Effects of continuous passive motion and elevation on hand edema

Vascular impulse technology versus elevation for reducing the swelling of upper and lower extremity joint fractures

Soft-tissue conditioning due to posttraumatic oedema after complicated joint fractures is a central therapeutic aspect both pre- and postoperatively. On average, 6-10 days pass until the patient is suitable for surgery. This study compares the decongestant effect of vascular impulse technology (VIT) with that of conventional elevation. In this monocentric RCT, 68 patients with joint fractures of the upper (n = 36) and lower (n = 32) extremity were included and randomized after consent in a 1:1 ratio. Variables were evaluated for all fractures together and additionally subdivided into upper or lower extremity for better clinical comparability. Primary endpoint was the time in days from hospital admission to operability. Secondary endpoints were total length of stay, oedema reduction, pain intensity, complications, and revisions. The time from admission until operability was reduced by 1.4 (95% CI - 0.4; 3.1) days in the mITT analysis (p = 0.120) and was statistically significant with 1.7 (95% CI 0.1; 3.3) days in the as-treated sensitivity analysis (p_AT = 0.038). Significantly less pain and a faster oedema reduction were found in the intervention group. Due to rare occurrences, nothing can be concluded regarding complications and revisions. Administration of VIT therapy did not lead to a significant reduction in time until operability in the whole population but was superior to elevation for soft-tissue conditioning and pain reduction. However, there was a significant reduction by 2.5 days (95% CI 0.7; 4.3) in the subgroup of lower extremity fractures. VIT therapy therefore seems to be a helpful tool in the treatment of posttraumatic oedema after complex joint fractures of the lower and upper extremity, especially in tibial head and lower leg fractures.

Peripheral vasoreactivity in acute ischemic stroke with hemiplegia

The association between vasomotor tone of the peripheral arteries and cerebral hemisphere function has not been established. This study analyzed the peripheral vasoreactivity of patients with acute ischemic stroke and hemiplegia using a modified Raynaud scan, which is a new technology for blood flow measurement. In this retrospective case–control study, we examined patients with unilateral weakness consistent with ischemic lesions who underwent brain magnetic resonance imaging and modified Raynaud scanning within five days from the onset of symptoms. The modified Raynaud scan was used to quantify the radioactivity of the bilateral fingertips during rest and cooling-heating thermal stress conditions and estimate vasoreactivity based on the change in the blood amount per time under rest-thermal stress. The subjects were classified into the preserved and impaired groups based on their degrees of vasomotor reaction. Based on the modified Raynaud scanning, 37 (mean age = 69.1 ± 10.6) and 32 (mean age = 62.6 ± 11.8) subjects were allocated to the preserved and impaired groups, respectively. Binary logistic regression showed that the affected limb edema (odds ratio (OR) 6.15; confidence interval (CI) 1.40–26.97; p = 0.016) and anterior circulation (OR 3.68; CI 1.01–13.48; p = 0.049) were associated with impaired vasoreactivity. The modified Raynaud scans confirmed that central lesions in the anterior circulation with hemiparesis may influence the vasoreactivity of edematous peripheral arteries. These results may inform treatment and rehabilitation for stroke patients with hemiparesis.

Rehabilitation Strategies Following Surgical Treatment of Upper Extremity Spasticity

Upper motor neuron injuries that occur in cases such as cerebral palsy, cerebrovascular accidents, and traumatic brain injury often have resulting upper extremity deformity and dysfunction. Multiple surgical options are available to improve upper extremity positioning, and, in some cases, motor control. Postoperative therapeutic management is imperative to assist the patient/caregiver in maximizing potential functional gains. This article provides an overview of postoperative guidelines for commonly performed surgeries to manage upper extremity dysfunction caused by spasticity and discusses acute management as well as therapeutic techniques for functional training and improved motor control.

Handgrip exercise by the non-affected hand increases venous return in the contralateral axillary vein in patients with stroke: a pilot study

Objective

Treatment of hand edema is important for maintaining upper limb function in patients with stroke, although the effects of many such treatments have been limited. This study aimed to examine, using ultrasound, the effect of handgrip exercise by the non-affected hand of stroke patients on venous return in the affected upper limb.

