Proceedings of the ASHT26th Annual Meeting

The ASHT 26th Annual Meeting washeld October 9–12, 2003, in Hollywood,California.

Every year, the ASHT Call for Ab-stracts provides an opportunity forauthors to submit original research tothe ASHT for presentation at the clinicaland scientific paper sessions at theAnnual Meeting. Abstracts are submit-ted to the ASHT early in the year and arereviewed by a panel of experts. Authors ofpapers selected by the panel are invited topresent their papers at the meeting.

The following author-prepared ab-stracts are of papers presented at the2003 meeting.

A Proposed Model for Systematic

Application of Progressive Force

Exercises to the Intrasynovial Flexor

Tendon Injury and Repair. Gail N.Groth, MHS, OTR, CHT

Postoperative rehabilitation for pa-tientswhohave sustained a lacerationto their intrasynovial flexor tendonapparatus is an important factorin maximizing functional outcome.Quality rehabilitation is partiallycharacterized by the developmentand implementation of a tailoredexercise regimen. Though suggestedstrategies are available for tailoringrehabilitation programs according toage, learning capabilities, and suturetechnique, there is currently no sys-tem available to tailor an exerciseregimen for a person with an atypicalphysiologic response pattern (i.e.,heavy or light collagen synthesis). Ifflexor tendon rehabilitation protocolswere classified according to the cri-terions of force and/or excursion, anda clinical method were available toassist in the identification of optimalforce and/or excursion application,then those individuals with atypicalresponse patterns could be treatedmore efficiently and effectively.

Purpose: The purpose of this man-uscript is to classify rehabilitationexercises for the healing intrasyno-vial flexor tendon along the criterionof progressive force. A systematicmethod of exercise prescription todetermine optimal force applicationwill also be presented.

Methods: Literature review and casestudy.

Observations: A classification ofprogressive force exercises to thehealing flexor tendon is conceptuallydeveloped. This classification con-sists of a pyramidal series of ninespecific rehabilitation exercises inthe following sequence: passive pro-tected extension, place and hold,active composite fist, hook andstraight fist, isolated joint motion,discontinuation of protective splint,resistive composite fist, resistive hookand straight fist, resistive isolatedjoint motion. Systematic applicationof the theory is accomplished throughthe implementation of a novelthree-point clinical adhesion-grad-ing system. The uniqueness of thetheory lies not in the exercises, butin the method of prescription. There-fore, clinical reasoning is at the fore ofall treatment progressions ratherthan predetermined time frames.Clinical application of the system ishighlighted with two case presenta-tions, high and low collagen synthe-sis.

Conclusions: A theoretical classifi-cation system of progressive forceexercises in conjunction with theirsystematic application has been de-veloped. Further substantiation isnecessary to validate the proposedtheory.

Relevance to hand therapy: The un-varied chronological implementationof force exercises results in sup-pressed clinical reasoning and erro-neous forceapplication.Theproposed

theory offers a methodology for

systematic clinical reasoning.

2003 ASHT PROCEEDINGS

78 JOURNAL OF HAND THERAPY

The Versatility of the Immediate

Controlled Active Motion Yoke

(ICAM). Sandra Robinson, OTR,

CHT, Jim Gyovai, PT, CHT, JulianneHowell, MS, PT, CHT

Purpose: To demonstrate alterna-

tive clinical applications for the im-

mediate active controlled motion

(ICAM) yoke.Methods: Eight patients from two

hand centers with various neurolog-

ical and/or orthopedic problems

affecting metacarpophalangeal

(MCP) joint alignment, balance, or

range of motion were fitted with

variations of the ICAM yoke. Patients

were photographed with and with-

out the ICAM yoke to document

improved alignment, balance, and

function. In the two cases where

increased range of motion (ROM) of

the metacarpophalangeal (MCP) or

proximal interphalangeal (PIP) joint

was the purpose of incorporating the

yoke into the patient’s program,

ROM measurements were docu-

mented on the day the yoke was

applied and after it was discontin-

ued. Diagnoses for which the ICAM

yoke has been utilized: 1) C5-6 dis-

cectomy with extensor lag of the

middle and ring digits; 2) metacarpal

fracture with extensor lag; 3) ulnar

nerve palsy with resultant MCP

hyperextension; 4) rheumatoid ar-

thritis (post-MCP arthroplasty);

5) Parkinson’s disease with ulnar

deviation and dislocation of the

extensor tendon of the middle digit;

6) metacarpal head fracture with

malalignment and ulnar deviation

deformity; 7) PIP joint stiffness (to

limit MCP hyperflexion while

exercising); 8) decreased MCP joint

flexion with digital composite flex-ion, elbow at 40 degrees of flexionwithout volitional control. NMESwas used to stimulate the antagonis-tic muscle groups consisting ofextensor carpi radialis longus andbrevis (ECRL/B), extensor digitorumcommunis (EDC), and triceps. Chan-nel 1 was applied to the triceps tofacilitate elbow extension for in-creased reach envelope for improvedfunctional use of the hand and easefor splinting. Channel 2 was appliedto the wrist extensors to facilitatewrist position and digital extensionfor appropriate pre-contact graspformation. This configuration wasapplied for 30 minutes using analternating ramped burst programwith an asymmetrical waveform forsame musculature. Channel 2 startedafter channel 1 had completed thecycle. Channel 1 gradually increasedintensity for 0.5 seconds, and thenheld a set intensity for 5.0 secondsand then decreased intensity over 0.5seconds. Channel one is then off for6.0 seconds. As channel intensity isdecreasing, channel 2 started increas-ing intensity, via the same pattern.The negative electrode was placed

method of using NMES and electro-mesh glove to initiate elbow exten-

sion, wrist extension, and digitalextension with abduction promotes

interference to the flexor synergistic

pattern of the upper extremity, elicit-ing motor contraction of previously

inactive extensor musculature.

