exploring hand therapy - liveconferences.comexploring hand therapy dba treatment2go …“i have...

Featured Article by John DiLorenzo, MS,OTR/L,CHT

Nancy Falkenstein OTR, CHT

Susan Weiss OTR, CHT

The PURPLE BOOK 3rd editon - NEW

•New illustrations•New questions•New chapters•NEW 3rd edition is

hereHand & Upper Extremity Rehabilitation: A Quick Reference Guide and Review”. Studying for the

CHT© exam See Purple Book (pages 8, 11) for details.As always EHT/Tx2go strives to bring you valuable education and products. Please visit our sponsors websites. If viewing online just click and go. Thank you to our sponsors for making this newsletter possible.This newsletter is for informational purposes only and is not intended to be a substitute for professional advise, diagnosis, or treatment. Opinions are that of the authors and not necessarily of EHT/Tx2go.

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In This Issue

1

Exploring Hand Therapy

Treatment2gowww.handtherapy.com

Featured Article DiLoTrax ........................1

2014 Philly Hand Conference ..................7

Purple Book ......................................8, 11

New Releases ........................................5

Learn & Earn FREE CEU ........................8

Quiz .......................................................10

Basics & Beyond CHT study ................12

Physical Agent Modalities ......................12

Volume 14, Issue 4 October - December 2013

We therapists, have always been challenged with treating tendon and nerve injuries. The founder of the DiLotrax, solved this dilemma by inventing an orthotic system to effectively address this challenges. This article features John Dilorenzo’s plight to creating a successful solution.

The DiLoTrax device was developed to enable therapists and doctors to apply effective, but easy, dynamic traction for various conditions. Initially, I (JD)designed the DiLoTrax device to be used for Flexor tendon

repairs incorporating the Kleinert protocol. I produced numerous

prototypesforflexortendoninjuries that were distributed to various hand therapists for clinical trials over a two-year period. During this trial period, there was a young woman who was diagnosed with radial nerve palsy/PIN palsy after sustaining a knife wound to her elbow. She became frustrated when the rubber bands of the prescribed dynamic outrigger because

they kept breaking and did not provide accurate and enough returnforfingerextension.Shewas becoming non-compliant due to poor orthotic design.That is when I decided to apply the DiLoTrax device system to the outrigger. The results were amazing and she was completely satisfied.Shewasabletoattachthe dynamic splint with ease and utilized the DiLoTrax device with a static volar splint to perform all her ADLS. It allowed her to become ADL independent and

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…“I have trigger fi nger and at the time I was given one of these splints, I was told I would have to have surgery to correct the constant pain I was experiencing. After wearing this at night for six weeks, the swelling had disappeared as had the pain … I highly recommend trying it.” Testimonial from Amazon web site 5/13/2010

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peform meaningful activities. Her independence was restored while healing and protection occured wearing the DiLoTrax device.Following hand therapy, in conjunction with daily use of the DiLoTrax device and customized orthosis, patient X regained herfullwristROMandfingerextension within 16 weeks.

Since these results were so favorable I knew I would need a lowprofileDiLoTraxoutriggertobe used for numerous diagnoses. So I developed such an outrigger. This device provides a simple, accurate spring-loaded system, whichcanbesetforflexortendon repairs, extensor tendon repairs, radial nerve/PIN palsy, MCP arthroplasty, muscle weakness, and joint stiffness.

Currently, I use multiple protocols forflexortendonrepairsandhave concluded that utilizing the

DiLoTrax device for home use with hand therapy two times per week results in the best outcome.

In a case study in which nine patients(withflexortendonrepairs zone 2) utilized the DiLoTrax device, all patients demonstrated full AROM of affected digits and regained complete hand function. In comparison, after receiving two referrals from hand surgeons toutilizetheflexorsynergist

dorsal orthosis (classic tenolysis orthosis), the results from these cases were not acceptable and later on, one of the patients required a tenolysis because of decreased AROM at the DIP.

The other patient, following the same protocol, had limited PIP and DIP AROM but normal PROM. This patient attended therapy for six months and was then discharged with adequate hand function but still had a significantdecreaseinAROMat the DIP joint. The option of tenolysis was recommended but the patient declined.

