Review Article

Therapy After Injury to the Hand

Abstract
Erik Dorf, MD
Carla Blue, OTR/L, CHT
Beth P. Smith, PhD
L. Andrew Koman, MD

From the Department of

Orthopaedic Surgery and
Rehabilitation, Wake Forest
University School of Medicine,
Winston-Salem, NC (Dr. Dorf,
Dr. Smith, and Dr. Koman), and the
Hand Therapy Center, Wake Forest
University School of Medicine
(Ms. Blue).
Dr. Koman or an immediate family
member serves as a board member,
owner, officer, or committee member
of DT Scimed and Keranetics;
serves as a paid consultant to or is
an employee of DT Scimed; has
received research or institutional
support from Datatrace, Allergan,
Biomet, DT Scimed, Johnson &
Johnson, Keranetics, Smith &
Nephew, Synthes, Wright Medical
Technology, and Zimmer; has stock
or stock options held in Wright
Medical Technology; and has
received nonincome support (such
as equipment or services),
commercially derived honoraria, or
other non-researchrelated funding
(such as paid travel) from Datatrace,
DT Scimed, and Keranetics. None of
the following authors or any
immediate family member has
received anything of value from or
owns stock in a commercial
company or institution related
directly or indirectly to the subject of
this article: Dr. Dorf, Ms. Blue, and
Dr. Smith.
J Am Acad Orthop Surg 2010;18:
464-473
Copyright 2010 by the American
Academy of Orthopaedic Surgeons.

464

Surgical and nonsurgical management of upper extremity disorders

benefits from the collaboration of a therapist, the treating physician,
and the patient. Hand therapy plays a role in many aspects of
treatment, and patients with upper extremity injuries may spend
considerably more time with a therapist than with a surgeon. Hand
therapists coordinate edema control; pain management;
minimization of joint contractures; maximization of tendon gliding,
strengthening, and work hardening; counseling; and ongoing
diagnostic evaluation. Modalities used to manage hand injuries
include ultrasound, splinting, Fluidotherapy (Chattanooga Group,
Chattanooga, TN), cryotherapy, various electrical modalities,
phonophoresis, and iontophoresis.

History of Hand Therapy

Upper extremity surgeons working
in military hospitals during World
War II treated a wide range of severe
injuries; much of the early literature
on treating hand injuries is based on
these surgical experiences. It was at
this time that the benefit of therapists dedicated to the treatment of
upper extremity disorders became
apparent. Together, surgeons and
therapists developed protocols for
the treatment of upper extremity war
injuries.1 Despite the evidence from
these experiences demonstrating the
benefits of therapy after upper extremity injury, the first Rehabilitation of the Hand Conference was not
held until 1975. The American Society of Hand Therapists was founded
in the United States that same year.2

Elements of Hand Therapy

Hand therapy addresses the physiologic stages that occur after injury,
with the intent of maximizing functional recovery and decreasing pain

(Table 1). There is often significant

temporal overlap in the use of techniques designed to address these
stages, and several stages may be addressed concurrently. Therapy after
hand injury can be divided into sequential steps, with the goal of leading patients from injury to recovery.
Patient education is essential during
all stages of care and should be initiated
at the first patient encounter. Linking
the importance of therapy to the eventual outcome of treatment enables better patient participation in ongoing care
and enhances compliance with treatment protocols. Bruyns et al3 demonstrated that patients who completed
a standardized therapy protocol following laceration of the median or
ulnar nerves were 3.5 times more
likely to return to work than patients
who did not complete the therapy
protocol.

Edema Control
Hand edema is the result of a collection of extracellular transudate and
exudate. The presence of proteinladen exudate in the interstitial space
at the site of injury leads to collagen

Journal of the American Academy of Orthopaedic Surgeons

Erik Dorf, MD, et al

Figure 1

Table 1

Figure 2

Basic Stages of Hand Therapy

Edema control
Wound management
Passive and active range of motion
Soft-tissue mobilization
Sensory reeducation and desensitization
Strengthening
Work hardening and conditioning
a

The stages are not necessarily sequential. Multiple stages may be undertaken
simultaneously.

deposition, scarring, and restriction

of movement. The increase in the
volume of the hand via both transudate and exudate disrupts hand biomechanics by flattening the longitudinal and transverse arches, blocking
motion on the volar surface, and restricting the pliable dorsal skin from
moving with joint flexion.4
Edema control should begin immediately following the insult to the upper extremity. Compressive dressings, extremity elevation, and early
range of motion (ROM) of the affected joint or joints are the primary
methods used to prevent excessive
swelling before referral to the therapist. A bulky compressive dressing
should be applied with the upper extremity in a functional position, that
is, one that maintains the transverse
arch and positions the metaphalangeal (MP) joint in 70 of flexion
and the proximal interphalangeal
joint in 0 to 5 of flexion. Bulky
dressings that maintain the hand in a
functional position diminish ligament contractures, resulting in optimal mobility (Figure 1). Dressings
are applied to exert even, gentle pressure on the extremity without restricting proximal blood flow. Optimally, elevation of the hand is
maintained above the level of the
right atrium. Splints are fabricated to
allow motion and prevent deleteriAugust 2010, Vol 18, No 8

Restrictive wrapping used to

decrease edema in an amputated
ring finger.

