Volume 6, Issue 2 www.exploringhandtherapy.com July 2006

From The Editors Desk In This Issue Hot summer days... we have some great EARN program. You can receive FREE Featured Article...... 1 What’s Hot...... 16 new releases to cool you off, check them CEU’s for reading this magazine. See In The Spotlight...... 3 Splinting Tips...... 16 out on page 8. details on page 14. See you online. In The Web ...... 6 Ask The Expert...... 17 If your are studying for Certification in Newly released courses...... 8 Test Answers...... 21 Hand Therapy, don’t miss the Hand EHT’s magazine is for informational Therapy Certification Package purposes only and is not intended to be a Political Corner...... 10 Ergo Tips and Tricks...... 23 Discount PROMO. This package is substitute for professional medical advice, LEARN & EARN...... 14 Modalities...... 24 designed to help you study for the big day. diagnosis or treatment. Always consult Check out details on page 8. with your supervisor before implementing POP Quiz...... 14 EHT’s hand club is designed for ideas. networking, sharing, and learning Thank you to our sponsors for making this Hand while having fun. All of your posts are ng Th magazine possible. Please click on their ri e o r answered. You can even post photos for ll a

ad (if viewing online) to learn more. pp

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those perplexing cases and the club will xx y

E E help you out. So don’t hesitate join today. ENJOY! w w m o w c . e T ® . See page 6 for details. x re o y p atm 2 G a p l o r ent e r i n g h a n d t h We had great response to our LEARN & Susan Weiss Nancy Falkenstein OTR, CHT OTR, CHT, CEES Featured Article By Debby Schwartz, OTR/L, CHT Tendon Transfer introducing donor muscles to take Now we will review each Rehabilitation: over the actions of the non-working of the fundamentals. Strategies for Success muscles. They help to enhance function. Positive outcomes require 1. Pre-operative Therapy Working with tendon transfer careful planning, preparation, and therapist creativity to facilitate patients can be a challenging The role of the hand therapist these donor muscles into action. yet an extremely rewarding doesn’t necessarily begin after experience. These are patients surgery. As part of a team who through trauma, a disease The following ten important approach, the hand therapist process, paralysis, or maybe a fundamentals will help to clarify contributes significantly to the congenital abnormality have lost the tendon transfer process, and preoperative care and treatment some vital component of upper guide you in establishing strategies of tendon transfer patients as well. extremity functioning. When for success with your patients. Perhaps you already know the speaking of the need for tendon 1. Pre-operative Therapy patient and have reached a plateau transfers, we are really speaking 2. Patient Education and in functional recovery after trauma, Conditioning of imbalance in the hand. The leaving your patient with significant 3. Patient History muscles that are no longer deficits. In anticipation of further 4. Protocol functioning have left their antagonist 5. Donors surgery, scar adhesions, edema muscles unchecked. And this 6. Splinting and soft tissue must be addressed can lead to additional problems 7. Functional goal setting and minimized. Joint contractures of contractures and deformity. 8. Activities or limits in passive range of motion The process of tendon transfers 9. Facilitation techniques can be treated with stretching and offers a rebalancing of the hand by 10. Strengthening continued on page 3

  splinting. You can help your patient (and patient’s family if working with there a traumatic event, multiple anticipate the benefits of the tendon a child) must understand what surgical procedures and/ or therapy transfer surgery by the use of can be accomplished with tendon visits before tendon transfer surgery splints that replicate the action of transfer surgery and what cannot was offered? Was this a deficit the transfer. For example, a wide be accomplished. The concept from birth that had never been thumb abduction cone helps the of a normal hand is simply not an addressed before? A paralysis patient realize the significance of option. However, significant and of one peripheral nerve, or a thumb abduction for better grasp important functional improvements disease process that progressively of objects. Better still, maybe you can become a reality if the patient worsened? It is helpful to note have been working on strengthening is up for the task and recognizes where previous scars formed, how muscles in advance of their use as his role. He must understand why the soft tissue feels in the extremity, donor muscles. All of these pre- a period of immobilization follows and the condition of the joints before operative interventions enhance the surgery, and what to expect when and after surgery. The success of tendon transfer surgery! active range of motion is initiated. patient’s tolerance for He should also have a sense of pain, ability to cope, 2. Patient Education how much therapy is anticipated, level of patience and when he will be seen by the and understanding The patient must have a solid surgeon in follow up visits. are also assessed. understand of the entire process This helps the and timing of surgery and 3. Patient History therapist develop rehabilitation. The therapist is best an appropriate and qualified for this role as patient The therapist in turn should have individual plan of educator especially if a patient- an equally solid understanding of intervention. therapist relationship has already what the patient has been through Continued on page 5 been established. The patient prior to arriving in the clinic. Was

