The Effectiveness of Early Mobilization After Tendon Transfers in The Hand

SCIENTIFIC/CLINICAL ARTICLE
The Effectiveness of Early Mobilization after

Tendon Transfers in the Hand: A Systematic
Review
Shaik Shaguftha Sultana, MPT ABSTRACT:

Faculty of Health Sciences, School of Health and Study Design: Systematic review.
Introduction: Over the past decade, early mobilization (initi-
Rehabilitation Sciences, Physical Therapy Field, University ated within a week) has become an increasing trend in postopera-
of Western Ontario, London, Ontario, Canada tive rehabilitation after tendon transfer surgery in the hand.
However, there are no published reviews summarizing the effec-
Joy C. MacDermid, MSc, PT, PhD tiveness of early mobilization protocols in comparison with con-
ventional immobilization in tendon transfer rehabilitation.
Health and Rehabilitation Sciences, Physical Therapy Purpose: To systematically review available evidence on the ef-
Field., University of Western Ontario, London, Ontario, fectiveness of early mobilization protocols to conventional immo-
Canada bilization protocol after tendon transfers in the hand.
Methods: A literature search of the Cochrane Library, PubMed,
Hand and Upper Limb Centre, Clinical Research PEDro, EMBASE, and CINAHL databases was conducted (1980 to
Laboratory, St. Joseph’s Health Centre, London, Ontario, date). Randomized controlled trials (RCTs), caseecontrol, and other
Canada study designs were included. Six articles were eligible for inclusion
Assistant Dean, School of Rehabilitation Science, in the analysis (five RCTs and one retrospective study) and 260 arti-
cles that did not meet inclusion criteria were excluded. Level of ev-
McMaster University, Hamilton, Ontario, Canada idence (Center for Evidence-based Medicine) and methodological
quality (Structured Effectiveness Quality Evaluation Scale [SEQES]
Ruby Grewal, MD, MSc, FRCSC score) of each study were assessed by two independent reviewers.
Results: This review found three high quality trials (SEQES
Hand and Upper Limb Centre, St. Joseph’s Health Care, score: 35e43 of 48), with level 1b and 2b evidence, supporting early
Division of Orthopedics, University of Western Ontario, mobilization of tendon transfers. The literature reports reduced to-
268 Grosvenor St, London, Ontario, Canada tal cost, total rehabilitation time, and demonstrates that early mo-
bilization is a safe approach with no incidence of tendon ruptures
or insertion pull out. In the initial phase of rehabilitation, outcomes
Santosh Rath, MS, PhD like range of motion, grip strength, pinch strength, total active mo-
Department of Orthopaedics, Hi-tech Medical College, tion of digits, deformity correction, and tendon transfer integration
Bhubaneswar, Orissa, India were significantly superior with early mobilization compared with
immobilization. However, in the long term, these outcomes were
similar in both the groups, suggesting that early mobilization pro-
tocol improves hand function in the initial phase of rehabilitation
(four weeks) and the long-term results (two months to one year)
are equivalent to immobilization.
Conclusions: Based on a limited number of small studies, there
is evidence of short-term benefit for early mobilization, but incon-
clusive findings for longer-term outcomes. Until the body of evi-
dence increases, clinicians should consider the clinical context,
their experience in optimizing patient outcomes after surgery,
and the patient’s preferences when selecting between early and
late mobilization after tendon transfer.
Level of Evidence: 2a.
J HAND THER. 2012;jj:jej.
Hand function requires complex integration of joint secondary to neuromuscular paralysis, injury or
structure, mobility, muscle strength, and coordina- disease of the muscles, tendons or central nervous
tion. Loss of movement in the hand, whether system can dramatically reduce a person’s ability to
perform normal activities of daily life (ADLs).
Deformity, reduced grip or pinch strength, reduced
Correspondence and reprint requests to Shaik Shaguftha Sultana,
MPT, Elborn College, 1201 Western Road, London, Ontario N6G range of motion (ROM), and/or loss of sensibility can
1H1, Canada; e-mail: <ssultan5@uwo.ca>. seriously compromise hand function.1 When muscle
0894-1130/$ - see front matter Ó 2012 Hanley & Belfus, an imprint function does not recover or never expected to re-
of Elsevier Inc. All rights reserved. cover, one treatment option is transferring active
http://dx.doi.org/10.1016/j.jht.2012.06.006 muscles (tendon transfers) to substitute for the
jej 2012 1
muscle action that has been lost.2 By definition, a recommendations and more conclusive results from
‘‘tendon transfer’’ is the process of relocating the in- the existing literature on the effectiveness and effi-
sertion of a functioning muscleetendon unit to re- ciency of postoperative rehabilitation protocols, com-
store lost movement and function at another site.3 paring early mobilization with early immobilization.
Tendon transfers are designed to reestablish the lost
function by moving the insertion or origin of a nearby
functioning muscle, which can be spared without sig- OBJECTIVE
nificant donor morbidity, to a location where it can
produce a required muscle action. A close working re- To systematically review and summarize available
lationship among patient, therapist, and surgeon is evidence on the effectiveness of early mobilization
thought to improve tendon transfer outcomes.1,4e6 protocols on hand function after tendon transfers in
Rehabilitation after tendon transfers is recognized comparison to conventional immobilization.
as critical to achieving functionality of the transferred
muscle tendon unit.1 Conventional postoperative
management after tendon transfers in the hand con-
METHODS OF REVIEW
sists of immobilizing the extremities in plaster cast
Search Strategy
for three to five weeks to allow the transferred tendon
attachment heal at its new insertion site. The rationale An extensive literature search of the following
was that immobilization imposed less tension on the databases was conducted: Cochrane Central
healing tendon,2 which was needed for optimized, Register of Controlled Trials and the Database of
safe healing.4,7,8 Abstracts of Effectiveness, The Cochrane Library,
The concepts around early motion in hand recon- PUBMED (January 1980 to present), EMBASE
struction arose after discoveries of the importance of (January 1980 to present), CINAHL (January 1982 to
early motion in improving tendon repair out- present), and PEDro (2000 to present). The search was
comes.1,4,9,10,11 Over the past decade, early mobiliza- limited to English language publications. The refer-
tion protocols initiated during the first week after ence lists of all identified articles were scanned for
tendon transfer surgery have been put forth as a additional relevant studies (Figure 2).
means of improving the effectiveness or efficiency Search terms included ‘‘tendon transfers’’ or ‘‘ten-
in attaining functional outcomes.8,11e15 The early mo- don transposition’’ or ‘‘tendon transplantation’’ or
bilization protocol in tendon transfer rehabilitation ‘‘tendon transfer surgery’’ and ‘‘physiotherapy’’ or
follows the common principles developed for tendon ‘‘physical therapy’’ or ‘‘exercise therapy’’ or ‘‘occupa-
repair rehabilitation, this involves mobilization of tional therapy’’ or ‘‘hand therapy’’ or ‘‘hand rehabil-
tendon in a restricted range and protection of the itation’’ or ‘‘mobilization’’ or ‘‘early mobilization’’ or
site of repair from stretch and dehiscence with or ‘‘early motion’’ ‘‘immediate motion’’ or ‘‘ immediate
without the use of an orthoses. Early active motion af- mobilization’’ or ‘‘early exercise’’ or ‘‘immobilization’’
ter tendon transfers in the hand improves tendon and ‘‘hand’’ or ‘‘hand function.’’ The detailed search
glide, excursion, and function. It also helps to reduce strategy is available from the authors. We included
the incidence of adhesion formation, swelling, mus- randomized controlled trials (RCTs), cohort, and other
cular atrophy, and joint stiffness.1 Several studies design studies (retrospective trials, prospective trials,
have compared the differences between early motion and caseecontrol series). Unpublished, conference
protocols and immobilization protocols by focusing proceedings, thesis, and dissertation (gray literature),
on outcomes such as total treatment time, time off and nonhuman and biomechanical studies were
work, cost, deformity correction, risk of tendon trans- excluded.
fer pull out, and restoration of hand function.13e15
Few studies evaluated the safety and applicability Selection for Inclusion
of early mobilization in tendon transfers by integrat-
ing the established principles of tendon repair reha- Studies in which patients had a tendon transfer
bilitation.1,8,11,12 In addition to this, a theoretical surgery in the hand that investigated the effect of
framework based on the literature specific to tendon rehabilitation (early controlled mobilization or early
transfers and knowledge about neuromuscular func- active mobilization and/or immobilization) and had
tion in general may also provide a tentative explana- described at least two groups: an intervention group
tion for how early mobilization affects outcomes after and a control group were eligible for inclusion. The
tendon transfer surgery (Figure 1). articles were selected for full review with the follow-
Until now, there has been no published review ing inclusion criteria: 1) Studies: RCTs, prospective
summarizing the effectiveness of early mobilization trials, retrospective trials, and case series; 2)
protocol in comparison to conventional immobiliza- Participants: Adults aged 20e80 years, both genders
tion in tendon transfer rehabilitation. Hence, this who had undergone tendon transposition surgery for
systematic review was conducted to provide the correction of finger deformities in the hand, either
2 JOURNAL OF HAND THERAPY