Results

Seven men participated, within 6 months of a unilateral first-ever stroke. With the patient supine, examinations were performed on the axillary vein of the affected side. The diameter and flow velocity of the axillary vein on the affected side were measured during two regimens: at rest or during rhythmic resistance exercise (30% of maximum grip strength for 20 s) performed by the non-affected hand. The venous flow volume in the axillary vein was then calculated using the data obtained. During resistance exercise by the non-affected hand, there were significant increases in both venous flow velocity (p = 0.01, d = − 0.80) and volume (p = 0.01, d = − 0.74) on the affected side, compared with baseline. The present preliminary study found that rhythmic resistance exercise with the non-affected hand increased venous flow velocity and volume in the affected upper limb of patients with stroke.

Is Continuous Passive Motion Effective in Patients with Lymphedema? A Randomized Controlled Trial

BACKGROUND

In this randomized controlled study, we aimed to evaluate the effect of shoulder flexion exercise using continuous passive motion (CPM) on lymphedema during the treatment of breast cancer-related lymphedema (BCRL).

METHODS

Thirty patients with BCRL were enrolled and completed the study. Fourteen patients were treated with complete decongestive therapy (CDT) and CPM in the intervention group, and 16 patients were treated with CDT alone (control group) for 15 sessions. The main outcome measures were included; the shoulder range of motion (ROM) assessed with a goniometer, limb volume difference measured using the water immersion method, function with the Disabilities of the Arm, Shoulder and Hand (DASH), and the quality of life using the Functional Assessment of Cancer Therapy for Breast Cancer (FACT-B4). Lymphedema volume measures were taken at baseline, on days 1, 2, 3, 4, 5, 10, and 15; and shoulder ROM, FACT-B4, and DASH were taken at baseline and on day 15.

RESULTS

All subjects were similar at baseline. After treatment significant improvement was found in ROM, volumetric differences, DASH, and FACT-B4 scores in both groups. No significant differences were observed in the volumetric differences, ROM, and the DASH, and FACT-B4 scores between the groups, except for the FACT-B4 physical well-being subscores, which were better in intervention group.

CONCLUSION

Our study results showed that CPM did not contribute to the reduction of BCRL.

Home-based hand rehabilitation with a robotic glove in hemiplegic patients after stroke: a pilot feasibility study

OBJECTIVE

To evaluate the feasibility and safety of home rehabilitation of the hand using a robotic glove, and, in addition, its effectiveness, in hemiplegic patients after stroke.

METHODS

In this non-randomized pilot study, 21 hemiplegic stroke patients (Ashworth spasticity index ≤ 3) were prescribed, after in-hospital rehabilitation, a 2-month home-program of intensive hand training using the Gloreha Lite glove that provides computer-controlled passive mobilization of the fingers. Feasibility was measured by: number of patients who completed the home-program, minutes of exercise and number of sessions/patient performed. Safety was assessed by: hand pain with a visual analog scale (VAS), Ashworth spasticity index for finger flexors, opponents of the thumb and wrist flexors, and hand edema (circumference of forearm, wrist and fingers), measured at start (T0) and end (T1) of rehabilitation. Hand motor function (Motricity Index, MI), fine manual dexterity (Nine Hole Peg Test, NHPT) and strength (Grip test) were also measured at T0 and T1.

RESULTS

Patients performed, over a mean period 56 (49-63) days, a total of 1699 (1353-2045) min/patient of exercise with Gloreha Lite, 5.1 (4.3-5.8) days/week. Seventeen patients (81%) completed the full program. The mean VAS score of hand pain, Ashworth spasticity index and hand edema did not change significantly at T1 compared to T0. The MI, NHPT and Grip test improved significantly (p = 0.0020, 0.0156 and 0.0024, respectively) compared to baseline.

CONCLUSION

Gloreha Lite is feasible and safe for use in home rehabilitation. The efficacy data show a therapeutic effect which need to be confirmed by a randomized controlled study.

Effectiveness of edema management techniques for subacute hand edema: A systematic review

STUDY DESIGN

Systematic review.

INTRODUCTION

Prolonged hand edema can have detrimental effects on range of motion and function. There is no consensus on how best to manage traumatic subacute edema. This is the first systematic review which examines the clinical effectiveness of edema treatments on hand volume.

PURPOSE OF THE STUDY

The purpose of this systematic review was to examine the evidence of effectiveness of treatments for sub-acute hand edema.

METHODS

A literature search of AMED, CINAHL, Embase, and OVID MEDLINE (from inception to August 2015) was undertaken. Studies were selected if they met the following inclusion criteria: randomized controlled or controlled trials in adults who have subacute swelling after a recent upper limb musculoskeletal trauma or cerebral vascular attack or after surgery. Two independent assessors rated study quality and risk of bias using the 24-point MacDermid Structured Effectiveness Quality Evaluation Scale (SEQES).

