the contracture occurred in fivejoints, one before 12 months, two at12 months, and two at 24 months.Recurrence severity ranged from20 to 40 degrees. Three of the pa-tients who had recurrences under-went fasciectomy.

Results: This study found thatcollagenase safely and effectivelyrestored normal finger extensionin the majority of patients. Theaverage of 1.4 injections was re-quired to normalize the con-tracted joints; clinical successwas achieved in one to 29 days.Clinical success was defined as0e5 degrees of flexion.

Adverse effects were localizedto the injection site, and weremild to moderate in severity andtransient in nature. Comparisonof adverse effects of this study tothe complication rates of surgerywere mild.

The researchers report that thedata from this study were consis-tent with earlier findings fromtheir phase II studies, which pro-vide additional evidence confirm-ing the effectiveness of collagenaseas a nonsurgical treatment for DC.The data also suggests a low re-currence rate after collagenasetreatment. Researchers state thatadditional long-term studies oflarger numbers of patients arewarranted to verify the effective-ness and recurrence rate with col-lagenase treatment.

EUGENIA PAPADOPOULOS, MOT,OTR/L, CHT

Experimental Joint ContractureCorrection with Low TorqueeLong Duration RepeatedStretching. Usuba M, et al. ClinOrthop Relat Res. 2007;456:70e8.

A study comparing stretch ofvariable torque and durationfound low torqueelong duration(LTLD) stretch was most effectivein increasing passive range ofmotion (PROM) in the contractedknees of laboratory rats. LTLDstretch was also more effectivein improving deformation and

load to failure in contracted per-iarticular connective tissue thanhigher torque stretches of long orshort duration. Measures of cap-sular viscoelasticity (phase lagand dynamic stiffness) improvedin all torque and durationvariations.

Sixty-six Wistar rats whose hindknees had been surgically immo-bilized unilaterally in flexion for 40days were randomly assigned tosix groups once joint remobiliza-tion was achieved. Of these sixgroups, four were establishedwith the following treatment pro-tocols: LTLD stretch, low tor-queeshort duration stretch, hightorqueelong duration stretch, andhigh torqueeshort durationstretch. The remaining two groupswere comprised of a natural recov-ery group that received no treat-ment and a group whose jointtissue was sampled for mechanicalanalysis immediately after jointremobilization. The nonimmobi-lized contralateral hind kneesserved as controls.

After the 40-day immobilizationperiod, a mean knee flexion con-tracture of 125 degrees wasachieved (normal PROM of hindknees in rats is 20e30 degreesshort of full extension). Four-leg-ged mobility in a cage was allowedduring immobilization and afterremobilization. Subsequent to re-mobilization, the treatment groupsreceived 12 treatment sessions un-der general anesthesia at threesessions a week for a period offour weeks. Stretch was applied ina uniform fashion in the directionof knee extension. High torquewas applied with a force of0.045 Nm and low torque was ap-plied at 0.02 Nm. Stretching timewas set at 20 minutes for short du-ration and 40 minutes for long du-ration. Stretching time was limitedto 40 minutes at the maximum topreserve animal viability underanesthesia.

Goniometric PROM measure-ments using uniform tensileforce were recorded at the endof each session. The investigator

measuring PROM was blinded tothe group affiliation of eachanimal. All animals were sacri-ficed at the end of the treatmentperiod for mechanical analysisof the periarticular connectivetissue.

Knee PROM increased gradu-ally in all treated and untreatedgroups. Compared to untreatednatural recovery, knee PROM in-creased most with LTLD(p , 0.0001) followed by high tor-queelong duration (p , 0.0001)and high torqueeshort duration(p , 0.0017). PROM of high tor-queelong duration and high tor-queeshort duration was similar.Knee PROM was least amongthe low torqueeshort durationand untreated natural recoverygroups, both of whom had simi-lar PROM.

Conclusion: LTLD-repeatedstretching lead to a higher resto-ration of PROM compared tohigh-torque and short-durationstretching.

CHRISTOPHER BROWN, OT, CHT

Dynamic Assist Splinting forAttenuated Sagittal Bands inthe Rheumatoid Hand. Chin-chalkar SJ, et al. Tech Hand Up Ex-trem Surg. 2006;10(4):206e11.

Purpose: The authors review thenormal biomechanics of exten-sion in the uninjured finger, andthe pathomechanics of extensionafter sagittal band injury. Afterthis review, they provide instruc-tion in how to fabricate a dy-namic MCP extension splint.The splint serves to restore func-tional extension and prevent thecomplications of sagittal bandrupture in rheumatoid hands.

