Featured Article by Nancy Falkenstein OTR/L, CHT

Nancy Falkenstein OTR, CHT

Susan Weiss OTR, CHT

continued on page 3

Courses on Demand

EHT did it again! Now you can take your

learning options to the next level!

You can now learn, watch & participate

on your Iphone, Ipad, tablets, smartphones,

PC, MAC and more.

The PURPLE BOOK is BACK! New illustrations, questions and chapters. The NEW 3rd edition is

coming.

Hand & Upper Extremity Rehabilitation: A Quick Reference Guide and Review”. We are in editing stages of the 3rd edition. We anticipate release early 2013. See inside for details.

As always EHT/Tx2go strives to bring you valuable education and products. Please visit our sponsors websites. If viewing online just click and go. Thank you to our sponsors for making this newsletter possible.

This newsletter is for informational purposes only and is not intended to be a substitute for professional advise, diagnosis, or treatment. Opinions are that of the authors and not necessarily of EHT/Tx2go.

In This Issue

1

Exploring Hand Therapy

Treatment2gowww.handtherapy.com

Featured Article ......................................1

Test Your Knowledge. .............................6

Philly Hand Conference...........................7

Purple Book ................................8, 11, 12

New Releases .........................................8

Learn & Earn ...........................................8

Quick Reference Tid Bits ........................9

Answers to Test Your Knowledge ..........10

Basics & Beyond CHT study ................12

Physical Agent Modalities ......................12

Volume 13, Issue 4 October - December 2012

Tenolysis Tips and Tricks!Introduction:Adhesions are devastating complications for most injuries but especially for tendon and soft tissue injuries. Adhesions following extensor tendon injury can result in extension lags and loss of flexion. Adhesions following flexor tendon injury can result in tendon gliding restrictions. Adhesions in

general can cause joint capsule restrictions. Regardless of the cause of adhesions, we know adhesions can result in decreased hand function. What can we, as therapists, do?

If the surgeon decides on a tenolysis surgery we must be knowledgeable in regards to expectations, procedures, and outcomes. Typically a tenolysis is chosen when there is a discrepancy between passive (full) and active (limited) range of motion after the patient has reached their hand therapy maximum or a plateau is noted. A successful tenolysis requires immediate mobilization post surgical intervention. The best candidate for tenoylsis

is a patient who has localized adhesions limiting tendon gliding. However, it is not uncommon for a patient who needs a tenolysis to also require a capsulectomy, tendon lengthening, pulley reconstruction, skin grafts to name a few; all of which can result in diminished tenolysis gains. Obviously, any procedure that compromises the ability to provide immediate movement will have a negative impact in regards to tenolysis. Unfortunately, there is little therapists can do if multiple surgical procedures are performed that contradicts the immediate post operative rehabilitation program. That is a decision the surgeon has to decide. Therapists must be Scar banding in a child Photo used with permission from

Eugenia Papadopoulos

Exploring Hand Therapy dba Treatment2go

…“I have trigger fi nger and at the time I was given one of these splints, I was told I would have to have surgery to correct the constant pain I was experiencing. After wearing this at night for six weeks, the swelling had disappeared as had the pain … I highly recommend trying it.” Testimonial from Amazon web site 5/13/2010

Do You Treat Trigger Fingers?

To order,

call 888.378.7763 www.3pointproducts.com

Block end range PIP joint fl exion to prevent triggering yet allow functional motion.

Effective to allow injections to take maximum effect prior to resuming full activity.

Protect following surgery, to facilitate gradual return to function.

Act as a nighttime “retainer” to prevent return of the condition.

For details on treating Trigger Finger, scan here or visit www.3pointproducts.com

Oval-8 Finger Splints block triggering without blocking hand function

®

EHT_O8TriggerAd_FCOLOR.indd 1 8/9/12 9:46 AM

2

Exploring Hand Therapy dba Treatment2go

3

aware of the negative impact of the surgeon performing multiple procedures together and realize the gains likely will be diminished. Hence setting realistic goals and a plan of care to address each specific case is critical for rehabilitative success. This does not mean that a multiple surgical approach is wrong. This decision is the surgeon’s judgment and we as therapists must work within that decision. Therefore, we must set our goals accordingly.

