Nerve and tendon gliding exercises and the conservative management of carpal tunnel syndrome.

While developments continue in the surgical management of carpal tunnel syndrome, little emphasis has been placed on the evaluation of a comprehensive non-surgical treatment. In this study, 197 patients (240 hands) presenting for treatment of carpal tunnel syndrome were divided into two groups. Patients in both groups were treated by standard conservative methods, and those in one group were also treated with a program of nerve and tendon gliding exercises. Of those who did not perform the nerve and tendon gliding exercises, 71.2% underwent surgery compared with only 43.0% of patients who did perform them. Patients in the experimental group who did not undergo surgery were interviewed at an average follow-up time of 23 months (range, 14-38 months). Of these 53 patients, 47 (89%) responded to this detailed interview. Of the 47 who responded, 70.2% reported good or excellent results, 19.2% remained symptomatic, and 10.6% were non-compliant. Thus, a significant number of patients who would otherwise have undergone surgery for failure of traditional conservative treatment were spared the surgical morbidity of a carpal tunnel release (p = 0.0001).

The Washington Regimen: rehabilitation of the hand following flexor tendon injuries.

This article describes the use of the "Washington Regimen" of early controlled motion in the rehabilitation of flexor tendon injuries of the hand. This regimen is derived from a combination of Kleinert's controlled active extension with rubber-hand passive flexion, Duran's controlled passive techniques, and the modification of the Kleinert orthosis that uses a palmar pulley system. Based on results of clinical investigations, this regimen of early controlled motion appears effective in inhibiting peritendinous scarring, joint contractures, and other complications that commonly occur secondary to flexor tendon repairs. A six-week staged regimen of postoperative rehabilitation is presented. Splint design, exercise regimen, and rationale for treatment are reviewed.

A comparison of results of extensor tendon repair followed by early controlled mobilisation versus static immobilisation.

To compare the functional results of early controlled mobilisation and static immobilisation following repair of extensor tendons, we conducted a comparative study between two centres. In one, a consecutive series of tenorrhaphy patients was treated post-operatively by the dynamic splinting technique. In the other, a consecutive group was treated by static splinting. All patients treated by dynamic splinting were graded excellent within six weeks following surgery; no tendon ruptures occurred and no secondary corrective tendon surgery was required. After static splinting, 40% were graded excellent, 31% good, 29% fair, and none poor; six fingers treated by static splintage subsequently required tenolysis. Following surgical repair of extensor tendons of the hand, patients treated by early controlled motion regain better flexion function in terms of grip strength and pulp-to-palm distance. Dynamic splinting is a more effective technique than static splinting in the prevention of extensor lag.

Controlled motion rehabilitation after flexor tendon repair and grafting. A multi-centre study.

We present a system for treatment by controlled motion after repair of flexor tendons in the hand. This Washington regimen incorporates both controlled active extension against passive flexion by rubber band and the use of controlled passive extension and flexion. We utilise the Brooke Army Hospital modification of the rubber band passive flexion splint; this provides for maximal excursion of the tendon with full passive flexion of the finger. The 66 patients (78 fingers) who form the basis of this study all sustained complete laceration of the flexor profundus and superficialis tendons in "no man's land". Results were evaluated by the Strickland formula of total active motion (TAM) of the proximal and distal interphalangeal joints. Sixty-two fingers (80%) were rated "excellent", 14 fingers (18%) were "good", two fingers (2%) were "fair", none was rated "poor". Our regimen of controlled motion rehabilitation has also been applied with equal success to cases of flexor tendon grafting.

Flexor tendon repair and rehabilitation in zone II open sheath technique versus closed sheath technique.

A comparative prospective study of the surgical management of the tendon sheath after repair of flexor tendons in zone II is reported. The study included only patients with lacerations of both flexor tendons and no other associated injuries. A modified Kessler suture was used to repair the profundus tendon and the superficialis tendon was repaired with a horizontal mattress suture. In 48 fingers the flexor tendon sheath was left open and it was closed in the second group of 42 fingers. When it was impossible to close the tendon sheath, a vein patch was taken from the dorsal veins of the hand. Both groups of patients were treated with the same regimen of controlled motion rehabilitation and supervised by the same hand therapist. Results were evaluated by the Strickland formula for total active motion of the proximal and distal interphalangeal joints. There was no statistical difference between the results of open sheath versus closed sheath in these two groups of patients treated postoperatively with the same controlled motion rehabilitation program.

A combined regimen of controlled motion following flexor tendon repair in "no man's land".

A program of controlled motion following repair of flexor tendons in the hand is presented. This regimen incorporates the features of active extension against rubber band passive flexion, as well as those of controlled passive extension and passive flexion. In this prospective study, 44 digits with complete lacerations of the flexor digitorum profundus and flexor digitorum superficialis in zone 2 were treated. Using the Strickland formula of total active motion of the interphalangeal joints, 36 fingers (82 percent) were rated "excellent"; 7 fingers (16 percent) were rated "good"; 1 finger (2 percent) was rated "fair"; none was rated "poor". There was no statistical difference between the results of delayed primary repair and immediate primary repair.

A dynamic traction splint for the management of extrinsic tendon tightness.

The dynamic traction splint designed by therapists at Walter Reed Army Medical Center is used for the management of extrinsic extensor tendon tightness commonly seen in brachial plexus injuries and traumatic soft tissue injuries of the upper extremity. The two components of the splint allow for simultaneous maximum flexion of the MCP and IP joints. This simple and economical splint provides an additional modality to any occupational therapy service involved in the management of upper extremity disorders.