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 | Is the state acquiring a lower level of hand therapists?
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Advanced practice now in play in CA
By Jessica LaGrossa
California's recent requirement for advanced practice certification
in hand therapy has been a source of some confusion and even
controversy among therapists there. While some are elated that the
need for a CHT (See ADVANCE, Oct. 9, 2000) has been eliminated,
others feel the state's certification allows non-qualified OTs to
treat hands.
Further uncertainty over the proper way of identifying those who are
state-certified in hand therapy has also left therapists unsure as
to whether or not they have adequately earned additional letters
(HTC) to follow their name.
In addition, employers are left to decide for themselves whether or
not they will attach more value to those practitioners certified
both by the state and the Hand Therapy Certification Commission
(HTCC), or if the state's certification alone is sufficient.
ADVANCE recently spoke to California Board of Occupational Therapy
(CBOT) President Luella Grangaard, MS, OTR, CHT, as well as other
predominant practitioners in the field to address these and other
growing concerns.
The Certification Process
It has been five years since then-California Governor Gray Davis
signed into law California's first licensure bill, effectively
requiring all therapists in the state to be licensed and assistants
to be certified in order to practice. It had been a 20-year fight to
get there, and one fraught with opposition from PTs and nurses. As a
compromise, to gain their backing, the Occupational Therapy
Association of California (OTAC) attached to the bill a requirement
that those therapists practicing specialized hand therapy earn their
CHT credential from the HTCC by 2005.
The credential requires five years of hand therapy practice plus
supervised clinicals and a passing grade in the HTCC exam. Many
California practitioners felt OTAC had sold out to PT in order to
gain licensure.
Privately, however, state OT leaders made it clear that they planned
to solve the problem when they drafted the regulations that would
determine how the law was put into practice.
In 2003 the state passed Senate Bill 1402, known as the "clean-up
bill," that required OTs who offer services in hand therapy, use
physical agent modalities (PAMs), and/or do swallowing assessment,
evaluation or intervention to demonstrate their competency by
obtaining certification from the state rather than HTCC. Since
Jan.1, 2004, practitioners must provide sufficient evidence of post-
professional education and training in the specialty area(s) of
their choice in order to earn the privilege of practicing in those
areas.
Grangaard says CBOT found some difficulty in deciding how to assess
practitioners' competency.
"An exam doesn't exactly prove competency; it just proves that they
can take an exam," she told ADVANCE. "And we didn't need to look
at
high-level skills because this is an entry-level advanced
[certification]."
The board weighed several options and ultimately chose practitioner
portfolios as the best and most informative way to evaluate a
person's knowledge, skill and ability.
CBOT created a portfolio review committee and trained two members of
its seven-member body (three occupational therapists, one
occupational therapy assistant and three public members) to review
and assess adult learning based on writing.
"We also needed to identify how to grandfather in those people who
had been doing [hand therapy] a long time and give them credit for
their past work experience," explained Grangaard. CBOT declared that
OTs certified by the HTCC as of Dec. 31, 2003, automatically
qualified for advanced practice certification in hand therapy and
physical agent modalities as long as they applied within the first
year of the law's activation.
Practitioners not certified by the HTCC but who had significant
prior experience were encouraged to apply for automatic
qualification as well.
Practitioners without prior experience—or those missing the deadline
for the grandfather clause—had to complete an application for
advanced practice certification, which does not include a fee or an
exam.
Today, applicants for hand therapy state certification must complete
45 hours of post-graduate education in their field. "We do an
approval of the education so that they are assured that if they
take 'X' course, it will be accepted," Grangaard explained.
Most continuing education opportunities are also acceptable.
Explanations of acceptable classes and CEs are posted on CBOT's Web
site.
In addition, applicants also need 480 hours of on-the-job training
under the supervision of either an occupational therapist certified
in hand therapy, a physical therapist or a physician.
But it is important that therapists understand who requires the
certification.
"I think some are applying for it and don't need it," explained
Grangaard. "People that are working with stroke patients or children
who have developmental disabilities don't need it; the certification
is for more orthopedic, musculoskelatal type treatment."