Illustration of a radial gutter splint,

which is used to maintain the hand
in a functional position.

ous contractures. Active and passive

motion are encouraged as long as
they do not damage the surgical repair. To stimulate venous return, motion is vigorous enough to enable
transient blanching of the dorsal skin
without causing undue pain. Forced
manipulation is avoided because of
the danger of increased inflammation
and swelling.5
Although some swelling of the extremity after injury is normal and expected, edema that persists beyond 1
to 2 weeks may portend additional
morbidity. Therapists employ multiple techniques to eliminate excess interstitial fluid. The most common
approaches for reducing edema include wrapping the extremity, massage, use of antiedema gloves, intermittent compression, and continuous
passive motion (CPM).6
Restrictive wrapping or string
wrapping may be used on the involved extremity or digit. A restrictive dressing (eg, Coban [3M, St.
Paul, MN]) is applied to the affected
part distal to proximal, thereby increasing interstitial pressure and promoting lymphatic and venous drain-

age. ROM exercises are performed

with the wrap in place (Figure 2).
String wrapping is performed distal
to proximal using a soft cord that is
left in place for 5 minutes. After the
cord is removed, the patient is encouraged to perform ROM exercises
with the extremity maintained in an
elevated position. String wrapping
of edematous digits with and without retrograde massage has demonstrated efficacy in reducing hand
edema. A combination of these techniques is significantly more effective
than either alone (P < 0.05).7
Kinesio Tape (KMS, LLC, Albuquerque, NM) has elastic properties similar
to those of skin and muscle. Optimal
application of the tape is obtained by
a 30% to 40% stretch of its original
length to redistribute fluid, thereby reducing edema. Kinesio Tape combined
with active motion redistributes fluid,
improves lymphatic motility, and decreases nociceptor stimulation. Such
therapy theoretically improves microvascular blood flow, facilitates lymphatic drainage, reduces inflammation,
and mediates pain.5
With intermittent pneumatic compression, a pneumatic sleeve is placed
over the edematous extremity, and the
sleeve is sequentially inflated and deflated for 30 minutes to 2 hours. The
pressure applied to the extremity must

465

Therapy After Injury to the Hand

be greater than the interstitial pressure

(25 mm Hg) but should not impede
blood flow to the extremity.8 Compared with placebo, pneumatic
sleeves decrease edema significantly
in patients with posttraumatic hand
swelling (P = 0.004).8,9 Intermittent
palmar pressure also decreases
edema, improves ROM, and diminishes discomfort. Pulsed forces applied to the palm increase extracellular pressure and transiently dilate
small vessels, which leads to improved circulation and decreased
pain.10
CPM reduces hand edema by increasing lymphatic and venous drainage
through the mechanical pumping mechanism of the hand (Figure 3). Limb elFigure 3

evation alone was compared with combined limb elevation and CPM in 16
patients with extremity pathology and
edema.11 A significant decrease in
hand edema was demonstrated following combined treatment.

Wound Management
Many therapists use a three-color
wound classification system to aid in
traumatic wound management and to
evaluate the effect of therapy on healing and function (Table 2) (Figure 4).
The goal is to eliminate black or necrotic tissue to facilitate the rapid progression to red or beefy granulating
wound tissue that is capable of healing
or suitable for grafting. The red wound
is protected until wound closure. Mechanical dbridement with soap and
water, pulsed lavage, frequent dressing

changes, and whirlpool therapy are the

most common methods used to maintain fragile developing granulation tissue while eliminating necrotic or infected debris. Although the goal is to
achieve a healthy granulating bed, exuberant granulation tissue or proud
flesh is the external manifestation of
a richly perfused microvascular subsurface. Beefy red granulation tissue often
is contaminated with bacteria, and
cleansing is required to facilitate wound
closure and grafting procedures. The
ideal wound surface is a pale pink,
smooth tissue bed characterized by
brisk capillary refill.
Whirlpool therapy for mechanical
dbridement involves submerging the
affected extremity into a bath of agitated water and injected air. To be effective, the water temperature should

Figure 4

A continuous passive motion

machine is used to decrease
edema and increase range of
motion during a hand therapy
session.

Three wounds representing the three-color wound classification system:

black (A), yellow (B), and red (C).

Table 2
Wound Classification by Color
Wound Color

Characteristics

Predominant Physiology

Black

Thick, necrotic tissue

Yellow

Yellow fibrous debris,

drainage, and slough

Macrophage dbridement and

early collagen synthesis. Inhibited fibroblast migration.
Bacterial stimulation of macrophage activity

Decrease macrophage
workload. Facilitate
fibroblast migration.
Decrease macrophage
workload. Progress to
red wound.

Red

Healing wound, pink or

beefy red with clear
borders

Endothelial angiogenesis, fibroblast collagen deposition, and

myofibroblast wound contraction

Protect ongoing cellular

activity.

466

Goal

Treatment
Surgical or enzymatic
dbridement
Cleanse with soap and
water, whirlpool treatment, antibiotic application
Clean dressings that
prevent desiccation

Journal of the American Academy of Orthopaedic Surgeons

Erik Dorf, MD, et al

be between 33.3C (92F) and

35.5C (96F). Rinsing the open
wound in clean water following agitated whirlpool treatment decreases
bacterial counts; when this is followed by active motion and elevation, it can also reduce edema.6,12
The negative aspects of whirlpool
therapy include the dependent position of the limb during treatment,
the possibility of cross-contamination between patients using the
same equipment, and the possibility
of excessive dbridement and destruction of healthy microvascular
beds.13
Ultrasound is used to facilitate
healing and ROM; treat joint contractures, pain, and inflammatory
conditions; and moderate scar formation. Ultrasound waves can be
used to warm soft tissues at 1.0 to
1.5 W/cm2 (ie, thermal effect) to
depths of 2 to 5 cm and are most
helpful during the remodeling phase
of wound healing. The proliferative
phase of wound healing may be influenced by the nonthermal effects of
ultrasound, at 0.3 to 1.0 W/cm2. Although this healing effect has been
demonstrated in the laboratory, the
results of clinical trials are mixed
with regard to the true potential for
ultrasound to affect wound healing.13
Ultrasound increases membrane permeability. Used in conjunction with
topically applied triamcinolone as a
coupling medium, ultrasound can
encourage collagenase activity and
the breakdown of existing scar.14