In the SPOTLIGHT! Laurie Roundtree, OTR/L, CHT

owned by our belated friend Ann England, On the reverse side, I love mallet one of the pioneers in hand therapy injuries, because they are so simple and predictable, and my results are Q: How long have you been doing hand therapy? nearly always excellent. The keys are patient education, skin care, and capable splinting. A: Fresh out of school in 1980 I began Q: What do you find is the most working for two Hand Surgeons. At that challenging diagnosis you treat? time there weren’t many hand therapists around. I learned a lot about surgeries and A: What I find most challenging equates Q: Where did you receive anatomy, and the importance of attending with another of my favorite diagnoses: your OT degree from? surgeons’ conferences periodically. complex crush injuries with multiple-system trauma that keep you constantly on your A: I graduated from Tufts Q: What is your favorite diagnosis and why? toes and necessitate problem-solving on University in Boston in 1980 a daily basis. If there are open wounds, Q: What type of setting A: MP arthroplasties are a lot of fun to me. I particularly enjoy the utilization of light do you work in? There’s nothing like the magic of a patient therapy (cold laser) and advanced wound seeing their hand normally aligned after dressings to accellerate the healing. A: I co-own a private practice in Thousand- years of deformity. I love the precision Q: What areas of hand and upper Oaks, California, with my best friend splinting involved, and enjoy fabricating Heidi Bowers-Dutra (Yes, it’s possible extremity rehab. do you want custom neoprene supports for the later to expand your expertise in? to be a business partner with your best phase. (I haven’t seen a commercial anti- Continued on page 6 friend!). The practice was originally ulnar-deviation splint that I like yet.)



4

tape…and then I think of all the tion.

gram in Oakland, CA. realize what they can do with this person with a little extra instruc-

Samuel Merritt College’s Hand Therapy pro-

therapist's satisfaction when they new therapist, and even the lay

Tracey is currently an Adjunct Instructor for

level in Rheumatology and Hand Therapy. with the tape is seeing another is friendly to the new user, the

the US including guest lectures at the University

than seeing my patient's improve Because of it's flexibility, the tape

in Canada and the US, taught seminars across

Tracey has presented at 6 national conferences The only thing more satisfying respond to the skill of the user.

been an educator and a program developer.

toire for many years to come. practice and has the flexibility to

1993. Throughout her career, she has always

Hand Center in Kentfield, CA since March, remain in my therapeutic reper- This is a tool that responds to

She has been a Hand Therapist at Kentfield

invention of Tex tape. It will or in palpating for a problem.

opening The Arthritis Center in San Mateo, CA.

ogy. She then moved to California to join in I couldn't be more grateful for the there is in myofascial techniques

3 years in general orthopaedics, and rheumatol-

there is art in the fingertips as

the University of Calgary (Foothills) Hospital for

University of Alberta in Canada. She worked at rehabilitation. There is clearly a science, but

of Science in Occupational Therapy at the

Tex tape at some point in their

Bachelor of Arts in Gerontology and a Bachelor

Tracey Airth-Edblom, OTR, CHT received a from at least one application of that particular layer of tissue.

than this, they could all benefit your tape application to affect

Though I choose more judiciously are taping, and how you intend

patients that stroll into our clinic. clear in your own mind what you

could easily apply to 99% of the know your anatomy, and to be

Tex tape is the one tool that I of the tissue. It helps, a lot, to

as well as the most versatile. knowledge as well as the depth

most powerful therapeutic tools that incorporates your depth of

I still find Tex tape is one of the there is a certain artistry to taping

grateful patients they will treat. Here it is several years later and injury differently. I've learned

 July Newsletter-jdc.qxp 6/23/2005 11:39 AM Page 4 4. Protocol on the surgeon’s preferences. Pronator Teres can become a wrist And it is always helpful to know extensor following radial nerve palsy Tendon transfer rehabilitation follows when the surgeon will be seeing because the Pronator Quadratus still a specific timetable of phases: the patient again in follow up. So is intact for pronation of the forearm. • Phase 1: Immobilization, be aware of dates and anticipate • Phase 2: Mobilization, and the next step in the process. • Phase 3: Strengthening. 5. Donor Muscles This holds true regardless of which muscles have been transferred. The The donor muscles are intact therapist must always be aware of muscles that have not been affected specific dates. The date of surgery by paralysis or trauma. The surgeon is crucial because from it the timing selects the donor muscles based of the rehabilitation process is on their excursion and direction of (Figure 1) Testing of FDS to the Ring finger derived. Immobilization usually pull. Here, too, the therapist can lasts 3 ½ - 4 weeks from the date of offer assistance preoperatively by 6. Splinting surgery. Active range of motion is performing accurate manual muscle typically initiated at that time. As the testing (figure 1). This ensures that At 3 ½ to 4 weeks after surgery patient progress with active motion the possible donor muscles are the post operative dressings are and functional tasks, more resistive indeed intact. Harvesting a donor removed. A thermoplastic splint exercises can be introduced. muscle for a new function should not is now fabricated protecting the This occurs at 8- 12 weeks after lead to additional loss of function. sutured tendons in a position that surgery. Splint wear to protect the Secondary muscles with similar eliminates tension on the repair transferred muscles continues for functions to the donor muscles site. Similar to protecting tendon about 6 weeks, depending of course are left intact. For example, the continued on page 12

