January 2015 No. 33
HOW CAN EACH THERAPY VISIT BE AS FOCUSED AND PRODUCTIVE AS POSSIBLE?
Many of us are familiar with the previously popular problem-oriented medical records. We listed every problem we could identify and created a treatment technique for each problem. This approach often created frustration as it was impossible to determine which treatment techniques were effective. Treatment to resolve one problem might exacerbate another — or at the very least the effects of simultaneous treatments might cancel each other out.
Another way we approach hand problems is to treat the diagnosis. Written protocols direct what treatment should take place when, based on a certain diagnosis. The fallacy in this approach is the negation of the many variables that must be considered for optimal treatment. This approach fails to appropriately individualize patient treatment.
An analytic review of the systems that can affect hand function can also lead to a treatment approach for each system involved:
1. Skeletal System
2. Muscular System
3. Vascular System
4. Nervous System
5. Integumentary System [skin, hair, nails, and exocrine glands]
6. Immune / Lymphatic Systems.
Regardless of the approach you take with hand patients, there are far more external demands and constraints currently placed upon us by the system in which we work than at any time previously. Number of visits, treatment time allocated, and reimbursement is scrutinized and limited, creating a demand that each therapy visit be as focused and as productive as possible. How can we achieve that?
My suggestion is that at each patient visit we ask the same question: “What is the single greatest impediment preventing this patient from having a functional hand?” Even though there are likely multiple factors, teaching our patient to concentrate on one at a time (at least until the next visit) will likely allow more consistent progress. We will know what is working and what is not working.
Here is a common example: Patient who underwent Zone II FDS and FDP repair in the ulnar three fingers 8 weeks ago is referred. Passive interphalangeal (IP) joint flexion and extension is significantly limited and active flexion of the IP joints is even more limited.
The patient initiates flexion at the metacarpophalangeal joints and is unable to initiate finger flexion with the extrinsic flexors; there is a miniscule amount of active interphalangeal joint motion.
Obviously the patient needs greater passive IP joint motion but also needs better flexor tendon pull-through. So is it the lack of passive joint motion that is the single greatest impediment preventing a functional hand? Or is it the lack of flexor tendon pull through?
Perhaps asking this differently helps answer:
• If passive joint motion is improved, will this create a more functional hand? I would say no; without the patient’s ability to increase active motion the function of the hand does not change.
• If active joint motion is improved, will this create a more functional hand? I would say yes, even if the improvement is only to the limits of the current passive motion.
Therefore, my focus with the patient would be to teach him/her how to accurately pull through the extrinsic flexors and I would provide whatever orthosis necessary to assist the patient in this repeated pull through (by preventing MP joint flexion). I would encourage the patient to concentrate on this exercise throughout the day having the single goal of being able to see active motion at the IP joints.
Although many of us believe and have been taught that passive range of motion must be increased prior to active motion increasing, I have observed that active motion only, done repeatedly and correctly, can increase passive joint motion — often more comfortably and effectively than intermittently applying a passive joint stretch.
To effectively use this focused treatment approach, at each visit the therapist must re-evaluate the patient’s hand with a fresh perspective, again critically determining the answer to these questions:
1. “What is the single greatest impediment preventing this patient from having a functional hand?”
2. “What treatment technique will be most effective to reduce this impediment?”
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Disclaimer: HandLab Clinical Pearls are intended to be an informal sharing of practical clinical ideas; not formal evidence-based conclusions of fact.