Scar Management
Therapy can influence the remodeling phase of wound healing. Hypertrophic scar and keloid both result
from abnormalities in the wound
healing process, resulting in fibroproliferation and disorganized collagen deposition. Keloids differ from
hypertrophic scars in that they extend beyond the zone of the initial
August 2010, Vol 18, No 8

insult, do not regress with time, have

a high rate of recurrence, and are less
amenable to therapeutic interventions.
Pressure therapy alters the structure of the extracellular matrix in hypertrophic scars.15 This is theorized
to be secondary to the downregulation of cytokines and the induction
of apoptosis of the hypertrophic scar
derma, resulting in decreased scar
proliferation.16 A pressure glove can
be used to manage a hand wound
(Figure 5). Custom and off-the-shelf
gloves in various sizes are available.
Daytime gloves are designed to extend only to the middle phalanges to
allow sensory input and integration
of the hand into activities of daily
living. The hand also can be
wrapped with an elastic bandage or
placed in a padded splint with an
elastic overwrap to provide compression into concave areas of the
hand (ie, palm). Other methods of
pressure application include selfadherent wraps that can be used for
individual fingers. Alternatively, elastomer or other putty-type materials
can be fitted into concave surfaces
and secured with a splint or elastic
wrap to provide pressure. To be effective, pressure therapy should be
applied at a level of 24 to 30 mm Hg
for 6 to 12 months. Pressure therapy
is particularly effective for patients
with burns and skin grafts.

Range of Motion
Therapy involving various combinations of active and passive ROM is
initiated unless there is a specific
contraindication. Early ROM, both
active and passive, decreases the incidence of joint contracture, facilitates
edema reduction, and decreases adhesion formation.17,18 With regard to
flexor tendon protocols, early ROM
leads to earlier recovery of tensile
strength and better tendon nutrition
than do protocols that immobilize

Figure 5

A properly fitting edema glove is

used between therapy sessions to
maintain edema control with the
hand in more dependent positions.

tendons.19 Early passive motion protocols were advocated by both Duran and Kleinert for the treatment of
flexor tendon repairs in zone II.20 In
a randomized clinical trial, Bulstrode
et al21 demonstrated improved early
motion in patients with extensor tendon injuries following two different
protocols that encouraged early active and passive ROM versus ROM
begun at 4 weeks.
Following tendon repair, passive
ROM may encourage tendon gliding, but it also has the potential for
placing a repaired structure at risk
for rupture. Aggressive passive motion should be avoided in patients
with complex regional pain syndrome (CRPS) because of the potential for increased inflammation and
edema.22 For these patients, active
motion may be preferred because it
may place less stress on the extremity
than does passive motion. Numerous
protocols for the management of
both surgically and nonsurgically
treated distal radius fractures advocate early passive and active ROM
of the fingers or wrist.23 A systematic review confirmed improved outcomes after early mobilization following extra-articular metacarpal and
phalangeal fractures.24

Splinting
Splinting provides pain relief, protects
the extremity from additional trauma,
corrects or prevents deformity, facili-

467

Therapy After Injury to the Hand

Figure 6

Figure 7

A, Photograph of a patient using textured dowels to decrease

hypersensitivity to touch following multiple fingertip amputations. B, Various
substances (eg, rice, popcorn, sand, dried beans) are used as immersion
particles to facilitate desensitization and sensory reintegration.
Photograph of a dynamic proximal
interphalangeal (PIP) joint
mobilization splint applied to the
small finger to encourage extension
in a patient with PIP flexion
contracture.

tates maintenance of fracture reduction,

and/or provides protection during functional activities. Splinting may be static
or dynamic, or a combination of both.
Static splints hold the affected motion
segment in a functional position and
protect injured structures at rest and
during functional activities. Dynamic
splints provide support and protection
and allow motion during activities. Examples of static splints include palmar
blocking splints, which are used to hold
the wrist and fingers in extension after
extensor tendon injury, and forearmbased wrist splints, which are used at
night to avoid positions of wrist flexion during sleep.
Protective splints may support inflamed soft tissue and injured or
compromised joints; stabilize weak
muscles, thereby preventing damage;
or neutralize unstable fractures. One
such splint is the dorsal extension
block splint, which is used after
flexor tendon repair (Figure 6). Static
positional splints stabilize fractures
and dislocations, prevent deformity,

468

and/or substitute for lost function.