 In the Spotlight (continued)

A: Learning more about various taping methods for the upper extremity, Q: Do you have an area of clinical expertise such as athletic taping and other ‘typically PT’ techniques, would be that you can share with us such as a tip or great. This would benefit not only my student and adult athletes, trick that we can try in our clinical practice? but workers who wear gloves (dental hygienists, nurses) or who A: Basal joint arthritis of the thumb is often an under-treated diagnosis. otherwise can’t wear splints or wraps. I’m a fan of Kinesiotape, but It can be absolutely debilitating, yet many therapists stop at giving it doesn’t meet all needs. I’d also like to expand my skills in tissue an uncomfortable splint and a few tips on joint protection. I urge mobilization and am considering taking the Graston Technique course. everyone to refine your splint skills in this area: be creative, try new patterns, wear the splint for half a day. One splint tip is to use a piece Q: What accomplishments would you like to of neoplush at the dorsal aspect of the first metacarpal in a splint such share with the hand therapy community? as Judy Colditz’s. It is easily held with 2 thin strips of hook Velcro, is A: I’m very proud of our practice, Hand Rehabilitation Specialists, and durable, and can be removed for cleaning. Be ready to give a thumb the 5 CHT’s and PT that comprise our staff. The spica if a short opponens is unsuccessful. Offer a soft splint such recent completion of our website was another as the Comfort-Cool as an alternative support as pain decreases. I achievement: www.hand-specialists.com. even make a separate night splint, hand-based and volar, to hold the I was also excited about a recent non-traditional thumb in slight radial abduction (reduces pain of shortened thenar consultation job: spending a day on set as a muscles and worn areas of cartilage). Go over joint protection in “technical advisor” to Jim Carrey for an upcoming detail and have lots of sample adaptive devices. Why do we take movie called The Number 23. More about that in the next newsletter… tennis elbow or deQuervain’s more seriously than CMC OA? We have the best skill set to address this increasing problem, and the Q: What do you do for fun when you are not busy in your hand clinic? aging community can benefit greatly from programs in our clinics.

A: I get a massage. A nice, long, deep one. Thanks Laurie, We can’t wait to hear more about Number 23.

In The WEB The FIRST and ONLY CLUB dedicated to the These two Hand Therapy Community sites have good articles YOUR EXCLUSIVE MEMBERSHIP IS featuring tendon JAM PACKED WITH BENEFITS! transfers with some diagrams, JOIN TODAY schematics and photos: • http://www.emedicine.com/ plastic/topic356.htm • http://www.emedicine.com/ MEMBERSHIP INCLUDES all this and MORE... orthoped/topic637.htm

• Free DVD or CD-ROM course with Membership This shows a nice review of how • Club member discounts an opponensplasty is performed: • http://www.eatonhand.com/ • Interactive Discussion Board img/IMG00095.htm • Case studies presented for open discussion • Q & A on the discussion boards Wheeless has some good articles on tendon transfers • Live Chat and is a good site to browse: • 20 page magazine mailed to your home quarterly • http://www.wheelessonline. • Network with other therapists com/ortho/tendon_transfers_for_ low_median_nerve_lesions • Prepare for the hand exam by networking and MORE. • http://www.wheelessonline.com/ ortho/low_ulnar_nerve_injury

