When Nancy Chee, OTR/L, CHT, began working as a hand therapist 22 years ago, patients who’d had digits replanted, or reattached, were made to wait several weeks and often more than a month to begin the lengthy course of therapy necessary to regain function in their severed fingers or thumbs. Today, it’s common for patients to start hand therapy days after their reattachments, said Chee, senior hand therapist in the hand therapy department at California Pacific Medical Center in San Francisco.
"Where you might have a finger put on years ago, because you didn’t want to disturb it, you kept it still. But now, with surgery being much improved, you can start movement much earlier," Chee said. "If a finger is replaced, we can start moving the wrist in a safe position and unaffected fingers in safe positions — to start eliminating the stiffness that comes with immobilization — as soon as the patient is off the blood thinners."
Positioning of the replanted digit often begins between seven and 10 days after surgery. When it comes to coaxing a digit to regain function — a process that can take anywhere from three months to a year — the phrase "use it or lose it" has merit, said David Spear, MS, OTR/L, CHT, clinical coordinator for Loyola University Medical Center outpatient clinic in Burr Ridge, Ill.
"You can cast a joint that doesn't have any problems, and by three weeks it’s starting to stiffen up — and that’s something without any trauma," Spear said. "So if you add in trauma and scarring, ligaments get tighter and tighter and regaining that motion is more difficult. As long as you’re not putting too much stress on the wound and it’s not opening, it’s beneficial to train the skin or other soft tissue that it needs to be long and flexible, to not be stagnant, in order to move.
"The more you can do to prevent contracture and heavy scarring, including tendon adhesions, that means you’re going to have fewer surgeries in the future. It’s very common for a surgeon to have to go back and do some sort of release, and if you can minimize that then they don’t have to go through another surgery. So you’re saving a lot of pain in that respect, as well as time and money."
Surgical advancements
More sophisticated screws, plates, sutures, connectors and optics allow for more precision and quicker healing, said Randy Bindra, MD, FRCS, professor in the department of hand surgery and director of the hand surgery fellowship program at Loyola University Medical Center in Chicago. "We have operating microscopes with better optics, foot controls with automatic zoom and focusing, swiveling arms and television monitors so other people in the room can see what I’m doing and be more involved," he said
Bone repair has been enhanced by smaller implements. For instance, some screws now measure only 1.1 millimeters in diameter, Bindra said.
Improved suturing technology, including swaged needles and thinner needles, has augmented tendon and blood vessel repair. And implementing tiny tubes, or conduits, allows better reconnection of severed nerves. "We can place the nerve into the conduit where it will grow though the tube, so we don’t have to bend the finger and stretch the nerve through it," Bindra said.
The combination of better surgical technology and earlier interventions has resulted in higher replantation success rates. In Chee’s clinic — which treats about one of these patients each week — between 90% and 95% graduate with regained function.
Quantifying success is difficult because every patient defines success differently, said Jennifer Durham, OTR/L, CHT, clinical coordinator at the Hayes Hand Center in Chattanooga, Tenn. "If they can use [the replanted digit] as an assist to get back to their daily routines as much as possible, when they can reenter their lives, that’s what we consider successful," Durham said. "Most of our patients achieve this type of success, but they have to have realistic expectations of what they’re going to do when they graduate."
Therapeutic innovations
Alternative therapeutic interventions play an important role in successes. "Our profession continues to grow along with the new surgical processes," said Kim Esposito, OTR/L, CHT, resource clinician at Loyola University Medical Center’s Outpatient Clinic in Burr Ridge, Ill. OTs continue to use modalities such as ultrasound, electrical stimulation and neuromuscular education to prepare patients for increased activity.
At Burr Ridge, where replantation clients typically injure themselves using snowblowers or hand saws, tissue expanders are employed to prevent skin from overly contracting and inhibiting movement. "They are a plastic film type of thing that is placed into the tissue," Esposito said. "The skin closes around the expander, so when you take the expander out, there’s a space there."
Spear said new procedures in casting allow therapists to immobilize patients in certain positions that stretch the skin. And new splinting materials, which are taking the place of thermoplastics, have properties that allow for better conformity and stability to help stretch joints or improve web spaces between digits.
At the Hayes Hand Center, Durham employs neurological methods that trick the reattached part into performing. "Neuromuscular electric stimulation, or NMES, bypasses the brain and goes straight to the muscle by telling the muscle to jump," she said. "It helps patients focus on the muscles and feel what it feels like for that muscle to move."
Another of Durham’s devices encourages movement through neurological restructuring. Mirror box therapy works by obscuring the injured hand behind a mirror and placing the uninjured hand in front of a mirror and then manipulating the uninjured hand.
"You’ll have them do something simple with the uninjured hand, like grasp and release, and many times behind the mirror, without them realizing it, they are mimicking that small motion," she said. "It amazes me that the technique would work, except it’s working with the brain — it’s something the brain can wrap around and then make [the hand] function."
(Source: todayinot.com)
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