Examples of positional splints include web space abduction splints,
which are used to prevent web space
contracture, and MP flexion splints,
which are used after release of MP
extension contracture.25
Static splints have no moving
parts. Dynamic splints may include
flexible components, hinges, and/or
devices (eg, outriggers) that provide
dynamic forces. Both types of splint
are used for immobilization and support. Serial adjustment or alteration
of static splints is referred to as static
progressive splinting. This type of
splinting is accomplished by locking
and unlocking hinges or by the serial
modification of solid splints. Examples of dynamic splints include MP
extension splints, radial nerve palsy
splints, and finger flexion splints
used for the Kleinert flexor tendon
protocol. Static progressive splints
incorporate components that can be
adjusted as ROM increases.26

Desensitization and
Sensory Reeducation
Depending on the nature of the injury,
a patient may benefit from therapy that
is specifically directed at sensory reed-

ucation or desensitization. This process

can be used during any phase of treatment and can begin almost immediately
after injury. Hypersensitivity following
nerve injury is characterized by severe
irritability in response to normal stimulation. Hyperpathia, allodynia, and
hypesthesia associated with CRPS complicate recovery and impair healthrelated quality of life and function.
Desensitization is used to send nonnoxious signals to the central nervous
system in an effort to cortically normalize nonpainful stimuli. The efficacy of
this process is explained by the gate theory of pain.27
Desensitization begins with a threepart hypersensitivity evaluation. First,
patients are asked to determine the irritability of 10 different texturesranging from moleskin to Velcromounted
on dowels (Figure 7, A). Second, patients rank the irritability of various immersion particles (Figure 7, B). Finally,
the irritability of a variety of vibratory
frequencies is discerned. The results of
the three-phase hand sensitivity test are
used to determine the most appropriate level of stimulation to be used in initial therapy sessions.28
Massage, percussion, heat, compression, contrast baths, Fluidotherapy (Chattanooga Group, Chatta-

Journal of the American Academy of Orthopaedic Surgeons

Erik Dorf, MD, et al

nooga, TN), and other physical

modalities are applied to the extremity in formal therapy sessions and at
home. Exposure to extremes of cold
and local irritants are specifically
avoided during the desensitization
process. The patient is sent home
with a selection of tolerable textures
and is encouraged to stimulate the
hand frequently without irritating it.
Three to four daily sessions of at
least 10 minutes each with the contact particles, dowels, and a home vibratory unit are recommended. Contrast baths consist of immersion of
the injured extremity in alternating
warm and cool water (typically 4
minutes in warm [tepid] water, followed by 1 minute in cool water).
Extremes in water temperature are
avoided during the desensitization
process. Warm water is theorized to
overload large fibers and block the
perception of pain. Desensitization
techniques are helpful in the management of type 2 CRPS, and contrast
baths may be beneficial for patients
with CRPS types 1 and 2.29 Patients
are periodically reevaluated using
both the three-phase hand sensitivity
test and other standardized tests of
dexterity and function to document
the course during therapy.
Recovery of discriminatory sensation
following nerve injury is often delayed,
and patients are frequently disappointed
with the level of sensation that eventually returns. Sensory reeducation uses
tactile stimulation to help patients recover functional sensibility in the damaged area using a combination of substitution and cortical reorganization,
allowing altered patterns of neural impulses to be reinterpreted.30 Sensory
reeducation is conducted in a quiet
room, using exercises that target localization of stimuli to simulate the
identification of textures and everyday objects. Exercises are performed
by the patient with the eyes both
opened and closed. Repetition of
August 2010, Vol 18, No 8

stimuli reinforces recognition patterns.

Soft-tissue Mobilization
Shortening of the soft tissue occurs
as a result of collagen cross-linking
and adaptation to muscle fiber resting length coincident with the decreased demand for joint motion.31
For example, maintenance of metacarpal joints in full extension results
in shortening of the true and accessory collateral ligaments. In patients
with spasticity and diminished joint
ROM, muscle tendon units shorten
to produce fixed contractures.
Soft-tissue mobilization (STM) of tissue planes relative to one another is believed to promote joint ROM, reduce
tissue stress, and stimulate lubrication
and nutrition. However, additional
research is required to determine
whether STM improves therapeutic
outcomes.32,33 STM techniques are
believed to optimize these factors
during the healing process, minimize
adhesions between adjacent tissue
planes, and decrease adaptive shortening.
The clinical effects of STM include
decreased fluid stasis, increased extensibility of shortened tissues, improved
blood flow, and proprioceptive awareness at the treatment site. The goals of
STM are to improve ROM and softtissue flexibility and to decrease pain.
Gliding, that is, the movement of tendons within their sheaths or muscles
within fascial compartments, is impeded by adhesions.

Strengthening
Strengthening protocols are initiated
following healing of the wound and
any repaired structures as well as
successful pain control. The goals of
strengthening include improved grip,
tip pinch, key pinch, and function.
Older patients with decreased grip
strength (<40 lb) report dissatisfaction with health-related quality of

life and function compared with patients with better grip strength (>60
lb).34 This reduction in grip strength
may be linked to sarcopenia and generalized frailty, which is common in
older patients. For patients with sarcopenia, therapeutic interventions that
improve muscle mass and strength may
prevent the onset of chronic disorders
that negatively affect health-related
quality of life.
The scope of a strengthening program depends on the nature of the
injury, status of the soft tissue, level
of pain, and biomechanics of the
fracture fixation and/or soft-tissue
repair. Strengthening protocols are
graduated, with progressive loading
and resistance; both eccentric and
concentric muscle contractions are
used. Strengthening or maintenance
of muscle tone is incorporated into
most active-motion protocols. Increasing muscle strength often improves ROM, facilitates lysis of adhesions, and improves excursion.
Neuromuscular electrical stimulation
can be used for patients who are unable to initiate muscle contractions
to generate sufficient force. Exercises
that incorporate functional activities
of daily living have been shown to
improve ROM and strength generation in young patients after hand injury.35
The Jamar Hand Dynamometer
(Asimow Engineering, Los Angeles,
CA) is the most commonly used instrument to measure grip strength.
Multiple studies have confirmed its
validity and reproducibility.36 Repeated measurements of grip, key
pinch, and tip pinch provide objective measures of improvement in
both strength and function.

