Orthotic interventions for restoring proximal interphalangeal joint motion for patients with hand injuries or conditions: A systematic review and meta-analysis.

BACKGROUND: Limitations to proximal interphalangeal joint (PIPJ) motion can result in significant functional impairment for people with hand injuries and conditions. The role of orthotic intervention to improve PIPJ motion has been studied; however, high-quality systematic reviews and meta-analyses are lacking. PURPOSE: This study aimed to determine the effectiveness of orthotic intervention for restoring PIPJ extension/flexion following hand injuries or conditions. STUDY DESIGN: Systematic review. METHODS: A comprehensive literature search was completed in MEDLINE, CINAHL, Embase, Cochrane Central, and PEDro using terms related to orthoses, finger PIPJ range of motion, and randomized controlled trial design. Methodological quality was assessed using the PEDro score, study outcomes were pooled wherever possible using random effects meta-analysis, and certainty of evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation. RESULTS: Twelve trials were included (PEDro score: 4-7/10). The addition of orthotic intervention was not more effective than hand therapy alone following Dupuytren's release for improving total active extension (mean difference [MD] -2.8°, 95% confidence interval [CI]: -9.6° to 4.0°, p = 0.84), total active flexion (MD -5.8°, 95% CI: -12.7° to 1.2°, p = 0.70), Disability of the Arm, Shoulder and Hand scores (MD 0.4, 95% CI: -2.7 to 3.6, p = 0.79), or patient satisfaction (standardized MD 0.20, 95% CI: -0.49 to 0.09, p = 0.17). Orthotic intervention was more effective than hand therapy alone for improving PIPJ extension for fixed flexion deformities following traumatic finger injury or surgery (MD -16.7°, 95% CI: -20.1° to -13.3°, p < 0.001). No studies evaluated orthotic intervention to improve PIPJ flexion. CONCLUSION: The addition of an extension orthosis following procedures to manage Dupuytren's contracture is no better than hand therapy alone for improving PIPJ extension. In contrast, the addition of a PIPJ extension orthosis in the presence of traumatic PIPJ fixed flexion deformities is more effective for improving PIPJ extension than hand therapy alone. Future studies are needed to evaluate the role of orthotic intervention for improving PIPJ flexion.

Orthotic intervention options to non-surgically manage adult and pediatric trigger finger: A systematic review.

BACKGROUND: The design and efficacy of orthotic intervention to non-surgically manage adult and pediatric trigger finger vary widely. PURPOSE: To identify types of orthoses (including relative motion), effectiveness, and outcome measurements used to non-surgically manage adult and pediatric trigger finger. STUDY DESIGN: Systematic review. METHODS: The study was undertaken according to The Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 Statement and registered with the International Prospective Register of Systematic Reviews Registry, number CRD42022322515. Two independent authors electronically and manually searched, and screened 4 databases; selected articles following pre-set eligibility criteria; assessed the quality of the evidence using the Structured Effectiveness for Quality Evaluation of Study; and extracted the data. RESULTS: Of the 11 articles included, 2 involved pediatric trigger finger and 9 adult trigger finger. Orthoses for pediatric trigger finger positioned finger(s), hand, and/or wrist of children in neutral extension. In adults, a single joint was immobilized by the orthosis, blocking either the metacarpophalangeal joint or the proximal or distal interphalangeal joint. All studies reported positive results with statistically significant improvements and medium to large effect size to almost every outcome measure, including the Number of Triggering Events in Ten Active Fist 1.37, Frequency of Triggering from 2.07 to 2.54, Quick Disabilities of the Arm, Shoulder and Hand Outcome Measure from 0.46 to 1.88, Visual Analogue Pain Scale from 0.92 to 2.00, and Numeric Rating Pain Scale from 0.49 to 1.31. Severity tools and patient-rated outcome measures were used with the validity and reliability of some unknown. CONCLUSIONS: Orthoses are effective for non-surgical management of pediatric and adult trigger finger using various orthotic options. Although used in practice, evidence for the use of relative motion orthosis is absent. High-quality studies based on sound research questions and design using reliable and valid outcome measures are needed.

Implementing an internal audit to change practice: Current evidence and review of patient outcomes enabled transition to the relative motion extension approach in the postoperative management of zones IV-VI extensor tendon repairs.