RESULTS

Ten studies met the inclusion criteria. Study quality ranged from 23 to 41 out of 48 points on the SEQES. A total of 16 edema interventions were evaluated across the studies. Due to heterogeneity of the patient characteristics, interventions, and outcomes assessed, it was not possible to pool the results from all studies. Therefore, a narrative best evidence synthesis was undertaken. There is low to moderate quality evidence with limited confidence in the effect estimate to support the use of manual edema mobilization methods in conjunction with standard therapy to reduce problematic hand edema.

CONCLUSION

Manual edema mobilization techniques should be considered in conjunction with conventional therapies, in cases of excessive edema or when the edema has not responded to conventional treatment alone; however, manual edema mobilization is not advocated as a routine intervention.

LEVEL OF EVIDENCE

2b.

Feasibility and efficacy of a robotic device for hand rehabilitation in hemiplegic stroke patients: a randomized pilot controlled study

OBJECTIVE

The purpose of the study was to evaluate the feasibility and efficacy of robot-assisted hand rehabilitation in improving arm function abilities in sub-acute hemiplegic patients.

DESIGN

Randomized controlled pilot study.

SETTING

Inpatient rehabilitation centers.

PARTICIPANTS

Thirty hemiplegic stroke patients (Ashworth spasticity index <3) were recruited and randomly divided into a Treatment group (TG) and Control group (CG).

INTERVENTIONS

Patients in the TG received intensive hand training with Gloreha, a hand rehabilitation glove that provides computer-controlled, repetitive, passive mobilization of the fingers, with multisensory feedback. Patients in the CG received the same amount of time in terms of conventional hand rehabilitation.

MAIN OUTCOME MEASURES

Hand motor function (Motricity Index, MI), fine manual dexterity (Nine Hole Peg Test, NHPT) and strength (Grip and Pinch test) were measured at baseline and after rehabilitation, and the differences, (Δ) mean(standard deviation), compared between groups. Results Twenty-seven patients concluded the program: 14 in the TG and 13 in the CG. None of the patients refused the device and only one adverse event of rheumatoid arthritis reactivation was reported. Baseline data did not differ significantly between the two groups. In TG, ΔMI 23(16.4), ΔNHPT 0.16(0.16), ΔGRIP 0.27(0.23) and ΔPINCH 0.07(0.07) were significantly greater than in CG, ΔMI 5.2(9.2), ΔNHPT 0.02(0.07), ΔGRIP 0.03(0.06) and ΔPINCH 0.02(0.03)] ( p=0.002, p=0.009, p=0.003 and p=0.038, respectively).

CONCLUSIONS

Gloreha Professional is feasible and effective in recovering fine manual dexterity and strength and reducing arm disability in sub-acute hemiplegic patients.

Treatment Interventions for the Paretic Upper Limb of Stroke Survivors: A Critical Review

Despite a threefold increase in treatment interventions studies during the past 10 years, “best practice” for the rehabilitation of the paretic upper limb is still unclear. This review aims to lessen uncertainty in the management of the poststroke upper limb. Two separate searches of the scientific literature from 1966-2001 yielded 333 articles. Three referees, using strict inclusion and exclusion criteria, selected 68 relevant references. Cohort studies, randomized control trials, and systematic reviews were critically appraised. Mean randomized control trial quality (n = 33) was 17.1/27 (SD = 5.2, 95% CI = 15.2–19.0, range = 6–26). Mean quality of cohort studies (n = 29) was 11.8/27 (SD = 3.8, 95% CI = 10.4–13.2, range = 4–19). Quantitative syntheses were done using theZ -statistic. This systematic review indicated that sensorimotor training; motor learning training that includes the use of imagery, electrical stimulation alone, or combined with biofeedback; and engaging the client in repetitive, novel tasks can be effective in reducing motor impairment after stroke. Furthermore, careful handling, electrical stimulation, movement with elevation, strapping, and the avoidance of overhead pulleys could effectively reduce or prevent pain in the paretic upper limb. Rehabilitation specialists can use this research synthesis to guide their selection of effective treatment techniques for persons with impairments after stroke.

Rehabilitation Interventions for Poststroke Hand Oedema: A Systematic Review

Objective/Background

To review the evidence of rehabilitation interventions for the management of poststroke hand oedema.