Early protected motion has proven increases in tendon strength and decreased adhesion formation, thus, restoring the tendon’s gliding surface and tendon excursion. The DiLoTrax device is designed with the palmer pulley preassembled within the device (which secures directly onto a customized thermoplastic orthosis). Designing the palmer pulley into the device ensures distal interphalangeal joint motion which provides for combined passive motion of both interphalangeals. The DiLoTrax device ensures a smooth frictionless normal motion of the digits. At night, the patient is instructed to strap the IPs in full extension within the dorsal blocking orthosis to prevent flexioncontractures.

The DiLoTrax device includes appropriate spring-loaded force tension against extension of digits starting at 65-195 grams

in full IP extension. The spring can easily be removed from device by the therapist in order to change any given tension depending on the patient’s needs. In comparison to the use of rubber bands, the patient is often unable, through pain or weakness, to extend against the tension of the rubber band. Often with rubber bands the force is unevenanddifficulttoinitiateor begin motion resulting in an unsteady friction movement.

I have also found that it is impossible when using rubber bands, elastic, and/or string to achieve a frictionless movement. All to often the elastic/bands/strings change length, break or tangle resulting in further frustration. In addition, all four-fingerprotocolscanbeutilizedbecause set up and fabrication when using the DiLoTrax device is easy for the the therapist/doctor to apply. Adjustments and/ormodificationscaneasilybemade, however strapping has to be applied appropriately.

This allows the therapist/doctor to bill for dynamic orthosis/splint using L codes (L3905 and/or L3806).

The DiLoTrax device has been successfully used for EDC zone six-repair utilizing short arcmotionwithactiveflexionof

continued page 4



4

MP joints and controlled PROM extension, later progression to full active MP, PIP and DIP flexion.Thedynamictractionwas set up in less than 15 minutes and it provides a smooth frictionless movement with a cosmeticallypleasing,lowprofileoutrigger. The DiLoTrax device is patent pending and utilizes the technologyofSurflonnylonwirewith stainless steel springs, all made in the U.S.A. The device can be easily attached and detached by the therapist and/or patient allowing the therapist to follow different protocols allotting for improved healing and decreased tendon adhesions.Therapists, doctors and patients aregreatlybenefitingfromtheDiLotrax device because of the quality construction, pleasing

cosmetics, and ease of use. In comparison to similar products, DiLoTrax has proven very successful outcomes all at a very reasonable price. DiLoTrax is a device that every clinic should have readily available for immediate use so patients can regain optimal function and quickly return to their premorbid status.

John DiLorenzo, MS,OTR/L,CHT(917) 797-8788

[email protected]

WWW.DILOTRAX.COM

Tenolysis

Tenolysis Tips and Tricks!

Adhesions are devastating complications for most injuries but especially for tendon and soft tissue injuries. Adhesions following extensor tendon injury can result in extension lags andlossofflexionresultingina loss of functional ADLs and meaningful activities. Adhesions followingflexortendoninjurycan result in tendon gliding restrictions. Adhesions in general can cause joint capsule restrictions. Regardless of the cause of adhesions, we know adhesions can result in decreased hand function decreasing ones quality of life. What can we, as therapists, do?

If the surgeon decides on a

tenolysis surgery we must be knowledgeable in regards to expectations, procedures, and outcomes. Typically a tenolysis is chosen when there is a discrepancy between passive (full) and active (limited) range of motion after the patient has reached their hand therapy maximum or a plateau is noted.

A successful tenolysis requires immediate mobilization post surgical intervention and patient compliance. The best candidate for tenoylsis is a patient who has localized adhesions limiting tendon gliding. However, it is not uncommon for a patient who needs a tenolysis to also require a capsulectomy, tendon lengthening, pulley reconstruction, skin grafts to

name a few; all of which can result in diminished tenolysis gains. Obviously, any procedure that compromises the ability to provide immediate movement will have a negative impact in regards to tenolysis. Unfortunately, there is little therapists can do if multiple surgical procedures are performed that contradict the immediate post operative rehabilitation program. That is a decision the surgeon has to decide. Therapists must be aware of the negative impact of the surgeon performing multiple procedures together and realize the gains likely will be diminished. Hence setting realistic goals and a plan of caretoaddresseachspecificcase is critical for rehabilitative