BACKGROUND: Evidence supports use of the relative motion extension (RME) approach following extensor tendon repairs in zones V-VI yielding good or excellent outcomes. PURPOSE: To demonstrate how a 3-year internal audit and regular review of emerging evidence guided our change in practice from our longstanding use of the Norwich Regimen to the RME approach using implementation research methods. We compared the outcomes of both approaches prior to the formal adoption of the RME approach. STUDY DESIGN: Prospective clinical audit. METHODS: A prospective audit of all consecutive adult finger extensor tendon repairs in zones IV-VII rehabilitated in our tertiary public health hand centre was undertaken between November 2014 and December 2017. Each audit year, outcomes were reviewed regarding the Norwich regimen and the RME early active motion approaches. As new evidence emerged, adjustments were made to our audit protocol for the RME approach. Discharge measurements of the range of motion of the affected and contralateral fingers and complications were recorded. RESULTS: During the 3-year audit, data was available on 79 patients (56 RME group including 59 fingers with 71 tendon repairs; 23 Norwich group including 28 fingers with 34 tendon repairs) with simple (n = 68) and complex (n = 11) finger extensor tendon zones IV-VI repairs (no zone VII presented during this time). Over time, the practice pattern shifted from the Norwich Regimen approach to the RME approach (and with the use of the RME plus [n = 33] and RME only [n = 23] approaches utilized). All approaches yielded similar good to excellent outcomes per total active motion and Miller's classification, with no tendon ruptures or need for secondary surgery. CONCLUSIONS: An internal audit of practice provided the necessary information regarding implementation to support a shift in hand therapy practice and to gain therapist or surgeon confidence in adopting the RME approach as another option for the rehabilitation of zone IV-VI finger extensor tendon repairs.

"Around the global hand table": Hand surgeon and therapist perspectives on overcoming barriers to relative motion orthotic intervention in the management of zones V-VI finger extensor tendon repairs.

INTRODUCTION: An international survey of therapists cited 2 barriers (physician preference and departmental policy) to the implementation of a relative motion extension (RME) orthosis/early active motion (EAM) approach. STUDY DESIGN: e-survey PURPOSE: To glean insight from hand surgeons and hand therapists regarding their awareness and experiences in implementing or not implementing an RME orthosis/EAM approach for management of finger zones V-VI extensor tendon repairs. METHODS: Two e-surveys, one to hand surgeons and the other to hand therapists were distributed. Participants were asked 8-open ended questions with the opportunity for additional comment. RESULTS: Nine of 11 surgeons and 10 of 11 therapists (clinicians/educators/administrators) who were surveyed, participated. All respondents from 7 countries were aware of the RME/EAM approach, with only 1 surgeon and 2 therapists not implementing. Surgeons once aware, quickly implement; therapists in this survey implemented about 2.5 years after learning of the approach. Surgeon use was influenced more by their peers than the evidence while therapist knowledge came from professional meetings. Therapists teaching at university-level and continuing education integrate the approach. DISCUSSION: Although the RME orthosis/EAM approach has been around for 4 decades, awareness for the hand surgeons and therapists surveyed has only been over the past 20 years. Surveyed surgeons like to visualize how the RME concept works and therapists depend more on the evidence. To overcome barriers to RME/EAM implementation, several strategies are outlined. CONCLUSION: Although a small survey, valuable comments provide insight for addressing the previously cited barriers. Strategies for increasing awareness and fostering implementation of an RME orthosis/EAM approach are offered by international hand surgeons and therapists surveyed regarding the commonly cited barriers of surgeon preference and department procedures.

The use of exercise relative motion orthoses to improve proximal interphalangeal joint motion: A survey of Australian hand therapy practice.