Methods

We conducted a systematic review of research articles in electronic databases published in English between 1999 and 2015. Two investigators working independently retrieved articles from the Cochrane Central Register of Controlled Trials, SCOPUS, Taylor & Francis Online, Wiley Online Library, CINAHL, Springer (MetaPress), ScienceDirect, PubMed, SAGE Journals Online, EBSCO, and Web of Science. Only controlled trials with outcome measures and interventions for poststroke hand oedema were included. Three investigators critically appraised the selected studies using the Physiotherapy Evidence Database Scale.

Results

Of the 189 articles identified, nine (5 randomized controlled trials, 3 nonrandomized controlled trials, and 1 crossover controlled trial) were selected. These studies are heterogeneous in terms of design and types of intervention for poststroke hand oedema. The interventions reducing hand oedema are Lycra pressure garments with glove splints, bilateral passive motion upper-limb exercises, laser therapy, and acupressure. However, due to these studies’ short intervention periods and the fact that hand oedema is not their primary outcome measure, it is not possible to draw a firm conclusion on their clinical significance for managing poststroke hand oedema.

Conclusion

Further study needs to focus solely on interventions for poststroke hand oedema and their long-term effects. No conclusion can be made on the most effective management of poststroke hand oedema until much more evidence is available.

Efficacy of Compression Gloves in Maintaining Edema Reductions After Application of Compression Bandaging to the Stroke-Affected Upper Limb

OBJECTIVE

We explored the efficacy of compression gloves in maintaining the benefits gained from compression bandaging of the stroke-affected upper limb.

METHOD

Four participants completed a single-case (ABC) design study consisting of a baseline period (Phase A) and compression bandaging of the hand and upper limb (Phase B), followed by the application of a compression glove (Phase C). Edema was measured with circumferential tape at five specified points from the phalanx to the midforearm. All measurements were represented graphically for visual analysis, and celeration lines were calculated to indicate the degree of slope within each phase.

RESULTS

Visual analysis indicated fluctuating edema volume during Phase A, decreasing edema volume during Phase B, and a mixed trend during Phase C.

CONCLUSION

Compression gloves had mixed benefits in managing reductions in edema volume poststroke. Further research may consider the material, sizing, and style of glove in the development of a maintenance strategy.

The effect of upper-extremity aerobic exercise on complex regional pain syndrome type I: a randomized controlled study on subacute stroke

BACKGROUND AND PURPOSE

Complex regional pain syndrome type I (CPRS I), is a complex of symptoms characterized by diffuse pain usually with associated swelling, vasomotor instability, and severe functional impairment of the affected extremity in stroke patients. Pain is a prominent feature and is often refractory to variety of treatment.

METHODS

To investigate the clinical, functional, and psychosocial effects of upper extremity aerobic exercise (UEAE) and compare the effect of aerobic exercise with that of conventional physiotherapy in patients with CPRS type I following stroke as a randomized controlled assesor blinded 4  week-study. A total of 52 inpatients with stroke [mean age: 65.95 ± 8.7 (min. = 53, max. = 80) years, and the mean age of the control group was 67.50 ± 11.2 years], all within 6  months post-stroke and diagnosed with CPRS I. The UEAE program consisted of an arm crank ergometer (10  W/min), in addition to a conventional physiotherapy (whirlpool, TENS, retrograd massage). Primary outcome measures were CPRS clinical determinants (pain, hyperalgesia, allodynia, and autonomic abnormalities) secondary outcome measures were functional independence measure (FIM), Nottingham Health Profile (NHP), and Beck Depression Scale scores that were performed at 0  month (baseline) and 4  weeks (post-treatment).

RESULTS

In UEAE group, patients reported significant pain relief (89.9%) and significant decline in CRPS signs and symptoms. The mean change in pain at shoulder, pain at the hand as well as and NHP and BDS scores between groups were statistically significant (P < 0.05).

CONCLUSIONS

UEAE made an excellent improvement in the symptoms and signs of CRPS I. Combined treatment of conventional physiotherapy and aerobic exercises may be an excellent synthesis for this syndrome in these patients.

