupational Therapy Department, Western Health, Footscray, Victoria, Australia
| | - Lisa O'Brien
- Department of Occupational Therapy, Faculty of Medicine, Nursing and Health Sciences, Monash University, Peninsula Campus, Frankston, Victoria, Australia
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Yates SE, Glinsky JV, Hirth MJ, Fuller JT. The use of exercise relative motion orthoses to improve proximal interphalangeal joint motion: A survey of Australian hand therapy practice. J Hand Ther 2023; 36:414-424. [PMID: 37031058 DOI: 10.1016/j.jht.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 12/05/2022] [Accepted: 12/06/2022] [Indexed: 04/10/2023]
Abstract
STUDY DESIGN Cross-sectional online survey. INTRODUCTION Exercise relative motion (RM) orthoses are prescribed by hand therapists to improve finger motion but there is limited scientific evidence to guide practice. PURPOSE OF THE STUDY To describe Australian hand therapists' use of exercise RM orthoses to improve PIPJ motion, including trends in orthosis design, prescription, clinical conditions, and their opinions on orthosis benefits and limitations. METHODS 870 Australian Hand Therapy Association members were sent an electronic survey that included multiple choice, Likert scale and open-ended questions under four subgroups: demographics, design trends, prescription, and therapist opinions. Data analysis consisted of predominantly descriptive statistics and verbatim transcription. RESULTS 108 Australian therapists completed the survey, over a third with ≥ 20 years of clinical experience. Exercise RM orthoses were prescribed weekly to monthly (82%) for between 2-6 weeks duration (81%) and used during exercise and function (87%). The most common differential MCPJ position was 11-30° extension (98%) or flexion (92%). Four-finger designs were most common for border digits (OR ≥3.4). Exercise RM orthoses were more commonly used for active and extension deficits compared to passive (OR ≥3.7) and flexion deficits (OR ≥1.4), respectively. Clinicians agreed that the orthosis allowed functional hand use (94%), increased non-intentional exercise (98%), and was challenging to use with fluctuating oedema (60%). DISCUSSION This survey highlights notable clinical trends despite only reaching a small sample of Australian hand therapists. Exercise RM orthoses were frequently being used for active PIPJ extension and flexion deficits. A common MCPJ differential angle was reported, while the number of fingers incorporated into the design depended on the digit involved. Therapists' preferences mostly agreed with the limited available evidence. CONCLUSION(S) This limited survey identified common exercise RM orthosis fabrication and prescription trends amongst Australian therapists. These insights may inform future biomechanical and clinical research on this underexplored topic.
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Affiliation(s)
- Sally E Yates
- Department of Health Sciences, Health and Human Sciences, Macquarie University, Australia.
| | - Joanne V Glinsky
- Department of Health Sciences, Health and Human Sciences, Macquarie University, Australia
| | - Melissa J Hirth
- Occupational Therapy Department, Austin Health, Australia; Malvern Hand Therapy, Melbourne, Malvern, Australia
| | - Joel T Fuller
- Department of Health Sciences, Health and Human Sciences, Macquarie University, Australia
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Bűhler M, Gwynne-Jones D, Chin M, Woodside J, Gough J, Wilson R, Abbott JH. Are the outcomes of relative motion extension orthoses non-inferior and cost-effective compared with dynamic extension orthoses for management of zones V-VI finger extensor tendon repairs: A randomized controlled trial. J Hand Ther 2023; 36:363-377. [PMID: 37045642 DOI: 10.1016/j.jht.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 02/10/2023] [Accepted: 02/12/2023] [Indexed: 04/14/2023]
Abstract
INTRODUCTION There is no comparative evidence for relative motion extension (RME) orthosis with dynamic wrist-hand-finger-orthosis (WHFO) management of zones V-VI extensor tendon repairs. PURPOSE OF THE STUDY To determine if RME with wrist-hand-orthosis (RME plus) is noninferior to dynamic WHFO for these zones in clinical outcomes. STUDY DESIGN Randomized controlled non-inferiority trial. METHODS Skilled hand therapists managed 37 participants (95% male; mean age 39 years, SD 18) with repaired zones V-VI extensor tendons randomized to RME plus (n = 19) or dynamic WHFO (n = 18). The primary outcome of percentage of total active motion (%TAM) and secondary outcomes of satisfaction, function, and quality of life were measured at week-6 and -12 postoperatively; percentage grip strength (%Grip), complication rates, and cost