STUDY DESIGN: Cross-sectional online survey. INTRODUCTION: Exercise relative motion (RM) orthoses are prescribed by hand therapists to improve finger motion but there is limited scientific evidence to guide practice. PURPOSE OF THE STUDY: To describe Australian hand therapists' use of exercise RM orthoses to improve PIPJ motion, including trends in orthosis design, prescription, clinical conditions, and their opinions on orthosis benefits and limitations. METHODS: 870 Australian Hand Therapy Association members were sent an electronic survey that included multiple choice, Likert scale and open-ended questions under four subgroups: demographics, design trends, prescription, and therapist opinions. Data analysis consisted of predominantly descriptive statistics and verbatim transcription. RESULTS: 108 Australian therapists completed the survey, over a third with ≥ 20 years of clinical experience. Exercise RM orthoses were prescribed weekly to monthly (82%) for between 2-6 weeks duration (81%) and used during exercise and function (87%). The most common differential MCPJ position was 11-30° extension (98%) or flexion (92%). Four-finger designs were most common for border digits (OR ≥3.4). Exercise RM orthoses were more commonly used for active and extension deficits compared to passive (OR ≥3.7) and flexion deficits (OR ≥1.4), respectively. Clinicians agreed that the orthosis allowed functional hand use (94%), increased non-intentional exercise (98%), and was challenging to use with fluctuating oedema (60%). DISCUSSION: This survey highlights notable clinical trends despite only reaching a small sample of Australian hand therapists. Exercise RM orthoses were frequently being used for active PIPJ extension and flexion deficits. A common MCPJ differential angle was reported, while the number of fingers incorporated into the design depended on the digit involved. Therapists' preferences mostly agreed with the limited available evidence. CONCLUSION(S): This limited survey identified common exercise RM orthosis fabrication and prescription trends amongst Australian therapists. These insights may inform future biomechanical and clinical research on this underexplored topic.

Systematic review: Zone IV extensor tendon early active mobilization programs.

STUDY DESIGN: Systematic review INTRODUCTION: Early active mobilization (EAM) of tendon repairs is preferred to immobilization or passive mobilization. Several EAM approaches are available to therapists; however, the most efficacious for use after zone IV extensor tendon repairs has not been established. PURPOSE OF THE STUDY: To determine if an optimal EAM approach can be identified for use after zone IV extensor tendon repairs based on current available evidence. METHODS: Database searching was undertaken on May 25, 2022 using MEDLINE, Embase, and Emcare with further citation searching of published systematic/scoping reviews and searching of the Australian New Zealand Clinical Trials Registry, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials. Studies involving adults with repaired finger zone IV extensor tendons, managed with an EAM program, were included. Critical appraisal using the Structured Effectiveness Quality Evaluation Scale was performed. RESULTS: Eleven studies were included, two were of moderate methodological quality, and the remainder was low. Two studies reported results specific to zone IV repairs. Most studies utilized relative motion extension (RME) programs; two utilized a Norwich program, and two other programs were described. High proportions of "good" and "excellent" range of motion (ROM) outcomes were reported. There were no tendon ruptures in the RME or Norwich programs; small numbers of ruptures were reported in other programs. CONCLUSIONS: The included studies reported minimal data on outcomes specific to zone IV extensor tendon repairs. Most studies reported on the outcomes for RME programs which appeared to provide good ROM outcomes with low levels of complications. The evidence obtained in this review was insufficient to determine the optimal EAM program after zone IV extensor tendon repair. It is recommended that future research focus specifically on outcomes of zone IV extensor tendon repairs. LEVEL OF EVIDENCE: I.

Photovoice to explore the patient experience of a relative motion orthosis following a hand injury.

BACKGROUND: Little is known about the patient experience of relative motion (RM) orthoses, or how they impact hand use and participation in occupational roles. PURPOSE: To explore the use of Photovoice methodology in hand-injured patients and the patient experience of wearing a RM orthosis. STUDY DESIGN: Photovoice methodology, Qualitative Participatory research, feasibility study METHODS: Purposive sampling was used to identify adult patients prescribed a RM orthosis as part of their therapy intervention for an acute hand injury. Over a 2-week period and using their personal camera device participants captured their experience of wearing a RM orthosis and its impact on their daily life. Participants shared 15-20 photos with the researchers. At a face-to-face semi-structured interview, 5 key photographs were selected by the participants with context and meaning explored. Interview data was transcribed, captions and context of images confirmed by member checking, and thematic analysis completed. RESULTS: Protocol fidelity was observed using our planned Photovoice methodology. Three participants (aged 22-46 years) shared 42 photos and completed individual interviews. All participants reported their involvement as a positive experience. Six themes were identified: adherence, orthosis factors, expectations and comparisons, impact on daily activities, emotions, and relationships. RM orthoses allowed freedom of movement enabling participation in a range of occupations. Challenges included water-based activities, computer use and kitchen tasks. Participants expectation of orthotic wear and recovery appeared to contribute to their overall experience, with RM orthoses viewed favourably when compared to other orthoses and immobilization methods. CONCLUSIONS: Photovoice methodology was a positive process for participant reflection and a larger study is recommended. Wearing a RM orthosis enabled functional hand use as well as providing challenges completing everyday activities. Participants had different demands, experiences, expectations, and emotions associated with wearing a RM orthosis, reinforcing the need for clinicians to take a client-centred approach.

