Hand Physiotherapy-RehabilitationAGP.pptx

FLEXOR TENDON INJURIES REHABILITATION PROTOCOLS

1. FLEXOR TENDON INJURIES REHABILITATION PROTOCOLS Dr. Akshai George Paul DNB Resident Department of Plastic surgery

2. GOALS OF REHABILITATION To promote intrinsic healing and reduce extrinsic scarring Decrease adhesions and to have smooth pop function Biologically alter the process of scar formation

3. PROTOCOLS IMMOBILIZATION EARLY PASSIVE MOBILIZATION EARLY ACTI VE MOBILIZATION

4. IMMOBILIZATION PROTOCOL ( Cifaldi Collins) Patients who are younger than 10 yrs Cognitive deficit Unable or unwilling to participate in complex rehabilitation program To protect other injuries like fractures.

5. a) Early Stage (0 to 3 or 4 weeks) 1) Splint Dorsal forearm based splint holds the wrist in 10-30 degree flexion, MP joints in 40-60 degree flexion,IP in full extension Splint is worn 24 hrs a day except for therapy visits one to two times a week, when splint may be removed by the therapist.

6. 2) Exercises Provided by the therapist one or 2 times a week for gentle protected PROM. The therapist hold adjacent joints in flexion while extending and flexing each joint Protected intrinsic stretch excercises are performed(Wrist flexed maximally and while MP joint in neutral and IP joints flexed passively)

7. b) Intermediate Stage ( 3 to 4 weeks) 1) Splint Modified to bring wrist in neutral

8. 2) Excercise Remove splint, with the wrist at 10 degree of extension, the patient perform 10 repeats of passive digit flexon and extension Followed by 10 repeats of active differential tendon gliding excercises .

9. After 3 or 4 days of therapy,tendon function is evaluated Total active and passive flexion at PIP and DIP is measured

10. c) Late Stage (4 to 6 wks) 1)Splint Dorsal blocking splint is discontinued 2) Excercise Gentle tendon blocking excercises for isolated FDP and FDS glide 4-6 times a day with 10 rpts Tendon gliding excercises continues

11. After 1 week if active flexion has not improved, the program is upgraded Towel gripping or putty squeezing excercises

12. Disadvantages:- Outcome may not be optimal Heavy adhesion formation and difficult to mobilise after wards

13. EARLY PASSIVE MOBILIZATION PROTOCOL Inhibit restrictive adhesion formation Improves synovial diffusion- promote intrinsic healing

14. A. DURAN and HOUSER a) Early stage (0 to 4.5 wks ) 1) Splint Wrist is held in 20 degree flexion and MP joint in relaxed position of flexion 2) Excercise With MP and PIP joint flexed the DIP joint is passively extended, them moving the FDP repair distally, away from FDS repair

15. Then with DIP and MP joint flexed, the PIP is extended, Both repair glide distally away from the site of repair and surrounding tissues. Duran and Houser demonstrated 3-5 mm glide is sufficient to prevent adhesion formation 6-8 repeats twice a day

16. b) Intermediate Stage(4.5 to 7.5 wks) 1)Splint After 4.5 wks , splint is replaced with a wrist band to which rubber band traction is attached

17. 2) Excercise Active extension excercise begin with in the limitation imposed by wrist band Active flexion (Blocking, FDS gliding and fisting) is initiated on the removal of wrist band at 5.5 wks

18. C) Late Stage(7.5 to 8 wks ) Resisted Flexion

19. B. KLEINERT and Colleagues a) Early Stage ( 0 to 3 wks ) 1)Splint Dorsal blocking splint blocked the wrist in 45 degree flexion and MP joint in 10 to 20 degree flexion Rubber band traction was directed to the finger nail from wrist or just proximal to the wrist

20. 2) Excercise Every hour the patient actively extends the fingers to the limits of the splint 10 times allowing the rubber band to flex the fingers

21. b) Intermediate stage(3 to 5 wks) 1)Splint Rubber band from injured digit is attached to a wrist band from 3 wks to 5 wks

22. 2) Excercise All active movements to the wrist and hand are encouraged although the injured digit is still teathered through 5 wks At 5 wks gentle active flexion may begin

