Tenets of hand therapy

According to the Hand Therapy Certification Committee (www.htcc.org/about/index.cfm), the specialty of hand therapy is defined in the following manner:

In optimal situations, hand therapists work closely with hand surgeons to maximize nonoperative and postoperative outcomes for patients with upper extremity conditions. The purpose of this chapter is to provide the plastic surgeon with an overview of the evaluative and rehabilitative approaches for patients with nerve, tendon, skeletal, and soft-tissue conditions as afforded by collaboration with a hand therapist.

Evaluative guidelines

A comprehensive evaluation provides valuable diagnostic and prognostic information to the plastic surgeon and hand therapist prior to intervention, and serves to inform clinical decision-making for management (nonoperative and postoperative) of patients with upper extremity conditions. In concert with the International Classification of Functioning, Disability and Health,¹ hand therapists are well versed in the clinical assessment of patients in areas of impairment, activity, and participation.

Assessment in the area of impairment and body structures includes edema, wound, vascularity, pain, range of motion, strength, and sensibility. Edema is most commonly assessed with circumferential measurement. However, it is more accurately assessed using volumetric displacement with a reported test–retest reliability within ±3 mL.² Wound assessment is characterized by both descriptive and objective components, including a detailed patient history and observation of wound size, color, drainage, odor, and temperature. Vascularity can be assessed both proximally and distally in the upper extremity using provocation maneuvers. In addition to the Allen’s test for circulation via the radial and ulnar arteries at the wrist, vascularity may be assessed more proximally using Adson’s maneuver at the subclavian artery; the costoclavicular maneuver and hyperabduction test assessed via the radial pulse; and the elevated arm stress test, as described by Roos.^3–5 Pain, certainly a subjective and multifaceted construct, should be assessed before, during, and after therapeutic interventions. Numeric, verbal, and visual analog scales are commonly used to rate pain intensity and have been identified as having good construct validity.⁶ Simple measures which assess only pain intensity may be inadequate to capture and measure the multidimensional aspects of the pain. The McGill Pain Questionnaire and the Short-Form McGill Pain Questionnaire (SF-MPQ) are the most widely used pain questionnaires to assess the multidimensional qualities of the pain experience and overall have been shown to possess good to excellent psychometric properties.^7–11 The SF-MPQ consists of a visual analog scale pain intensity, the present pain intensity index, and 15 pain adjectives (11 sensory, four affective) to calculate the pain-rating index.

Video1,2

Goniometric measurement is used to assess passive and active range of motion. While electrogoniometers and costly systems are available for clinical use, standard manual goniometers are easily portable and inexpensive (video 1). In a recent study, high intrarater reliability was found in multiple techniques to assess wrist range of motion, with a dorsal volar approach demonstrating the highest interrater reliability.¹² Ellis and Bruton found composite finger flexion measurements to be as reliable as manual goniometry between raters, with manual goniometry demonstrating increased intrarater reliability for measurement of the proximal interphalangeal joint.¹³ Manual muscle testing is employed to isolate strength of individual muscles and often graded using the Medical Research Council (MRC) grade 0–5 classification.¹⁴ In a review, Cuthbert and Goodheart reported good evidence to support the use of manual muscle testing for patients with neuromusculoskeletal dysfunction.¹⁵ Sensory impairment is most often assessed using monofilaments for threshold testing (video 2) and/or two-point discrimination for innervation density.^16–22 Using standardized techniques, good validity and reliability have been shown using these types of assessment tools.^{16,17,19,23–25} The Ten Test was introduced as a quick assessment of light touch sensation and has been shown to be a valid measure as compared to monofilament testing.^26,27

Clinical assessment may also include grip and pinch strength testing.^28–31 A calibrated, hand-held dynamometer is used to measure grip strength in a standard position of glenohumeral adduction, elbow flexion, and neutral forearm rotation.²⁹ One trial has been identified as equally reliable to the best or average of three trials and elicits less patient discomfort.²⁸ The influences of hand size and span have also been identified as factors to consider when selecting the grip handle position.^32–34 Calibrated gauges are also used to measure both lateral and tip pinch.