Work Hardening and

Conditioning
For the patient who has been out of
work for a prolonged period, an integrated therapy approach is often

469

Therapy After Injury to the Hand

necessary to ensure safe return to

work. Work conditioning, in which
an injured hand is incorporated into
the process of completing a work
task, encompasses the biomechanical, neuromuscular, and metabolic
demands of the extremity. A program is developed to reestablish the
required physical capacity within the
context of job-specific requirements.
Work hardening addresses the psychosocial functions, incorporating issues of behavior, safety, and efficiency, with the goal of returning the
patient to work in a productive and
safe role.37-40

documented significantly increased

soft-tissue temperatures (P < 0.001)
and decreased sensory nerve action
potential latency in the radial nerve
(P < 0.001) after Fluidotherapy treatment in healthy subjects. Randomized controlled trials evaluating the
efficacy of treatment with Fluidotherapy are lacking.

Paraffin Therapy

The term modalities describes a variety of treatment agents and techniques

used by hand therapists. Modalities
may be classified as thermal (hot and
cold), motion, and electrical.

Paraffin therapy involves submerging

the involved hand in a bath of warm
(53C) paraffin wax. After a period
of hand warming, ROM exercises
and strengthening activities are performed. In a 2002 Cochrane review,
paraffin wax baths combined with
exercises provided short-term benefits for arthritic hands.43 However,
evidence supporting the use of paraffin therapy is limited because of the
poor quality of the trials used to
evaluate its effects.

Fluidotherapy

Cryotherapy

Fluidotherapy is a superficial heat

modality that transfers heat to exposed tissue via heated air and cellex
particles (corn cob particles ground
to the approximate granularity of
sand). The patient submerges the injured hand into an agitated bath of
cellex through a sleeve. The hand remains submerged for 10 to 20 minutes with the temperature maintained at 46 to 49C. Patients may
perform active ROM exercises during the treatment. Fluidotherapy is
primarily used to improve ROM in
patients who experience hand stiffness during healing, to desensitize
hypersensitive soft tissue, and to improve circulation.
The effects of heat on soft tissue
are well documented. Borrell et al41
demonstrated that joint capsule and
muscle temperatures increase significantly during Fluidotherapy compared with either paraffin bath treatment or hydrotherapy. Kelly et al42

Cryotherapy involves the application of

a cold substance to injured tissue to decrease tissue temperatures, thereby producing a therapeutic effect. Cooling is
used to control edema in the acute injury phase, moderate pain, decrease inflammation, and affect soft-tissue
extensibility. A Cochrane review published in 2002 did not identify any longterm objective or subjective benefits of
cryotherapy for the management of
rheumatoid arthritis.43

Modalities

470

Continuous Passive Motion

The use of CPM in hand therapy is believed to encourage passive ROM, increase circulation, and decrease edema.
However, one recent Cochrane review
concluded that because of insufficient
evidence, CPM therapy as a means to
increase strength and ROM after
metacarpophalangeal arthroplasty in
patients with rheumatoid arthritis is not
recommended.44 Another Cochrane
review identified one study providing

weak evidence of short-term increases in ROM in patients who underwent wrist CPM following the removal of external fixators to manage
distal radius fractures.23 A third Cochrane review that evaluated the efficacy of various motion modalities
for the management of flexor tendon
injuries concluded that there was
insufficient evidence to identify the
most effective rehabilitation strategy.45

High-voltage Pulsed
Galvanic Stimulation
High-voltage pulsed galvanic stimulation (HVPGS) involves the use of a
pulsed direct current applied at high
voltage; these are usually twin pulses
of short duration. HVPGS can be
used to decrease edema and accelerate wound healing. Basic science investigations have demonstrated that
pulsed current therapy is associated
with increased migration of neutrophils, macrophages, and fibroblasts.
One study demonstrated improved
collagen production and wound tensile strength compared with controls
following HVPGS.46 Evidence from
several randomized controlled trials
indicates that these effects accelerate
wound healing in vivo.47
Edema reduction following HVPGS
is thought to be the result of a decrease
in microvascular permeability after
electrical stimulation.48 Griffin et al9
demonstrated a clinically significant
decrease in edema in patients who
received HVPGS after distal radius
fractures compared with control patients who did not receive HVPGS.
This decrease in edema was similar to that produced by intermittent pneumatic compression.9 Cheing
et al49 demonstrated decreased swelling and improved ROM with pulsed
electromagnetic fields plus cold therapy (ie, ice) after distal radius fractures compared with sham pulsed
electromagnetic fields without ice.