data at week-12. Following the intention-to-treat principle non-inferiority was assessed using linear regression analysis (5% significance) and adjusted for injury complexity factors with an analysis of costs performed. RESULTS RME plus was noninferior for %TAM at week-6 (adjusted estimates 2.5; 95% CI -9.0 to 14.0), %TAM at week-12 (0.3; -6.8 to 7.5), therapy satisfaction at week-6 and -12, and orthosis satisfaction, QuickDASH, and %Grip at week-12. Per protocol analysis yielded 2 tendon ruptures in the RME plus orthoses and 1 in the dynamic WHFO. There were no differences in health system and societal cost, or quality-adjusted life years. DISCUSSION RME plus orthosis wearers had greater injury complexity than those in dynamic WHFOs, with overall rupture rate for both groups comparatively more than reported by others; however, percentage %TAM was comparable. The number of participants needed was underestimated, so risk of chance findings should be considered. CONCLUSIONS RME plus management of finger zones V-VI extensor tendon repairs is non-inferior to dynamic WHFO in %TAM, therapy and orthotic satisfaction, QuickDASH, and %Grip. Major costs associated with this injury are related to lost work time.
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Affiliation(s)
- Miranda Bűhler
- Dunedin Hospital, Southern District Health Board, Dunedin, New Zealand.
| | - David Gwynne-Jones
- Dunedin Hospital, Southern District Health Board, Dunedin, New Zealand; Dunedin School of Medicine, Department of Surgical Sciences, University of Otago, Dunedin, New Zealand
| | - Michael Chin
- Dunedin Hospital, Southern District Health Board, Dunedin, New Zealand; Dunedin School of Medicine, Department of Surgical Sciences, University of Otago, Dunedin, New Zealand
| | - Joshua Woodside
- Dunedin Hospital, Southern District Health Board, Dunedin, New Zealand
| | - Jamie Gough
- Dunedin Hospital, Southern District Health Board, Dunedin, New Zealand
| | - Ross Wilson
- Dunedin School of Medicine, Department of Surgical Sciences, University of Otago, Dunedin, New Zealand
| | - J Haxby Abbott
- Dunedin School of Medicine, Department of Surgical Sciences, University of Otago, Dunedin, New Zealand
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Pilbeam Kirk CE, Howell JW, Hirth MJ, Johnson N. Implementing an internal audit to change practice: Current evidence and review of patient outcomes enabled transition to the relative motion extension approach in the postoperative management of zones IV-VI extensor tendon repairs. J Hand Ther 2023; 36:389-399. [PMID: 37385903 DOI: 10.1016/j.jht.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 05/07/2023] [Accepted: 05/15/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Evidence supports use of the relative motion extension (RME) approach following extensor tendon repairs in zones V-VI yielding good or excellent outcomes. PURPOSE To demonstrate how a 3-year internal audit and regular review of emerging evidence guided our change in practice from our longstanding use of the Norwich Regimen to the RME approach using implementation research methods. We compared the outcomes of both approaches prior to the formal adoption of the RME approach. STUDY DESIGN Prospective clinical audit. METHODS A prospective audit of all consecutive adult finger extensor tendon repairs in zones IV-VII rehabilitated in our tertiary public health hand centre was undertaken between November 2014 and December 2017. Each audit year, outcomes were reviewed regarding the Norwich regimen and the RME early active motion approaches. As new evidence emerged, adjustments were made to our audit protocol for the RME approach. Discharge measurements of the range of motion of the affected and contralateral fingers and complications were recorded. RESULTS During the 3-year audit, data was available on 79 patients (56 RME group including 59 fingers with 71 tendon repairs; 23 Norwich group including 28 fingers with 34 tendon repairs) with simple (n = 68) and complex (n = 11) finger extensor tendon zones IV-VI repairs (no zone VII presented during this time). Over time, the practice pattern shifted from the Norwich Regimen approach to the RME approach (and with the use of the RME plus [n = 33] and RME only [n = 23] approaches utilized). All approaches yielded similar good to excellent outcomes per total active motion and Miller's classification, with no tendon ruptures or need for secondary surgery. CONCLUSIONS An internal audit of practice provided the necessary information regarding implementation to support a shift in hand therapy practice and to gain therapist or surgeon confidence in adopting the RME approach as another option for the rehabilitation of zone IV-VI finger extensor tendon repairs.