23. c) Late Stage (Starting at 6 wks) Resisted Excercises In nutshell Elastic pull acts as the repaired flexor tendon without flexor muscle contraction Passive flexion and active extension of digit

24. Drawbacks of Kleinert Flexion contracture at PIPJ Loss of active DIP motion

25. EARLY ACTIVE MOBILIZATION PROTOCOL

26. A. BELFAST and SHEFFIELD a) Early Stage ( Upto 4 to 6 wks ) 1 ) Splint Wrist at 20 degree flexion,MPJ at 80 to 90 flexion allowing full IPJ extension 2) Excercise Zone 3-After 24 hrs Zone 2 -After 48 hrs

27. Excercise performed every 4 hrs within splint, include all digits and consists of 2 repetition each of full passive flexion, active flexion and active extension

28. b) Intermediate stage (Beginning at 4-6 wks) 1)Splint Discontinue at 4 wks - If tendon glide is poor 5wks - In most 6wks - in good gliding

29. 2) Excercises Protected passive IP extension Blocking excercises and tendon glide excercises at 6 wks Heavier hand use at 8 wks Full function by 12 wks

30. B. STRICKLAND (Indiana Hand Center-Controlled “place and hold”) a) Early Stage( upto 4 wks ) 1)Splint Dorsal Blocking splint- For Most times Exercise Splint- Hinged wrist allowing full wrist flexion, but wrist extension is limited to 30 degree. Full digit flexion and extension are allowed, but MP extension is limited to 60 degree

31. 2) Excercise Every hour patient perfom 15 rpts of PROM to the PIP and DIP in the Dorsal blocking splint Followed by 25 repetition of digit flexion in excercise splint Patient actively extend the wrist with simultaneous passive digit flexion

32. b) Intermediate Stage (4 to 7 or 8 wks) 1)Splint Excercise splint discontinued Dorsal blocking splint continue except during excercise 2) Excercise Exercise continue every 2 hrs with 15 min repetition of active flexion and extension excercise for wrist and digits

33. c) Late Stage (7 to 8 wks) Splint is discontinued and resistance excercise initiated

34. C. EVAN and THOMPSON Minimal tension is required to overcome the viscoelastic resistance of the antagonistic muscle tendon unit. Active motion component is performed only by therapist upto 3 wks

35. D. SILVERSKIOLD and MAY 1.Spint Dorsal blocking splint hold the wrist in neutral position,MCP 50 to 70 degree flexion,IP in full extension and finger tips have a elastic traction through a palmar pulley

36. 2) Excercise Active extension/ passive flexion with elastic traction to the distal palmar crease are performed 10 times hrly Active motion is only under supervision Splint is removed at 8 wks

37. COMBINED PASSIVE AND ACTIVE (NANTONG)REGIMEN a)Splint After surgery, the hand is protected in a dorsal thermoplastic splint, with the wrist at 20–30° flexion, MCP joint at slight flexion, and the IP joints in extension for the initial 2.5 weeks (3 weeks or slightly longer when the trauma is severe or digital edema is remarkable)

38. b) Excercises 1.Three days to 2.5 weeks We do not encourage the patients to move the finger in the initial postoperative days Exercise starts at 3–5 days after surgery. The patient is instructed to perform at least 4–6 sessions of combined passive–active motion daily across the morning, noon,evening,and before sleep.

39. More sessions can be implemented as needed, while hourly exercises are not required. At beginning of each exercise session, the finger is passively flexed 10–30 times to lessen the overall resistance of finger joints and soft tissues during subsequent active flexion.

40. The passive motion is followed by actively flexing the finger with gentle force 20–30 times up to the range the patients feel comfortable with (usually from full extension to one-third or one-half of entire flexion range, and may even increase to two-thirds if achieved with ease).

41. Active flexion over full range is not encouraged, unless it can be achieved very easily. In this 2.5-week period, full active extension is particularly encouraged,and prevention of extension deficits rather than achieving full range active flexion is emphasized.