Single-case design evaluation of compression therapy for edema of the stroke-affected hand

OBJECTIVE. To explore the efficacy of low- and high-stretch compression bandaging for edema management in the stroke-affected upper limb. METHOD. A single-case, ABA-design study was conducted with 8 participants alternately allocated to receive low- or high-stretch bandaging. Edema was measured with circumferential tape at four specified points from the hand to the mid-forearm. All measurements were represented graphically for visual analysis, and celeration lines were calculated to indicate the degree of slope in each phase. RESULTS. Visual analysis indicated fluctuating edema volume in the first baseline phase, decreasing edema volume in the intervention phase, and increasing edema volume in the second baseline phase. The results did not clearly distinguish between the two bandaging groups. CONCLUSION. Compression bandaging may have benefits in the management of edema after stroke. Further research is required to identify factors contributing to the long-term maintenance of reductions gained after compression bandaging.

Cable-Driven Finger Exercise Device With Extension Return Springs for Recreating Standard Therapy Exercises

Finger therapy exercises, which include table top, proximal-interphalangeal blocking, straight fist, distal-interphalangeal blocking, hook-fist, and fist exercises, are important for maintaining hand mobility and preventing development of tendon adhesions in postoperative hand-injury patients. Continuous passive motion devices act as an adjunct to the therapist in performing therapy exercises on patients; however, current devices are unable to recreate these exercises well. The current study aimed to design and evaluate a finger exercise device that reproduces the therapy exercises by adopting a cable-actuated flexion and spring-return extension mechanism. The device comprises of phalanx interface attachments, connected by palmar-side cables to spooling actuators and linked by dorsal-side extension springs to provide passive return. Two designs were tested whereby the springs had similar (design 1) or different stiffnesses (design 2). The device was donned onto a model hand and actuated into the desired therapy postures. Our findings indicated that design 1 was able to recreate table top, straight fist, and fist exercises while design 2 was capable of further replicating distal-interphalangeal blocking, proximal-interphalangeal blocking, and hook-fist exercises. This work demonstrated the possibility of replicating finger therapy exercises using a cable-actuated flexion and spring-return extension design, which lays the groundwork for prospective finger exercise devices that can be donned on patients to assess the efficacy in postoperative joint rehabilitation.

Prevention and treatment of hand oedema after stroke

PURPOSE

As there is no evidence for a specific treatment for post-stroke-induced hand oedema, rehabilitation centre Blixembosch formalized a best practice protocol. We investigated whether the Blixembosch hand oedema protocol is usable in daily practice and leads to lower incidence (prevention) and shorter duration (treatment) compared with care as usual.

METHODS

In a non-randomised comparative trial, we investigated 206 post-stroke patients admitted to two Dutch rehabilitation centres. Hand volumes were measured at least bi-weekly using a volumeter. Treatment was started according the protocol (Blixembosch) or following care as usual (Leijpark). Usability was assessed with a survey among professionals.

RESULTS

In the Blixembosch group, 16% developed oedema after admission, compared with 21% in the control group (p = 0.019). Average duration of oedema (both developed before and after admission) was 6.5 weeks in the Blixembosch group compared with 3.1 weeks in the control group (p = 0.000). Professionals were positive about the protocol.

CONCLUSION

The study showed that the protocol is usable in daily practice and has a small beneficial effect on hand oedema incidence rates compared with care as usual. The negative effect on duration of hand oedema could also be caused by the difference in prognosis between the two groups.

Reliability of the standard goniometry and diagrammatic recording of finger joint angles: a comparative study with healthy subjects and non-professional raters

Background

Diagrammatic recording of finger joint angles by using two criss-crossed paper strips can be a quick substitute to the standard goniometry. As a preliminary step toward clinical validation of the diagrammatic technique, the current study employed healthy subjects and non-professional raters to explore whether reliability estimates of the diagrammatic goniometry are comparable with those of the standard procedure.

Methods

The study included two procedurally different parts, which were replicated by assigning 24 medical students to act interchangeably as 12 subjects and 12 raters. A larger component of the study was designed to compare goniometers side-by-side in measurement of finger joint angles varying from subject to subject. In the rest of the study, the instruments were compared by parallel evaluations of joint angles similar for all subjects in a situation of simulated change of joint range of motion over time. The subjects used special guides to position the joints of their left ring finger at varying angles of flexion and extension. The obtained diagrams of joint angles were converted to numerical values by computerized measurements. The statistical approaches included calculation of appropriate intraclass correlation coefficients, standard errors of measurements, proportions of measurement differences of 5 or less degrees, and significant differences between paired observations.

Results

Reliability estimates were similar for both goniometers. Intra-rater and inter-rater intraclass correlation coefficients ranged from 0.69 to 0.93. The corresponding standard errors of measurements ranged from 2.4 to 4.9 degrees. Repeated measurements of a considerable number of raters fell within clinically non-meaningful 5 degrees of each other in proportions comparable with a criterion value of 0.95. Data collected with both instruments could be similarly interpreted in a simulated situation of change of joint range of motion over time.