Credential Puzzle
ADVANCE recently spoke to a California therapist who in her cited
credentials included "HTC," which she identified upon question as
her hand therapy certification from the state.
But when Arlie Haviland, OTR/L, CHT, owner of Arrowhead Rehab Clinic
in Yucaipa, CA, was asked for his credentials, he identified himself
only as an OTR/L and CHT, and did not include HTC. He seemed unaware
of any right to attach professional initials to the state
credential. Haviland explained, "A 'certified hand therapist'—that
is a legal titlehas the right to practice and call himself a
certified hand therapist (CHT); but a California OT who is certified
to treat hands cannot call himself a certified hand therapist,
although the practitioner could be certified to do hand therapy [by
the state]."
Deborah Amini, MEd, OTR/L, CHT, chair of AOTA's subspecialty SIS in
hand therapy, said, "Apparently some OTs in California started to
create this credential," she said, "But there really is no such
credential, and they aren't supposed to use it; they can write on
their resume that they are hand-therapy certified, but they can't
put it after their name like a credential."
ADVANCE questioned Grangaard as to whether therapists could
use "HTC" after their names once they are hand-therapy certified
by
the state, to which she replied, "I think they can use it, but I
would need to call the board office." Moments later, she called
ADVANCE and further stated that, "According to [CBOT's] lawyer, it
is perfectly legit for therapists to use HTC as a credential."
CHT Vs HTC?
Some therapists in California feel that dropping the required HTCC
certification is resulting in less qualified practitioners.
Haviland had been practicing hand therapy there for nearly 20 years
without any form of specialized certification when OTs began seeking
licensure. When he foresaw the steps being taken to carry hand
therapy in the direction of an advanced practice certification,
Haviland took and passed HTCC's exam and became certified. Once the
revisions to the licensure law were made in 2003, Haviland fell
under the grandfather clause and received California's hand therapy
and PAMs certification.
"But now that the one-year clause has ended, no one can be
grandfathered in—you have to prove to the board that you are
qualified," Haviland said. "That is where I have qualms because I
don't feel that they scrutinize enough the qualifications or
supervision.
"Now that the CHT isn't used, the HTC should be at the level of the
CHT," he added. "But it isn't."
Amini said that is a matter of perspective.
In applying for the HTCC certification, Amini pointed out, an
applicant could have seen wrist fractures once a week for five years
and legitimately say he or she has been "practicing hand therapy."
Treating delicate hand cases such as tendon repairs and
arthroplasties, she explained, would be a better indication of
expertise in treating hands. "HTCC doesn't exactly require hours
that are any more specific than California'syou can create your
hours [for HTCC] however you would like to, and then you take the
test."
But Grangaard made clear that there is a deliberate difference
between the two certifications.
"Ours is entry level," she emphasized, "and I hope that
therapists
are not telling themselves that [the two credentials] are in any way
equal."
CBOT has a statement to that effect on the board's Web site:
"The laws and regulations identify the type and amount of post
professional education and training required to demonstrate minimal
or entry level competence. However, the certified hand therapists
(CHTs) are experts in hand therapy, and the board recognizes this
fact."
Amini sees the integrity of the CHT being challenged, however,
because "it doesn't matter now if you are CHT-certified; it matters
if you are state-certified. The CHT becomes nothing more than just a
feather in your cap."
The Employer Factor
Much of the reasoning behind advanced practice certification in
California came from a need to pacify PTs and SPLs, and Amini noted
that "the ramifications down the road have been unfortunate,
especially with the [effects on the] coveted CHT."
In Long Beach, CA earlier this year for the AOTA national
conference, Amini said she was approached by a California therapist
who said she was having difficulty finding a job. "She had her CHT,
but now that she has moved to a rural area of the state, there
aren't any facilities large enough [with enough the staff] to let
her come in to get those supervision hours," Amini told ADVANCE.
"So
she has a CHT but can't use it in California."
Grangaard said she hasn't been informed of situations such as
this. "Personally, in my own clinic, we have been training people to
help them get the credentials," she said
Will having a CHT in addition to being certified by the state help a
therapist land a job? Not necessarily according to Haviland, who
said that in his experience, having both the CHT and HTC credentials
has not been a benefit to him when applying for jobs. "Employers out
there just want a therapist, and they are not even savvy to [the
credentials]," he explained. "If you have [CHT] after your name, I
don't think there is much validity to it whatsoever.'