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 Newly Released CEU Courses! Hand Therapy Certification biomechanics and kinematics Neurodynamics of Package Discount PROMO of these complex structures. the Upper Extremity Splinting, stretching, exercises, Evaluation and Treatment This package includes, treatment activities, and modalities Strategies : It’s Not Basics and Beyond, 3 online are presented in great detail. Just About The Hand practice exams, two bonus DVD movie courses (A Royal Fractures of the Upper Learn ways to evaluate proximal Pain in the Thumb and Lateral Extremity: I’ve Fallen problems that may result in distal Epicondylitis- You Have and I Can’t Get Up symptoms. These evaluation Control) and membership strategies will help determine in our popular hand club! This is the most comprehensive if the symptoms are distal or fracture course you will ever if there is a complex of upper Intrinsics: Unravel take. Learn therapeutic and quadrant problems such as: the Mystery surgical intervention neck, shoulder, postural or of fractures from scapular dysfunction. This This course is in movie format and the shoulder, elbow, course will describe the neural is designed to teach the clinician forearm, wrist and continuum as well as special to effectively identify, and treat hand. You don’t tests to determine what nerve intrinsic problems. It is a mixed want to miss this structure is involved. Emphasis level learning course. A thorough comprehensive movie course. will be placed on understanding anatomy session is completed to and performing upper extremity ensure the understanding of the neurodynamic testing.

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Political Corner Update on Quality person qualified in trimming, Update on Competitive Standards for Suppliers: bending, modeling, assembling, Bidding: or customizing (orthotics) and is As of May/June 2006 CMS governered by a national board. On May 23, 2006 EHT joined has not completed their Quality At present the draft mentioned the CMS Competitive Bidding Standards for Suppliers review. the expert as being certified by open phone forum. CMS is We were informed that over the Am. Board of Certification planning on launching the 5,000 physicians, therapists, in Orthotics and Prosthetics. program by January 2007. patients, and others responded AOTA/HTCC/APTA/ASHT are Competitive bidding will follow to this very important issue. not mentioned as a governoring the Quality Standards for CMS is still reviewing the board in the draft. Obviously, our Suppliers recommendations comments and has not made concern is to get the language when determining who is a a decision. EHT will keep you to include OTs and PTs. qualified splint fabricator. The posted on this critical issue. rest of the proposal is dealing Thank you for all who flooded with DME providers and all the The splint issue in a nutshell: CMS with concerns. Our new regulations. EHT will keep CMS is identifying what discipline voice was hopefully heard. you posted on this as well. is considered an expert for fabricating and dispensing To learn more about these issues, visit the Center for Medicare and Medicaid orthotics/splints. An expert is Services (CMS) at: www.cms.gov defined (according to Quality Standard for Suppliers) as a

10 Naabox

11 lacerations, the splint immobilizes 7. Functional goal setting and older patients as well. Our the donor muscles with their new clinic now utilizes many different insertions. Initially the splint is worn The therapist plays a key role children’s toys and games in our full time except when performing in helping the patient define functional activities (figure 3). You exercises. Gradually the splint subjective functional goals for will be surprised when you realize can be taken off to perform active the surgery. The Canadian the various grip and holding range of motion exercises and then activities of daily living as well. Occupational Performance patterns required for playing Measure (COPM) is an excellent cards, memory games, building Here are some examples of the way to determine outcome blocks and more. Progress protected positions following measures as it looks at patient the therapeutic intervention tendon transfers for: performance, satisfaction, and along to work simulation tasks, • Radial nerve palsy: wrist and performance in areas of self (fig. 4) even without heavy MP blocking splint with the care, productivity, and leisure. weights or resistance, in order wrist positioned in 30º of wrist Filling out the COPM with your to gain familiarity with the active extension, the MP’s in 0 to 10º patient allows you insight as to range of motion required. of flexion (fig 2). The thumb what is important to your patient, is supported in full extension and clues you in on meaningful if included in the surgery. activities. You, in turn, can (Figure 3) The elbow may be splinted introduce these activities later Holding playing in 90ºof flexion to protect the as part of your therapeutic cards with origin of the donor muscles. intervention. Another alternative wrist extended following • Opponensplasty to restore evaluation form is the Patient transfers for thumb opposition and extension Rated Wrist Evaluation (PRWE) radial nerve or abduction: The wrist is which subjectively rates both palsy. positioned in slight flexion and pain and function on a scale the thumb in wide abduction. of 1- 10. The functional tasks listed can help to elicit more Wrist position depends upon (Figure 4) Work donor muscle selection information from your patient simulation task of and routing of transfer. regarding activities of daily pipette pick up for living and work tasks in which pharmaceutical • Ulnar nerve palsy transfer to technician following decrease clawing and aid in he seeks to gain competency. tendon transfer MP flexion: Similar to dorsal surgery for radial blocking splint following flexor 8. Activities nerve palsy. tendon repair, wrist in 30º flexion, MP’s flexed around Knowing what is important 9. Facilitation techniques 60º and IP’s extended. and meaningful to your patient helps you plan the appropriate Facilitation refers to the process activities to keep him focused and of getting the donor muscle to involved in therapy. It shows that contract with its new insertion, you value him as a person and thereby performing the desired want to create an individualized function. Sometimes this occurs and tailored therapy program easily for the patient, especially just for him. Always begin with if he was able to isolate and simple activities of daily living contract the donor muscle prior and encourage incorporation of to surgery. But for most patients, (Figure 2) Splint following tendon facilitation requires concentration transfers for radial nerve palsy these tasks into the daily routine. Introduce leisure activities and and patience. Initially, simple make therapy fun for younger Continued on page 13 12 place and hold exercises (figure Practice this maneuver to action, holding objects in the 5) are usually performed for reinforce the connection. desired position and giving short periods. For example, resistance to the donor muscles. following tendon transfers for wrist extension, place the (Figure 5) 10. Strengthening Place and patient’s wrist in an extended hold wrist position, and have him hold it for extension Strengthening is initiated only ten seconds initially. The donor after the patient can readily muscles fatigue rapidly! Aim contract the donor muscle for short sessions of facilitation and move the specific joints and fewer repetitions of good easily. The patient must be strong contractions. The patient able to perform good steady builds up endurance gradually (Figure 6) contractions without rapid fatigue for repeated exercises. Activate Forearm before resistance is added. the donor muscle in its previous pronation Try to eliminate compensatory function along with its new with wrist movement patterns as they extension. function. For example, following interfere with the transferred transfer of Pronator Teres muscles’ actions. Promote to ECRL for wrist extension, normal grasp and release have the patient pronate their Other facilitation techniques patterns of function as much forearm while simultaneously include using visual and verbal as possible. Passive range of extending their wrist (fig. 6). cues to perform the desired continued on page 15 5)&
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13 LEARN and EARN EHT has a FREE gift for our Valued Readers!