Conclusions

The paper goniometer and the standard goniometer can be used interchangeably by non-professional raters for evaluation of normal finger joints. The obtained results warrant further research to assess clinical performance of the paper strip technique.

The Long-term relationship between duration of treatment and contracture resolution using dynamic orthotic devices for the stiff proximal interphalangeal joint: a prospective cohort study

STUDY DESIGN

Descriptive design with a prospective cohort.

INTRODUCTION

Little is known about the long-term relationship between the duration of treatment using dynamic orthoses (splints), and contracture resolution in the stiff proximal interphalangeal (PIP) joint.

PURPOSE OF THE STUDY

To examine the long-term relationship between weeks of treatment using dynamic orthoses and contracture resolution, in both flexion and extension deficits of the PIP joint.

METHODS

Forty-one participants were treated with a dynamic orthotic device (splint) for either a flexion or extension deficit of the PIP joint (n=48 joints). The relationship between contracture resolution and weeks of treatment was examined controlling for baseline range of motion (ROM), weekly total end range time, pretreatment joint stiffness, time since injury, and diagnosis. Outcome was measured via change in torque and active ROM.

RESULTS

Outcome with orthotic use was significantly associated with the weeks of treatment (p<0.001). ROM increased in a linear fashion although faster progress was observed when treatment was aimed at improving flexion rather than extension. Flexion deficits appeared to maximize gains with orthotic treatment after 12 weeks. However, extension deficits continued to demonstrate slow and continuous improvement beyond the 17 weeks of recorded data. Less treatment duration (in weeks) was needed to restore flexion than extension.

CONCLUSIONS

The duration of orthotic use (weeks of treatment) is significantly associated with the extent of contracture resolution. Slower recovery of ROM and a longer duration of orthotic use may be expected when the treatment goal is to improve extension rather than flexion.

LEVEL OF EVIDENCE

2b.

Finger circumference measurements: inter- and intra-rater reliability

Background

Finger oedema can occur for a variety of reasons, including traumatic injuries to the fingers and as a consequence of stroke or diabetes. The purpose of this study was to determine the intra- and inter-rater reliability for finger circumference measurements.

Methods

Eight hand therapists assessed the middle finger circumference of 11 healthy adults using the Richardson Products finger circumference device for three trials over two testing days. Intraclass reliability analysis and analysis of variance were used to assess the consistency and stability of measures. Level of significance was set at P ≤ 0.05.

Results

Significant differences ( P < 0.001) were found between raters for circumference measurements with a range difference of 0.5 cm. Intrarater reliability was 0.98–0.99 (single measure intraclass coefficient). Inter-rater reliability coefficients ranged from 0.94 to 0.95.

Conclusions

These results provide clinicians with evidence for using a specific finger circumference device and issues associated with various therapists assessing finger circumference. A device with a way of assessing tension at the end of the tape measure or cloth pulled around the finger is warranted.

Therapy after injury to the hand

Surgical and nonsurgical management of upper extremity disorders benefits from the collaboration of a therapist, the treating physician, and the patient. Hand therapy plays a role in many aspects of treatment, and patients with upper extremity injuries may spend considerably more time with a therapist than with a surgeon. Hand therapists coordinate edema control; pain management; minimization of joint contractures; maximization of tendon gliding, strengthening, and work hardening; counseling; and ongoing diagnostic evaluation. Modalities used to manage hand injuries include ultrasound, splinting, Fluidotherapy (Chattanooga Group, Chattanooga, TN), cryotherapy, various electrical modalities, phonophoresis, and iontophoresis.

The physical therapist as a musculoskeletal specialist in the emergency department

Because patients with musculoskeletal injuries commonly seek intervention in the emergency department (ED), it has been proposed that practitioners with expertise in musculoskeletal practice can be of benefit in this setting. This clinical commentary describes the rationale for utilizing physical therapists as musculoskeletal specialists in the ED. Evidence indicates that physical therapists have the knowledge and skills to provide such expertise. Literature describing ED practice suggests that the management of patients with musculoskeletal conditions would be improved through the consistent integration of evaluation and treatment principles associated with physical therapy practice. Furthermore, early access to physical therapy, as can be provided in the ED setting, has the potential to positively influence patient recovery. Based on prior research and recent evolution of practice, further consideration of physical therapists as consultants in the ED is warranted, and, therefore, additional dialogue on the subject should be encouraged.