Yet Haviland continues to keep up his CHT credentials. "I worked
hard to obtain that and I want to continue to keep it," he
explained. "There are others who may let it expire; I don't want to
say it's worthless because to me it has value, but I don't know if
anybody else recognizes it."
Education & Supervision
Haviland, a strong advocate of the need for better hand therapy
education in the schools, was unhappy with the initial version of
the licensure law requiring the CHT credentials in order to treat
hands. "[Instead, I felt we should] qualify students at the academic
level, like PT does," he said.
Haviland told ADVANCE that he initiated discussions in the late
1990s with AOTA and local chapters about instituting new educational
standards as opposed to requiring specialized certifications. "My
reasoning was that if OTs had been a dominant force in the
specialized field of hand therapy for years across the nation and
world, then it stood to reason that at some point the schools should
put together and require programs that had a more orthopedic,
technological knowledge based program for the outgoing students," he
explained.
Amini noted that although OT students do learn anatomy and
physiology, "unfortunately, our program standards are so broad (to
allow the schools flexibility) that [they] never really spell it
out."
The circumstance in California should be a lesson learned for the
Accreditation Council for Occupational Therapy Education (ACOTE),
Amini added. "We need to be more specific in our standards as to
what it is we do, so that when something like this comes up, we can
say 'we absolutely can do this; we are trained'."
But the issue at hand now is whether or not OTs seeking specialty
certification in hand therapy are receiving appropriate advanced
education.
"I know of cases where therapists are seeing in-depth trauma and
post-surgical cases, and their level of experience is very
rudimentary," Haviland told ADVANCE. "They act as though they are
seasoned therapists in hand therapy, but all they did was get a few
hours of adjunct training in education; they have little to no
knowledge and are very unskilled."
CBOT depends on the requirements of the law in regards to education
when considering an application for certification, and therapists
also need to take the requirements into consideration, Grangaard
said. "Sometimes, people will put down training in how to use a BET
or Kinesiotape, which may not necessarily meet the requirements,"
she explained. "And others put down NDT, which is definitely not
included as a requirement under the law."
In addition to the question of education is the reliability of
credible supervision, a requirement that some practitioners may be
taking too lightly. "All you have to do is get a friend to sign off
[on the application documents] and that qualifies as your
supervision," Haviland told ADVANCE, adding that he has witnessed
this practice.
"That could happen," admitted Grangaard. "But if we were to
go back
and find that those documents were fraudulent in any way, that would
really compromise [the practitioner's] license, because they are
swearing that the information that they are telling us is true."
Grangaard added that CBOT has recently added supervision guidelines
to the board's Web site for clarification on what is and isn't
considered approved supervision. "Under the guidelines, supervision
does not need to be on site," she explained, "It can be a variety
of
types of supervision, including mentorship, in which it depends on
the mentor to determine what level of supervision a practitioner
needs."
Down the Road
In the end, Haviland is concerned that the state is going to acquire
a lower level of hand therapists. But Grangaard says he is missing
the point of the state's certification. "I would encourage a
therapist who wants to specialize in hand therapy to become a
certified hand therapist [through HTCC]," she told ADVANCE.
Jessica LaGrossa is ADVANCE associate editor. |
For some of the selected articles refer to this website: Articles
on UE
| Vol. 14 •Issue 4 • Page 49
Tendon Trouble
Fluoroquinolones, a class of antibiotics, may induce tendinopathies that
mimic repetitive trauma disorders.
By Jeremy Normington, DPT
The goal of medicine is to help, not hinder, patients in the quest to
cure injuries, ailments and diseases.
Fluoroquinolones, a class of antibiotics that stop bacterial replication,
may address both of these factors. While fluoroquinolones are necessary to
treat infections of the urinary tract, respiratory tract, skin and soft
tissue, bones and joints, the effects of diarrhea, gynecological problems
and surgical prophylaxis,1 they may also play a role in creating
tendinopathies.