Early Mobilization
Reduced Reduced
Early Reduced edema through Reduced Increased patient
atrophy, better
activation of joint active motion scarring and engagement in
contractile
motor cortex stiffness adhesions tendon
function of
rehabilitation
muscle
Less pain and
Better joint joint stiffness Better tendon
Better Better strength Increased
motion excursion
recruitment of of transferred adherence and
the transferred availability motivation
muscle
muscle
Better
adherence to Better pull
Better exercise through of Greater
excursion with Enhanced grip transfer persistence with
recruitment of and stability functional
More TT
activation of Better training
functional response to Better active
tasks therapy motion and
Increased Better control enhanced hand Better
effectiveness of object function functional
of exercise Improved manipulation outcomes
Better outcomes
functional
performance
Better
response to
therapy
Improved
outcomes
FIGURE 1. Theoretical framework.
after peripheral nerve injury or disease (e.g., leprosy nervous system disorder; 3) If the study used only
or Hansen’s disease) or any other orthopedic condi- one protocol without a comparison.
tion, occurred due to traumatic or nontraumatic The initial selection of the studies, based on titles
injury or rheumatologic causes (e.g., tendon ruptures and abstracts, was first performed by one reviewer
or rheumatoid arthritis or distal radius fracture or and then reviewed by a second. If there was any
severe carpel tunnel syndrome/or idiopathic); 3) uncertainty of eligibility for inclusion, a full-text
Intervention: Inpatient- or institution-based physical review was conducted. The full text of all eligible
therapy conducted by physiotherapist, occupational studies was obtained and reviewed for the inclusion
therapist, or hand therapist or supervised home criteria described previously. In total, 266 English
programs with early active mobilization or early language articles were identified through the biblio-
controlled mobilization protocols; orthotic devices graphic literature search (Figure 2). Based on the title
were either dynamic or static (removable during and abstract, 253 studies were not eligible and ex-
exercises); 4) Outcome measures: Patient-centered cluded. The full texts of the remaining 13 were subse-
outcomes such as, pain, swelling, deformity correc- quently reviewed. Based on the previously described
tion, satisfaction, and health-related quality of life inclusion and exclusion criteriae, an additional seven
(QOL); measures of physical impairment such as articles were excluded for the following reasons: lack
ROM, strength, hand functions, manual dexterity of comparison (n ¼ 1), lack of an early intervention
and coordination; return to work, total rehabilitation protocol (n ¼ 3), duplicate publication with new out-
time; as well as cost analysis; 5) Only full-length, come measures (n ¼ 1), individual case study (n ¼ 1),
original articles in English. and an in vitro evaluation (n ¼ 1). This left six articles
The articles were excluded for our final review if for the final evaluation and inclusion into our system-
they met any of the following criteria: 1) Studies: atic review. Two independent evaluators then as-
In vitro, expert opinion, biomechanical, and individ- sessed the selected articles using a standardized
ual case studies and case reviews; and technical and critical appraisal form and process previously de-
epidemiology articles; 2) Participants: Progressive scribed.16,29 The level of evidence of each study was
neuromuscular diseases (multiple sclerosis), obstetric also graded (one to four) based on the Sacket’s level
brachial palsy, complete brachial plexus palsy, spinal of evidence scale (Center for Evidence-based
cord injury, congenital disorder, and any other central Medicine [CEBM]).17
jej 2012 3
Databases searched:
PubMed -145
PEDro- 2
Cochrane- 8
EMBase -76
CINAHL -35
Citations identified and screened
on the basis of titles and abstracts
in Total = 266
Articles included for Identified by hand Excluded = 251

detailed evaluation search from references of
=11 included articles = 2 Did not meet the
inclusion criteria.
[First search] [Secondary search]
Articles included for evaluation after first and

secondary search = 13
Excluded after evaluation = 7

Retrieved eligible Reasons:
In vitro study -1
Articles FOR Not early Intervention -3
Case report-1
final assessment = 6 Second publication in different language-1
No comparison group-1
FIGURE 2. Flow chart for search strategy.
The structured appraisal was performed using the SEQES checklist. The results were then compared,
Structured Effectiveness Quality Evaluation Scale any discrepancies were discussed, and the scores
(SEQES) published previously,29 and used in other re- were reevaluated assigning a final consensus score
views where consistent high reliability has been for each article. The consensus scores were used for fi-
shown (Table 1). The SEQES score rates the quality nal evaluation.
of the article methodology through examination of
seven general categories: study question, study de- Data Synthesis
sign, subjects, intervention, outcomes, analysis, and
recommendations. Each category has several criteria The following aspects of the selected studies were
and each criterion was scored zero, one, or two. A summarized by means of a predefined data extrac-
score of zero meant that the criterion was not met at tion form: design, population, intervention, evalua-
all, one meant that the criterion was partially met, tions, outcome measures, and results. The studies
and two that meant the criterion was fully met accord- were divided into two groups, namely immobiliza-
ing to the published SEQES guidelines (Appendix, tion and early mobilization. Early mobilization is
see appendix on the journal’s Web site at www.else- defined as mobilization of the tendon through active
vier.com). Using the SEQES scores, high-, moderate- or passive flexion and extension starting within one
, and low-quality levels were assigned. High-quality week of surgery. There are two different types of
studies had SEQES scores between 33 and 48. early mobilization: early active mobilization or early
Moderate-quality studies had SEQES scores between controlled mobilization. Early active mobilization
17 and 32, and low-quality studies had scores #16. means active flexion and extension of the involved
Each article was independently scored using the digit or digits. This may be unrestricted motion,

TABLE 1. Evaluation of Study Design (SEQES)
SEQES Criteria
Study question
1. Was relevant background work cited to establish a foundation for the research questions?
Study design
2. Was a comparison group used?
3. Was patient status at more than one time point considered?
4. Were data collection performed prospectively?
5. Were patients randomized to groups?
6. Were patients blinded to the extent possible?
7. Were treatment providers randomized to the extent possible?
8. Was an independent evaluator used to administer the outcome measures?
Subjects
9. Did sampling procedures minimize sample/selection biases?
10. Were inclusion/exclusion criteria defined?
11. Was an appropriate enrollment obtained?
12. Was appropriate retention/follow-up obtained?
Intervention
13. Was the intervention applied according to established principles?
14. Were biases due to the treatment provider minimized?
15. Was the intervention compared with the appropriate comparator?
Outcomes
16. Was an appropriate primary outcome defined?
17. Was an appropriate secondary outcomes considered?
18. Was an appropriate follow-up period incorporated?
Analysis
19. Was an appropriate statistical test(s) performed to indicate differences related to the intervention?
20. Was it established that the study had significant power to identify treatment effects?
21. Was the size and significance of the effects reported?
22. Were missing data accounted for and considered in interpreting results?
23. Were clinical and practical significance considered in interpreting results?
Recommendations
24. Were the conclusions/clinical recommendations supported by the study objectives, analysis, and results?
Scoring methodology
0—criterion was not met
1—criterion was partially met
2—criterion was fully met
Total quality score
Low (0e16)
Moderate (17e32)
High (33e48 points)
SEQES ¼ Structured Effectiveness Quality Evaluation Scale.
limited range, or protected within an orthotic device, Because of the limited number of controlled trials
but its key characteristic is the active contraction. In and a large variability with respect to the type of
the case of tendon transfers, early active motion is patients, surgery, outcome measures, and the rehabil-
typically performed within a limited ROM, but can itation regimens, we were not able to perform statis-
involve periods without orthotic protection. Early tical pooling of the results (meta-analysis). Where
controlled mobilization means movement of the data allowed standardized mean, differences (effect
joints in an orthotic device within a restricted size) were calculated for continuous outcomes. We
ROM; but the antagonist performed active motion performed a best evidence synthesis by attributing
while the agonist motion is produced passively. This levels of evidence based on the design of the studies
commonly occurs with elastic bands to produce the (CEBM)17 and the assessment of methodological qual-
function of the transferred muscle during the early ity16 described previously and categorized them into
healing phase. There are variations in early con- low, medium, and high quality. To determine the in-
trolled mobilization protocols, based on the tendons terrater reliability of the quality appraisal tool and
involved. For example in tendon transfer for finger the level of agreement or disagreement between the
flexion, active extension is followed by passive flex- two raters, kappa statistics for individual criterion,
ion through the stored force (potential energy) percentage of agreement, and overall correlation (in-
within the elastic band. When a tendon transfer is traclass correlation coefficient [ICC]) was calculated
used to provide finger extension, the reverse process and graded according to Landis and Koch.28 Landis
occurs. and Koch28 have proposed the following as standards
jej 2012 5
TABLE 2. Description of Study Background (Patient, Intervention, and Outcome Measures)
6
Study Patients Intervention Evaluations