Journal of the American Academy of Orthopaedic Surgeons

Erik Dorf, MD, et al

Neuromuscular Electrical
Stimulation
Neuromuscular electrical stimulation
(NMES) is achieved by passing an electrical impulse from a device through
electrodes placed on the skin over targeted muscles. Individual muscle bellies
or muscle groups are stimulated to produce contraction with a pulsating alternating current. NMES selectively stimulates large muscle fibers and can be
used to decrease edema, slow disuse atrophy associated with reinnervated
muscles, retrain muscles following tendon transfer, and facilitate tendon gliding after tendon repair or tenolysis.
NMES decreases edema by producing
muscle contractions that promote increased circulation and improved lymphatic drainage.50

Transcutaneous Electrical
Nerve Stimulation
A transcutaneous electrical nerve
stimulation (TENS) unit emits a lowfrequency pulsed current that interrupts painful sensations with electrical impulses. TENS units are used to
manage pain in multiple anatomic
locations. Hand therapists use TENS
units primarily for the management
of acute and chronic pain in the upper extremity. Patients may use the
units at the therapists office or at
home. TENS sessions typically last
30 to 40 minutes and are performed
up to four times per day.
The evidence for the efficacy of
TENS is mixed. Most studies provide
inconclusive evidence because of the
lack of statistical power. However, a
few adequately powered studies have
been designed to assess the effectiveness of TENS in the management of
chronic and acute pain.51
Johnson and Martinson51 performed a meta-analysis including 38
randomized controlled trials to evaluate the efficacy of electrical nerve
stimulation for the relief of chronic
pain. A significant decrease in rest
August 2010, Vol 18, No 8

pain was demonstrated following the

use of electrical nerve stimulation (P
< 0.0005). They also reported increased efficacy with percutaneous
electrical nerve stimulation versus
TENS. However, this study included
patients with several different pain
locations (including the low back)
who were treated with several different electrical modalities. A Cochrane review of the effect of TENS
on pain associated with rheumatoid
arthritis concluded that TENS was a
valuable therapeutic modality for the
management of upper extremity pain
associated with rheumatoid arthritis.52

Phonophoresis and
Iontophoresis
Phonophoresis and iontophoresis involve transdermal delivery of lowdose medication. Phonophoresis uses
ultrasound to increase skin permeability and enhance delivery of topically applied medications. Typical
medications used for phonophoresis
include salicylates, lidocaine, hydrocortisone, and dexamethasone. Iontophoresis uses a low-voltage direct
galvanic current to transfer topically
applied ions into target tissue. Polarized substances are more easily transferred through tissue with iontophoresis. Common ions used for
iontophoresis and phonophoresis include dexamethasone, saline, salicylates, and lidocaine. Both techniques
may be used for pain, inflammation,
and the prevention of scar formation.
Although both phonophoresis and
iontophoresis have been shown to effectively increase tissue penetration
of steroids,53,54 the results of clinical
trials have been less convincing. A
systematic review of the literature
concluded that there was insufficient
evidence to recommend iontophoresis for the treatment of inflammatory
musculoskeletal conditions.55

The Therapist and Patient

Care
Experienced hand surgeons recognize the importance of hand therapists and their knowledge of the use
of clinical applications to promote
patient recovery. The results of treatment using combined modalities employed by hand therapists are difficult to quantify. Positive interactions
with other hand patients during their
treatment, encouragement offered by
therapists, and the ability of the therapist to objectively quantify and
evaluate progress are important factors in encouraging patient compliance with therapy, and these variables have a positive impact on
outcomes.
Compliance with therapy is an independent determinant for return to
work after median, ulnar, and combined nerve injury.3 A randomized
trial involving patients with Colles
fractures demonstrated no significant
difference in outcomes between patients who received therapy and
those who did not.56 Although the
randomization of patients to therapy
versus no therapy in this study did
not demonstrate a statistically significant difference in mean outcome
measures, there may be a specific
group of patients with Colles fracture who benefit from therapy. Experienced surgeons may be able to selectively prescribe therapy to patients
who would benefit from it.
Therapists should have access to
the surgical note, including information regarding the expected course of
therapy and the surgeons expectations for patient outcomes. Availability of this note is particularly important for the therapist to properly
appreciate the extent and severity of
traumatic disorders. The quality of
fixation of tendons and bone, the
tension on a nerve or vessel, and the
durability of the repair play a signifi-

471

Therapy After Injury to the Hand

cant role in the ability of the therapist to help the patient successfully
move through the therapy protocol
at the appropriate rate so as to facilitate healing without compromising
the repair.

Summary
Therapy after hand injury can be divided into sequential steps, with the
goal of leading patients from injury
to recovery. In the early phases, hand
therapy addresses edema control and
wound management. Depending on
the injury, both passive and active
ROM protocols may be initiated in
these early phases. STM begins after
the wound is healed; it is used to facilitate musculotendinous motion.
Sensory reeducation and desensitization are integral throughout the rehabilitation process following nerve
injury. Strengthening, work conditioning, and work hardening make
up the final stage of rehabilitation.
Although rigorous scientific validation of specific indications is lacking,
there is uniformity of utilization of
therapy for many indications (eg,
tendon repair, chronic pain) and immense variation for other conditions.
Patient education as well as communication between therapists and
surgeons is critical for successful rehabilitation. Close coordination between surgeons and therapists specially trained in the care and
management of upper extremity disorders enables patients to progress as
rapidly as is appropriate, with the
goal of earlier recovery and maximized return of function.

35, 44, 45, 47, 49-51, 53, and 54 are

level II studies. References 8, 10, 11,
21, 23, 34, 37, 38, 42, 43, and 52 are
level III studies. References 3, 7, 12,
13, 15-20, 36, 39, and 41 are level IV
studies. References 5, 22, 25-27, 29,
31, 40, 46, and 55 are level V expert
opinion.

12.

Niederhuber SS, Stribley RF, Koepke

GH: Reduction of skin bacterial load
with use of the therapeutic whirlpool.
Phys Ther 1975;55(5):482-486.

13.

Hess CL, Howard MA, Attinger CE: A

review of mechanical adjuncts in wound
healing: Hydrotherapy, ultrasound,
negative pressure therapy, hyperbaric
oxygen, and electrostimulation. Ann
Plast Surg 2003;51(2):210-218.