Fluoroquinolone-induced tendinopathies present with signs of swelling and
discomfort around an affected tendon. Tendinopathies range from tendinitis
to complete ruptures.
Studies show that tissues suffering from
fluoroquinolone-induced
tendinopathies mimic repetitive trauma disorders in a way that decreases
cell proliferation and the tissue's ability to heal microtraumas. Research
also shows that there's a destruction of the extracellular matrix and
decreased collagen content, which decreases the tendon's ability to store
energy. This mimics the effects of immobilization.
Examining the Effects
Fluoroquinolones exhibit a bactericidal effect primarily by inhibiting
DNA-gyrase.1 DNA-gyrase is essential for cell
reproductionbacteria dies without it. Common fluoroquinolones include
ciprofloxacin, enoxacin, levofloxacin, norfloxacin and pefloxacin. This
class of drug gained popularity due to its excellent gastrointestinal
absorption, tissue diffusion and long half-life.2 Side effects of
the drug are rare, but they include headaches, fatigue, nausea and diarrhea.
People may also experience musculoskeletal disorders, such as arthralgia,
joint pain or stiffness, back pain, inflammation, and neck or chest pain.3
Bailey et al. documented the first known case of
fluoroquinolone-induced
tendinopathy in 1983.4 The research described norfloxacin-induced
tendinitis in patients who were being treated with the drug.
Achilles tendon pathologies are commonly associated with
fluoroquinolones,
since the tendon is extremely vulnerable to daily microtrauma and injury
because of its weight-bearing role. But no conclusive research supports this
statement, with respect to fluoroquinolones.5
In extreme cases, bilateral simultaneous Achilles tendon ruptures were
reported. This is magnified by the fact that only 10 cases of bilateral
simultaneous Achilles tendon ruptures were reported in the literature by the
mid-1980s.6 While this tendon appears to be the Achilles heel of
patients using fluoroquinolones, the literature also describes lateral
epicondylitis, rotator cuff dysfunctions and other tendinopathies.7,8
This research helped establish the indisputable relationship between
fluoroquinolones and tendinopathies. As a result, researchers attempted to
determine the mechanism of these disorders. The effects of fluoroquinolones
on juvenile and adult cartilage may significantly inhibit the growth of
chondrocytes, contribute to cartilage erosion and produce bursts in the
amount of immature articular cartilage.9,10 As a result, the
Federal Drug Administration (FDA) issued a warning about using
fluoroquinolones in patients under age 18.
Histological studies looked at the effects of fluoroquinolones on
tendons. Microscopic evaluations examined collagen fiber arrangements, cell
proliferation, matrix deterioration, and other processes that may lead to
overall tendon degradation and injury.
Impact of Case Studies
Literature has documented studies that connect tendon injuries to
fluoroquinolones. Huston related tendinopathies to fluoroquinolones in 1994
when he described an 85-year-old man with polymyalgia rheumatica who was
being treated with the steroid prednisone.10
The patient's condition improved over several months, until a urinary
tract infection prompted his urologist to prescribe enoxacin, a
fluoroquinolone. Seven days after enoxacin therapy began, he noted pain in
both calves. The pain radiated into his heels and caused minor swelling.
One week later, an exam revealed ambulation difficulties secondary to
pain and tenderness over bilateral Achilles tendons. Although the enoxacin
was discontinued and his condition stabilized, the patient still had trouble
ambulating. Magnetic resonance imaging revealed a complete rupture of the
right Achilles tendon three centimeters above the calcaneous insertion.
Studies by Szarfman et al. and Pierfitte et al. noted over 100 cases of
tendon inflammation that was reported to French pharmacology companies by
1992.11 There were also more than 30 tendon ruptures ranging from
the long head of the biceps to the long extensor of the thumb. Data analysis
of these patients showed a 3-to-1 ratio of men to women and a mean age of 63
years. The average time from beginning of treatment to onset of symptoms was
13 days, with some as early as 1 to 2 days.