Continued on page 6

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Tenolysis

6

success. This does not mean that a multiple surgical approach is wrong. This decision is the surgeon’s judgment and we as therapists must work within that decision. Therefore, we must set our functional goals accordingly. Before we look at rehabilitation, let us look at what a tenolysis is. It is important to know; a tenoylsis strips the tendon of soft tissue connections and can endanger tendon nutrition, which increases the likelihood of rupture. So, now it brings us to a million dollar question. When should a patient undergo a tenolysis? This is not an easy question and ultimately it is up to the surgeon’s judgment. With that said, I have seen in the literature anywhere from 2 months to 9 months post initial surgery. Most surgeons’ believe adequate wound remodeling and wound softening is mandatory. The point of this discussion is that some authors believe delaying the tenolysis procedure will allow the tendon to get the appropriate nutrition for healing and increase the ultimate outcome and minimize risk of tendon rupture.

Rehabilitation following a Tenolysis:

Your focus is on restoring functional hand motion to complete ADLs and IADLs. If the surgeon performed multiple procedures you will need to treat the most fragile and go from there. Always call the doctor to discuss his expectations and surgical gains and if possible obtaintheoperativeandoffice

visit notes. The scenario described in this article will be based on a tenoylsis performed without additional procedures. It is not unusual for the patient to arrive to therapy with a catheter that provides a local anesthetic. This catheter is inserted surgically and typically is left for 1 week to help control the pain. Normally a non-constrictive dressing is used to allow immediate active and passive range of motion to maintain the gains from surgery. The patient should begin hand therapy on post op day 1and therapy should focus on controlled aggressive active and passive range of motion. It is best if the patient is seen daily for 2 to 4 weeks and then decreases the frequency. Research has shownthatthefirstweekiscriticaland if improved motion is gained in week one (1) and maintained through week three (3) typically functional motion is maintained.

Edema Control and Pain Management:

Edema must be controlled and the easiest and cheapest way is by elevating the extremity above the heart to avoid the dependent position. A good exercise to help control edema is to have the patient perform overhead pumping exercises by making a fist5to15timeseveryhour;thisalso is great for active motion exercises. Cold packs may be applied up to 4X/day for 15 minute sessions. When applying cold remember to protect the wound and keep it dry and teach

the patient to check for vascular status. If these interventions do not control edema you may need to initiate self-adherent elastic wrapslooselyfit(notension)and typically best if applied in afigureof8distaltoproximalfashions. Therapeutic gloves are anoptionbutaretypicallydifficultto don/doff which may increase pain. Use with caution initially. Pain may be managed via the previously mentioned catheter but if needed the therapist may implement a TENs unit to the involved extremity to help manage discomfort and pain. Also orthotic positioning may assist with pain management. ROM may need tobemodifiedifedemaandpain is so intense as to keep the progress moving towards your goals.

Continuous Passive Motion (CPM):

CPMdevicesmaybebeneficialespecially if joint contractures are released alongside the tenolysis. Caution is needed because CPM devices cannot replace active motion. Active range of motion is the most important exercise following a tenolysis and must remain the primary motion so it is critical you instruct the patient using a CPM device to remove, as instructed, to get the best results.

Orthotics:

Immobilization and mobilization orthotics are utilized following a

Continued on page 9



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Chairmen:

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Hand & UE Rehabilitation: A Quick Reference Guide and Review, 3rd ed

A Quick Reference Guide& Review | Falkenstein & Weiss

3rdEdition

Upper ExtremityRehabilitation

Hand&


Hand&

A Quick Reference Guide& Review

3rdEdition

Nancy Falkenstein, OtR/l, CHt

President

Susan Weiss, OtR/l, CHt

Chief executive Officer www.handtherapy.com

isBn: 978-0-9884606-0-7 $249.00

tHis One-OF-a-kind guide provides a comprehensive, easy-to-followoverview of hand and upper extremity rehabilitation. Questions with detailed answers and explanations provide the reader with the essentials of hand re-habilitation. The reader will also appreciate the “Clinical Gems” throughout the text which provide additional useful tips or hints about key topics.