A paradigm shift towards increased incorporation of qualitative and patient-reported data into outcomes assessment is strongly encouraged as a means of assessing participation.³⁵ Clinical evaluation tools, such as range of motion, which assess physical impairments, have demonstrated poor validity and limited responsiveness as compared to patient self-report measures.^36–39 Research has also shown a weak relationship between patient perception of health-related quality of life and ratings from healthcare providers.⁴⁰ Patient perception of ability has been suggested as more valuable than functional evaluations.⁴¹ In addition, patient assessment of the importance of change in health status is preferable to that interpreted by the healthcare professional.⁴² Despite numerous tools and support in the literature, the incorporation of self-report outcome measures is inconsistent in clinical practice.⁴³

The Disabilities of the Arm, Shoulder, and Hand (DASH), one of the most recognized self-report outcome measures for the upper extremity, was published as a joint effort of the American Academy of Orthopedic Surgery and the Institute for Work and Health.⁴⁴ The DASH was created as a tool that would allow comparison of conditions throughout the upper extremity while considering it a single, functional unit.^44,45 Careful development of this tool, including an extensive literature review and consideration of questions and attribution, has made it a popular tool in upper extremity research and clinical practice.

Compression neuropathies

Postoperative care following surgery for compression neuropathies is a balance between protecting the surgical repair site and maintaining neural mobility. To minimize adhesions and scarring, early motion is advocated. However the definition of “early motion” following release of an entrapment site is variable and is determined by the surgical procedure performed and surgeon preference.^46,47 Compared to the historical reports in the literature, the tendency has been to decrease the length of time of immobilization and to use less restrictive postoperative dressings.^25,48 Range-of-motion exercises are instituted and restoration of muscle balance is also a goal of postoperative care.

In the acute postoperative stage, consideration is given to edema control and pain management, and the patient is instructed in strategies to minimize edema and pain. Even in the early stages following surgery, nerve-gliding exercises are instituted with range-of-motion exercises to the distal and proximal joints which are not included in the bulky dressing. These types of exercise will provide some longitudinal movement of the nerve to minimize adhesions.

Nerve repair

Changes in the peripheral and central nervous system begin shortly after injury and continue through recovery. The ultimate functional outcome depends upon reinnervation of the sensory receptors and motor end plates and the appropriate remapping of the motor and sensory cortex. Based upon these proximal changes, rehabilitation is maximized by including strategies directed towards these cortical alterations.

Sensory re-education

Following sensory nerve reconstruction, sensory re-education is commonly included in the rehabilitation program to improve hand sensibility and function. These strategies have been used to maximize sensory recovery and also to decrease pain and for desensitization related to allodynia and/or hyperalgesia.^68–73 Desensitization exercises using different textures and vibration techniques may be used to decrease allodynia and/or hyperalgesia. The concept of vibration for desensitization relates to the gate control theory of pain and stimulation of large A-beta fibers with vibration.⁷⁴ The use of small-amplitude vibration for desensitization is most tolerated by patients and may be obtained by using an electric shaver with the cap on it. This will provide an easy technique for the patient to continue this exercise in a home program. With decreasing sensitivity, the area of allodynia may be challenged with different types of texture to promote sensory re-education and appropriate cortical mapping.

With evidence of reinnervation of the sensory receptors, sensory re-education is advocated.⁶⁹ This typically includes a structured program with an emphasis on textures, localization, and discriminatory tasks.⁶⁹ The exercises are progressed to challenge the sensory system as the patient’s sensation improves, beginning with varying textures, localization exercises, and then discriminatory tasks. However, strategies to enhance and promote cortical remapping have been also advocated in the earlier phases following surgery. Rosen and Lundborg have described re-education programs using mirror imagery, visuotactile training, and audiotactile interaction to enhance the functional reorganization of the sensory cortex in the early phases of recovery before there is evidence of sensory receptor reinnervation.⁷⁵

Mirror visual feedback has been extensively used for treatment in patients following stroke and with amputation injuries and has been more recently reported for use in patients with pain syndromes or nerve injury.^76,77 The concept of mirror visual feedback is that patients observe their reflected image in the mirror, which would appear as the contralateral limb (Fig. 39.1) and thus activate the brain. Patients may perform specific exercises or movements with the unaffected hand or extremity and in the mirror it would appear as normal movement to the affected hand or extremity. With improvement in sensory function or decreased pain, more complex activities may be introduced.