Fluoroquinolone-induced Achilles tendinopathies have been documented by a
long list of authors.5,10,11-15 These cases include: a
33-year-old with end stage renal failure; a 68-year-old with peripheral
vascular disease; a 92-year-old with rheumatoid arthritis; a 34-year-old
with osteomyelitis; and a 67-year-old with chronic obstructive pulmonary
disease and hypertension. In these cases, trends surfaced. For instance,
advanced age is seen in many cases of fluoroquinolone-associated
tendinopathies, which may be the result of normal aging effects on tendons
in conjunction with fluoroquinolones.
Aging is associated with a decrease in tendon collagen content and
stiffness.16 With aging, researchers also noted a decrease in
viscosity.16 Thus, a tendon's ability to tolerate loads decreases
with age. Some authors have suggested that the tendon's ability to combat
adverse effects and heal traumas decreases when fluoroquinolones are used.
Histological Exams
The exact mechanism of fluoroquinolone-induced tendinopathies is unknown.
In 1994, Szarfman et al. provided an early hypothesis.17 The
disruption of the extracellular matrix or cartilage and the depletion of
collagen in animal models led Szarfman to hypothesize that similar
degradation may occur in humans with tendon ruptures.17
In another study, Gillet et al. viewed three Achilles tendons of
symptomatic fluoroquinolone therapy patients with magnetic resonance
imaging.18 Clinical findings were typical of Achilles tendonitis
in all cases. Two cases showed thickening of the tendon and one case
exhibited prominent peritendinous edema.
Another study by Koeger et al. looked at tendons of asymptomatic
fluoroquinolone users.19 Researchers observed hypersignals that
indicated common increased cellular activity (4-out-of-10) in tendons of
asymptomatic patients. This suggests that tendon metabolism is altered in
the absence of clinical signs.
Le Huec et al. examined two human tendon lesions that were induced by
fluoroquinolones and noted the presence of giant cells.8 This
usually indicates a reaction to a foreign body. Le Huec speculated that
fluoroquinolones may be toxic to tendons because of the sudden onset of
symptoms after a single dose.
Based on this research, Movin et al. performed a histological evaluation
on a healthy 49-year-old male who was given ciprofloxacin as a prophylaxis
after a routine appendectomy.14 After 2 weeks, the patient
developed localized pain at the right Achilles tendon and experienced
ambulation difficulties. The symptoms were minimal at rest and with normal
living. Several months later, the patient still couldn't take long walks or
run. A clinical exam didn't reveal a rupture, but the histological exam
wasn't normal.
A microscopic evaluation showed irregular collagen arrangement,
hypercellularity, and increased interfibrillar glycosaminoglycans. These
findings suggest deficient healing, and are similar to pathological features
of tendon overuse injuries.14,18,19
A recent histological exam was aimed at understanding the direct
pathologic mechanism underlying fluoroquinolone-induced tendinopathies.
Williams et al. suggests that fluoroquinolones alter fibroblast metabolism.
The study examined the effects of one type of fluoroquinoloneciprofloxacinon
the fibroblast metabolism of canine Achilles tendons, paratenons and
shoulder capsules.2
Researchers looked at fibroblast metabolism from three standpoints: cell
proliferation, matrix synthesis (collagen and proteoglycan) and matrix
degrading activity. The study revealed the following: a 66 percent to 68
percent decrease in fibroblast proliferation; a 36 percent to 48 percent
decrease in collagen synthesis; and a 14 percent to 60 percent decrease in
proteoglycan synthesis, compared to control groups. Ciprofloxacin also
induced a significant increase in matrix degrading activity over 72 hours.
Fluoroquinolones have been called one of the success stories of modern
antimicrobial chemotherapy.1 However, many physicians are still unaware of
tendinopathies induced by fluoroquinolones, despite the fact that side
effects are listed in the Physicians' Desk Reference and more than 200 cases
have been reported to the FDA.
Precautions have surfaced and helped decrease the amount of adverse
tendinopathies. For instance, don't use these antibiotics with pediatric and
older patients, or with people who have renal insufficiency. One author
reports that 41 percent of reported cases were caused, in part, by
corticosteroid use.6 However, the exact mechanism of
fluoroquinolone-induced tendinopathies may never be fully understood.
Fluoroquinolones appear to produce lesions in tendons. These lesions are
replaced by fibrotic tissue, which is normal with most tendon injuries.