Comparison of two relative motion extension approaches (RME with versus without an additional overnight orthosis) following zones V-VI extensor tendon repairs: A randomized equivalence trial.

STUDY DESIGN: Multi--center randomized controlled trial with two intervention parallel groups. An equivalence trial. INTRODUCTION: Relative motion extension (RME) orthoses are widely used in the postoperative management of finger extensor tendon repairs in zones V-VI. Variability in orthotic additions to the RME only (without a wrist orthosis) approach has not been verified in clinical studies. PURPOSE OF THE STUDY: To examine if two RME only approaches (with or without an additional overnight wrist-hand-finger orthosis) yields clinically similar outcomes. METHODS: Thirty-two adult (>18 years) participants (25 males, 7 females) were randomized to one of two intervention groups receiving either 1) a relative motion extension orthosis for day wear and an overnight wrist-hand-finger orthosis ('RME Day' group), or 2) a relative motion extension orthosis to be worn continuously ('RME 24-Hr' group); both groups for a period of four postoperative weeks. RESULTS: Using a series of linear mixed models we found no differences between the intervention groups for the primary (ROM including TAM, TAM as a percentage of the contralateral side [%TAM], and Millers Criteria) and secondary outcome measures of grip strength, QuickDASH and PRWHE scores. The models did identify several covariates that are correlated with outcome measures. The covariate 'Age' influenced TAM (P = .006) and %TAM (P = .007), with increasing age correlating with less TAM and recovery of TAM compared to the contralateral digit. 'Sex' and 'Contralateral TAM' are also significant covariates for some outcomes. DISCUSSION: With similar outcomes between both intervention groups, the decision to include an additional night orthosis should be individually tailored for patients rather than protocol-based. As the covariates of 'Age' and 'Sex' influenced outcomes, these should be considered in clinical practice. CONCLUSIONS: A relative motion extension only approach with or without an additional overnight wrist-hand-finger orthosis yielded clinically similar results whilst allowing early functional hand use, without tendon rupture.

Exploring the patient experience of telehealth hand therapy services during the COVID-19 pandemic.

STUDY DESIGN: Electronic Survey. INTRODUCTION: Internationally the COVID-19 pandemic has resulted in an unprecedented shift from face-to-face therapy to telehealth services. PURPOSE OF THE STUDY: This paper explores the patient experience and satisfaction with telehealth hand therapy in a metropolitan setting during a period (March 1 to May 31, 2021) of 'moderate' COVID-19 risk when there was minimal community transmission of COVID-19. METHODS: Patients attending telehealth services were invited to participate in an English language online survey at the conclusion of their therapy session via a pop-up invitation. RESULTS: During the recruitment period there were 123 survey responses (29% response rate; 98% completion rate). Half of the respondents (n = 78, 53%) reported saving between 10 and 29 minutes of travel time (each way) by attending a telehealth appointment, while 36% (n = 44) saved more than 30 minutes (each way). Almost all respondents (n = 117, 95%) noted telehealth should be used in the future. The main benefit for telehealth was more easily fitting appointments around other commitments, followed by reducing stress and costs surrounding hospital attendance. Most participants (n = 97, 79%) reported no challenges using telehealth. The most cited challenges included the therapist not being able to provide hands on treatment (n = 14, 11%) and for seven respondents getting the technology to work (6%). DISCUSSION: The elevated level of participant satisfaction of attending telehealth sessions informs us that this mode of therapy delivery could benefit patients in a post-pandemic environment. CONCLUSIONS: Metropolitan funding models prior to the pandemic did not allow for this mode of therapy and hence consideration for an ongoing hybrid funding model of both face-to-face and telehealth should be considered by policy makers, insurance and government funding bodies.