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Affiliation(s)
- Chloë E Pilbeam Kirk
- Pulvertaft Hand Centre, Royal Derby Hospital, Derby, UK; Rheumatology Department, Florence Nightingale Community Hospital, Derby, UK.
| | - Julianne W Howell
- Self-employed hand and upper extremity consultant, Saint Joseph, MI, USA.
| | - Melissa J Hirth
- Occupational Therapy Department, Austin Health, Heidelberg, Victoria, Australia; Malvern Hand Therapy, Malvern, Victoria, Australia.
| | - Nick Johnson
- Pulvertaft Hand Centre, Royal Derby Hospital, Derby, UK.
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Howell JW, Hirth MJ. The ongoing evolution of a clinical innovation: Relative motion concept and orthoses. J Hand Ther 2023; 36:248-250. [PMID: 37648340 DOI: 10.1016/j.jht.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
- Julianne W Howell
- Self-employed Hand and Upper Extremity Consultant, Saint Joseph, MI, USA
| | - Melissa J Hirth
- Occupational Therapy Department, Austin Health, Heidelberg, Victoria, Australia; Malvern Hand Therapy, Malvern, Victoria, Australia
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Howell JW, Hirth MJ. "Around the global hand table": Hand surgeon and therapist perspectives on overcoming barriers to relative motion orthotic intervention in the management of zones V-VI finger extensor tendon repairs. J Hand Ther 2023; 36:400-413. [PMID: 37037729 DOI: 10.1016/j.jht.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/26/2023] [Accepted: 02/07/2023] [Indexed: 04/12/2023]
Abstract
INTRODUCTION An international survey of therapists cited 2 barriers (physician preference and departmental policy) to the implementation of a relative motion extension (RME) orthosis/early active motion (EAM) approach. STUDY DESIGN e-survey PURPOSE: To glean insight from hand surgeons and hand therapists regarding their awareness and experiences in implementing or not implementing an RME orthosis/EAM approach for management of finger zones V-VI extensor tendon repairs. METHODS Two e-surveys, one to hand surgeons and the other to hand therapists were distributed. Participants were asked 8-open ended questions with the opportunity for additional comment. RESULTS Nine of 11 surgeons and 10 of 11 therapists (clinicians/educators/administrators) who were surveyed, participated. All respondents from 7 countries were aware of the RME/EAM approach, with only 1 surgeon and 2 therapists not implementing. Surgeons once aware, quickly implement; therapists in this survey implemented about 2.5 years after learning of the approach. Surgeon use was influenced more by their peers than the evidence while therapist knowledge came from professional meetings. Therapists teaching at university-level and continuing education integrate the approach. DISCUSSION Although the RME orthosis/EAM approach has been around for 4 decades, awareness for the hand surgeons and therapists surveyed has only been over the past 20 years. Surveyed surgeons like to visualize how the RME concept works and therapists depend more on the evidence. To overcome barriers to RME/EAM implementation, several strategies are outlined. CONCLUSION Although a small survey, valuable comments provide insight for addressing the previously cited barriers. Strategies for increasing awareness and fostering implementation of an RME orthosis/EAM approach are offered by international hand surgeons and therapists surveyed regarding the commonly cited barriers of surgeon preference and department procedures.