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Test Your Knowledge... POP Quiz! 1. What is the goal of 7. True or tendon transfers? False: It is 2. The surgeon selects the not always donor muscles based on essential what principles? to regain 3. According full wrist flexion after to Debby tendon transfers for Schwartz, wrist extension. what two tools 8. List the three phases does she recommend in of tendon transfer helping the patient define rehabilitation. subjective functional 9. True/False: The patient goals for the surgery? must have a solid 4. Facilitation techniques understanding of the entire refer to what? process and timing of 5. List some facilitation surgery and rehabilitation. techniques Debby 10. Name four of the discusses in this article. ten tendon transfer 6. When should strengthening fundamentals. be initiated? Answers on page 21

14 motion exercises can be Deborah A. Schwartz has been an Ms. Schwartz currently works at introduced at this time, but only if Occupational Therapist for 21 years, a private hand center in Marlton, necessary for specific activities. For specializing in hand therapy for 18 New Jersey. She is very committed example, it is not always essential years. Her specialty is working with to international hand therapy tendon transfer patients. In 2004, she topics and has recently joined the to regain full wrist flexion after presented two talks on Tendon Transfer ASHT’s international committee. tendon transfers for wrist extension. Rehabilitation at the International Federation of Societies of Hand Working with patients after tendon Therapy conference in Edinburgh, transfer surgery requires your Scotland. She has also presented innovative input! Here is where you on this topic at the Philadelphia Hand utilize your background knowledge Meeting and at the ASHT meeting in of anatomy and kinesiology, and Charlotte, NC in 2005. Her article, mix in your activity analysis and “Tendon Transfers for Enhanced Wrist Extension: A Case Report” was creativity to construct appropriate recently published in the British Journal and meaningful therapeutic of Hand Therapy. Ms. Schwartz sessions. Patients begin to see is the 2004 recipient of the Evelyn progress gradually so it is essential Mackin Traveling Hand Therapist to stay positive and focused. Award. She traveled to Norway and Tendon transfers really do succeed Great Britain where she visited hand to enhance function. It is important therapy clinics and presented on to realize that you are an essential tendon transfers and hand therapy EHT wants to part of the process! Enjoy the in America. An article about her thank Debby for challenge and take pride in your experiences will be published in an her inspiring and upcoming Journal of Hand Therapy. role as an active participant! informative article.

15 What’s Hot... Do you treat OA or RA? Do you treat burns Looking for a table to or wounds? treat your hand patients? If you want a splint that looks great and is durable try, Then check out the PSI Burn Look no further. The new HT2 DigiSplint. Used regularly, Glove. This glove provides an hand therapy table is the ideal Digisplints can delay or stop effective and protective cover solution for a variety of therapy the progression of degenerative for your burn patients. The PSI environments. This table is or inflammatory arthritis and Burn Glove is a great time saving durable, versatile, and easy to other pathologies affecting technique for dressing changes. maneuver. The high density musculotendinous imbalance. It allows for the patient to perform polyethylene top is virtually You can also add lateral supports vital range of motion to encourage indestructible, easy to clean, and pressure plates. Visit and restore functional hand use. It and can quickly and easily be has an effective barrier to liquids adjusted to any height between DigiSplint at www.digisplint.ca & micro-organisms. Water vapor 21 ½” to 32 ½”. To learn more can pass for exudating wounds. visit www.HandTherapyTable.com