Postoperative hand therapy management of zones V and VI extensor tendon repairs of the fingers: An international inquiry of current practice.

STUDY DESIGN: Electronic Web-based survey. INTRODUCTION: Evidence supports early motion over immobilization for postoperative extensor tendon repair management. Various early motion programs and orthoses are used, with no single approach recognized as superior. It remains unknown if and how early motion is used by hand therapists worldwide. PURPOSE OF THE STUDY: The purpose of this study was to determine if there is a preferred approach and identify practice patterns for constituents of International Federation of Societies for Hand Therapy full-member countries. METHODS: Participation in this English-language survey required respondents to have postoperatively managed at least one extensor tendon repair within the previous year. Approaches surveyed included programs of immobilization, early passive (EPM), and early active (EAM) with motion delivered by resting hand, dynamic, palmar/interphalangeal joints (IPJs) free, or relative motion extension (RME) orthoses. Survey flow depended on the respondent's answer to their "most used" approach in the previous year. RESULTS: There were 992 individual responses from 28 International Federation of Societies for Hand Therapy member countries including 887 eligible responses with an 81% completion rate. The order of most used program was EAM (83%), EPM (8%), and immobilization (7%). The two most used orthoses for delivery of EAM were RME (43%) and palmar/IPJs free (25%). The RME orthosis was preferred for earlier recovery of hand function and motion. Barriers to therapists wanting to use the RME/EAM approach related to preference of surgeon (70%) and clinic (24%). DISCUSSION: In practice, many therapists select from multiple approaches to manage zone V and VI extensor tendon repairs. Therapists believed TAM achieved with the RME/EAM approach was superior to the other approaches. Contrary to the literature, in practice, many therapists modify forearm-based palmar/IPJs free orthosis to exclude the wrist to manage this diagnosis. CONCLUSIONS: The RME/EAM approach was identified as the favored approach. Practice patterns and evidence did not always align.

Relative motion extension management of zones V and VI extensor tendon repairs: Does international practice align with the current evidence?

STUDY DESIGN: Electronic Web-based survey. INTRODUCTION: Therapists participating in an international survey selected relative motion extension (RME) as the "most used" approach for the postoperative management of zones V and VI extensor tendon repairs. A subgroup of respondents identified RME as their preferred approach and were asked about their routine RME practices. PURPOSE OF THE STUDY: The purpose of this study was to capture data from routine RME users about their practices and compare this with the RME evidence. METHODS: An English-language survey was distributed to 36 International Federation of Societies for Hand Therapy full-member countries. Participation required therapists to have postsurgically managed at least one extensor tendon repair within the previous year. Those who selected RME as their "most used" approach were asked to identify which variation of the RME approach they favored: RME plus (with wrist orthosis), RME only, or "both" RME plus and RME only, and then were directed to additional questions related to their choice. RESULTS: Respondents from 28 International Federation of Societies for Hand Therapy full-member countries completed the survey. RME users (N = 368; 41.5% of sample) contributed to this secondary data. Respondents favored the RME variation "RME plus" (47%), followed by "both" (44%), then "RME only" (9%) with most managing single digit/simple injuries (n = 287, 81%) versus multiple digit/complex injuries (n = 96, 27%), and partial repairs (n = 278, 79%). DISCUSSION: Practices not aligning with limited level II-IV evidence includes half of RME only users not adding/substituting an overnight orthosis; use of RME plus versus RME only for both repairs of independent extensor tendons and repairs proximal to the juncturae tendinum; fabrication of three not four-finger orthotic design; and restricting use to only repairs of one or two fingers. CONCLUSIONS: RME plus and RME only are used interchangeably depending on surgeon preferences and patient/tendon factors. Compared with RME plus, from this survey, it appears that the RME only approach yields similar uncomplicated, early return of motion and hand function.

Postoperative management of zones V-VI extensor tendon repairs: A survey of practice in Malaysia and comparison to IFSHT member countries.