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Affiliation(s)
- Julianne W Howell
- Self-employed hand and upper extremity therapy consultant, Saint Joseph, MI, USA.
| | - Melissa J Hirth
- Occupational Therapy Department, Austin Health, Heidelberg, Victoria, Australia; Malvern Hand Therapy, Malvern, Victoria, Australia
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Newington L, Bamford E, Henry SL. Relative motion flexion following zone I-III flexor tendon repair: Concepts, evidence and practice. J Hand Ther 2023; 36:294-301. [PMID: 37029053 DOI: 10.1016/j.jht.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 04/09/2023]
Abstract
STUDY DESIGN Narrative review and case series. INTRODUCTION The relative motion approach has been applied to rehabilitation following flexor tendon repair. Positioning the affected finger(s) in relatively more metacarpophalangeal joint flexion is hypothesized to reduce the tension through the repaired flexor digitorum profundus by the quadriga effect. It is also hypothesized that altered patterns of co-contraction and co-inhibition may further reduce flexor digitorum profundus tension, and confer protection to flexor digitorum superficialis. METHODS We reviewed the existing literature to explore the rationale for using relative motion flexion orthoses as an early active mobilization strategy for patients after zone I-III flexor tendon repairs. We used this approach within our own clinic for the rehabilitation of a series of patients presenting with zone I-II flexor tendon repair. We collected routine clinical and patient reported outcome data. RESULTS We report published outcomes of the clinical use of relative motion flexion orthoses with early active motion, implemented as the primary rehabilitation approach after zone I-III flexor digitorum repairs. We also report novel outcome data from 18 patients. DISCUSSION We discuss our own experience of using relative motion flexion as a rehabilitation strategy following flexor tendon repair. We explore orthosis fabrication, rehabilitation exercises and functional hand use. CONCLUSIONS There is currently limited evidence informing use of relative motion flexion orthoses following flexor tendon repair. We highlight key areas for future research and describe a current pragmatic randomized controlled trial.
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Affiliation(s)
- Lisa Newington
- Hand Therapy, Guy's and St Thomas' NHS Foundation Trust, London, UK; MSk Lab, Department of Surgery and Cancer, Imperial College London, Sir Michael Uren Hub, London, UK.
| | - Emma Bamford
- Pulvertaft Hand Unit, King's Treatment Centre, Royal Derby Hospital, Derby, England
| | - Steven L Henry
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX, USA; Ascension Plastic and Hand Surgery, Austin, TX, USA
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Shaw AV, Verma Y, Tucker S, Jain A, Furniss D. Relative motion orthoses for early active motion after finger extensor and flexor tendon repairs: A systematic review. J Hand Ther 2023; 36:332-346. [PMID: 37037728 DOI: 10.1016/j.jht.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND The relative motion (RM) orthosis was introduced over 40 years ago for extensor tendon rehabilitation and more recently applied to flexor tendon repairs. PURPOSE We systematically reviewed the evidence for RM orthoses following surgical repair of finger extensor and flexor tendon injuries including indications for use, configuration and schedule of orthosis wear, and clinical outcomes. STUDY DESIGN Systematic review. METHODS A PRISMA-compliant systematic review searched eight databases and five trial registries, from database inception to January 7, 2022. The protocol was registered prospectively (CRD42020211579). We identified studies describing patients undergoing rehabilitation using RM orthoses after surgical repair of acute tendon injuries of the finger and hand. RESULTS For extensor tendon repairs, ten studies, one trial registry and five conference abstracts met inclusion criteria, reporting outcomes of 521 patients with injuries in zones IV-VII. Miller's criteria were predominantly used to report range of motion; with 89.6% and 86.9% reporting good or excellent outcomes for extension lag and flexion deficit, respectively. For flexor tendon repairs, one retrospective case series was included reporting outcomes in eight patients following zones I-II repairs. Mean total active motion was 86%. No tendon ruptures were reported due to the orthosis not protecting the repair for either the RME or RMF approaches. DISCUSSION Variation was seen in use of RME plus or only, use of night orthoses and orthotic wear schedules, which may be the result of evolution of the RM approach. Since Hirth et al's 2016 scoping review, there are five additional studies, including two RCTs reporting the use of the RM orthosis in extensor tendon rehabilitation. CONCLUSIONS There is now good evidence that the RM approach is safe in zones V-VI extensor tendon repairs. Limited evidence currently exists for zones IV and VII extensor and for flexor tendon repairs. Further high-quality clinical studies are needed to demonstrate its safety and efficacy.