42. 2.After 2.5 weeks After 2.5 weeks (or 3 weeks, or slightly later), a new thermoplastic splint is made, and the wrist is splinted at 30° extension . Exercise of finger flexion, both passively and actively, is emphasized in this period. Active motion up to the midrange is required, and can proceed up to two-thirds (or full range). However, digital flexion from the mid-range to full range, in particular over the final one-third of the flexion range, usually is achieved passively.

43. In this period, we ensure passive flexion over a full range to prevent joint contracture and active flexion over an increasingly greater range gradually approaching full flexion range, but discourage active forceful flexion of the finger over the final range where the tendon is subjected to the greatest load and is more vulnerable to rupture. Differential FDS and FDP motion exercise is encouraged throughout the first 5 weeks.

44. From the sixth week, full active finger flexion is encouraged (which can be started earlier when the flexion is judged to have less resistance). From 6 or 8 weeks, the splint is removed or used only at night or when going out.

45. LATEST ADVANCES Robotic Therapy Ultrasound therapy Matrix Rhythm therapy LASER therapy Cryo ultrasound therapy

46. CONCLUSION Application of the “right” force to move the digits is important to moving the repaired tendon while avoiding repair rupture. “Proper” positioning of the joints is important to reducing tension in the tendon. An ideal protocol improves gliding of a repaired tendon, avoids repair rupture or gapping potential,and leads to a better functional return .

47. A variety of protocols are available, which should be selected and modified according to the extent of trauma to the tendon, strength of the tendon repair, and compliance of the patient.

48. Deviation from a regimen is a common practice because each individual patient presents with specific factors that can affect the decision of use of specific components of regimens. It is possible to use multiple aspects of different protocols to fit the patient’s needs or physiologic profile change.

49. GENERAL POST OPERATIVE PHYSIOTHERAPY Department of Plastic Surgery Aster MIMS Calicut

50. A.Immediate Post operatively Dorsal plaster splint applied in the operative room with wrist in 20 to 30 degree flexion,MCPJ in 60 to 70 degrees of flexion and IPJ in full extension

51. B.Three days postoperative a)Splint A thermoplastic splint dorsally with wrist at 20 to 30 degree of flexion,MCPJ at 70 degree flexion and IPJ in full extension Rubber band or elastic thread traction may be attached proximal to wrist crease If elastic traction is not used,digits are maintained in extension via Velcro strap to dorsum of splint.Strap removed for exercise.

52. b)Exercise Active IPJ extension A active joint wedge that passively flexes MP joints may be used to facilitate full PIPJ extension Passive flexion by isolating MCPJ,PIPJ and DIPJ respectively Passive composite flexion to the distal palmar crease and protected passive extension

53. c) Edema Control d)Pain Control e)Wound care

54. C.Two weeks postoperative Wrist may be brought to neutral in splint

55. D.Three weeks postoperative Tendon glide to be checked If tendon become quickly adherent,AROM into flexionmay begin at 3 weeks If early tendon gliding excercises is excellent,Probably minimal adhesions-Tendon should be protected upto 2-3 weeks longer a)Splint Continue

56. b)Exercise Progress from place and hold to AROM (Full fist/Flat fist) to active blocked ROM

57. E)Four weeks postoperative a)Splint Dorsal forearm based splint at night and in crowds or wristlet with rubber band traction in worn at all times b)Exercise Continue as abobe and add active hook fist and active MCP/IPJ extension avoiding combined wrist and digital extension

58. c)Scar Management d)Light activities in daily living

59. F)Six weeks postopertaive a)Splint Protectve splint or wristlet is discontinued Gentle dynamic extension splinting to alleviate PIPJ contractures Gentle progressive extension splint to control flexor tendon tightness b)Exercise Continue as above and for adherent tendons minimal resistance may be initiated with surgeons approval

60. G)Eight weeks post perative Progressive strengthening Graded work simulation may be initiated

61. H)Twelve weeks postoperative Return to unrestricted activity Heavy works assesment

62. REFERENCES Hand rehabilitation Gaylord L Clark-1 st edition Greens operative Hand surgery-6 th edition Neligan-4 th edition Karoon Agarwal -1 st edition