Introduction: A survey of International Federation of Societies for Hand Therapy (IFSHT) member countries identified relative motion extension as the preferred approach to management of zones V-VI extensor tendon repairs. The aims of this survey were to identify and compare hand therapy practice patterns in Malaysia (a non-IFSHT member country) with findings of the IFSHT survey including an IFSHT subset of Asia-Pacific therapists and to investigate if membership status of the Malaysian Society for Hand Therapists (MSHT) influenced therapy practice patterns. Methods: An online English-language survey was distributed to 90 occupational therapists and physiotherapists including MSHT members and non-members. Participation required management of at least one extensor tendon repair in the preceding year. Five approaches were surveyed: immobilisation, early passive motion (EPM) with dynamic splinting, and early active motion (EAM) delivered by resting hand (RH), palmar resting interphalangeal joints free (PR), and relative motion extension (RME) splints. Results: Thirty-seven of the 53 therapists (68%) who commenced the survey completed it. The most used approach was dynamic/EPM (28%), followed by RH/immobilisation (22%) and RH/EAM (22%). A preference for RME/EAM was identified with implementation barriers being surgeon preference and hand therapist confidence. Discussion: Approach selection for Malaysian therapists differed from the combined IFSHT and Asia-Pacific respondents, with the former using dynamic/EPM and RH/immobilisation compared to IFSHT respondents who predominately used RME/EAM and PR/EAM. This survey provides valuable insights into Malaysian hand therapists' practices. If implementation barriers and therapist confidence are addressed, Malaysian practice patterns may change to better align with current evidence.

Two case reports-Use of relative motion orthoses to manage extensor tendon zones III and IV and sagittal band injuries in adjacent fingers.

STUDY DESIGN: Case report. INTRODUCTION: Injuries to adjacent fingers with differing extensor tendon (ET) zones and/or sagittal band pose a challenge to therapists as no treatment guidelines exist. PURPOSE OF THE STUDY: This report highlights how the relative motion flexion/extension (RMF/RME) concepts were combined into one orthosis to manage a zone IV ET repair (RME) and a zone III central slip repair (RMF) in adjacent fingers (Case 1); and how a single RME orthosis was adapted to limit proximal interphalangeal joint motion to manage multi-level ET zone III-IV injuries and a sagittal band repair in adjacent fingers (case 2). METHODS: Adapted relative motion orthoses allowed early active motion and graded exercises based on clinical reasoning and evidence. Outcomes were standard TAM% and Miller's criteria. RESULTS: 'Excellent' and 'good' outcomes were achieved by twelve weeks post surgery. Both cases returned to unrestricted work at 6 and 7 weeks. Neither reported functional deficits at discharge. DISCUSSION: Outcomes in 2 cases involving multiple digit injuries exceeded those previously reported for ET zone III-IV repairs. CONCLUSIONS: Relative motion orthoses can be adapted and applied to multi-finger injuries, eliminating the need for multiple, bulky or functionally-limiting orthoses. LEVEL OF EVIDENCE: 4.

Relative motion orthoses in the management of various hand conditions: A scoping review.

STUDY DESIGN: Scoping review. INTRODUCTION: The relative motion (RM) concept and immediate controlled active motion (ICAM) program, originally applied after zones IV-VII extensor tendon repairs, have been modified and extended to a variety of hand conditions, such as sagittal band injury, boutonniere deformity, and extensor lag. PURPOSE OF THE STUDY: To scope the published and unpublished literature to review ICAM modifications, hand conditions for which the RM concept is used, and describe the preferred degree of relative metacarpophalangeal joint extension/flexion reported and spectrum of orthosis design. METHODS: Electronic and manual searches of scientific and gray literature and expert consultation were conducted. Documents with quantitative data were assessed with Oxford Levels of Evidence and the Structured Effectiveness Quality Evaluation Scale. RESULTS: Fifteen references met the inclusion criteria; 1 was level III evidence, and others were level IV evidence. RM-ICAM modifications, preferred degree of relative extension/flexion, orthotic design, management of other hand conditions and knowledge gaps were identified. CONCLUSION: RM orthoses may improve outcomes in a variety of hand conditions; however, high-quality studies that contribute to the evidence base for its use are needed. LEVEL OF EVIDENCE: Not applicable.