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Affiliation(s)
- Abigail V Shaw
- Department of Plastic & Reconstructive Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.
| | - Yash Verma
- Department of Plastic & Reconstructive Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Sarah Tucker
- Department of Plastic & Reconstructive Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Abhilash Jain
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom; Imperial College London NHS Trust, St Mary's Hospital, London, United Kingdom
| | - Dominic Furniss
- Department of Plastic & Reconstructive Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
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Wajon S, Howell JW. Prescription of exercise relative motion orthoses to improve limited proximal interphalangeal joint movement: A prospective, multi-center, consecutive case series. J Hand Ther 2023; 36:378-388. [PMID: 35039211 DOI: 10.1016/j.jht.2021.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Prospective, multicenter, consecutive case series INTRODUCTION: There are 3 categories of relative motion orthoses; protective, exercise and adaptive, with only 2 unpublished studies that prescribed for exercise. These orthoses are of 2 types: relative motion extension (RME) orthoses and relative motion flexion (RMF) orthoses. PURPOSE OF STUDY To describe prescription of relative motion (RME and RMF) exercise orthoses when used to assist recovery of proximal interphalangeal joint (PIPJ) movement after injury or surgery. METHODS Therapists enrolled patients who had limited PIPJ movement after injury or surgery and demonstrated greater passive than active isolated PIPJ movement. Relative motion exercise orthoses and usual hand therapy treatments were implemented for 6 weeks. Measures of PIPJ motion, pain, and patient-report of orthotic wear time and perceived benefit were recorded at the time of orthotic intervention, at 3 weeks and at 6 weeks. RESULTS Eight therapists from 4 private hand therapy clinics implemented RM exercise orthoses in 14 patients with limited PIPJ flexion (RME orthoses) and 6 patients with limited PIPJ extension (RMF orthoses). One participant prescribed a RMF orthosis failed to complete the study. Isolated PIPJ active flexion improved for those prescribed RME orthoses (n = 14/14) and isolated PIPJ active extension improved for those prescribe a RMF orthosis (n = 2/5). Most patient-reports were positive about the relative motion experience. DISCUSSION Although diagnoses and prescription times differed, the outcomes of this patient series prescribed relative motion exercise orthoses agree with those of 2 unpublished case series; all in support relative motion exercise orthoses to improve limited PIPJ movement. CONCLUSION Future studies implementing relative motion exercise orthoses to recover limited PIPJ movement after injury or surgery may be worthwhile.
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Affiliation(s)
- Sally Wajon
- Macquarie Hand Therapy: Suite 403/2 Technology Place, Macquarie University Hospital, Clinic Building Macquarie University, NSW, Australia
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O'Brien L, Robinson L, Parsons D, Glasgow C, McCarron L. Hand therapy role in return to work for patients with hand and upper limb conditions. J Hand Ther 2022; 35:226-232. [PMID: 35491301 DOI: 10.1016/j.jht.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 02/15/2022] [Accepted: 03/27/2022] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Electronic Web-based survey INTRODUCTION: Evidence supports the use of health-focused interventions combined with service coordination and work modification components to reduce the individual, community, and societal burden associated with acute and chronic musculoskeletal conditions. The levels of engagement, skill, and confidence of Australian hand therapists in assisting their patients to return to work (RTW) are currently unknown. PURPOSE OF THE STUDY To identify current practices, skill, and the need for additional training in management of the RTW process from a sample of Australian hand therapists. METHODS An electronic survey was sent to current members of the Australian Hand Therapy Association. Data collected included training and/or professional experience, caseload and/or workplace, scope of and barriers to vocational practice, and satisfaction with own contribution to the RTW process for patients. RESULTS A total of 99 individual responses (12.4% of total membership) were included, with most indicating a limited role in the RTW process. Only 52.7% said they regularly monitored and adjusted their patients' RTW program. Most plans were informed by formal tests of underlying body structure and function components rather than the patient's ability to perform of a specific work role or task. Median satisfaction with the quality of RTW service they provided was 6 of 10, with 42% scoring ≤ 5 of 10, indicating considerable scope for improvement. CONCLUSIONS Practice patterns are described for planning and monitoring RTW, and these did not always align with the evidence-base. Further exploration of clinician barriers to implementing RTW interventions is warranted, as is upskilling for those indicating a lack of confidence in this field.