Before we look at rehabilitation, let us look at what is a tenolysis procedure. It is important to know; a tenoylsis strips the tendon of soft tissue connections and can endanger tendon nutrition, which increases the likelihood of rupture. So, now it brings us to a million dollar question. When should a patient undergo a tenolysis? This is not an easy question and ultimately it is up to the surgeon’s judgment. With that said, I have seen in the literature anywhere from 2 months to 9 months post initial surgery. Most surgeons’ believe adequate wound remodeling and wound softening is mandatory. The point of this discussion is that some authors believe delaying the tenolysis procedure will allow the tendon to get the appropriate nutrition for healing and increase the ultimate outcome and minimize risk of tendon rupture.

Rehabilitation following a Tenolysis:If the surgeon performed multiple procedures you will need to treat

the most fragile and go from there. Always call the doctor to discuss his expectations and surgical gains and if possible obtain the operative and office visit notes. The scenario described in this article will be based on a tenoylsis performed without additional procedures. It is not unusual for the patient to arrive to therapy with a catheter that provides a local anesthetic. This catheter is inserted surgically and typically is left for 1 week to help control the pain. Normally a non-constrictive dressing is used to allow immediate active and passive range of motion to maintain the gains from surgery. The patient should begin hand therapy on post op day 1and therapy should focus on controlled aggressive active and passive range of motion. It is best if the patient is seen daily for 2 to 4 weeks and then decreases the frequency. Research has shown that the first week is critical and if improved motion is gained in week one (1) and maintained through week three (3) typically functional motion is maintained.

Edema Control and Pain Management: Edema must be controlled and the easiest and cheapest way is by elevating the extremity above the heart to avoid the dependent position. A good exercise to help control

edema is to have the patient perform overhead pumping exercises by making a fist 5 to 15 times every hour; this also is great for active motion exercises. Cold packs may be applied up to 4X/day for 15 minute sessions. When applying cold remember to protect the wound and keep it dry and teach the patient to check for vascular status. If these interventions do not control edema you may need to initiate self-adherent elastic wraps loosely fit (no tension) and typically best if applied in a figure of 8 distal to proximal fashions. Therapeutic gloves are an option but are typically difficult to don/doff which may increase pain. Pain may be managed via the previously mentioned catheter but if needed the therapist may implement a TENs unit to the involved extremity to help manage discomfort and pain. Also orthotic positioning may assist with pain management.

Continuous Passive Motion (CPM): CPM devices may be beneficial especially if joint contractures are released alongside the tenolysis. Caution is needed because CPM devices cannot replace active motion. Active range of motion is the most important exercise following a tenolysis and must remain the primary motion so it

continued page 4

Exploring Hand Therapy dba Treatment2go

4

is critical you instruct the patient using a CPM device to remove, as instructed, to get the best results.

Orthotics: Immobilization and mobilization orthosis are utilized following a tenolysis procedure for various reasons. One such reason may be to maintain range of motion gained in surgery. Additionally, orthosis may be used for rest, protection, and positioning. Dynamic or static progressive orthosis may be used in conjunction with other therapy as well, to provide additional stretch to tight joints. Typically if the surgeon performed a flexion contracture release during the surgery an extension orthoses is worn all the time and removed for hourly exercise. The variety of orthosis that can be utilized is too vast to cover in this chapter but it is important to have an open mind for orthotic application to facilitate motion gains. Additionally, night orthosis may be used for an extended period of time.

Scar Management:Around 3 weeks post operatively the scar enters the remodeling or maturation phase when cross linking becomes stronger and adhesions can become problematic. Scar remodeling is characterized by the rapid ongoing production of new collagen and the removal of the old collagen. The initial gel-like collagen with its randomly arranged fibrils and low tensile strength is gradually replaced with stronger and more highly

organized collagen. This is when therapeutic intervention can have the greatest benefits and optimize functional outcomes. Pressure to control scars is well accepted and the pressure assists with flattening the scar making the scar suppler. There are numerous techniques and products to assist with scar management to soften the scar. They are too numerous to discuss in this article.