JOURNAL OF HAND THERAPY
N, Age, Sex, Disorder,

Design Surgery, Group Type/mode Time Design Type, when Administered
Germann et al.,8 2001;
Randomized N ¼ 20 (15 M; 5F) 1: Outrigger forearm 1: Controlled active flexion 1: After 3 wk, removal of Range of motion (ROM;
prospective trial Rupture of extensor pollicis orthoses with rubber bands. of IP joint at 458 in first week, forearm orthoses computer based-
longus after trauma or Wrist in 208 extension, 608 in second week. Hand therapy: Supported goniometer)
rheumatoid arthritis (RA) thumb in full extension and Unlimited flexion in third active flexion, extension, Grip strength (Jamar
Transfer of extensor indices abduction week and resistance to motion dynamometer)
proprius to extensor pollicis 2: Forearm cast, wrist 208 2: No movement for 3 wk Occupational task training Pinch grip (electronic gauge)
longus tendon for thumb extension, thumb full with weights Duration of treatment
extension extension and abduction 2: Removal of cast after 3 wk Time off work
1: Early dynamic motion Hand therapy as in group 1 Cost analysis
protocol (n ¼ 10), age: 52 yr Both groups 1 and 2: Follow-up:
(range: 23e76) Allowed full function after 3, 4, 6, and 8 wk after
2: Immobilization (n ¼ 10), 3 wk of hand therapy surgery
age: 42 yr (range: 24e62) Exercise dosage not * Results expressed as
specified compared with the opposite
side
Rath,11 2006; Prospective
trial N ¼ 12 (39 M; 11 F) 1: Until second day after 1: Removal of cast 48 h after 1: Inpatient therapy twice a Tendon transfer pullout in
Age: range, 16e22 yr surgery, use of plaster of surgery day for the first 2 wk and group 1 measured before
Hansen’s disease—lower Paris cast molded into the Transfer actively mobilized thereafter once a day and after exercise therapy
median nerve paralysis first web space to keep the on second day until fourth First week: Isolation (a sudden or progressive
Transfer for opposition of thumb in maximum week exercises 10 reps of transfer decrease in the RAA and
thumb with flexor digitorum abduction/rotation. In 2: No movement for 3 wk in eliminated gravity, with active range abduction
superficialis (ring finger) or addition, for pain relief, a Transfer actively mobilized wrist in neutral and then in (ARA) of the thumb)
extensor indicis proprious. dorsal orthotic device was on fourth week 308 of flexion Results of opposition
1: Immediate active motion applied to the wrist in The resting abduction angle transfer in both groups
protocol (n ¼ 5) neutral position (RAA) was recorded daily to assessed by:
2: Immobilization protocol 2: Plaster of Paris cast with detect any loss of tension in 1) Thumb ARA
(n ¼ 7) the thumb in full abduction the transfer (ARA ¼ AAA e RAA)
for 3 wk The active abduction angle * Scores graded as, 5 (.458 )
* To avoid thumb adduction, (AAA) was recorded at the and 0 (#358 )
hands in both groups were end of each week ii) Pinch pattern: opposition
supported in an orthotic Second week: Integration tendon transfer that restores
device for the first web, after exercises for thumb, pinch, adequate abduction and
therapy, until end of third and opposition for digits rotation will enable pulp-to-
week With RAA at 408 e508 , tripod pulp pinch, and those with
pinch by index and middle limitation will achieve only
fingers was initiated pulp-to-side or key pinch
Patients with earlier pain * An evaluation score of 2 was
relief and quicker allocated to pulp-to-pulp
integration progressed to pinch and a score of 1 for key
activities such as picking up pinch
small light objects ,100 g iii) Pinch strength:
(e.g., plastic balls and Handheld pinch gauge
wooden pegs). * Pinch strengths graded in
Third week: Strengthening, relation to unaffected side
coordination exercises. as: good (.50%), fair
Underwater exercises (between 21% and 50%),
Thumb adduction avoided poor (,20%)
until third week. Activities Follow up
of daily living (ADLs) 1: Early outcome
trained within a limited assessments at 16 wk and
range of thumb abduction late assessments at 7 mo
(e.g., holding an empty glass after surgery
with a maximum weight 2: Early assessment at 19 wk
limit of 250 g) and late assessment $8 mo
after surgery
* All above scores are added
and the combined score is
graded on an Evaluation
scale of 10 (Mehta and
Malaviya30): good (8e10),
fair(5e7), and poor (#4)
Megerle et al., 2008;
Randomized trial N ¼ 21 (11 M; 10 F) 1: Outrigger dynamic 1:From second day after 1: After 3 wk, removal of Active ROM (AROM), IP
Rupture of extensor pollicis extension orthoses with surgery, controlled active outrigger dynamic orthoses joint, MCP joint (small
longus after trauma/RA/ rubber traction mechanism flexion of IP joint at 458 in Self-conducted ROM goniometer)
idiopathic 2: No orthoses. Immediate first week and 60 8 after that exercises Bilateral grip
Transfer of extensor indicis active motion of IP joint (with a thermoplastic flexion Passive thumb extension by Strength (Jamar dynamometer)
proprius to extensor pollicis For both groups: second day block) elastic rubber traction Thumb-index tip-pinch
longus tendon to restore of surgery, removal of 2: From second day of Exercises 10 reps/h strength (pinch
thumb extension plaster cast and donning of surgery, active flexion of IP Visit a hand therapist three dynamometer)
1: Early dynamic motion fabricated thermoplastic joint at 458 in first week and times per week Follow-up: 3, 4, 6, and 8 wk
protocol (n ¼ 10), Age: 51 yr orthoses (dynamic extension 608 after that (with a Complete removal of after surgery
(range: 26e73) orthoses) with the wrist in thermoplastic flexion block). orthoses after 3 wk of Results expressed as mean
2: Early active motion 208 extension, and thumb * After passive thumb therapy and initiation of percentages of AROM of
protocol (n ¼ 10), age: 59 yr MCP joint in full extension extension in group 1 and complex and coordinative MCP joint and IP joint
(range: 33e78) * Both groups were active extension in group 2, physical therapy (PT), and compared with contralateral
immobilized between the the MCP joint was held in occupational therapy (OT) thumb
exercises extension in an orthotic training * Grip and Tip-pinch strength
device to isolate IP joint 2: Active thumb extension data not given
motion Self-conducted exercises,
10 reps/h
Visit therapist three times
per week
jej 2012
No orthotic device used after

3 wk of therapy
Progressed to complex
coordinative PT and OT
training
7
(continued on next page)

8
TABLE 2 (Continued )

13
Rath, 2008; Prospective
trial N ¼ 12 (49 M; 14 F) 1: Until second day after 1: Removal of cast after 48 h. 1: First and second week (in Tendon insertion pull out
Age range: 16e22 yr surgery for pain relief, the Transfer actively mobilized patient): removal of the cast i) MCP, PIP joint angles:
Hansen’s disease—complete hand supported in a plaster on second day until fourth after 48 h AROM (handheld
ulnar nerve paralysis of Paris dorsal cast, week Active flexion of the MCP goniometer)
Tendon transfer with flexor extending to the PIP joint 2: No movements for 3 wk joint keeping PIP joint in full a) Open hand position: MCP
digitorum superficialis of With the wrist in neutral and Transfer actively mobilized extension and then fist and PIP extension
middle finger, four-tail the MCP joint in 708 flexion in fourth week closure by active PIP joint b) Intrinsic plus position:
pulley insertion for four- 2: Patients had plaster of flexion MCP flexion, PIP extension.
digit claw deformity Paris casts applied in the Opening the fist, by active (This position is a
correction above position for 3 wk extension of PIP joint at first comprehensive measure of
1: Immediate active motion * Hands in both groups were keeping the MCP joint flexed tendon transfer activity and
protocol (n ¼ 31 patients and supported after hand and then MCP joint integration following claw
32 hands), mean age: 27 yr therapy with a 708 dorsal extension to achieve an open correction)
(range 13e55 yr; SD: 10.79) blocking orthotic device in hand position c) Fist closure: fingertips to
2: Immobilization protocol the first week and a 508 Overstretching of transfer reach the distal palmar
(n ¼ 32 patients, 32 hands), dorsal blocking orthotic avoided by therapist’s hand crease or proximal palmar
mean age: 31 yr (range: 14e device in the second week. with a dorsal MCP joint crease, or an inability to
55 yr; SD: 13.14) In third week, it was block at 308 touch the palm with active
reduced to 308 and later used From maximum MCP joint fist closure
only at nights for 3 mo extension in open hand d) Total active motion of the
position, the flexion 3 digit joints
sequence was repeated to ii) Tendon transfer
fist closure integration results, graded
Third and fourth week: according to Palande’s
initiation of transfer criteria (good, fair, and poor)
strengthening exercises and a) Deformity correction
light functional activities b) Transfer integration in
At the end of third week of intrinsic plus position
therapy, occupational c) Fist closure
therapy for ADLs restricted iii) Morbidity: time from
to a weight limit of 453 or surgery to discharge with
500 g initiated good hand function
Dorsal blocking orthoses Follow-up:
used only at night for 3 mo Once a month for 3 consecutive
Patients discharged from mo, then at 3-mo intervals
rehabilitation when they for 1 yr, and subsequently
were able to perform ADLs once a year
independently (dressing, * Patients with good transfer
grooming, and eating) integration and strength
allowed to return to
2: Removal of plaster cast sedentary occupations, and
after 3 wk at 8 wk unrestricted
Digital orthoses with PIP activities
joint in full extension
applied during therapy to
assist transfer integration
exercises
* Rehabilitation protocol in
group 1 during the first,
second, third, and fourth
postoperative weeks
corresponded to group 2
during fourth, fifth, sixth,
and seventh postoperative
weeks
Rath et al.,14 2009;
Randomized N ¼ 50 (39 M; 11 F) 1: Until second day after 1: Removal of cast after 48 h. 1: First and second week Primary outcome measures:
controlled trial Hansen’s disease—claw surgery, hands were Transfer actively mobilized (inpatient): Active flexion of a) AROM of each digit
hand deformity due to supported in plaster of Paris, on second day after surgery MCP, while attempting to (calculated by subtracting
median nerve or ulnar nerve and a dorsal orthotic device until fourth week keep the PIP in full extension angles at open hand position
or combined nerve paralysis with MCP in 708 flexion and 2: No movements for 3 wk and then fist closure by from fist closure angles. All
Transfer of the middle finger PIP in extention, and wrist in Transfer actively mobilized active PIP flexion angles in the individual
flexor digitorum neutral position on fourth week Fist opening by PIP active patients were recorded in
superficialis tendon to 2: Circular plaster of Paris extension, keeping the MCP steps of 58 )
correct claw deformity cast applied in a similar flexed and then extending b) Tendon transfer pullout
1: Immediate active motion position to that of group MCP to achieve an open incidence (assessed by rapid
protocol, n ¼ 25, age: 31 yr 1 for 3 wk hand position. extension of MCP in open
(610) * Hands in both groups were A 308 dorsal MCP joint block hand position with loss of
2: Immobilization protocol, supported after therapy in used by the therapist to MCP flexion in intrinsic plus
n ¼ 25, age: 28 yr (610) dorsal blocking orthotic avoid overstretching of the position. A decrease in
device, which kept MCP transfer AROM of MCP indicates
joint in 708 of flexion in first From open hand position, transfer insertion pullout)
week, 508 in second week, again flexion is performed in c) Time until discharge
and thereafter reduced to 308 sequence Secondary outcomes:
of flexion, donning only at Third week: Strengthening a) Swelling (measured by
night for 3 mo to prevent exercises and light measuring the volume of the
stretching of the transfer functional activities initiated operated hand using a water
Occupational therapy for displacement method).
ADL restricted to a weight b) Pain (Visual Analogue
limit of 453 or 500 g Scale assessed at the end of
Patients discharged after each week)
achieving independent ADL c) Grip strength (Jamar
jej 2012
(dressing, grooming, and dynamometer)