Contact Mike Deutsch for more or call Terry information: [email protected] Sanderson at 360-424- 1129 ext. 14

Splinting Tips and Tricks from Nancy Falkenstein TIP: I have found prefabricated intrinsic tightness -- fabricate your patient’s arm and secure it outriggers save me time. They an MPJ extension block splint in the “flared” area of the splint. simplify fabrication of custom in slight hyper-extension, This creates a nice lining for fit dynamic hand splints while allowing full IPJ flexion. This a potentially troubled area. allowing me to implement my will allow for the intrinsicis to knowledge and creativity. stretch while performing active TIP: For ease of adjusting gliding. You will love the results tension on dynamic splints, I and so will your patients. recommend using a slip knot. The slip knot allows the patient and therapist to adjust the tension Intrinsic and length of the traction in splint for one easy step. This eliminates home having to re-thread, readjust TIP: I like to use the dynasplint program tension/dynamic line, or re-knot. MPJ extension splint to regain extension of multiple Visit the site listed to learn how to tie a slip knot: http://www. digits following Dupuytren’s indoorclimbing.com/Slip_Knot.html release. It is comfortable for TRICK: When splinting over the patient and effective. bony prominences, apply a piece of padding to the bony area TIP: See photo for a nice before molding. When splint is home splint when battling hard, remove the padding from

16 Ask The Expert.... Debby Schwartz Q: Are all tendon transfers • Transfers for radial nerve in stages? Please share immobilized between 3-4 palsy after humeral fractures. an example or two. weeks or are some mobilized These transfers include sooner or later? If so, which ones are mobilized muscles for powering wrist A: There are cases where sooner or later and why? extension (usually Pronator reconstructive surgery will be done in teres (PT) to Extensor carpi stages. This is demonstrated in the radialis longus (ECRL) and care of patients with tetraplegia. After A: The majority of tendon transfers Extensor carpi radialis brevis are immobilized for 3-4 weeks, spinal cord injuries, these patients are (ECRB); muscles for finger often left with multiple deficits in upper allowing for the healing of the repair extension (Flexor carpi ulnaris site and surrounding tissues. Although extremity function. Yet upon evaluation, (FCU) to Extensor digitorum certain muscle can be transferred tendon transfer surgical sites are communis (EDC); and muscles well planned and strong repairs, this without causing additional functional to restore thumb extension deficits as other muscles remain intact. immobilization period is essential as the (Palmaris longus (PL) to repair gradually decreases in strength Extensor pollicis longus (EPL). An example of this would be a young and is most vulnerable at about two male spinal cord patient who lacked weeks afterwards. It is important elbow extension and pinch ability Q: When is it prime time for to protect the transfers throughout the surgeon to perform a due to his injury at C6-C7. First, this phase. Always check with the tendon transfer after nerve the Biceps to Triceps transfer was surgeon regarding the quality of the injury? In other words, how used to power elbow extension. A tendons utilized and the strength of many months post injury is a year later, the Brachioradialis (BR) the repair. Each surgeon will have transfer usually performed? muscle was transferred into the specific protocols based on the Flexor pollicis longus (FPL) for tendons used and the patient involved. A: After a nerve injury, an appropriate active pinch. The reason for the amount of time is allocated for nerve delay was simply scheduling around Q: What are the most common repair, healing of the surrounding school and summer vacations. tendon transfers you see tissues and possible nerve Children with Cerebral palsy might in your clinical practice? regeneration. During this time, also face the possibility of multiple positional splinting is used to replace reconstructive surgeries. Tendon A: The most common tendon transfers the function of the denervated muscles. transfers are often used to power I see in my clinic are the following: Joint mobility is maintained to prevent enhanced wrist extension via FCU contractures. If contractures develop (Flexor Carpi ulnaris) and ECU • Opponensplasty: Flexor from lack of appropriate splinting, Extensor carpi ulnaris (ECU) transfers digitorum superficialis (FDS) these must be addressed prior to to ECRL and ECRB. Later, additional of the ring finger or the surgical intervention to restore muscle surgeries might be performed to Palmaris Longus (PL) tendon power. So it is impossible to state overcome elbow flexion posturing, and/ is transferred to Abductor before hand when tendon transfers or extensor thumb adductor posturing. pollicis brevis (APB) to restore will be performed. Many aspects The staging allows for adequate opposition. This is often need to be taken into consideration. healing and retraining of muscles, and seen with advanced cases It is safe to say that most surgeons time for the patient to return to their of carpal tunnel syndrome. would wait about four to six months normal routine before the next phase. • Extensor indicis (EIP) to before exploring the possibility of Extensor pollicis longus (EPL): additional reconstructive surgery. This transfer is indicated with Q: When a patient has ruptures of EPL that occur a complicated multiple with rheumatoid arthritis or nerve injury, does the surgeon perform transfers following wrist fractures. Continued on page 18