Fluoroquinolones decrease collagen and cause irregular alignment. It's also
hypothesized that nitrous oxide and the seventh position substitute may play
a part in these tendinopathies. This stems from the fact that two of its
most potent inhibitors completely stopped all lesions by the drug.
In addition, most toxic drugs had the same substitute. And researchers
believe that fluoroquinolones inhibit fibroblast metabolism and stimulate
matrix-degrading activity to resemble the effects of tendon immobilization.
Tendons are biological tissues that respond to mechanical stresses placed
on them by constant catabolic and anabolic activity. If the healing phase
can't keep up with the injury phase, overuse injuries occur. If cell
proliferation is decreased in tendons as a result of fluoroquinolones,
tendons can't keep up with the repair of normal daily microtraumas. Rupture,
inflammation and pain may result. With the decrease of collagen and
proteoglycan synthesis, and the destruction and malalignment of collagen,
tendons are in prime position for injury.
If you see that a patient is using a
fluoroquinolone, such as Cipro® or Levaquin®, be aware of potential side effects and take appropriate action
to avoid further damage to structures. But avoid telling the patient
outright that a fluoroquinolone-induced tendinopathy may occur. Instead,
contact the primary care physician to discuss the situation.
A simple call can alert the physician to a potential problem so he can
stop the medication or find an alternative. And it may help you gain new
respect from referring physicians.
For a list of references, go to www.advanceweb.com/REHAB
and click on the references tool bar.
Jeremy Normington, DPT, is director of physical medicine and
rehabilitation at Sioux Valley Memorial Hospital in Cherokee, Iowa.
 |
Ring
Splint Protocol For Extensor Tendon
Zone
V post Junctura,
Sept, 2005 |
Negative effects of total immobilization
during the inflammatory and fibroblastic stages of healing on tendon
biochemistry are: Loss of glycosaminoglycan concentration, loss of water,
decreased fibronectin concentration and decreased tendon
healing. Biochemically, the immobilized tendon looses tensile strength in the
first 2 weeks after repair and looses gliding function by the first 10 days
after repair.
Management
of the inflammatory state, timing of stress application, judicious application
of controlled stress, and the effects of active versus passive motion, splint
geometry, the position of exercise, external load application with stress
application and the duration and ease of exercise all influence either
positively or negatively the healing and remodeling of this fibrous connective
tissue.
Rationale:
Effects
of controlled stress:
Stress
induced electrical potential may increase the connective tissue healing
potential. Early active assisted motion increases the fibronectin concentration
and fibroblastic chemo-taxis at the tendon repair site and that some degree of
controlled functional motion with increased compliance could reduce the
complication associated with immobilization.
Researches
have raised the question of actual tendon excursion with passive motion. A
component of controlled active motion may be necessary to increase some proximal
migration of the tendon repair site and that passive motion may cause the
repair site to fold or buckle instead of gliding proximally. This is the
rationale for controlled early active assisted motion as opposed to controlled
passive motion in the post-op management of the repaired tendon.
To
safely apply stress to a healing tendon, the therapist must understand tendon
excursion as it relates of joint motion, suture techniques and healing
schedules.
1.
Loss of extensor autonomy has been attributed to the fibrous
connecting bands within the muscle belly of the EDC in the forearm as well as
the integrity of the juncture tendinum.
2.
EDC, despite distinct bellies, involved in active extension of the
uninvolved finger may provoke a muscle contraction in the involved finger due to
the juncture. This probably does occur, but is such a contraction harmful or
helpful? If the patient is not actually attempting to extend the finger and
instead is using the hand for normal activities, this may infact increase the
tensile strength of the repair and increase the excursion rather than cause
deleterious repair deformation and rupture. Many therapists have observed that
their best results are in those patients who cheat just a little in their
program with light intermittent active extension.
3.
Some patients appear to scar more heavily than others. Tendon
glide is extremely difficult in those patients even after close adherence to a
program that has worked well for other patients. Patients who scar heavily may
need to start earlier with active/resistive exercises, and their program may be
more vigorously pursued as the tendons may become bound by adhesions by the 10th
day after repair.
4.