eating).
9
10

* Treatment protocol in group d) Key Pinch strength (pinch
1 during the first, second, dynamometer)
third, and fourth e) Dexterity (timed pick-up
postoperative weeks, test).
corresponded to group 2 f) Return to work, at 3-mo
during the fourth, fifth, follow-up after discharge
sixth, and seventh Outcome assessments of
postoperative weeks both groups were compared
2: Fourth week: A digital with two time periods:
orthoses with PIP in full 1) discharge from
extension is applied to assist rehabilitation (discharge
transfer integration exercises analysis) and
The hand is supported after 2) Last follow-up, more than
therapy with a 708 dorsal 1 yr after the surgery
blocking orthotic device (follow-up analysis)
Fifth and sixth weeks: Follow up:
Transfer strengthening monthly once for 3 mo after
exercises and light discharge, followed by once
functional activities every 3 mo for 1 yr thereafter
End of sixth week, once a year
occupational therapy for
ADL, restricted to a weight
limit of 453 or 500 g initiated
Patients discharged if they
achieve independent ADL
(dressing, grooming, and
eating)
* Exercise dosage not
specified
Justan et al.,15 2009;
Retrospective trail N ¼ 20 (6 M; 14 F) 1: Dynamic extension 1: Controlled active flexion 1: After 1 or 2 d of surgery, Postrehabilitation ROM:
Rupture of extensor pollicis orthoses with rubber bands of IP joint until 4e5 wk plaster cast removed Flexion of IP joint
longus after trauma, to extend thumb After that progressed to Hand therapy initiated in Extension lag (standard
arthritis, iatrogenic 2: Plaster cast applied with passive and light active dynamic extension orthosis goniometer)
Transfer of extensor carpi thumb in extension movements ROM exercises, 10 reps ROM scored according to
radialis longus to extensor 2: No movements for 4e5 every 2 h. total active motion system
pollicis longus tendon to wk Removal of dynamic (ASSH).
restore thumb extension orthosis after 4e5 wk Total time of rehabilitation
Follow-up: 12.2 wk after
surgery
for strength of agreement for the kappa coefficient:
#0 ¼ poor, 0.01e0.20 ¼ slight, 0.21e0.40 ¼ fair,
0.41e0.60 ¼ moderate, 0.61e0.80 ¼ substantial, and
0.81e1.00 ¼ almost perfect.
M ¼ male; F ¼ female; SD ¼ standard deviation; MCP ¼ metacarpophalangeal joint; PIP/IP ¼ proximal/interphalangeal joint; ASSH ¼ American Society for Surgery of the Hand.
RESULTS
Summary of Level of Evidence
One RCT,14 four prospective randomized tri-
thumb movements initiated
passive exercises, and then

Passive exercises and light
als,8,11e13 and one retrospective study15 met the crite-

2: Removal of plaster cast
progressed to light active
device during night or in
* Exercise dosage specified

Orthotic immobilization
between during the day

after 4e5 wk of surgery
without orthoses using

Hand therapy initiated
Use of a static orthotic

ria for inclusion and retrieved for a final assessment.
thumb movements
The characteristics of the included studies are shown
only for group 1

in Table 2. Summary of study results is presented in
after removal
during night
Tables 3e5. Four of six studies were found to have

high SEQES scores8,12e14 and were graded with
2b8,12,13 and 1b14 level of evidence, respectively. The
remaining two studies, graded as level 3 evidence
were ranked moderate on SEQES scores.11,15 The
methodological quality of these studies is listed in
Table 6.
The reliability of the assessment was very high
based on total scores and variable on individual
items. There was a high interrater reliability for the
total scores according to ICC statistics (ICC ¼ 0.95
[95% confidence interval ¼ 0.66e0.99]). The percent
of absolute agreement across all individual items
ranged from 50% to 100%. The chance-corrected
agreement (weighted kappa for 3 categories) ranged
from poor to perfect. Most items (62%) had ‘‘substan-
tial’’ to ‘‘almost perfect’’ chance-corrected agreement,
whereas 25% had ‘‘moderate’’ to ‘‘fair’’ agreement
and the remaining 12% (3 items) had ‘‘slight’’ to
‘‘poor’’ agreement. On these three items, scores
only differed by one point, but chance agreement
was high.
Immobilization Versus Early Active Mobilization
Three studies compared immobilization with early

protocol, n ¼ 10, age: 52.6 yr
protocol, n ¼ 10, age: 46.5 yr

2: Immobilization or static
active mobilization in patients with Hansen’s disease

1: Early dynamic motion
who underwent tendon transfer for ulnar, median, or

combined nerve paralysis.11,13,14 Two of these stud-
ies13,14 were of high quality, and one trial11 was of
(range: 29e79)
(range: 21e67)
moderate quality. Rath13 found a significantly better

total active motion of digit flexion (128 more,
p ¼ 0.001), deformity correction, and integration in
fist closure in early active mobilization group com-
pared with immobilization group at late follow-up
(21 months vs. 51 months), whereas integration in in-
trinsic plus position was significant (p , 0.05) both at
discharge (four week vs. eight week) and late follow-
up. Although the results of tendon transfer integra-
tion (graded according to Palande’s criteria) have
highly significant p-values in favor of early mobiliza-
tion group, the difference was not considered clini-
cally significant because the difference of mean
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12
TABLE 3. Results Evaluated at Third, Fourth, Sixth, and Eighth Week8,12

Results Level
Absolute Changes and p-Values (if Available) for All Outcomes *Time to
Return to Work
*Cost Analysis
*Total
Rehabiliation
Time Sacket’s
*Other Level
Study 3 wk 4 wk 6 wk 8 wk Outcomes of Evidence
Megerle et al., 1.1: MCP AROM: Mean % (SD) 1.1: MCP AROM: Mean % (SD) 1.1: MCP AROM: Mean % (SD) 1.1:MCP AROM: Mean % (SD) N/A 2b
2008 of opposite thumb: 48 (SD ¼ 29) of opposite thumb: 47 (SD ¼ 27) of opposite thumb: 67 (SD ¼ 35) of opposite thumb: 83 (SD ¼ 19)
ES ¼ 0.31 1.2: IP AROM: Mean % (SD) of 1.2: IP AROM: Mean % (SD) of ES ¼ 0.66
First assessment, MCP AROM, opposite thumb: 83 (SD ¼ 42) opposite thumb: 93 (SD ¼ 51) Last assessment, MCP AROM,
between 1.1 and 2.1 2.1: MCP AROM: Mean % (SD) of 2.1: MCP AROM: Mean % (SD) between 1.1 and 2.1
1.2: IP AROM: Mean % (SD) of opposite thumb: 59 (SD ¼ 20) of opposite thumb: 69 (SD ¼ 20)1.2: IP AROM: Mean % (SD) of
opposite thumb: 72 (SD ¼ 18) 2.2: IP AROM: Mean % (SD) of 2.2: IP AROM: Mean % (SD) of opposite thumb: 99 (SD ¼ 47)
* Significant difference between opposite thumb: 63 (SD ¼ 14) opposite thumb: 77 (SD ¼ 28) 1.3: Final Mean Grip strength 66%
groups, p ¼ 0.027 Tip pinch strength 73% of the
2.1: MCP AROM: contralateral side.
Mean % (SD) of opposite thumb: 2.1: MCP AROM: Mean % (SD) of
39 (SD ¼ 29) opposite thumb: 69 (SD ¼ 23)
2.2: IP AROM: 2.2: IP AROM: Mean % (SD) of
Mean % (SD) of opposite thumb: opposite thumb: 82 (SD ¼ 23)
49 (SD ¼ 19) ES ¼ 0.45
ES ¼ 0.21 Last assessment, IP AROM between
First assessment, IP AROM, 1.2 and 2.2
between 1.2 and 2.2 2.3: Final mean grip strength 63%
Tip pinch strength 71% of the
contralateral side
Germann 1.1: MCP AROM: 1.1: MCP AROM: 49 (range: 1.1: MCP AROM: 63 (range: 1.1: MCP AROM: 66 (range: 47e88) 1: Overall cost 2b
et al.,8 30 (range: 0e50) 20e90) 40e92) 1.2: IP AROM: 84 (range: 67e100) ($): $440
2001 1.2: IP AROM: 59 (range: 27e78) 1.2: IP AROM: 74 (range: 52e100) 1.2: IP AROM: 86 (range: 71e100) 1.3: Grip strength (%): 75 (range: 2: Overall cost
1.3: Grip strength (%): 41 (range: 1.3: Grip strength (%): 60 (range: 1.3: Grip strength (%): 65 (range: 50e86) ($): $1020
22e90) 38e92) 46e95) 1.4: Pinch grip (%): 78 (range:
1.4: Pinch grip (%): 36 (range: 1.4: Pinch grip (%): 64 (range: 1.4: Pinch grip (%): 69 (range: 65e100)
15e56) 41e73) 59e80) 2: MCP AROM: 63 (range: 46e83)
2.1: MCP AROM: 43 (range: 2.1: MCP AROM: 55 (range: 2.1: MCP AROM: 67 (range: 2.2: IP AROM: 70 (range: 47e92)
23e63) 50e63) 33e92) 2.3: Grip strength (%): 59 (range:
2.2: IP AROM: 31 (range: 0e62) 2.2: IP AROM: 50 (range: 0e62) 2.2: IP AROM: 74 (range: 22e76) 56e96)
2.3: Grip strength (%): 11 (range: 2.3: Grip strength (%): 45 (range: 2.3: Grip strength (%): 44 (range: 2.4: Pinch grip (%): 80 (range:
11e68) 21e79) 33e81) 61e94)
2.4: Pinch grip (%): 20 (range: 2.4: Pinch grip (%): 55 (range: 2.4: Pinch grip (%): 70 (range:
0e38) 0e100) 38e89)
MCP ¼ metacarpophalangeal joint; PIP/IP ¼ proximal/interphalangeal joint; AROM ¼ active range of motion; ES ¼ effect size; N/A ¼ not available.
TABLE 4. Results Evaluated from 2 mo to 1 yr11,15
Results Level
Absolute Changes and p-Values (if available) for All Outcomes *Time to Return to Work
*Cost Analysis
*Total Rehabiliation Time Sacket’s Level
Study 2 mo to 1 yr or last follow-up *Other Outcomes of Evidence
Rath,11 2006 Early assessments: Rehabilitation time: Group 1 saved 3
Group 1 at 16 wk an average of 19 d.
Group 2 at 19 wk * A reduction of 40% postoperative
1) No tendon pull out in group 1 rehabilitation time compared with group 2
2) Thumb active range abduction
a) All hands .508 (range: 508 e608 )
b) 5 hands .458
2 hands ,408
3) Pinch pattern: Both groups achieved tripod pinch
4). Pinch power: Both groups achieved an average of 68% (range: 65e75%) as that of opposite hand
a) Good pinch (.50%)
b) Good pinch (50%)
Fair pinch (21%)
Late assessments:
Group 1 at 7 mo
Group 2 at 8 mo
1) Thumb active range abduction
a) All hands .508
b) All hands .508
2) Pinch pattern: Both groups achieved tripod pinch
3) Pinch power: Both groups achieved an average of 68% (range: 65e75%) as that of opposite hand
a) Good pinch (.50%)
b) Good pinch (.50%)
Comparison of results on Evaluation Scale of 10 (modified Mehta and Malaviya30):
* No difference in outcomes between the two groups at early and late assessments
1) Good (score: 8e10)
2) Good (score: 8e10)
Justan et al.,15 2009 1) Mean time of hospitalization (in d): Total rehabilitation time: 3
Mean (SD): 1) 10.2 wk
a) 3.80 6 1.62 2) 14.2 wk
b) 3.30 6 1.49
ES ¼ 0.32
2) Mean time between surgery and end of rehabilitation:
10e15 wk in both groups
3) Follow-up:
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Average 12.2 wks in both groups