This book is ideal for those studying for specialty certification including the CHT® exam. This is a reference book that can’t be missed by anyone in the hand therapy industry as its values are limitless for the hand care practitioner.

Most treasured new features:

• 5 New chapters have been added to this edition: Psychosocial Aspects of Impairment, Ergonomics/Return to work, Spinal Cord/CNS/Brachial Plexus, Ligamentous and Muscular Injuries, and Edema/Lymphedema/Vascular Disorders.

•Every chapter has been completely revised with new questions, content, clinical gems and references to allow previous readers to enjoy an up-to-date resource book.

•More than 550 illustrations/photos—most of them new or updated.•The convenient Quick Reference Guide in the beginning of the

book has been updated. • Reviews the latest rehabilitation advances and techniques are ad-

dressed.•Includes a NEW appendix to practice labeling anatomical structures.• Fresh new perspectives from a diverse set of contributors.•Interactive vendor list.

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Hand U

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Tenolysis

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tenolysis procedure for various reasons. One such reason may be to maintain range of motion gained in surgery. Additionally, orthosis may be used for rest, protection, and positioning. Dynamic or static progressive orthotics may be used in conjunction with other therapy as well, to provide additional stretch to tight joints. Typically if thesurgeonperformedaflexioncontracture release during the surgery an extension orthoses is worn all the time and removed for hourly exercise. The variety of orthosis that can be utilized is too vast to cover in this chapter but it is important to have an open mind for orthotic application to facilitate motion gains. Additionally, night orthosis may be used for an extended period of time.

Scar Management:Around 3 weeks post operatively the scar enters the remodeling or maturation phase when cross linking becomes stronger and adhesions can become problematic. Scar remodeling is characterized by the rapid ongoing production of new collagen and the removal of the old collagen. The initial gel-like collagen with its randomly arrangedfibrilsandlowtensilestrength is gradually replaced with stronger and more highly

organized collagen. This is when therapeutic intervention can have thegreatestbenefitsandoptimizefunctional outcomes. Pressure to control scars is well accepted and the pressure assists with flatteningthescarmakingthescar suppler. There are numerous techniques and products to assist with scar management to soften the scar. They are too numerous to discuss in this article.

Home Program:With everything it is critical to have a well thought out written and illustrated home program. It is not good enough to verbally instruct the patient. Remember this is all new to the patient and the patient is likely on pain medication and the entire process is overwhelming. Therefore, it is highly advised to provide the patient with a well written easy to follow home program which includes precautions and what to do if a concern arises. Every patient is different and you must consider everything when designing a home program. A typical, initial home program is to instruct AROM and have him/her perform 8 to 15 repetitions hourly; as mentioned previously the patient can perform elevated overheadfistpumpingexerciseshourly as well. Obviously if you have an overzealous patient or

low pain threshold patient you will modify your home program and perhaps you may either decrease the number of repetitions per hour, decrease the number of sessions a day, or both. Home program will also consist of edema control instructions, orthotic instruction and any other programs you establish for the patient.

Goals:It is encouraged to begin the hand into light functinal ADLs immediately and by week six to begin light strengthening and increase the incorporation with ADLs. By week 12 full use of the hand is expected with all ADLs and return the patient to work.

Summary:A tenolysis is a serious decision and commitment of the patient. The outcome results are mixed but, all in all, if the candidate is good, the surgery will often be successful. If hand therapy is initiated immediately after surgery the chances for functional motion and obtainging meaningful functional goals are greatly improved.

References:• Wolfe,Hotchkiss,Pederson,Kozin(eds)Green’s

Operative Hand Surgery 6th ed.• Skirven, Osterman, Fedorczyk, Amadio, (eds)

Rehabilitation of the Hand and Upper Extremity 6th ed.


http://handcare2014.com


10

Quiz

Quiz: Test your knowledge

1. What is the name of the tendon device John DiLorenzo developed?

2. List at least two diagnosis thatcanbenefitfromusingtheDiLoTrax device with.

3. True/False: A tenolysis does not strip the tendon of soft tissue connections. If it did it would endanger tendon nutrition.