Continuous passive motion after tenolysis in hand therapy patients: a retrospective study

Continuous passive motion (CPM) is a common adjunct to the postoperative therapy program. Use of CPM has been advocated for a variety of diagnoses in hand rehabilitation. This retrospective study compares two groups of patients who underwent digital tenolysis (and/or capsulectomy) and evaluates the use of CPM in their postoperative therapeutic management. Both groups had initial injuries of fractures, tendon lacerations, and/or crush injuries resulting in surgical intervention. After therapeutic rehabilitation, the patients failed to gain satisfactory active ROM and elected to proceed with a secondary surgical procedure. Fifteen patients (19 digits) who used CPM machines in addition to their home exercise program were compared to 21 patients (24 digits) who did not use CPM. Primary outcome comparisons for this study were change in total active motion (TAM) over time (preoperative to discharge from therapy), duration of therapy, and total number of therapy visits. There was no significant difference (F=1.16, p=0.29) in the change in TAM for patients using CPM (39.89 degrees ) compared to those not using CPM treatment (31.83 degrees ). Furthermore, CPM users were seen for significantly more therapy sessions than non-CPM users (25.7 therapy visits compared to 18.54 therapy visits). Rehabilitation lasted approximately the same amount of weeks for both groups (CPM users 10.21 weeks vs. non-CPM users 11.42 weeks).

Poststroke hand swelling and oedema: prevalence and relationship with impairment and disability

OBJECTIVE

To examine the prevalence of swelling and oedema of the hand in stroke patients and relationships with impairments and disability.

DESIGN

Cross-sectional.

SETTING

Stroke unit at Rehabilitation Centre De Hoogstraat, The Netherlands.

SUBJECTS

Eighty-eight adult stroke patients who were admitted for clinical rehabilitation during one year (2000).

MEASUREMENTS AND METHODS

Assessment took place two weeks after admission to the rehabilitation centre. Degree of swelling was measured with a hand volumeter and oedema was defined as a volumeter score deviating more than two standard deviations from the expected score derived from population data. Further assessment included tonus (Modified Ashworth Score), sensibility, tactile inattention, carefulness, and motor function (Utrecht Arm/Hand Test). Arm disability was measured with Frenchay Arm Test and Nine-hole Peg Test.

RESULTS

Some degree of hand swelling was present in 72.7% and oedema in 33.0% of our patients. Swelling and oedema were significantly more often seen in patients with hypertonic fingers and impaired sensibility. Patients with hand oedema had significantly worse Frenchay Arm Test and Nine-hole Peg Test scores.

CONCLUSIONS

Swelling and oedema of the hand are common among stroke patients in clinical rehabilitation.

The intertester and intratester reliability of hand volumetrics

The purpose of this study was to examine the intertester and intratester reliability of hand volumetric measurements comparing two different protocols. The first protocol involved three clinicians at an outpatient facility interpreting the manufacturer's volumeter instructions. At the second university site, three testers utilized a modified version of the American Society of Hand Therapists' recommended protocol. Three measurements were taken of each of 30 nonedematous hands per site. Reliability was assessed using only the first measurement and using the mean of the three measurements. Results for both protocols revealed very high intertester reliability (ICC=0.99) whether using the first measurement or the mean of three measurements. Intratester reliability was also very high (ICC=0.99) using either protocol. Standard error of measurement values are included and additional variables, which may affect the reliability of hand volumetrics, are discussed. The authors conclude that there is high reliability with volumetric measurements.

Optimal daily total end range time for contracture: resolution in hand splinting

Reduced passive range of motion (PROM) of the joints of the hand is a common sequela of traumatic upper limb injury. Although mobilizing splinting is a common modality used by hand therapists to improve PROM, limited empirical evidence is available to guide therapist prescription. This study investigated the importance of the timing of splint application per 24-hour period, daily total end range time (TERT), via a prospective sequential clinical trial. A total of 43 subjects with joint contractures of the hand after traumatic upper limb injury were randomly allocated to one of two splint programs. Subjects in group A used their splint for less than 6 hours per day, and subjects in group B used their splint for 6 to 12 hours per day. Daily TERT was recorded by subjects in a splint diary. Passive torque range of motion (TROM) was used to measure the extent of contracture resolution over four weeks of splinting. High intrarater, interrater, and test-retest reliability of the TROM technique was established for this sample (intraclass correlation coefficients 0.993 to 0.998). Sequential analysis showed a statistically significant preference for group B, daily TERT of 6 to 12 hours per day (p < 0.05). Pretreatment joint stiffness (p = 0.162) and joint type (p = 0.463) did not influence final TROM significantly. These findings help to provide some controlled data from which therapists may base future prescription (dose) of daily TERT.