4) Difference in degrees of flexion of IP joint between groups:
Mean (SD):
a) 51 6 13.90
b) 43.75 6 24.74
13

Sacket’s Level
proximal interphalangeal (PIP) joint and metacarpo-
of Evidence
phalangeal (MCP) joint angles for both groups was
Level less than 58 . He also reported a reduced morbidity
by 21 days (p , 0.001) in the early mobilization group
compared with immobilization group, facilitating an
earlier return (33 days vs. 54 days) to activities. These
authors reported PIP joint flexion deformity of donor
digits (16% vs. 25%) and deteriorated PIP joint angles
in both groups (88 vs. 118 ) at late assessment.
*Total Rehabiliation Time
*Time to Return to Work
In contrast to above, results of two studies conduct-

ed by same senior authors11,14 found no difference be-
*Other Outcomes
*Cost Analysis
tween early active mobilization and immobilization at

discharge and follow-up assessments. The study of
patients with opposition transfer11 demonstrated no
significant difference in active range of abduction in
thumb, pinch pattern, and pinch strength between
the two groups, with all opposition transfers achieving
good results on the evaluation scale (modified
Malaviya) both during early assessments (16 weeks
vs. 19 weeks) and late assessments (seven months vs.
eight months). The results were similar in both groups,
but the treatment time was significantly reduced and
patients were discharged 19 days earlier after early
MCP ¼ metacarpophalangeal joint; PIP/IP ¼ proximal/interphalangeal joint; SD ¼ standard deviation; ES ¼ effect size.
mobilization compared with immobilization.

An RCT14 comparing the differences between early
active mobilization and immobilization, following
Absolute Changes and p-Values (if available) for All Outcomes
claw deformity correction, reported similar results

at discharge (four weeks vs. eight weeks) and
Results
follow-up (18 months vs. 17 months). There was no

significant difference in ROM, deformity correction,
timed pick-up test, swelling, dexterity, pinch strength,
2 mo to 1 yr or last follow-up
and grip strengths (p . 0.05) between the groups.

However, early mobilization group had an earlier res-
toration of hand function, quicker resolution of pain
(three weeks vs. six weeks), and significant reduction
of morbidity (36 days vs. 54 days) when compared
with the immobilization. The authors also com-
5) Difference in extension lag between groups:
mented that the cost of training therapists in their re-

habilitation center might exceed the benefits of earlier
patient discharge.
There was no incidence of transferred tendon fail-
6) Total active motion in degrees:
ure in any of the three trials. All studies demonstrated

earlier restoration of hand function, early return to
work or ADL, and reduction of morbidity with early
active mobilization protocols. Given the available
data, the current summary is that early mobilization
b) 12.50 6 14.88
protocols provided better short-term results but there

a) 1.50 6 3.75
Mean (SD):
was no benefit shown for long-term outcomes.

ES ¼ 1.0
ES ¼ 0.36
b) 58.758
a) 87.58
Mean:
Immobilization Versus Early Controlled Mobilization
Two studies,8,15 one high-8 and one moderate-

quality trial15 compared immobilization with early

controlled mobilization. Germann et al.8 studied
patients receiving extensor indicis proprius trans-
fer for thumb extension and found that hand func-
Study
tion recovered more quickly after early dynamic

motion or early controlled mobilization than after

TABLE 5. Results Evaluated at Fourth and Eight Week and Two months to One Year13,14
Results Level
Absolute Changes and p-Value Values (if Available) for All Outcomes *Time to
Return to Work
*Cost Analysis
*Total
Rehabiliation Sacket’s
Time Level of
Study 4 wk 8 wk 2 mo to 1 yr or Last Follow-up *Other Outcomes Evidence
Rath et al., 14
a. Zero pain level achieved, in group 1: a. Zero pain level achieved, in group 2: b. Follow-up analysis at 18 6 5 months in 1b
2009 Week (mean 6 SD): 3 6 1 (p , 0.001) Week (mean 6 SD): 6 6 1 (p , .001) group 1 (n ¼ 23):
b. Discharge analysis in group 1 (n ¼ 25): b. Discharge Analysis in group 2 (n ¼ 25): 1.1:AROM of digits:
1.1: AROM of digits: 2.1: AROM of digits: MCP Flexion angles in Intrinsic Plus Position:
MCP flexion angles in intrinsic plus position: MCP Flexion angles in Intrinsic Plus Position: ES ¼ 0.28
ES ¼ 0.15 Last assessment, MCP AROM, between 1.1 and 2.1
First assessment, MCP AROM, between 1.1 and 2.1
Finger Mean(0) 6 SD(0) Finger Mean(0) 6 SD(0) Finger Mean(0) 6 SD(0) (p-value)
(p-value) (p-value)
Index 71 6 6 (0.595) Index 70 6 7 (0.595) Index 75 6 8 (0.359)
Middle 71 6 6 (0.229) Middle 69 6 8 (0.229) Middle 76 6 8 (0.312)
Ring 70 6 6 (0.327) Ring 68 6 6 (0.327) Ring 75 6 9 (0.125)
Little 67 6 7 (0.832) Little 67 6 7 (0.832) Little 75 6 8 (0.703)
Total digits (n ¼ 100) 70 6 6 (0.146) Total digits (n ¼ 100) 69 6 7 (0.146) Total digits (n ¼ 92) 75 6 8 (0.051)
1.2: AROM of digits: 2.2: AROM of digits: 1.2: AROM of digits:
MCP angles in open hand position: MCP angles in open hand position: MCP angles in open hand position:
ES ¼ 0.29 ES ¼ 0.12
First assessment, MCP AROM, between Last assessment, MCP AROM, between 1.2 and 2.2
1.2 and 2.2
(p-value) (p-value)
Ring 34 6 9 (0.378) Ring 36 6 8 (0.378) Ring 11 6 19 (0.635)
1.3: AROM of digits: 2.3: AROM of digits: 1.3:AROM of digits:
PIP angles in open hand position: PIP angles in open hand position: PIP angles in open hand position:
ES ¼ 0.40 ES ¼ 0.10
First assessment, difference Last assessment, difference between 1.3 and 2.3
between 1.3 and 2.3
(p-value) (p-value)
Ring 1 6 10 (0.065) Ring 4 6 9 (0.065) Ring 8 6 23 (0.973)
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PIP angles in intrinsic plus position: PIP angles in intrinsic plus position: PIP angles in intrinsic plus position:
ES ¼ 0.60 ES ¼ 0.04
First assessment, difference between 1.4 and 2.4 Last assessment, difference between 1.4 and 2.4
15