4. According to this article when is it best to perform a tenolysis ?

5. What is the easiest and cheapest way to manage edema?

6. CPM is most indicated following a tenolysis when?

7. When is an orthosis recommended for continuous use following a tenolysis?

8. What do we call a synergistic type of splint?

9. When does scar enter the remolding or maturation phase?

10. True or False: It is important for all patients to follow the same

protocol after a tenolysis to ensure excellent results.

1. DiLoTrax

2.Diagnosisthatmaybenefitform the DiLoTrax device:

•Flexor tendon •Extensor tendon•PIN palsy•MCP arthroplasty•Muscle weakness•Joint stiffness

3. False: Tenolysis does indeed strip the tendon of its soft tissue connections, putting the tendon

at risk.

4. Typically when adequate wound remodeling and wound softening is achieved. It basically is up to the surgeon and patient.

5. Elevation

6. CPM most indicated when:•When a joint contracture was

present and released. •Typically in conjunction with

multiple procedures

7.Typicallywhenaflexioncontracture release is performed in conjunction with the tenolysis.

8. Hinge splint; tenolysis splint

9. Around 3 weeks post operatively.

10. False. Every patient is different with different tissue response, psychological adjustments,financialandemotional. Treat each patient individually.



11

Order the Purple Book now and $ave!!

3rd Edition:“Hand & Upper Extremity Rehabilitation: A Quick ReferenceGuideandReview” 3rd edition is a question/answer book with referenced explanations. Every chapter in the 3rd edition has new content, revised content, new photos and drawings. Also we added:

5 Amazing New Chapters •Spinal Cord/CNS/Brachial

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Techniques •Orthotics: Design/

Fabrication/Training •Edema/Lymphedema/

Vascular Disorders •Wounds/Infection/Grafts/

Burns •Fractures/Dislocations/

Subluxations •Ligamentous and Muscular

Injuries •Arthritis and Related

Disorders •CRPS/Fibromyaligia •Tendon Injuries and

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Tendon Transfers •Cumulative Trauma

Disorders •Tumors/Cysts/Dupuytrens •Congenital Anomalies/

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Management

A Quick Reference Guide& Review | Falkenstein & Weiss

3rdEdition


Hand&


Hand&

A Quick Reference Guide& Review

3rdEdition

Nancy Falkenstein, OtR/l, CHt

President

Susan Weiss, OtR/l, CHt

Chief executive Officer www.handtherapy.com

isBn: 978-0-9884606-0-7 $249.00

tHis One-OF-a-kind guide provides a comprehensive, easy-to-followoverview of hand and upper extremity rehabilitation. Questions with detailed answers and explanations provide the reader with the essentials of hand re-habilitation. The reader will also appreciate the “Clinical Gems” throughout the text which provide additional useful tips or hints about key topics.

This book is ideal for those studying for specialty certification including the CHT® exam. This is a reference book that can’t be missed by anyone in the hand therapy industry as its values are limitless for the hand care practitioner.

Most treasured new features:

• 5 New chapters have been added to this edition: Psychosocial Aspects of Impairment, Ergonomics/Return to work, Spinal Cord/CNS/Brachial Plexus, Ligamentous and Muscular Injuries, and Edema/Lymphedema/Vascular Disorders.

•Every chapter has been completely revised with new questions, content, clinical gems and references to allow previous readers to enjoy an up-to-date resource book.

•More than 550 illustrations/photos—most of them new or updated.•The convenient Quick Reference Guide in the beginning of the

book has been updated. • Reviews the latest rehabilitation advances and techniques are ad-

dressed.•Includes a NEW appendix to practice labeling anatomical structures.• Fresh new perspectives from a diverse set of contributors.•Interactive vendor list.

Occupational Therapy Physical Therapy

Hand Rehabilitation

3rdEdition

Hand U

pper Extrem

ity Rehabilitation

&

A Quick Reference

Guide& Review

Falkenstein & Weiss

Exp l

oring Hand TherapyEx

p lorin

g Hand Therapy

Treatment 2 Go®

w w w . h a n d t h e r a p y . c o m

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