The effects of neuromuscular stimulation-induced muscle contraction versus elevation on hand edema in CVA patients

The purpose of this study was to evaluate the efficacy of the use of neuromuscular stimulation (NMS)-induced contraction of the paralyzed muscles to produce an active muscle pump for removing excess fluid and compare its effect with elevation of the upper extremity. The effects of 30 minutes of NMS of the finger and wrist flexors and extensors were compared with the effects of 30 minutes of limb elevation alone. Each of eight cerebrovascular accident (CVA) patients with visible hand edema received both treatments, one on each of 2 consecutive days. Measures of hand and arm volume and upper and lower arm girth were taken before and after each treatment. Analyses comparing mean percentage change scores for both treatments showed large and significant treatment effects for all dependent measures. The finding suggests that NMS was more effective for reduction of hand edema than limb elevation alone for this sample of eight CVA patients.

Objective measures of joint stiffness

Objective measures of joint stiffness allow for the evaluation of the effectiveness of treatment modalities. Without this, the effectiveness of therapy is not quantifiable. Presently, joint stiffness can be quantified by either passive range of motion (PROM) measurement or torque range of motion (TqROM) measurement. PROM measurement does not control the force applied, nor does it require that the other joints in the kinematic chain be held fixed. Also, it demonstrates poor interrater reliability. An idealized device melding existing technologies of constant passive motion devices and computerized workstations is proposed to allow for easier measurement of TqROM angles for analysis data for the determination of the effectiveness of treatment modalities.

Continuous passive motion in hand rehabilitation

This paper reviews the literature comparing the results obtained in applying regimes involving motion with those involving rest following injury or surgery. The deleterious effects of immobilisation are compared to those obtained under conditions of passive motion and intermittent passive motion. It is concluded that continuous passive motion (CPM) represents an improvement on intermittent motion. Models of CPM machines are described and some results presented. It is proposed that "intelligent" CPM would represent a further improvement in technique and a prototype machine for this purpose and some preliminary results are described.

Reliability of torque range of motion: a preliminary study

The clinical reliability of torque range of motion (TROM) has not been tested. This preliminary review was performed to determine the intra- and interrater reliability of TROM. The proximal interphalangeal joints of the index and middle fingers of 14 normal subjects, 56 digits, were tested by applying extension forces of 200 g, 400 g, 600 g, and 800 g. Data were collected using both the hand-held Haldex orthotic gauge with the dial goniometer (manual) and the cantilever-beam force transducer and electrogoniometer (digital) as testing instruments. The testing order of digits, sides, and devices was randomized and tested separately by three different test teams. Results of the analysis of variance showed a significant difference of the means between raters at all force levels (p < 0.0001) and between instruments at 600-g and 800-g forces (p < 0.01). The Pearson product-moment correlation coefficient test, used to test the consistency, resulted in moderate consistency of measures of intrarater reliability between trials, and between instruments used (digital and manual). Intraclass correlation coefficients (ICCs) were calculated with results that were nearly identical to those of the Pearson. Intrarater reliability was in more consistent agreement at the 600-g and 800-g levels. There was significantly high agreement between the tests of tester B, compared with moderate correlations of the tests of testers A and C.

Circumferential finger measurements utilizing a torque meter to increase reliability

The purpose of this study was to compare the reliabilities of two methods of measuring finger circumference. Traditionally, finger circumference is determined clinically by the use of a tape measure. In this study, a tape-measure device for recording finger circumference utilizing a torque meter was compared with the traditional method to determine reliability differences. Ninety-two occupational therapists and occupational therapy students obtained circumferential measurements of the author's left index finger at the middle of the proximal phalanx utilizing the two methods. The readings obtained for each method were analyzed to determine the coefficient of variation and to compare their variances. The coefficient of variation for the traditional method was 2.92 and for the device utilizing the torque meter was 0.75. The F ratio was 15.63, which is significant at the 0.01 level. The results of this study indicate greater interrater reliability using a device that can accurately measure torque and allow the therapist to control the amount of tension applied when obtaining circumferential measurements using a tape measure.