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Affiliation(s)
- Lisa O'Brien
- Department Occupational Therapy, Monash University, Victoria, Australia; Department of Nursing & Allied Health, School of Health Sciences, Swinburne University of Technology, Victoria, Australia.
| | - Luke Robinson
- Department Occupational Therapy, Monash University, Victoria, Australia
| | - Dave Parsons
- Curtin School of Allied Health, Curtin University, St. John of God Midland Public and Private Hospitals, Perth, WA, USA
| | - Celeste Glasgow
- School of Health and Rehabilitation Sciences, University of QLD, EKCO Hand Therapy, QLD
| | - Luke McCarron
- Department Occupational Therapy, Bond University, Orthopaedic Department, Gold Coast Hospital and Health Service
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Howell JW, Hirth MJ, Chai SC, Brown T, O’Brien L. Postoperative management of zones V-VI extensor tendon repairs: A survey of practice in Malaysia and comparison to IFSHT member countries. HAND THERAPY 2021; 26:134-145. [PMID: 37904834 PMCID: PMC10584052 DOI: 10.1177/17589983211031259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 06/21/2021] [Indexed: 11/01/2023]
Abstract
Introduction A survey of International Federation of Societies for Hand Therapy (IFSHT) member countries identified relative motion extension as the preferred approach to management of zones V-VI extensor tendon repairs. The aims of this survey were to identify and compare hand therapy practice patterns in Malaysia (a non-IFSHT member country) with findings of the IFSHT survey including an IFSHT subset of Asia-Pacific therapists and to investigate if membership status of the Malaysian Society for Hand Therapists (MSHT) influenced therapy practice patterns. Methods An online English-language survey was distributed to 90 occupational therapists and physiotherapists including MSHT members and non-members. Participation required management of at least one extensor tendon repair in the preceding year. Five approaches were surveyed: immobilisation, early passive motion (EPM) with dynamic splinting, and early active motion (EAM) delivered by resting hand (RH), palmar resting interphalangeal joints free (PR), and relative motion extension (RME) splints. Results Thirty-seven of the 53 therapists (68%) who commenced the survey completed it. The most used approach was dynamic/EPM (28%), followed by RH/immobilisation (22%) and RH/EAM (22%). A preference for RME/EAM was identified with implementation barriers being surgeon preference and hand therapist confidence. Discussion Approach selection for Malaysian therapists differed from the combined IFSHT and Asia-Pacific respondents, with the former using dynamic/EPM and RH/immobilisation compared to IFSHT respondents who predominately used RME/EAM and PR/EAM. This survey provides valuable insights into Malaysian hand therapists' practices. If implementation barriers and therapist confidence are addressed, Malaysian practice patterns may change to better align with current evidence.