16
Results Level
Return to Work
*Cost Analysis
*Total
Time Level of
Finger Mean( ) 6 SD( )

0 0
Finger Mean( ) 6 SD( )
0 0
Finger Mean(0) 6 SD(0) (p-value)
(p-value) (p-value)
Ring 11 6 11 (0.053) Ring 17 6 11 (0.053) Ring 16 6 20 (0.972)
1.5: AROM of digits in flexion: 2.5: AROM of digits in flexion: 1.5: AROM of digits in Flexion:
Total active motion of digit flexion: Total active motion of digit: Total active motion of digit:
ES ¼ 0.22 ES ¼ 0.09
(p-value) (p-value)
Ring 195 6 28 (0.350) Ring 188 6 24 (0.350) Ring 219 6 34 (0.845)
1.6: Grip strength: 2.6: Grip strength: 1.6: Grip strength:
Mean 6 SD (range), kg 6 6 3 (1e12) Mean 6 SD (range), kg 7 6 4 (2e12) Mean 6 SD (range), kg 19 6 6 (10e33)
% of Preoperative strength 31 % of Preoperative 41 % of Preoperative 101
strength strength
ES ¼ 0.28 ES ¼ 0.36
First assessment, difference between 1.6 and 2.6 First assessment, difference between 1.6 and 2.6
1.7: Pinch strength 2.7: Pinch strength 1.7: Pinch strength
Mean 6 SD (range), kg 3 6 2 (1e9) Mean 6 SD (range), kg 2 6 1 (0e4) Mean 6 SD (range), kg 3 6 1 (1.5e6)
% of Preoperative strength 75 % of Preoperative 63 % of Preoperative strength 94
ES ¼ 0.63 strength ES ¼ 0
1.8: Timed pick-up test 2.8: Timed pick-up test: *Follow-up analysis of timed pick-up test as % of
preoperative pick-up time:
% of preoperative pick-up time 96 6 31 (0.8) % of preoperative pick-up time 100 6 41 (0.8) % Mean 6 SD: 1.8: 88 6 41
% mean 6 SD (p-value) % Mean 6 SD 2.8: 102 6 86 (0.5)
ES ¼ 0.20
Last assessment, difference between 1.8 and 2.8
ES ¼ 0.11
First assessment, difference between 1.8 and 2.8
c. Swelling % increase of preoperative volume: b. Follow-up analysis at 17 6 4 mo in group 2 (n ¼ 23):
% Mean 6 SD (p-value): 2.1: AROM of digits:
1: 16 6 12 MCP flexion angles in intrinsic plus position:
2: 14 6 14 (0.07)
ES ¼ 0.15, difference between groups
Index 73 6 6 (0.359)
Middle 73 6 6 (0.312)
Ring 72 6 6 (0.125)
Little 74 6 7 (0.703)
Total digits (n ¼ 92) 73 6 6 (0.051)
2.2: AROM of digits:
MCP angles in open hand position:
Index 11 6 11 (0.484)
Middle 13 6 9 (0.311)
Ring 13 6 15 (0.635)
Little 16 6 19 (0.744)
Total digits (n ¼ 92) 13 6 14 (0.243)
PIP angles in open hand position:
Index 10 6 13 (0.532)
Middle 20 6 25 (0.418)
Ring 9 6 19 (0.973)
Little 9 6 14 (0.719)
Total digits (n ¼ 92) 12 6 18 (0.553)
PIP angles in intrinsic plus position:
Index 21 6 21 (0.551)
Middle 22 6 27 (0.627)
Ring 16 6 22 (0.972)
Little 9 6 15 (0.433)
Total digits (n ¼ 92) 17 6 22 (0.784)
2.5: AROM of digits in flexion Total active motion
of digit:
Index 225 6 22 (0.606)
Middle 216 6 39 (0.470)
Ring 217 6 35 (0.845)
Little 210 6 28 (0.980)
Total digits (n ¼ 92) 217 6 31 (0.479)
2.6: Grip strength:
Mean 6 SD (range), kg 17 6 5 (8e26)
% of Preoperative strength 103
2.7: Pinch strength
Mean 6 SD (range), kg 3 6 1 (1e6)
% of Preoperative strength 84
Rath,13 a. Discharge Analysis in group 1 (n ¼ 32 patients): a. Discharge analysis in group 2 (n ¼ 31 Follow-up analysis at 21 mo (range: 9e30 mo), SD: 6.01 Morbidity: 3
2008 1.1: MCP ROM (n ¼ 127): patients): in group 1 (n ¼ 32 hands, 127 digits): 1: Mean 33 d (range:
Mean 6 SD: 41 6 12.04 2.1: MCP ROM (n ¼ 128): 1.1: MCP ROM (n ¼ 127): 28e37 d), SD ¼ 2.256
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p-Value: 0.765 Mean 6 SD: 42 6 14.36 Mean 6 SD: 64 6 12.18 2: Mean: 54 d (range:
95% CI of the difference (lowereupper): (3.77, 2.77) p-Value: 0.765 p-Value: 0.001 39e62 d), SD ¼ 5.719
ES ¼ 0.03 95% CI of the difference (lowereupper): 95% CI of the difference (lowereupper): (3.53, 10.41) * Morbidity reduced by
First assessment, difference between 1.1 and 2.1 (3.77, 2.77) 21 d (39%) in group 1
17
18
Results Level
Return to Work
*Cost Analysis
*Total
Time Level of
ES ¼ 0.51 compared with

Last assessment, difference between 1.1 and 2.1 Group 2 (p ¼ .001)
95% CI: (18.8, 23.25)
1.2: AROM of digits: 2.2: AROM of digits: 1.2: AROM of digits: Donor digit
MCP angles in intrinsic plus position (n ¼ 127): MCP angles in intrinsic plus position (n ¼ 128): MCP angles in intrinsic plus position (n ¼ 127): deformity:
Mean 6 SD: 69 6 6.63 Mean 6 SD: 72 6 8.04 Mean 6 SD: 73 6 7.54 1: 16% of PIP flexion
p-Value: 0.003 p-Value: 0.003 p-Value: 0.003 deformity
95% CI of the difference (lowereupper): 95% CI of the difference (lowereupper): 95% CI of the difference (lowereupper): (1.16, 5.53) 2: 25% of PIP flexion
(4.60, 0.96) (4.60, 0.96) ES ¼ 0.34 deformity
ES ¼ 0.20 Last assessment, difference between 1.2 and 2.2
MCP angles in open hand position (n ¼ 128): MCP angles in open hand position (n ¼ 127): MCP angles in open hand position (n ¼ 128):
Mean 6 SD: 28 6 9.333 Mean 6 SD: 28 6 11.492 Mean 6 SD: 12 6 8.40
p-Value: 0.76 p-Value: 0.76 p-Value: 0.46
95% CI of the difference (lowereupper): 95% CI of the difference (lowereupper): 95% CI of the difference (lowereupper): (5.54, 0.05)
(2.99, 2.18) (2.99, 2.18) ES ¼ 0.21
ES ¼ 0 Last assessment, difference between 1.3 and 2.3
PIP angles in open hand position (n ¼ 127 digits): PIP angles in open hand position (n ¼ 128): PIP angles in open hand position (n ¼ 127 digits)
(3.01, 0.57) (3.01, 0.57) ES ¼ 0.25
PIP angles in intrinsic plus position (n ¼ 127): PIP angles in intrinsic plus position (n ¼ 128): PIP angles in Intrinsic plus position (n ¼ 127):
(7.02, 1.06) (7.02, 1.06) ES ¼ 0.24
Total active motion of digit flexion (n ¼ 127): Total active motion of digit flexion (n ¼ 116): Total active motion of digit flexion (n ¼ 127):
(0.236, 11.44) (0.236, 11.44) ES ¼ 0.22
ES ¼ 0.11
b. At discharge, between group 1 and group 2: 1.7: PIP ROM between groups (n ¼ 127):
Results on ManneWhitney U test for deformity Mean 6 SD: 92 6 15.3
correction, transfer integration, fist closure: p ¼ 0.016
i. Open hand position: p ¼ 0.139 95% CI of the difference (lowereupper): (1.09, 10.31)
ii. Intrinsic plus position: p , 0.001*
iii. Fist closure: p ¼ 0.291
Here, * refers to better result in
group 1
ES ¼ 0.40
a. Follow-up analysis at 56 mo (range: 9e132 mo
[SD: 38.58]) in group
(n ¼ 32 hands, 127 digits):
2.1: MCP ROM (n ¼ 127):
Mean 6 SD: 57 6 15.48
p ¼ 0.001
95% CI of the difference (lowereupper): (3.53, 10.41)
MCP angles in intrinsic plus position (n ¼ 127):
Mean 6 SD: 70 6 9.95
p ¼ 0.003
MCP angles in open hand position (n ¼ 127):
Mean 6 SD: 15 6 13.28
p ¼ 0.046
95% CI of the difference (lower-upper): (5.54, e0.05)
PIP angles in open hand position (n ¼ 127):
Mean 6 SD: 16 6 19.020
p ¼ 0.068
PIP angles in intrinsic plus position (n ¼ 127):
Mean 6 SD: 18 6 19.177
p ¼ 0.06
Total active motion of digit flexion (n ¼ 112):
Mean 6 SD: 238 6 30.13
p ¼ 0.001
2.7: PIP ROM between groups (n ¼ 127):
Mean 6 SD: 86 6 20.4
p ¼ 0.016
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b. At Late follow-up, between group 1 and group 2:
Results on ManneWhitney U test for deformity
correction, transfer integration, fist closure:
i. Open hand position: p , 0.001*
19
20
Results Level
Return to Work
*Cost Analysis
*Total
Time Level of
ii. Intrinsic plus position: p , 0.001*

iii. Fist closure: p ¼ 0.606
Here, * refers to better result in
group 1
MCP ¼ metacarpophalangeal joint; PIP/IP ¼ proximal/interphalangeal joint; ROM ¼ range of motion; AROM ¼ active ROM; ES ¼ effect size; SD ¼ standard deviation; CI ¼ confidence interval.
TABLE 6. Summary of Methodological Quality of Studies (SEQES Scores)