Citation numbers printed in bold type

indicate references published within
the past 5 years.

14.

deLinde LG, Knothe B: Therapists

management of the burned hand, in
Hunter JM, Mackin EJ, Callahan AD,
eds: Rehabilitation of the Hand and
Upper Extremity, ed 5. St. Louis, MO,
Mosby, 2002, pp 1492-1526.

15.

Costa AM, Peyrol S, Prto LC,

Comparin JP, Foyatier JL, Desmoulire
A: Mechanical forces induce scar
remodeling: Study in non-pressuretreated versus pressure-treated
hypertrophic scars. Am J Pathol 1999;
155(5):1671-1679.

1.

2.

Hand Therapy Certification

Commission: History of Hand Therapy
Certification. Available at: https://
www.htcc.org/about/aboutk.cfm.
Accessed May 6, 2010.

16.

3.

Bruyns CN, Jaquet JB, Schreuders TA,

Kalmijn S, Kuypers PD, Hovius SE:
Predictors for return to work in patients
with median and ulnar nerve injuries.
J Hand Surg Am 2003;28(1):28-34.

Ren F, Sabbatini M, Lombardi F, et al:

In vitro mechanical compression induces
apoptosis and regulates cytokines release
in hypertrophic scars. Wound Repair
Regen 2003;11(5):331-336.

17.

4.

Sorenson MK: The edematous hand.

Phys Ther 1989;69(12):1059-1064.

Carter PR: Crush injury of the upper

limb: Early and late management.
Orthop Clin North Am 1983;14(4):719747.

5.

Mackin EJ: Prevention of complications

in hand therapy. Hand Clin 1986;2(2):
429-447.

18.

Schneider LH, McEntee P: Flexor tendon

injuries: Treatment of the acute problem.
Hand Clin 1986;2(1):119-131.

6.

Villeco JP, Mackin EJ, Hunter JM:

Edema: Therapists management, in
Hunter JM, Mackin EJ, Callahan AD,
eds: Rehabilitation of the Hand and
Upper Extremity, ed 5. St. Louis, MO,
Mosby, 2002, pp 183-193.

19.

Strickland JW: The scientific basis for

advances in flexor tendon surgery.
J Hand Ther 2005;18(2):94-111.

20.

Pettengill KM: The evolution of early

mobilization of the repaired flexor
tendon. J Hand Ther 2005;18(2):157168.

7.

Flowers KR: String wrapping versus

massage for reducing digital volume.
Phys Ther 1988;68(1):57-59.

21.

8.

Oosterveld FG, Rasker JJ: The effect of

pressure gradient and thermolactyl
control gloves in arthritic patients with
swollen hands. Br J Rheumatol 1990;
29(3):197-200.

Bulstrode NW, Burr N, Pratt AL,

Grobbelaar AO: Extensor tendon
rehabilitation a prospective trial
comparing three rehabilitation regimes.
J Hand Surg Br 2005;30(2):175-179.

22.

Li Z, Smith BP, Smith TL, Koman LA:

Diagnosis and management of complex
regional pain syndrome complicating
upper extremity recovery. J Hand Ther
2005;18(2):270-276.

23.

Handoll HH, Madhok R, Howe TE:

Rehabilitation for distal radial fractures
in adults. Cochrane Database Syst Rev
2002;2:CD003324.

24.

Feehan LM, Bassett K: Is there evidence

for early mobilization following an
extraarticular hand fracture? J Hand
Ther 2004;17(2):300-308.

25.

Wong SK: Classification of hand

splinting. Hand Surg 2002;7(2):209-213.

26.

Schultz-Johnson K: Static progressive

9.

10.

References
Evidence-based Medicine: Levels of
evidence are described in the table of
contents. In this article, reference 56 is
a level I study. References 9, 24, 32,

472

Stanton DB: Building collaborative

partnerships: ASHT Presidential address
at the annual meeting, San Antonio,
September 2005. J Hand Ther 2006;
19(1):51-55.

11.

Griffin JW, Newsome LS, Stralka SW,

Wright PE: Reduction of chronic
posttraumatic hand edema: A
comparison of high voltage pulsed
current, intermittent pneumatic
compression, and placebo treatments.
Phys Ther 1990;70(5):279-286.
Chen AH, Frangos SG, Kilaru S, Sumpio
BE: Intermittent pneumatic compression
devices: Physiological mechanisms of
action. Eur J Vasc Endovasc Surg 2001;
21(5):383-392.
Giudice ML: Effects of continuous
passive motion and elevation on hand
edema. Am J Occup Ther 1990;44(10):
914-921.

Journal of the American Academy of Orthopaedic Surgeons

Erik Dorf, MD, et al

splinting. J Hand Ther 2002;15(2):163178.
27.

Melzack R, Wall PD: Pain mechanisms:

A new theory. Science 1965;150(699):
971-979.

28.

Walsh MT, Muntzer E: Therapists

management of complex regional pain
syndrome (reflex sympathetic
dystrophy), in Hunter JM, Mackin EJ,
Callahan AD, eds: Rehabilitation of the
Hand and Upper Extremity, ed 5. St.
Louis, MO, Mosby, 2002, pp 17071724.

29.

Koman LA, Smith TL, Smith BP, Li Z:

The painful hand. Hand Clin 1996;
12(4):757-764.

30.

Dellon AL: Re-education of sensation, in

Dellon AL, ed: Evaluation of Sensibility
and Re-Education of Sensation in the
Hand. Baltimore, MD, Williams &
Wilkins, 2009, pp 203-246.