Thumb and Pinch Weakness in De

Quervain’s Disease. Katia Fournier,

BScOT, Daniel Bourbonnais, PhD, JoseeArsenault, MScOT, Patrick Harris, MD

Purpose: Although de Quervain’sdisease affects tendons involved in

the abduction and extension of thethumb, strength impairments caused

by this disease are often measuredwith a pinch gauge that quantifies the

thumb flexion and opposition forces.The purpose of this preliminary

study was to describe strength

impairments associated with deQuervain’s disease in adduction,

extension, abduction, and flexion ofthe thumb using a bi-axial dyna-

mometer and in palmar pinch usinga pinch gauge.

Subjects: Convenience sample of 14subjects aged 36 to 68 with unilateral

flexion, status/post gunshot woundto the metacarpal.

Results: In all patients, there wasa high compliance rate with wearingthe yoke. We believe the patientsfitted to improve alignment or bal-ance complied because the yoke issmall and comfortable and theirfunction improved. In fact, three ofthe patients discharged from therapyhave subsequently returned for fab-rication of a replacement of their‘‘permanent adaptive splint.’’ Thetwo patients who wore the splint toassist in increasing ROM gainedflexion of the MCP or PIP joints beingaddressed. Their ROM charts will bepresented.

Conclusion: The ICAM yoke is welltolerated and effective in balancingor aligning many hand problemsaffecting the biomechanics of theMCP joint. The improved functionexperienced by some of the patientsfitted is demonstrated by their desireto have replacements or ‘‘back-upyokes’’ fabricated. The ICAM yokeis also an effective splint to positionone or more finger MCP joints inrelative extension or flexion to gainmotion at the MCP or PIP joints.

Inhibition of Flexor Tone. Beth U.Coon, PT, CHT, William R. Mattingly,OTR/L

Purpose: The purpose of this studyis to demonstrate a progressive useof neuromuscular electrical stimula-tion (NMES) by using a systematicapproach to the reduction of spastic-ity. Spasticity can limit function inpatients after a cerebral vascularaccident (CVA). Flexor synergisticpatterns present with variable toneand frequently respond well toelectrotherapy. Previous treatmentprotocols use the approach ofstimulating spastic musculature tofatigue or antagonistic musculatureto strengthen and facilitate (Currier,1983). This protocol utilizes an elec-tromesh glove after 30 minutes ofantagonistic muscle facilitation tostimulate intrinsic muscle contrac-tion, allowing facilitation of digitalextension and abduction, thereforereducing tone and allowing staticprogressive splinting to minimizetone.

Method: Three patients presentedafter left-sided flexor synergistic toneat approximately 60 degrees of wrist

over motor point with cycle ratesused to produce tetany at 25–50 pps(the minimum rate that produceda good tetanized contraction de-pendent on tone) (Kahn 1987). Anelectromesh glove was fitted withrepositioning of proximal electrodesutilizing channel 2, after stimulationof the antagonistic musculature per-mitted positioning of the wrist inneutral. The electromesh glove wasworn for an additional 30 minutes. Astatic progressive splint with a wristhinge hand portion was fabricatedover the electromesh glove. Thesplint is to be worn after applicationof the above NMES protocol permitswrist at neutral or into extension.

Observation: The patients presentedwith the wrists at neutral after a pro-gression of NMES to triceps andECRL/B and EDC. Reduction ofhand intrinsic musculature tightnesswas achieved after use of the electro-mesh glove along with reduction ofextrinsic flexor synergistic tone. Re-duction of tone allowed ease of staticprogressive splinting with a hingedwrist splint.

Conclusion: Flexor spasticity can bea hindrance to personal hygiene andimpedes functional activity. This

de Quervain’s disease. Subjects hadto be free of any other pathological

condition affecting the hand. Nine

subjects were affected on their dom-inant side.

Method and materials: A bi-axial

dynamometer was used to assess

isometric maximal voluntary con-traction (MVC) exerted in the trans-

verse plane at the proximal phalanxof both thumbs of subjects. MVC was

tested in four directions: adduction,extension, abduction, and flexion,

four trials being made per direction.

Directions of efforts required andsubjects MVC were displayed on

a monitor giving a visual feedback.Palmar pinch strength measurements

were also taken for both hands witha pinch gauge (three trials).

Analysis: A two-way repeated-measures analysis of variance (AN-

OVA) was performed on the MVCvalues obtained with the bi-axial

dynamometer (factors: sides and di-rections) and a paired Student’s t-test

was performed on the MVC values

obtained with the pinch gauge. Ra-tios of MVC (symptomatic/asymp-

tomatic side) were also calculated forboth instruments.

January–March 2004 79