Study ?* Design Subjects Intervention Outcomes Analysis Ry Tz
Items 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Germann et al.,8 2001 1 2 2 2 2 1 2 2 2 1 0 2 2 1 2 2 2 2 2 0 1 1 1 2 37
Megerle et al.,12 2008 2 2 2 2 2 1 1 1 2 2 0 1 2 1 2 2 2 1 2 0 1 1 1 2 35
Rath et al.,14 2009 2 2 2 2 2 1 1 2 2 2 2 2 2 1 2 2 2 2 2 1 1 2 2 2 43
Justan et al.,15 2009 2 1 1 0 0 1 1 1 1 1 0 1 1 1 2 2 1 1 0 0 0 1 1 1 21
Rath,11 2006 2 2 1 1 0 1 1 2 2 2 0 2 2 1 2 1 1 2 0 0 0 2 2 2 31
Rath,13 2008 2 1 1 1 0 1 1 2 2 2 0 2 2 1 2 0 1 2 2 1 2 1 2 2 33
SEQES ¼ Structured Effectiveness Quality Evaluation Scale.
*Research question, R.
yRecommendation.
zTotal score out of 48.
immobilization, shortening total rehabilitation achieving 66% and 73%, respectively of the contralat-
time (55 vs. 65 days), and making dynamic motion eral side in early controlled group, and 63% and 71%,
treatment highly cost-effective ($440 vs. $1,020). respectively of the contralateral side in early active
Evaluations included postoperative ROM, grip group. Three complications, one due to rupture in
strength, duration of treatment, and time off early controlled group and the other two in early ac-
work. Follow-up examinations were performed tive group, occurred during a one-year follow-up.
three, four, six, and eight weeks after surgery. At The cause of complications in early active group
three weeks, total ROM of the interphalangeal (IP) was adhesions and inadequate joint motion, second-
joint was almost twice as good (598 ) in the dynamic ary to poor tendon tensioning at the time of initial
motion group compared with immobilization surgery. Although the group sizes were small, the
group (318 ; p , 0.05). At six weeks, no significant current evidence concludes that both methods pro-
differences between the groups were found. A sim- vide comparable clinical results. The early active mo-
ilar pattern for grip strength and pinch grip was bilization protocol does not have lower costs than the
found after three weeks, the dynamic motion group early controlled mobilization because it involved us-
had significant results than immobilization group age of fabricated orthotic device in between training
(p , 0.05). Although the dynamic motion group sessions to immobilize the joints. The early active
still had better results after four weeks, hand func- protocol does not have a notably higher complication
tion was similar in both groups after six and eight rate but fails to accelerate rehabilitation.
weeks. Due to the limitations in the presented data, we
The study of Justan et al.15 also compared immobi- could only determine the effect size on four studies
lization with early controlled mobilization in patients for selective outcome measures.12,13e15 According to
who underwent extensor carpi radialis longus trans- the data presented in Megerle et al.,12 the calculations
fer for extensor pollicis longus rupture. They demon- showed a small effect size when comparing active
strated that the early controlled mobilization group ROM of thumb MCP and IP joints with respect to
had shorter recovery times (rehabilitation time ten the contralateral side, during the first and last assess-
week vs. 14 weeks), shorter time off work (12.2 ments. Calculations from Justan et al.15 showed a
weeks), and significantly better movement of the small effect size when comparing mean time of hos-
thumb (total active motion, 87.58 vs. 58.758 ) when pitalization (in days) and degrees of IP joint flexion
compared with immobilization. between the groups, whereas the difference in de-
These studies concluded that the outcomes were grees of extension lag showed a larger effect size
identical in both groups with an added advantage of (1.0), with immobilization group having more lag
reduced rehabilitation time, shorter time off work, compared with early controlled mobilization group.
and a direct or an indirect cost benefit with dynamic Calculations obtained from Rath et al.14 showed
motion or early controlled mobilization protocol small effect sizes (,0.50) for all outcome measures
compared with the conventional static or immobili- (ROM of digits, grip strength and pinch strength,
zation protocol. Given that mobilization achieves timed pick-up test, and swelling) when comparing
similar results to conventional immobilization with the mean differences between the groups at discharge
significantly lower costs and less recovery time, there and follow-up. Small effect sizes (,0.50) were found
is little support for conventional immobilization on all outcomes (MCP and PIP joint ROM, total active
protocols. motion of digits, ROM in intrinsic plus position, and
open hand position) in the data presented by Rath13
Early Controlled Mobilization Versus Early Active when comparing the mean differences between
Mobilization groups at discharge and follow-up assessments.
One high-quality study compared early controlled

mobilization with early active mobilization. Megerle DISCUSSION
et al.12 included patients with extensor indicis pro-
prius transfer after extensor pollicis longus rupture. This systematic review comparing the effectiveness
At three weeks postoperatively, the early controlled of early motion protocols (early active and early
mobilization group demonstrated a significantly bet- controlled motion) over conventional immobilization
ter active ROM (79%) in the IP joint than that of the protocols after tendon transfers in the hand found a
early active mobilization group (49%). However, no small body of level 1b and 2b evidence.8,12,14 These
significant difference was found during further trials8,12,14 report no long-term differential benefit in
course of study in both groups, resulting in a final impairment and function, but state that early mobiliza-
mean IP joint active ROM of 698 in early controlled tion reduces total cost,8 total rehabilitation time, and is
group and 588 in early active group. The mean a safe approach with no increased risks of tendon in-
grip strength and tip-pinch strength did not differ sertion pull out. In the initial phase of rehabilitation,
significantly after eight weeks with patients outcomes such as ROM, grip strength, pinch strength,
jej 2012 21
total active motion of digits, deformity correction, and (ROM, grip and pinch strength, and deformity cor-
tendon transfer integration were significantly superior rection) in the early phase of rehabilitation.
with early mobilization compared with immobiliza- Several factors limit our ability to make strong
tion. However, long-term results demonstrate that recommendations for or against any treatment ap-
these outcomes were similar in both the groups, sug- proach at this time. Although there is some prelim-
gesting that early mobilization protocols improve inary support for early motion protocols compared
hand function in the initial phase of rehabilitation with early immobilization, the number of studies
(four weeks) and the long-term results (two months done are small, of variable quality, address heteroge-
to one year) are equivalent. These conclusions were neous populations, and have variable intervention
tempered by the fact that sample sizes tend to be small protocols. A number of studies have an overall high
and some patients are lost to follow-up in most studies quality but loose points due to their small sample
making it difficult to differentiate longer-term benefits size. Even in the presence of a high -quality score,
that are of small-to-moderate effect sizes. low- sample size should be concerned because it
When evaluating across studies it appears that, the means that the study was underpowered to detect
short-term benefits are apparent up to four weeks. differences. Given that tendon transfer is not one of
Three studies8,13,15 reported better hand function in the more common procedures performed, small
the initial phase (four weeks) when treated with early sample sizes are an inherent risk in this type of
active or early controlled mobilization compared with research. Thus, the evidence is still insufficient and
immobilization. However, there are conflicting results does not allow strong conclusions to be made. This
about benefits after this time point. German et al.8 suggests that multicenter research might be needed
showed no difference between the groups in function to prove the estimates of effect sizes between treat-
after six and eight weeks, whereas Rath13 and Justan ment options. Overall, this review provides a weak
et al.15 found better function at both early (four weeks) evidence in support of the use of early motion
and late follow-up assessments (12 weeks to one year). protocols after tendon transfer surgery in ulnar or
In addition to better function, Rath13 reported donor median or combined nerve paralysis due to Hansen’s
digit flexion deformity and deteriorated PIP joint disease or Leprosy11,13,14 and extensor pollicis longus
angles in both groups at last follow-up. tendon ruptures8,12,15 after trauma.
We cannot be confident whether there is a differ- It has been suggested that a theoretical framework
ence between early active and early controlled mo- can inform a narrative synthesis by allowing one to
bilization because only one study12 addressed this check whether outcomes observed follow an ex-
issue. These authors found a significantly better pected pattern.18 Because no theoretical framework
ROM in the group treated with early controlled mobi- was presented in previous literature, we synthesized
lization three weeks postoperatively. However, there one in this review that provides an overview of the
was no difference in hand function after six weeks in expected benefits of early mobilization after tendon
both the groups. They also reported three complica- transfers (Figure 1). The nature and direction of
tions in both the groups during a one-year follow-up. some of the outcomes that were directly measured
Although the number of studies is small and there in the studies reported within this review were con-
are some studies showing positive benefits for early sistent with the benefits expected from early motion
mobilization, at present there is insufficient evidence based on this theoretical framework. For example,
of long-term differences in treatments across any of less pain, reduced edema and joint stiffness, early
the current rehabilitation approaches. Two stud- joint mobility, better active motion, strength and en-
ies11,14 showed no difference between the early active hanced grip, better hand function reflect the concep-
mobilization and immobilization groups at late tual benefits of early motion. Other potential benefits
follow-ups (two months to one year). However, the of earlier motion from our framework, such as early
early motion group did demonstrate earlier restora- activation of motor cortex, reduced adhesion/scar
tion of hand function, quicker resolution of pain, formation, better tendon excursion, better response
and significant reduction of morbidity when com- to therapy, better functional performance, better mo-
pared with immobilization. Hence, the cost/benefit tivation, and increased patient engagement in tendon
of early recovery should be considered when select- rehabilitation, are not directly measured by any of the
ing a treatment approach. studies in this review. However, indirect effects of
Overall, the evidence suggests that local contextual these factors would be reflected in better active joint
factors and surgeon/therapist experience may influ- motion and muscle strength. Hence, there is indirect
ence which treatment option is preferable. The results sport that these factors may have been at play and
of this review conclude that early mobilization is a should be considered in future studies, who wish to
safe, efficient protocol that reduces total treatment include hypotheses about the mechanisms of action,
time,8,12,14,15 time off work,8,15 and may provide sig- for different hand therapy approaches.
nificant cost reduction8 compared with immobiliza- Experts have alluded to these benefits of early
tion. It also produces improved hand function mobilization.1,19,20 In a recent ‘‘Letter to the Editors’’