Home Program:With everything it is critical to have a well thought out written and illustrated home program. It is not good enough to verbally instruct the patient. Remember this is all new to the patient and the patient is likely on pain medication and the entire process is overwhelming. Therefore, it is highly advised to provide the patient with a well written easy to follow home program which includes precautions and what to do if a concern arises. Every patient is different and you must consider everything when designing a home program. A typical, initial home program is to instruct AROM and have him/her perform 8 to 15 repetitions hourly; as mentioned previously the patient can perform elevated overhead fist pumping exercises hourly as well. Obviously if you have an overzealous patient or low pain threshold patient you will modify your home program and perhaps you may either decrease the number of repetitions per hour, decrease the number of sessions a day, or both. Home program will also consist of edema control

instructions, orthotic instruction and any other programs you establish for the patient.

Goals:It is expected by week six to begin light strengthening and by week 12 to return the patient to work.

Summary:A tenolysis is a serious decision and patient commitment is vital. The outcome results are mixed but, all in all, if the candidate is good, the surgery will often be successful. If hand therapy is initiated immediately after surgery the chances for functional motion are greatly improved.

References:• Wolfe, Hotchkiss, Pederson, Kozin (eds) Green’s

Operative Hand Surgery 6th ed.• Skirven, Osterman, Fedorczyk, Amadio, (eds)

Rehabilitation of the Hand and Upper Extremity 6th ed. \

Exploring Hand Therapy has two fascinating well presented

digital ebooks; Extensor Tendon Management and

Flexor Tendons Get a Grip.See page 5 for details

Exploring Hand Therapy dba Treatment2go

5

Extensor Tendon Managementhttp://liveconferences.com/product.asp?cid=226

AOTA Approved Provider Course for 1.0 CEUs or NBCOT 12.5 Contact HoursInstructor: George LaCour OTR, CHT Description: Excellent 10 contact hour AOTA (NBCOT) approved digital course with FLASH videos. Extensor tendon injuries are commonly treated by therapists but they are often overlooked in terms of research and education by the flexor tendons. The purpose of this course is to provide a more thorough understanding of the extensor mechanism beginning with a strong basis in anatomy and biomechanics and ending with extensive discussion on treatment. The most successful therapists are the ones who take the time to understand the concept of treatment interventions and not just simply memorize a set protocol. Understanding unlocks the door to success. NOTE you can watch this PDF course and take the exam via your IPAD. You cannot view the FLASH video embedded clips on your IPAD.

Objectives:Identify anatomical structures involved in the extensor mechanism.

Recognize the biomechanical aspects of the extensor tendon system.

Identify the aspects of therapy evaluation following injury.

Identify a basic understanding of surgical technique.

Determine the importance of suture technique, placement, and strength.

Identify the phases of healing following tendon repair.

Differentiate the different protocols used in extensor tendon rehabilitation.

Distinguish treatment according to zone of injury.

Flexor Tendons: Get A Grip on Rehabhttp://liveconferences.com/product.asp?cid=210&ap=226

AOTA Approved Provider Course for 1.0 CEUs or NBCOT 12.5 Contact HoursInstructors: George LaCour OTR, CHT Description: This interactive online digital text course with FLASH movie demonstrations is for every therapist who has searched for a more thorough understanding of flexor tendon injury, surgery, and rehab. Flexor tendon rehab is one of the most complicated and demanding conditions to treat in the upper extremity and it can quickly test the skills of any therapist. It has been said that knowledge is power and in the treatment of flexor tendons this is definitely true. This course will cover topics from anatomy to surgical technique to rehab protocols and will equip therapists with the tools necessary for success in flexor tendon rehab. Instructional method: Video clips, Powerpoint, text format, test your knowledge course labs, discussion forum, and online exam. This is a large course and may take 5 seconds to 120 seconds to load. We recommend high speed internet access to open and navigate this course at its max. benefits/speed. NOTE you can view the course text portion and illustration, and Powerpoint via your IPAD. You can also take the exam via your IPAD. You cannot view the FLASH embedded video clips on your IPAD. NOTE most all other manufactures of other brand idevices do allow flash video on their tablets.Objectives: Identify anatomical structures involved in the flexor mechanism

Identify the biomechanical aspects of the flexor tendon pulley system

Determine the primary aspects of evaluation following injury

Demonstrate a basic understanding of surgical handling technique

Recognize the importance of suture technique, placement, and strength

Identify the phases of healing following tendon repair

Differentiate the different protocols used in flexor tendon rehab

Determine a plan for success in flexor tendon rehab

Exploring Hand Therapy dba Treatment2go

6

Answers on page 10

Test Your EHT Newsletter Knowledge

S I N G L E PAT I E N T U S ER O M T H E R A P Y

SUPERIORDESIGN.

