Hand Rehab for Extensor Tendon Injuries: What Works?
One good way to decide what's the best course of treatment in hand therapy is to do a search of articles published on a topic of interest. In this case, the focus is on rehab for surgically repaired extensor tendon injuries. What works best: immobilization (no movement), early but controlled mobilization (some movement), or early and active mobilization (full movement)?

Researchers from the Department of Rehabilitation at the University of Amsterdam in the Netherlands conducted a search of four major and well-known databases (Cochrane Library, PEDro, CINAHL, EMBASE) to answer this question. The search covered a period of 20 to 50 years, depending on how long the database had been in existence.

In the recent past, a summary of this type was researched, summarized, and published on flexor tendon injuries of the hand. This is the first time a similar study has been done on extensor tendon injuries. Patients with hand and wrist injuries involving the extensor tendons that were surgically repaired were included.

Evidence on the effects of different rehab protocols after this type of surgery can be very helpful information for hand therapists. It helps them keep up on what's the latest -- what works, what's outdated? In the past, immobilization was the standard post-operative treatment. But that has been replaced with early controlled mobilization and early active mobilization in many places.

There are different schools of thought on the best approach to use. The goal is to protect the repair site until it heals while preventing scar tissue and adhesions from forming. Movement is usually the best way to prevent scar formation -- but it's also the best way to disrupt the newly forming tissue needed for a successful repair.

Active finger motion keeps the healing tendons sliding and gliding through the tendon sheath (outer covering) and strengthens the tendon faster than a program of controlled motion. The decision about which way to go is usually made by the team, which is made up of the hand surgeon, the hand therapist, and the patient.

Without evidence to provide a consensus on what protocol gives the best outcomes, there can be a wide range of treatment programs designed for the same problem. If there's one program that's most effective, everyone wants to know about it!

After searching the four databases, the authors found 40 possible articles. Analyzing the data and reviewing details of the articles narrowed this down to seven that were acceptable quality to be included. An independent review of these seven articles excluded two of the seven articles for a final tally of five articles offering best evidence about this topic.

The studies were divided into the three treatment groups mentioned. Rehabilitation method was the key target area. Here's what they found:

  • Early controlled mobilization results in better range-of-motion at the end of six weeks (compared with immobilization). At the end of 12 weeks, there was no difference in motion between the two groups.
  • Grip strength comes back faster and stronger with controlled mobilization compared with immobilization.
  • Overall results are better at the end of six weeks with mobilization (compared to immobilization). But by the end of six months, both groups had the same final results in terms of motion and strength.
  • There is conflicting evidence about the short-term effects of early controlled mobilization versus active mobilization. But all studies agreed that the long-term results are the same.

    All in all, it looks like early controlled mobilization is the superior approach for postoperative rehab following surgical repair of extensor tendon injuries. Even though there are no apparent long-term benefits of active motion, an earlier return to full function and strength may improve the patient's quality of life and satisfaction.

    There are only a few limited studies on which to base these recommendations. And there are still many unknowns. For example, how long should rehab last? What kind of splinting (if any) should be used? How often should the exercises be done? What level of intensity is advised? And when should the patient be progressed from active motion to resisted exercises?

    Hand therapy is a complex form of rehabilitation that requires careful evaluation and tweaking according to the patient's individual needs. Having a basic protocol to follow formulated from the best evidence available is a helpful place to start. Before more specific instructions can be offered, further studies to answer these and other questions must be done.
    Eelkje Talsma, MSc, et al. The Effect of Mobilization on Repaired Extensor Tendon Injuries of the Hand: A Systematic Review. In Archives of Physical Medicine and Rehabilitation. December 2008. Vol. 89. No. 12. Pp. 2366-2372.