section of Journal of Hand Surgery, Brandsma20 ex- reported making it difficult to replicate findings in fu-
claimed that he always wondered why early active ture studies. Typically, a systematic review should
motion was practiced with delicate end-to-end su- enhance confidence in results by allowing one to
tures after tendon repairs and not with secure inter- pool results but this was not possible given these var-
woven tendons after tendon transfers, which he has iations. Although some aspects of the study design
been advocating since last ten years. Evidence-based were well done, sample sizes were relatively small.
practice suggests that expert opinion and patient pref- Small-to-moderate differential benefits in the long-
erences be considered in addition to evidence when term undoubtedly require larger sample sizes that
making decisions about treatment choices. Where have been currently reported.
there is sufficient evidence to guide a strong recom- The involved studies did not adequately address
mendation between two treatment choices, patient adverse events occurring immediately after early
preferences play a larger role in tipping the balance to- mobilization. Only two studies12,13 documented com-
ward a specific course of action. For example, in pa- plications, which were not directly related to early in-
tients where geography, resources, or other patient’s tervention. The studies conducted by Rath et al.11,13,14
individual circumstances suggest they may not par- did not adopt a consistent and direct method to calcu-
ticipate in or adhere to a therapy program in the early late tendon transfer failure or tendon transfer pull out
postoperative period, then the scale might be tipped across the three trials. But they used indirect mea-
toward immobilization. Conversely, in a highly sures, such as deformity correction, assessment of
resourced specialty hand unit where a motivated pa- ROM, and transfer integration during open hand po-
tient who requires early return to activity the balance sition, fist closure, and intrinsic plus positions, to ob-
might be tipped more toward early active mobiliza- serve tendon ruptures or abnormalities at the new
tion. It is important for therapist to note that positive insertion site.
outcomes following tendon transfer surgery can Variability in outcome measures complicates the
be achieved in a range of circumstances, and this synthesis of evidence. To compare studies unambig-
provides considerable latitude in customizing the uously, the same definitions and outcome classifica-
therapy protocol to the patient’s individual needs. tion methods need to be used. Especially within the
Given that there is a preliminary indication, early assessment of ROM and total active motion, there
mobilization may prove to be beneficial if future re- are many options. Because different classification
searchers address this issue in larger sample sizes systems use different cutoff points for the assign-
and considered decision rules about who would ben- ment of ROM into the poor, fair, or good categories, it
efit from different treatment options. has to be questioned whether comparability be-
tween these studies is warranted. Furthermore, ref-
erence values for an unimpaired ROM differ as well
LIMITATIONS as the method for the calculation of total active
motion. To be comparable, a universal classification
Although these studies demonstrated the feasibility system of ROM and total active motion should be
and safety of early active or controlled mobilization used. With the standardization of outcome measure-
after tendon transfers without many complications, ments, further improvement of hand rehabilitation
the major limitation was that three of the six studies will be facilitated.
used had retrospective data, which lacked reliable Another problem regarding the generalizability of
historical information on outcomes like pain, swell- the results of this review is the lack of monitoring of
ing, hand function, and strength. Among them, two patient compliance. Megerle et al.12 discussed the in-
studies compared prospective cohorts with retrospec- fluence of patient-related factors in the early postop-
tive controls11,13 and one retrospective study15 com- erative period by stating that early mobilization
pared the patient records selected at two different protocols could lead to an earlier recovery of motion
time frames. only in motivated and understanding patients. In the
Although RCTs are considered high-quality evi- remaining articles, although compliance was men-
dence, there are reasons why they may not have tioned as a determinant of outcome, it was never ob-
provided this level of confidence in this review. The jectively assessed in any study. It is therefore
three RCTs8,12,14 had large variability within each reg- unknown whether a possible lack of compliance
imen regarding the duration of the rehabilitation, the influenced the results. New outcome measures in
frequency and intensity of exercises, and start of re- hand rehabilitation like correlating self-reported
sistive exercises and return to unrestricted occupa- compliance of patients with their exercise proficiency
tional tasks. It is unknown to what extent these demonstrated that greater compliance positively cor-
differences and decisions regarding the protocol related with greater exercise proficiency.21 Hence,
and outcomes made by the surgeon and therapists af- proficiency evaluations are a useful tool to provide
fect the outcome of rehabilitation. Furthermore, the a more objective and comprehensive assessment of
specifics of treatment protocols tend to be poorly compliance and should therefore be taken into
jej 2012 23
account. Evaluation of loss of work compensation tendon) is directly proportional to the thickness of
data will provide a realistic assessment of cost sav- donor tendon. The authors proposed that early mo-
ings with early mobilization. Hence, cost analysis tion was possible only with thickethick connections,
should be included in future trials along with the the strength of the thickemedium connection was on
QOL reports (QOL questionnaires). the border of indications for the active rehabilitation
The International Classification of Functioning protocol and the thickethin connection strength
Disability and Health (ICFDH) encompasses a com- was sufficient only for the passive rehabilitation pro-
prehensive and universally accepted framework to tocol.25 Therefore, future studies can focus on devel-
classify and describe functioning, disability, and oping a standardized rehabilitation protocol to test
health. This framework enhances comparability of the reliability of these biomechanical findings.
outcome data, and applying ICFDH thus might lead Neurophysiological changes (cerebral responses)
to a decrease of variability within the assessment and can be compared between immobilization and early
description of the tendon rehabilitation after tendon mobilization groups after tendon transfer surgery to
surgery.22 The studies in this review focused on out- evaluate the process of tendon transfer integration
comes of physical impairment and body function into movement patterns at its new site of insertion.
(i.e., ROM and grip strength) and not on measures Studies have demonstrated reversible cortical ch-
like activity limitation (difficulty in executing a task) anges with immobilization of hands in volunteers
or participation restriction (difficulty in executing a that induces only temporary loss of cortical repre-
task in real-life situation). To know whether the reha- sentation and later the functional restoration of
bilitation regimens translate impairments into a better movement occurred with use of the hand.26 It was
work productivity and independence, measures of hypothesized that early mobilization of tendon
activity and participation should also be used. The ac- transfer allows the brain to immediately use the ac-
tivity and participation items are generally included tivation of preexisting synergistic cortical finger
in self-reported functional disability scales. The movement programs, whereas immobilization may
Michigan Hand Questionnaire, the Disabilities of the temporarily erase these neuronal networks.27 A
Arm Shoulder and Hand, the Patient-rated Wrist comparative study of tendon transfers in sensate
and Hand Evaluation, and other upper limb scales versus insensate hands could provide insight into
should be included in future trials to provide a pressure ulcer prevention by deformity correction.
broader understanding of health outcomes.23 Further studies could check for movement patterns
using isokinetic equipment and other functional
dexterity tests.
RESEARCH GAPS/DIRECTIONS
Future research should focus on reducing variabil- CONCLUSION

ity and enhancing comparability between and within
studies. High-quality RCTs should be designed, in Although there is level 1b and 2b evidence, which
which well-defined rehabilitation protocols are com- shows that early mobilization is safe, reduces cost,
pared for all types of transfers after neuromusculos- and total rehabilitation time when compared with
keletal injuries of the hand separately. Furthermore, it immobilization, overall there is an insufficient evi-
is imperative to identify outcome mediators that dence to support its usage after tendon transfers in
might be influential in determining the final outcomes the hand. Given the small number of studies and
achieved with tendon transfers such as tensile their diversity, it is premature to be confident that
strength of a suture, the type of connections between these effects will persist across future trials. However,
different-sized tendons (thick to thick or thick to thin), due to fewer complications and no incidence of
sensibility of the hand and cerebral responses to rupture in the transferred tendons with improved
movement after surgery. results during early phase, clinicians should consider
Because of the differences between studies regard- the use of early mobilization as a potential treatment
ing surgical techniques, suture material used, and option in tendon transfer rehabilitation, and should
testing procedures, it is often difficult to make direct perform high-quality RCTs to obtain more evidence
comparisons. A strong side-to-side (SS cross-stich) about the effectiveness and feasibility of replicating
tendon suture24 and a maximum load to failure ex- this technique in research and practice.
ceeding 95 N in the transferred tendon is proved to
be sufficient for early active mobilization after tendon Acknowledgment
surgeries.25 In a recent biomechanical study investi-
The authors acknowledge their senior author (SR), who
gating the safe suture technique that allows active re-
was consulted after the completion this review, for his
habilitation after tendon transfers, it was shown that valuable inputs on the rationale, clinical implications, and
the maximum load at failure (tendon pull out or in- concepts behind tendon transfer surgeries and rehabilita-
trasubstance rupture with increasing loads on tion approaches.

APPENDIX 14. Rath S, Schreuders TAR, Selles RW, Stam HJ, Hovius SER. Ran-
domized clinical trial comparing immediate active motion
with immobilization following tendon transfer for claw defor-
SUPPLEMENTARY MATERIAL mity. J Hand Surg. 2009;34A:488–94.
15. Justan I, Bistoni G, Dvorak Z, Hyza P, Stupka I, Vesely J. Eval-
Supplementary data associated with this article uation of early dynamic splinting versus static splinting for
can be found, in the online version, at doi:10.1016/ patients with transposition of extensor carpi radialis longus
to extensor pollicis longus. In Vivo. 2009;23:853–8.
j.jht.2012.06.006 16. MacDermid JC. Critical appraisal of study quality for psycho-
metric articles. Evaluation form. In: Law M, MacDermid J
(eds). Evidence-based Rehabilitation. Thorofare, NJ: Slack
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jej 2012 25

The Effectiveness of Early Mobilization After Tendon Transfers in The Hand

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The Effectiveness of Early Mobilization After Tendon Transfers in The Hand

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SCIENTIFIC/CLINICAL ARTICLE

The Effectiveness of Early Mobilization after

Shaik Shaguftha Sultana, MPT ABSTRACT:

2 JOURNAL OF HAND THERAPY

FIGURE 1. Theoretical framework.

Articles included for Identified by hand Excluded = 251

Articles included for evaluation after first and

Excluded after evaluation = 7

FIGURE 2. Flow chart for search strategy.

4 JOURNAL OF HAND THERAPY

Study Patients Intervention Evaluations

N, Age, Sex, Disorder,

No orthotic device used after

(continued on next page)

Study Patients Intervention Evaluations

(dressing, grooming, and dynamometer)

Study Patients Intervention Evaluations

passive exercises, and then

als,8,11e13 and one retrospective study15 met the crite-

progressed to light active

device during night or in

* Exercise dosage specified

between during the day

without orthoses using

Use of a static orthotic

The characteristics of the included studies are shown

only for group 1

Tables 3e5. Four of six studies were found to have

Immobilization Versus Early Active Mobilization

Three studies compared immobilization with early

protocol, n ¼ 10, age: 46.5 yr

active mobilization in patients with Hansen’s disease

who underwent tendon transfer for ulnar, median, or

moderate quality. Rath13 found a significantly better

TABLE 3. Results Evaluated at Third, Fourth, Sixth, and Eighth Week8,12

Average 12.2 wks in both groups

(continued on next page)

In contrast to above, results of two studies conduct-

tween early active mobilization and immobilization at

mobilization compared with immobilization.

claw deformity correction, reported similar results

follow-up (18 months vs. 17 months). There was no

and grip strengths (p . 0.05) between the groups.

mented that the cost of training therapists in their re-

ure in any of the three trials. All studies demonstrated

protocols provided better short-term results but there

was no benefit shown for long-term outcomes.

Immobilization Versus Early Controlled Mobilization

Two studies,8,15 one high-8 and one moderate-

quality trial15 compared immobilization with early

tion recovered more quickly after early dynamic

14 JOURNAL OF HAND THERAPY

Little 5 6 8 (0.434) Little 7 6 9 (0.434) Little 11 6 18 (0.719)

(continued on next page)

Finger Mean( ) 6 SD( )

ES ¼ 0.51 compared with

95% CI of the difference (lowereupper): (1.09, 10.31)

ii. Intrinsic plus position: p , 0.001*

TABLE 6. Summary of Methodological Quality of Studies (SEQES Scores)

One high-quality study compared early controlled

22 JOURNAL OF HAND THERAPY

Future research should focus on reducing variabil- CONCLUSION

24 JOURNAL OF HAND THERAPY