Fig. 39.1 Re-education can be optimized with the use of mirror imagery. This allows the patient to visualize the uninjured hand as the contralateral hand and perform the task.

(Courtesy of Christine B. Novak PT PhD.)

Nerve transfers

Historically, motor nerve transfers were used as a salvage procedure when nerve repair or graft was not possible due to avulsion of the proximal nerve source, and there was limited potential for excellent outcome. However, the utilization of nerve transfers has increased, particularly with proximal nerve injuries, where recovery is limited due to the distance from the injury to target muscle fibers and prolonged time for reinnervation.^82–84 Because a nerve transfer can provide a closer innervation source, the distance and time for reinnervation are shorter and the results following these types of transfer have been very encouraging.^85–93 However, optimal results depend not only on the number of regenerating motor axons and reinnervation of muscle fibers but also on cortical plasticity and remapping. Previously established motor patterns and cortical maps are no longer relevant because a new proximal nerve source is used with a nerve transfer. Studies have evaluated cortical mapping following nerve transfers, muscle transfers, and toe-to-thumb transfers.^{78–80,94–97} Collectively, these studies have illustrated shifts in the motor cortex following transfers and the importance of effective relearning to optimize outcome. Therefore rehabilitation programs should include not only range-of-motion and strengthening exercises to regain muscle balance, but also motor re-education to promote normal movement patterns and cortical mapping.^98,99

With nerve transfers, there is alteration of the proximal nerve source, therefore muscle contraction is initially recruited with “contraction” of the muscle from the donor nerve because of the established motor pattern. The new recruitment pattern from the new proximal nerve source from the donor nerve has yet to be recognized. Even with evidence of muscle reinnervation, the newly innervated muscle may not contract with initiation of the intended action, but rather requires “contraction” of the muscle from the donor nerve. To facilitate relearning, contraction of the muscles on the uninjured contralateral side will provide cortical input of a normal movement. The relearning associated with nerve transfers is similar to relearning following tendon transfers. In general, relearning is more straightforward following a transfer (nerve, muscle, or tendon) when the donor is from a muscle with a synergistic action. While it is possible to relearn an action that is from a muscle with an antagonistic action (such as triceps-to-biceps muscle transfer), the relearning is more difficult compared to a synergistic muscle action.

In patients with brachial plexus avulsion injuries, an intercostal to musculocutaneous nerve transfer is often performed to restore elbow flexion. Postoperative education often includes deep-breathing exercises to provide a stimulus to the intercostal nerves for contraction of the biceps and brachialis muscles, which are innervated via the musculocutaneous nerve. While deep breathing does initiate contraction of the newly innervated elbow flexors, it is difficult to provide a prolonged contraction for re-education and strengthening. The abdominal muscles and intercostal muscles are activated with core abdominal exercises. Therefore core-strengthening exercises will also provide contraction of the biceps and brachialis muscles in patients who have had an intercostal-to-musculocutaneous nerve transfer. The muscle activity in the elbow flexors associated with trunk flexion has been shown by Chalidapong and colleagues.¹⁰⁰ Core exercises which use the abdominal and intercostal muscles may begin early in the rehabilitation stages (Fig. 39.2) and with early reinnervation will recruit the muscle fibers in the brachialis and biceps.

Fig. 39.2 Following an intercostal-to-musculocutaneous nerve transfer, the patient is performing an abdominal crunch to initiate contraction of the intercostal muscles and thus initiate contraction of the biceps and brachialis muscles.

(Courtesy of Susan E. Mackinnon.)