PROVENOUTCOMES.

JAS and JAS ez are trademarks of Bonutti Technologies, Inc. Covered by one or more U.S. patents. Other patents pending. ©2010 Bonutti Technologies, Inc. All rights reserved.Licensed in the State of Illinois.

AVAILABLE FOR COMMERCIAL PURCHASEQualifying dealers, physician and therapy practices – for details on commercial program

and pricing, contact 800-879-0117 or e-mail info@jointactivesystems.com

• Light Weight, Low Profile • Simple to Apply, Easy to Use • Optimal Comfort and Compliance

JAS QUALITY AND PERFORMANCE NOW IN A SINGLE-PATIENT USE DESIGNUNMATCHED SPS SOLUTIONS FOR ROM RECOVERY

KneeFlexion

KneeExtension Toe

Finger

Wrist Pro/Sup

Shoulder Elbow

C

M

Y

CM

MY

CY

CMY

K

1. What is a tenolysis procedure?

2. When should you be thinking about discussing a tenolysis with your patient?

3. True or False: It is recommended to perform a pulley reconstruction at the same time as a tenolysis.

4. Why is a tenolysis chosen?

5. Who is the best candidate for a tenolysis?

6. It is not uncommon for a patient to require a tenolysis to also require additional procedures. Name at least two.

7. What is considered an effective readily available edema control technique?

8. True or False: Pain management is often assisted with a surgically placed catheter.

9. True or False: CPM can give a false sense of improvement following a tenolysis.

10. True or False: Exploring Hand Therapy (EHT) is taking PRE-ORDERS for their popular “PURPLE BOOK” titled “Hand and Upper Extremity Rehabilitation: A Quick Reference Guide & Review” 3rd edition.

11. True or False: In regards to early motion fl exor protocols; most clinicians today use the originally described Duran-Houser Early Passive Mobilization program.

12. Return to work following a tenolysis is expected when?

13. True or False: It is advised to provide a well written home program consisting of illustration for home rehabilitation programs.

14. When does the remodeling phase begin?

Exploring Hand Therapy dba Treatment2go

Surgery and Rehabilitation of the Hand

With Emphasis on the WristAPRIL 6-9, 2013 | One day pediatric pre-course on Friday, April 5, 2013

2013 PHILADELPHIA MEETING

Contact Information:

URL: www.handfoundation.org

Email: hrf@handfoundation.org

Phone: 610-768-5958

Endorsed by: Supported by:

Jefferson Health System

Hand Rehabilitation Foundation

American Association of Hand Surgery POSNA

Sponsored by:

Honored Professors: Pat McKee, M.Sc., OT Reg.(Ont.), OT(C)William W. Walsh, MBA, MHA, OTR/L, CHTGregory I. Bain, FRACS, PhD Elisabet Hagert, MD, PhDJohn D. Lubahn, MD, Alexander Y. Shin, MDScott W. Wolfe, MD

Chairmen:Terri M. Skirven, OTR/L, CHTSusan M. Blackmore, MS, OTR/L, CHTJane M. Fedorczyk, PT, PhD, CHTJenifer M. Haines, MS, OTR/L, CHTA. Lee Osterman, MD

CME Credits Available

28181_HRF_Therapy_ad_Layout 1 9/19/12 3:26 PM Page 1

7

Exploring Hand Therapy dba Treatment2go

8

Hand & UE Rehabilitation: A Quick Reference Guide and Review, 3rd ed

Pre-order Now!& while waiting until

the 3rd ed. is released we will give you

the 2nd ed. online including

2.45 CEUs FREEhttp://liveconferences.com/package.asp?pid=63

3rd editionin progress and

will be available 1st Quarter 2013Pre-order

Now!$199.00

Offer Expires 1/15/2012PURPLE BOOK

New Releases:• Dupuytren’s Disease: Advances and Trends in Treatment

http://liveconferences.com/product.asp?cid=32

• Brachial Plexus: Secrets of Treating TOShttp://liveconferences.com/product.asp?cid=241