17 Q: Do you see opponensplasties of the IP joints) is treated by several Median nerve palsy results in the routinely performed with different tendon transfers. The Stiles- “ape hand” deformity where the carpal tunnel releases? Bunnel Procedure uses the FDS thumb loses its ability to oppose. As tendon to the ring finger (and often a mentioned above, common muscles A: Opponensplasties are often second finger as well). Slips of the FDS for opponensplasty are the palmaris performed with carpal tunnel tendon are attached to radial incisions longus tendon or FDS to the ring finger. on each digit to either the lateral band surgery when warranted by atrophy Common tendon transfers for Radial or the lateral aspect of the proximal of the thenar muscles and loss of nerve palsy were previously mentioned. phalanx. The hand is immobilized opposition and function. I would not say they are done routinely as with the MCP joints in flexion while more and more patients are seeking the transferred tendons heal. Q: Do you use biofeedback after tendon transfers? earlier surgical relief of their carpal Another method is called the Brand And if yes, when? tunnel symptoms, hopefully before Procedure. Here, the ECRL tendon significant muscle atrophy occurs. with a graft from the Palmaris longus is routed either through muscle or dorsally, A: Biofeedback can be very helpful after tendon transfers when the Q: What tendons are most divided into four slips and inserted commonly used for transfers into the radial lateral band of the long, patient is having trouble isolating for claw hand, ape hand and ring and small digits and the ulnar a specific muscle. The electrodes other commonly seen palsies? lateral band of the index, pulling the provide auditory and/ or visual input signaling correct or incorrect muscle A: Ulnar nerve palsy can result in the proximal phalanges into MCP flexion. activity. I know that the pediatric “claw hand” deformity. The resultant intrinsic plus position (lack of active Continued on page 20 flexion of the MCP joint and extension

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19 population enjoys the challenge of the surgical scars are adherent or biofeedback. However, often the particularly sensitive and tender. These g Hand T surface electrodes used are large and modalities are easily tolerated and allow in h not specific enough to pick up single for tissue healing, increased circulation, r e o r muscle contractions. Theoretically, and increased pain tolerance, prior ll a

biofeedback could be used as soon to active motion and activities. pp pp

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as muscle retraining begins. However, E it is important for the patient to Q: Do you have any good w experience some degree of success w m references for those o w c so as not to get easily frustrated. I . e T ® . interested in learning more x re o y p atm 2 G a p would use biofeedback with caution about tendon transfers that l o r ent e r i n g h a n d t h in the early stages of retraining. you can recommend?

Q: Do you use neuromuscular electrical stimulation A: The following are excellent after tendon transfers? resources regarding tendon transfers: And if yes, when? Exploring Hand Therapy • Amini D, Jacobs N, Arras N, (EHT) wants to thank Debby A: I have found neuromuscular et al. Treatment Guidelines for her excellent expert input. electrical stimulation (NMES) to be for Tendon Transfers. particularly helpful in the strengthening American Society of Hand EHT welcomes any and all phase. The patient can now isolate Therapists. 2002. articles. If you are interested the muscle easily, but fatigue sets in • Hunter JM, Mackin EJ, Callahan in sharing your skills, quickly. NMES allows for increased AD, Skirven TM, Schneider LH, knowledge, tips and tricks repetitions, provides a timing sequence Osterman AL. Rehabilitation of EHT wants to hear from of contractions and is easily tolerated. I the hand and upper extremity. you. Please submit your typically do not include NMES until six Fifth edition. Mosby: St. article to Susan Weiss at: weeks after surgery, although some Louis; 2002: 779-879. [email protected] clinics might incorporate it earlier. • Cannon NM. et al. Diagnosis and treatment manual for Please include your name, physicians and therapists. Third discipline, credentials, edition. The Hand Rehabilitation and your submission Center of Indiana. 2001. title for a newsletter I would also like to add my recently article. Thank you. published article on tendon transfers with Cerebral palsy to the list!