More recent descriptions of nerve transfers to restore elbow flexion have included donor pectoral nerves and fascicles from the median and ulnar nerves.^87,93 To assist with the retraining following these types of nerve transfer, re-education may begin preoperatively with education on the unaffected extremity and contraction of the muscles from the donor nerve and recipient muscle. In this way, the patient may practice co-contraction of these muscle groups to understand better the re-education that will be required with reinnervation of the denervated muscles. For a medial pectoral-to-musculocutaneous nerve transfer, the patient will simultaneously contract the pectoral and the biceps (and brachialis if included) muscles (Fig. 39.3). This is initially done bilaterally and then only to the injured side. Using place-and-hold positioning in 90° of elbow flexion, an isometric contraction is performed. Once the patient is able to hold this contraction against gravity, the degree of flexion may be altered and progressed through a full range of motion. A double fascicular transfer from the median and ulnar nerves to restore elbow flexion will require contraction of the wrist flexors to initiate contraction of the biceps and brachialis muscles (Fig. 39.4).

Fig. 39.3 To facilitate understanding and relearning following a motor nerve transfer, re-education begins with a muscle contraction on the unaffected side. (A) With a medial pectoral-to-musculocutaneous nerve transfer, the patient begins on the unaffected side with contraction of the pectoralis major muscle and (B) then contraction of both the pectoralis major and the biceps muscle. (C) This is followed by simultaneous contraction of the pectoralis major muscle on the affected side, (D) followed by bilateral contraction of these muscles. (E) The contraction is then isolated to the affected side and (F) finally dissociation of the donor muscle from the target muscle.

Fig. 39.4 The relearning associated with a partial ulnar and median nerve transfer from the forearm to the elbow flexors is illustrated. Initially, simple grip-strengthening exercises and/or gentle wrist flexion will initiate contraction of the biceps and brachialis muscles. (A) The patient begins on the unaffected side with a contraction of the forearm flexors and (B) then simultaneously contracts biceps/brachialis muscles and the forearm flexors. (C, D) The next step is bilateral contraction of these muscles and (E) then the exercise is isolated to the affected side. (F) The final exercise is to dissociate contraction of the donor muscle from the target muscle.

To restore innervation to the ulnar nerve intrinsic muscles, an anterior interosseous nerve (AIN) to deep motor branch of the ulnar nerve transfer may be performed.⁸⁸ With an AIN to deep motor branch of the ulnar nerve transfer, attempts by the patient to pinch must be combined with forearm pronation to recruit the newly innervated intrinsic muscles from the AIN proximal source (Fig. 39.5). With motor retraining, cortical remapping, and relearned motor patterns, the patient will be able to complete the ulnar motor nerve actions independent of the action of forearm pronation.

Fig. 39.5 With an anterior interosseus nerve to deep motor branch of the ulnar nerve transfer, forearm pronation is combined with pinching to recruit the innervated intrinsic muscles and facilitate relearning.

(Courtesy of Christine B. Novak PT PhD.)

As outlined previously in this chapter, the evidence in the literature does not support the efficacy of direct current electrical stimulation with denervated muscles. With evidence of muscle reinnervation, some have advocated the use of electrical muscle stimulation using an alternating current to increase the force of the muscle contraction and thereby increase muscle strength. Theoretically with an innervated muscle, it is possible to use an alternating current to elicit a muscle contraction. However, with a reinnervated muscle, there may be scarcity of reinnervated fibers to produce the intended muscle contraction via electrical stimulation. Passive muscle contraction will not assist in the relearning of motor patterns. Therefore it is our recommendation that these types of modality should not be considered as the primary treatment but may be used as an adjunct to therapy as a “sensory stimulus” for relearning if necessary.

Functional relearning may be facilitated with visual or auditory feedback which can provide immediate response to the patient regarding the muscle contraction. Simple biofeedback units with external surface electrodes may be used to facilitate muscle contraction or to minimize aberrant co-contraction of an antagonistic muscle action. Using a two-channel or four-channel biofeedback unit, the electrodes may be placed on the appropriate muscles to increase or decrease muscle contraction. To facilitate relearning, the action should be performed on the unaffected side first to allow the patient to understand better the strategies necessary to enhance or minimize the intended action. It is also useful to perform these actions simultaneously with the affected and unaffected extremity. This will provide immediate feedback on the “normal” contraction and motor pattern and provide the opportunity for the patient to reproduce the action in the newly reinnervated muscles. With adequate muscle reinnervation, the patient will receive feedback by observing and “feeling” the muscle contraction. Specific exercises to promote muscle contraction without a specific biofeedback unit will allow the patient to perform the exercises more frequently as a home program.

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