• Orthotics: Creative Mobilization splintinghttp://liveconferences.com/product.asp?cid=224

• Orthotics: Creative Immoblization Splintinghttp://liveconferences.com/product.asp?cid=223

• Hand Therapy Boot Camphttp://liveconferences.com/product.asp?cid=228

• Therapeutic Exercises of the Upper Extremityhttp://liveconferences.com/product.asp?cid=227

• Cumulative Trauma Disorders: An Evidence-Based Approachhttp://liveconferences.com/product.asp?cid=229

EHT has another LEARN & EARN opportunity by reading this jam packed

publication!

Earn 1.0 AOTA 1.25 NBCOT PDU contact hour for FREE if you enter PROMO CODE EHTFREE. Read this publication & complete an online exam. Your certifi cate is immediately emailed upon successful completion of the exam. It is that easy.

Register at: http://liveconferences.com/product.asp?cid=245

Course title: tenolysisLearn & Earn Vol. 26

PROMO CODE: EHTFREE

Learn and Earn

Exploring Hand Therapy dba Treatment2goQuick Reference Tid Bits

o

9

Flexor Tendon Protocols Quick ReferenceProtocol Positions Rationale NotesKleinertDorsal Blocking Forearm/Hand Orthosis

Wrist @ 30 -45 degrees flexion: MPJ @ 40 degrees flexion; IPJ varies due to positioned in dynamic flexion traction

Elastic bands attach to fingers and active extension is permitted within confines of orthosis. Motion will promote healing and improve functional outcomes. Wrist and MPJ in slight flexion to protect the repair site. Dynamic tension permits active extension within the splint against tension.

• Wrist and MPJ position may vary such as decrease wrist flexion and increase MPJ flexion.

• At night gently strap the IPJs into extension this will help minimize contractures.

• Many therapists include a palmar guide bar to faciliate DIPJ flexion.

Modified Duran -Early Passive MobilizationDorsal Blocking Forearm/Hand Orthosis

Wrist @ 20 degrees flexion; MPJs @ 40-45 degrees flexion; PIPJ and DIPJ are free

Within the confines of the orthosis passive exercises are permitted to impart tendon glide of the repaired tendons. Passive composite flexion and extension while in splint and active extension only.

• Wrist can be from 20 degrees of extension to 20 degrees of flexion

• No rubber band traction.• Strap IPJs in extension between

exercises and at night.

Early Active MobilizationDorsal Blocking Forearm/Hand Orthosis extending beyond fingers to inhibit use of the hand

Wrist @ 20 degrees flexion; MPJ @ 80 degrees flexion; IPJ allow full extension

Many patient’s using the passive protocols would “cheat” by minimally using the fingers during active motion with favorable results. The early mobilization protocol is based on moving. Repair techniques have greatly improved over the past decades allowing for early mobilization because of stronger repairs and improved sutures (less bulky).

• Multiple alternatives depending on author.

• Active place/hold various among authors but all agree it is a valuable segment of tendon repair rehabilitation.

• Timing to begin hand therapy varies but most agree within 48 hours for best results.

• Recent studies state to begin hand therapy between day 5 to 7 days post flexor tendon repair.

Duran - Early Passive Mobilization

Photo from EHT’s Flexor Tendons: Get a Grip Ebook Course see page 5 for details

Kleinert- Photo from EHT’s Flexor Tendon Get a Grip course instructor George LaCour, OTR/L, CHT

Early Active Mobilization protocol Place/Hold. Photo from EHT’s Flexor Tendon: Get a Grip Ebook Course instructor George LaCour OTR/L, CHT

Exploring Hand Therapy dba Treatment2go

10

Answers to Quiz (from page 6)

Twist & FlipIt’s the latest move in

Precision Sensibility Testing

Order all your hand therapy supplies on-line at:

www.danmicglobal.comDanMic Global, LLC • 2188 Vizcaya Circle • Campbell, CA 95008 • USA • p:408.626.0153 • f:408.628.4731 • www.danmicglobal.com

Rotating sleeve protects precision filament while in closed position

Color-coded sleeves and numbered filament heads

1. Tenolysis strips the tendon of the soft tissue connections and can endanger tendon nutrition. Tenolysis is chosen because hand function is impaired due to lack of active motion.