The duration of daily controlled motion interval is a significant
variable in tendon excursion. Adding to the problem of tendon adhesions is the
frequency and duration of exercise and expectation from the patients to exercise
at regular intervals. Thus, frequency of controlled motion in postoperative
tendon management protocols is a significant factor in acceleration the healing
response after tendon repair.
5.
ROM after immobilization may lead
6.
Junctura (anatomy/anomalies): Repair to the EDC distal to juncture in the
long finger can be adequately protected with the ring splint by placing the
middle finger at 0 degree and adjacent finger in 30 degree flexion. This
position relieves tension at the repair site while maintaining extensibility of
collateral ligaments. Tension is reduced on the anastomosis of the EDC when the
repair site is distal to the junctura tendinum if the adjacent fingers are held
in mild flexion. This position advances the proximal end of the severed tendon
by a force of intertendinious connections.
Communication:
Schedules
for application of controlled stress and progressive
exercise,
depends on the tensile strength of the repair technique and the stage of wound
healing. Motion may enhance the diffusion of synovial fluid with the tendon in
the synovial region.
Communication
between the surgeon and the therapist regarding the quality of repair, type of
repair alteration in the tendon length, the integrity of the tissue, the status
of surrounding tissue, tendon anomalies (i.e. presence or absence of juncture)
and any additional pathologic conditions that might alter the amount of
controlled stress that the healing tendon can accommodate. The patient can be
evaluated in terms of anticipated
compliance.
Therapeutic
management with this splint is considered in terms of biochemical and
biomechanical events of wound healing and the effects that this management
technique has on these events.
Protocol:
Controlled
stress is applied 3 days after surgery by allowing the repaired tendons to glide
5 mm within the ulnar gutter splint and a ring splint.
Stress
is relieved at the repair site for the finger extensors by placing the wrist in
approximately 40 degrees of wrist extension in the ulnar gutter splint and the
ring splint with the middle finger in 0 degrees flexion and adjacent fingers in
30 degrees flexion.
The
combination splint is worn for 4 weeks, when the ulnar gutter is removed and the
patient continues to wear the rings for another 2-3 weeks. A night time static
extension component could be added to prevent sustained forced flexion posture
while sleeping.
Patient
is allowed light daily activities, and contraindicated from gripping or sports
activities.
Result:
This
provides regular controlled motion at the repair site without the risk of
rupture and decreases the need for the patient to remember a rigorous exercise
routine as it incorporates with the daily activities, thus increasing the
compliance with the splint wear and exercise. This also decreases the frequency
and duration of treatment needed for scar management.
Splint Design:
The
splint is designed to provide the least amount of tension and maximal protection
at the repair site and at the same time allow for function while wearing the
splint.
As
mentioned earlier, the wrist is kept in 40 degrees extension via the Ulnar
Gutter Splint. Appropriate padding is provided at the Ulnar Styloid. The width
of each ring is the length of P1 minus 4mm to allow for joint motion at the PIP
joint and some motion at the MCP joint. The thermoplastic strips are place
circumferentially around each finger with the diameter of the PIP joint taken
into account for easy glide of the rings. Once each ring is individually formed,
another strip measuring in the same width but longer in length is cut.
With
the Rings on the fingers and the Ulnar Gutter in place the thermoplastic strip
is passed dorsum to the Index finger keeping it in 30 degree flexion, then
continuing volar to the Middle finger keeping it in neutral and then passing
dorsal again to the Ring finger maintaining 30 degree flexion at the MCP joint.
After the strip is secured the patient is allowed to move his fingers.
As
the rings incorporate the entire length of P1 along with the thickness of the
splint material, the patient is allowed enough motion to bend the IP and slight
MP motion but not enough to make a full fist.
A Velcro Loop may be added to the dorsum of the middle ring piece and the
dorsum of the Ulnar Gutter splint. A fishing line with a Hook at each end
maintains neutral position of the Middle finger at night.
About Petzoldt Memorial Hand and
Physical Therapy
This article is submitted by
Saba
Kamal
, OTR, CHT Ms. Kamal, has attended the Hand
Therapy Fellowship Program offered by TWU and later was one of the clinical
instructors for the program. She was also mentored by Dr. David Lichtman.
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