31.

32.

33.

34.

35.

36.

37.

Beissner KL, Saunders RL, McManis BG:

Factors related to successful work
hardening outcomes. Phys Ther 1996;
76(11):1188-1201.

38.

Feuerstein M, Callan-Harris S, Hickey P,

Dyer D, Armbruster W, Carosella AM:
Multidisciplinary rehabilitation of
chronic work-related upper extremity
disorders: Long-term effects. J Occup
Med 1993;35(4):396-403.

39.

Johnson LS, Archer-Heese G, CaronPowles DL, Dowson TM: Work

hardening: Outdated fad or effective
intervention? Work 2001;16(3):235-243.

40.

Schultz-Johnson K: Work hardening: A

mandate for hand therapy. Hand Clin
1991;7(3):597-610.

41.

Sutton GS, Bartel MR: Soft-tissue

mobilization techniques for the hand
therapist. J Hand Ther 1994;7(3):185192.
Conroy DE, Hayes KW: The effect of
joint mobilization as a component of
comprehensive treatment for primary
shoulder impingement syndrome.
J Orthop Sports Phys Ther 1998;28(1):
3-14.

42.

Fedorczyk JM: Therapists management

of elbow tendinitis, in Hunter JM,
Mackin EJ, Callahan AD, eds:
Rehabilitation of the Hand and Upper
Extremity, ed 5. St. Louis, MO, Mosby,
2009, pp 1271-1281.

43.

Sayer AA, Syddall HE, Martin HJ,

Dennison EM, Roberts HC, Cooper C: Is
grip strength associated with healthrelated quality of life? Findings from the
Hertfordshire Cohort Study. Age Ageing
2006;35(4):409-415.
Guzelkucuk U, Duman I, Taskaynatan
MA, Dincer K: Comparison of
therapeutic activities with therapeutic
exercises in the rehabilitation of young
adult patients with hand injuries. J Hand
Surg Am 2007;32(9):1429-1435.
Mathiowetz V, Weber K, Volland G,
Kashman N: Reliability and validity of

August 2010, Vol 18, No 8

chronic leg ulcer size and appearance.

Phys Ther 2003;83(1):17-28.

grip and pinch strength evaluations.

J Hand Surg Am 1984;9(2):222-226.

44.

Borrell RM, Parker R, Henley EJ,

Masley D, Repinecz M: Comparison of
in vivo temperatures produced by
hydrotherapy, paraffin wax treatment,
and fluidotherapy. Phys Ther 1980;
60(10):1273-1276.
Kelly R, Beehn C, Hansford A, Westphal
KA, Halle JS, Greathouse DG: Effect of
fluidotherapy on superficial radial nerve
conduction and skin temperature.
J Orthop Sports Phys Ther 2005;35(1):
16-23.
Robinson V, Brosseau L, Casimiro L,
et al: Thermotherapy for treating
rheumatoid arthritis. Cochrane Database
Syst Rev 2002;2:CD002826.
Massy-Westropp N, Johnston RV, Hill
C: Post-operative therapy for
metacarpophalangeal arthroplasty.
Cochrane Database Syst Rev 2008;1:
CD003522.

45.

Thien TB, Becker JH, Theis JC:

Rehabilitation after surgery for flexor
tendon injuries in the hand. Cochrane
Database Syst Rev 2004;4:CD003979.

46.

Broughton G II, Janis JE, Attinger CE:

Wound healing: An overview. Plast
Reconstr Surg 2006;117(7 suppl):1e-S32e-S.

47.

Houghton PE, Kincaid CB, Lovell M,

et al: Effect of electrical stimulation on

48.

Reed BV: Effect of high voltage pulsed

electrical stimulation on microvascular
permeability to plasma proteins: A
possible mechanism in minimizing
edema. Phys Ther 1988;68(4):491-495.

49.

Cheing GL, Wan JW, Kai Lo S: Ice and

pulsed electromagnetic field to reduce
pain and swelling after distal radius
fractures. J Rehabil Med 2005;37(6):
372-377.

50.

Man IO, Morrissey MC, Cywinski JK:

Effect of neuromuscular electrical
stimulation on ankle swelling in the early
period after ankle sprain. Phys Ther
2007;87(1):53-65.

51.

Johnson M, Martinson M: Efficacy of

electrical nerve stimulation for chronic
musculoskeletal pain: A meta-analysis of
randomized controlled trials. Pain 2007;
130(1-2):157-165.

52.

Brosseau L, Judd MG, Marchand S,

et al: Transcutaneous electrical nerve
stimulation (TENS) for the treatment of
rheumatoid arthritis in the hand.
Cochrane Database Syst Rev 2003;3:
CD004377.

53.

Gurney AB, Wascher DC: Absorption of

dexamethasone sodium phosphate in
human connective tissue using
iontophoresis. Am J Sports Med 2008;
36(4):753-759.

54.

Saliba S, Mistry DJ, Perrin DH, Gieck J,

Weltman A: Phonophoresis and the
absorption of dexamethasone in the
presence of an occlusive dressing. J Athl
Train 2007;42(3):349-354.

55.

Hamann H, Hodges M, Evans B:

Effectiveness of iontophoresis of antiinflammatory medication in the
treatment of common musculoskeletal
inflammatory conditions: A systematic
review. Physical Therapy Reviews 2006;
11:190-194.

56.

Wakefield AE, McQueen MM: The role

of physiotherapy and clinical predictors
of outcome after fracture of the distal
radius. J Bone Joint Surg Br 2000;82(7):
972-976.

473