2. 3 to 9 months; enough time to allow the tendon to heal.

3. False

4. When there is a discrepancy between full passive motion and limited active motion.

5. The best candidate is a patient who has localized adhesions limiting tendon gliding.

6. Capsulectomy, tendon lengthening, pulley reconstruction, skin grafts, capsulectomy

7. Elevation with overhead pumping (active fisting).

8. True

9. True

10. True

11. False. Duran-Houser is antiquated and if using an early passive mobilization protocol many clinicians will use the modified Duran protocol

12. 12 weeks post tenolysis

13. True

14. 3 weeks post injury/repair

Exploring Hand Therapy dba Treatment2go

11

Amazing Limited Time Promotion Ends January 15, 2012 - Order Now and $ave

3rd Edition:“Hand & Upper Extremity Rehabilitation: A Quick Reference Guide and Review” 3rd edition is a question/answer book with referenced explanations. Every chapter in the 3rd edition has new content, revised content, new photos and drawings. Also we added:

5 Amazing New Chapters • Spinal Cord/CNS/Brachial

Plexus• Ergonomics/Return to Work• Psychosocial Aspects of

Impairment• Ligamentous and Muscular

Injury• Edema/Lymphedema and

Vascular Disorders

4 Fantastic Appendixes:• Anatomy Labeling• Vendor Listing• Drugs in Hand Therapy• Practice Exams

Chapters:• Clinical Anatomy • Evaluation • Neuroanatomy/Nerve Injury/

Sensory Reeducation • Physical Agent Modalities • Assorted Treatment

Techniques • Orthotics: Design/

Fabrication/Training • Edema/Lymphedema/

Vascular Disorders • Wounds/Infection/Grafts/

Burns • Fractures/Dislocations/

Subluxations • Ligamentous and Muscular

Injuries • Arthritis and Related

Disorders • CRPS/Fibromyaligia • Tendon Injuries and

Conditions • Complex Traumatic Hand/

Tendon Transfers • Cumulative Trauma

Disorders • Tumors/Cysts/Dupuytrens • Congenital Anomalies/

Amputations/Prosthetics • Sports Injuries • Wrist • Elbow • Shoulder • Spinal Cord/CNS/Brachial

Plexus • Ergonomics/Return to Work • Psychosocial Aspects of

Impairment • Professional Practice

Management

For full description and to Pre-order go to:http://liveconferences.com/package.asp?pid=63

PRE-ORDER the3rd edition forOnly $199.00 Pay now and receive the

2nd edition of the purple book FREE

online and earn 2.45 CEUs

absolutelyFREE

$399.00 value Free with pre-orders.

Anticipate 3rd edition release 1st quarter 2013

Offer Expires 1/15/2013

Purple BookPre-orders

Order now to receive your Free CEUs for the

Purple Book

Hand Therapy Certifi cation Promotional Discount Package

#1 CHT® Prep ProgramThis package includes:

• Basics and Beyond Part 1 Everything you Need to Know; Shoulder to Finger

• Basics and Beyond Part 2 Everything you Need to Know; Shoulder to Finger

• Cervical Spine • Hand Club • Practice Exam (1) • Practice Exam (3) • Practice Exam (5) • Therapy Potpourri

CEUs: 6.0 Contact Hours: 60

Practice ExamsBe Prepared!

http://liveconferences.com/package.asp?pid=17

©©

©

Physical Agent Modalities Occupation Based Thermal and Electrical Agents

The only occupational based modalities course on the market.

View up close lab sessions & lectures

PAM course complies with most state requirements for PAM certifications

Apply 45 contact hours for your CEU requirements (4.5 AOTA CEUs)

Movie course can be viewed on DVD

See up to date modality intervention techniques

CourseThermal and Electrical Agents

Great