• Schwartz DA. Strategies for Q: Do you use any modalities facilitation of tendon transfers after tendon transfers? And if yes, when? for enhanced wrist extension in cerebral palsy: A case report British Journal of Hand Therapy. A: When mobilization begins after 2005; (10) No. 1: 10-16. 3-4 weeks, I add heat modalities such as heat packs, warm soaks and/ or This month’s featured expert... fluidotherapy prior to beginning active exercises. I also add ultrasound if

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Test Your Knowledge Answers We Need You 1. To rebalance the muscles and hold exercises and Want to work in our booth at 2. The muscle excursion A/AA ROM exercises the ASHT meeting in Atlanta and its direction of pull 6. After the patient can Georgia? We have a spot open 3. The Canadian Occupational readily contract the donor for an energetic dynamic worker. Performance Measure muscle and move the (COPM) & Patient Rated specific joints easily Wrist Evaluation (PRWE) 7. True 4. The process of getting the 8. Phase 1: Immobilization donor muscle to contract Phase 2: Mobilization with its new insertion, Phase 3: Strengthening thereby performing the 9. True desired function 10. The 10 fundamentals: 5. Facilitation techniques • Pre-operative Therapy • Patient Education and Conditioning The meeting is September include using visual and • Patient History 14th - 16th 2006. verbal cues to perform • Protocol the desired action, holding • Donors • Splinting To receive more information objects in the desired • Functional goal setting about this great opportunity position and giving • Activities please send resume to resistance to the donor • Facilitation techniques • Strengthening Susan Weiss at: muscles as well as place [email protected]

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22 Ergo Tips and Tricks It’s Not Just Sitting! neck flexion, compensation of • Seat pan not the proper size upper body, & increased stress on causing feet to dangle We all know that office ergonomics muscles, ligaments, & tendons. is a critical area and is becoming an We want to put the support more Solutions to typical area of expertise. In fact, therapists at the ischial tuberosity to balance chair problems: who are experts in seating and the pelvic muscle groups allowing • Easily adjustable seat height ergonomic workplace design are the body to be positioned over the with pneumatic pedestal base working as industrial consultants ischial tuberosity (like in horseback allowing one hand adjustments for seating considerations. In riding) and not behind the seat • Easily adjustable backrest this issue, we are going to look at base. There are many variations to support the lower spine some of the specifics of seating of lumbar supports, wedges and vertically (height) and horizontally and how it effects the worker. back slings. You must know the (forward & backward) duties of the worker, chair functions, • Independent seat forward We know from research that disc and general sitting habits of the & backward tilt pressure is increased when sitting employee to accurately recommend • Waterfall (curved) seat pan edge vs. standing. From radiographs a lower back support. Also, there • Proper seat pan depth to we know when sitting the pelvis are specially designed chairs to help accommodate the buttocks rotates backward and the lumbar alleviate the mentioned problems • Adjustable armrests ensure spine flattens which may cause by having built in support and they are small & low enough disc herniation. And we know that meeting specific specifications. to fit under the work surface disc pressure is greatest when & support the back sitting and slouching are combined. Legs: • Seat cushion is appropriate for So our job is to promote correct employee’s build and comfort sitting posture and comfort for A chair that is too high or a seat pan • Employee training is critical to the employee while increasing too deep can cause compression ensure familiarity with the features productivity and reducing risk of the sciatic nerve and increase and adjustment of the chair of injury. WOW! That can be a leg and foot swelling. If the chair challenge. Although there are is too high this promotes forward So looking at a few of the many ways to accomplishing leaning and increases stress on many facets of seating you can this, including: psychosocial, the back & soft tissues. One easy appreciate that proper sitting administrative support, and the way to fix this problem is to adjust is a complex area of the work office equipment itself. We are only the seat height so the feet are firm station. It is not just sitting but going to touch on some aspects of on the floor or footrest. Ensure proper sitting that is critical to the office worker’s sitting posture. there is 1 inch or a fist between the promote comfort, productivity edge of the seat and the back of the and reduce the risk of injury. We know that the “proper axial knees. Encourage the employee relation between the thorax and the to take frequent movement breaks Like all areas of expertise it takes pelvis must be restored by bringing to avoid lower body swelling. on-the-job training combined with the upper trunk over the hips”. (Jacobs knowledge and skill to perfect 223) One common area of concern Typical problems with chairs: your style. For more information is the universal use of a standard • Backrest not easily adjusted on this topic read: Ergonomics for lumbar support. When the worker’s • Hard to turn knobs Therapists, 2nd ed by Karen Jacobs, job requires close table top, bench • Awkward body postures Butterworth & Heinemann 1999. work, or writing tasks, the lumbar required to adjust the seat support positioned at the seat base • Armrests that are too wide, will increase the distance from too low or too high the employee to the work surface • Backrest not used and worker sits promoting poor posture, such as: forward unsupported on the seat

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