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Affiliation(s)
| | - Melissa J Hirth
- Occupational Therapy Department, Austin Health, Heidelberg, Victoria, Australia
- Malvern Hand Therapy, Malvern, Victoria, Australia
- Department of Occupational Therapy, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Siaw Chui Chai
- Occupational Therapy Programme, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Ted Brown
- Department of Occupational Therapy, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Lisa O’Brien
- Department of Occupational Therapy, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
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Newington L, Ross R, Howell JW. Relative motion flexion splinting for the rehabilitation of flexor tendon repairs: A systematic review. HAND THERAPY 2021; 26:102-112. [PMID: 37904882 PMCID: PMC10584049 DOI: 10.1177/17589983211017584] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 04/22/2021] [Indexed: 11/01/2023]
Abstract
Introduction Relative motion splinting has been used successfully in the treatment of extensor tendon repairs and has recently been applied in flexor tendon rehabilitation. The purpose of this systematic review was to identify articles reporting use of relative motion flexion (RMF) splinting following flexor tendon repair and to examine indications for use and clinical outcomes. Methods Seven medical databases, four trials registries and three grey literature sources were systematically searched and screened against pre-specified eligibility criteria. Screening, data extraction and quality appraisal were independently performed by two reviewers. Results A total of 12 studies were identified, of which three met the review eligibility criteria: one retrospective case series; one cadaveric proof of concept study; and one ongoing prospective case series. The type of splint (including metacarpophalangeal joint position and available movement), exercise programme, and zone of tendon injury varied between studies. Both case series presented acceptable range of movement and grip strength outcomes. The prospective series reported one tendon rupture and two tenolysis procedures; the retrospective series reported no tendon ruptures or secondary surgeries. Discussion We found limited evidence supporting the use of RMF splinting in the rehabilitation of zones I-III flexor tendon repairs. Further prospective research with larger patient cohorts is required to assess the clinical outcomes, patient reported outcomes and safety of RMF splinting in comparison to other regimes. Application of the relative motion principles to flexor tendon splinting varied across the included studies, and we suggest an operational definition of relative motion in this context.
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Affiliation(s)
- Lisa Newington
- Hand Therapy, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- MSk Lab, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Rachel Ross
- Hand Therapy, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Fiona Stanley Hospital, Perth, Australia
| | - Julianne W Howell
- Independent Hand and Upper Extremity Consultant, Saint Joseph, MI, USA
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Henry SL, Howell JW. Use of a relative motion flexion orthosis for postoperative management of zone I/II flexor digitorum profundus repair: A retrospective consecutive case series. J Hand Ther 2021; 33:296-304. [PMID: 31350131 DOI: 10.1016/j.jht.2019.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 05/10/2019] [Accepted: 05/16/2019] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN A retrospective, single-center, consecutive case series. INTRODUCTION In concept, a relative motion flexion (RMF) orthosis will induce a "quadriga effect" on a given flexor digitorum profundus (FDP) tendon, limiting its excursion and force of flexion while still permitting a wide range of finger motion. This effect can be exploited in the rehabilitation of zone I and II FDP repairs. PURPOSE OF THE STUDY To describe the use of RMF orthoses to manage zone I and II FDP 4-strand repairs. METHODS Medical record review of 10 consecutive zone I and II FDP tendon repairs managed with RMF orthosis for 8 to 10 weeks in combination with a static dorsal blocking or wrist orthosis for the initial 3 weeks. RESULTS Indications included sharp lacerations (n = 6), ragged lacerations (n = 2), staged flexor tendon reconstruction (n = 1), and type IV avulsion (n = 1). In 8 of the 10 cases that completed follow-up, the mean arc of proximal interphalangeal/distal interphalangeal active motion were as follows: sharp, 0° to 106°/0° to 75°; ragged, 0° to 90°/0° to 25°; reconstruction, 0° to 90°/10° to 45°; and avulsion, 0° to 95°/0° to 20°. Grip performance available for 6 of 10 cases was 62% to 108% of the dominant hand. There were no tendon ruptures, secondary surgeries, or proximal interphalangeal joint contractures. CONCLUSION Based on this small series, the RMF approach appears to be safe and effective. It can lead to similar mobility and functional recovery as other early active motion protocols, with certain practical advantages and without major complications. Further investigation with larger, multicenter, prospective, longitudinal cohorts and/or randomized clinical trials is necessary.
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Affiliation(s)
- Steven L Henry
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas, Austin, TX, USA
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