Review: The sagittal bands cen-tralize the extensor tendons overthe MCP joints, limit the distal ex-cursion of the extensor tendons,and transmit the extensor forcesthat extend the MCPs. When thesagittal bands are disrupted, theextensor tendons become unstableand may sublux or dislocate

JanuaryeMarch 2009 93

Comparison of TherapeuticActivities with TherapeuticExercises in the Rehabilitationof Young Adult Patients withHand Injuries. Guzelkucuk U,Duman I, Taskaynatan MA,Dincer K. J Hand Surg. 2007;32:1429e35.

Purpose: The purpose of thisstudy was to compare the efficacyof therapeutic activities thatmimic activities of daily living(ADL) with that of traditionaltherapeutic exercises in the reha-bilitation of young adult patientswith injured hands.

Method: Thirty-six patients withfunctional hand impairmentswere enrolled in the study.Diagnostic inclusion were thosepatients who experienced bone,tendon, or peripheral nerve injuryto the hand or wrist. Diagnosesexcluded were bilateral injury,brachial plexus lesions, shoulderor elbow injuries, rheumatoid dis-eases involving the hand, burnedhands, solely small and ring fin-ger injuries, and complex regionalpain syndrome. Patients wererandomized into two groups.The study group included 20 pa-tients and the control group in-cluded 16 patients. The controlgroup completed traditional ther-apeutic exercises consisting ofpassive range of motion, activeassisted range of motions, activerange of motion (AROM),strengthening exercises, andphysical agent modalities twiceper day for 30 minutes each ses-sion. The study group completedthe same traditional therapeuticexercises as the control group forone session per day for 30 min-utes. The second session consistedof 25 therapeutic activities simu-lating ADL for 30 minutes. Bothgroups were seen five times perweek for a duration of threeweeks. Evaluation was completed

ulnarly. When this occurs, activeMCP extension is impaired orlost. Due to the transmission offorces through the juncturaetendinum, injury to one digit willaffect the extensor function of allthe digits. When a sagittal band in-jury allows the extensor tendon todislocate between the metacarpalheads, it may be possible to ac-tively hold the involved finger inextension after it is passively ex-tended, but may not be possibleto actively extend from a positionof full flexion. Use of a dynamicMP extension splint compensatesfor this impairment in active ex-tension and improves function.

In addition to restoring func-tion, the use of a dynamic exten-sion splint also prevents swanneck deformity and volar sublux-ation of the MCPs, which are com-plications of sagittal band injuries.Subluxation of the extensor ten-dons after sagittal band injurycauses the intrinsic muscles torest in a shortened position, whicheventually results in myostaticcontracture. Contracture of the in-trinsic muscles then leads to swanneck deformity.

Subluxation of the extrinsictendons also results in decreasedextrinsic extensor force. The in-trinsic muscles compensate forthis lack of extensor force bycontracting more forcefully.Constant loading on the proximalphalanges by the intrinsics con-tributes to volar subluxation ofthe proximal phalanges. This vo-lar subluxation further shortensthe resting length of the intrinsicmuscles, thus worsening themyostatic contracture.

Splint rationale: The authorscontend that the dynamic MCPextension splint serves to stabi-lize and relocate the extensortendons by reducing the tensionon the extensor mechanism as itassists MCP extension.Positioning the MCP joints in ex-tension and eliminating the needfor the intrinsics to contract ex-cessively combats the tendencytoward intrinsic tightness and

94 JOURNAL OF HAND THERAPY

interrupts the sequence of eventsleading to the complications de-scribed above. The dynamic ex-tension splint can be used as afunctional splint while awaitingsagittal band reconstruction orin lieu of reconstructive surgerywhen surgery is not indicatedor desired.

Splint fabrication: Fabrication ofthe hand-based dynamic MCPextension splint is described andphotos of the finished splint arefound in the article. The materialsused for the splint are two 1-instrips of 1/8th-in thick aquaplast,two coil springs, two rubber bandposts made of piano wire, andelastic bands. One of the aqua-plast strips is molded circumfer-entially around the proximalphalanges, whereas the otherstrip is molded circumferentiallyaround the palm, proximal tothe distal palmar crease andMCP heads. Each of the two coilsprings is attached to the dorso-lateral aspect of the palmar com-ponent and the volar lateralaspect of the finger component.The coils are lined up with thesmall and index finger MCPjoints and the springs are ori-ented so that they provide dy-namic extension pull. If the coilsdo not provide enough tensionto position the MCP joints inextension, the rubber band postsare attached to the dorsum ofthe two splint components, overthe fifth metacarpal and proximalphalanx. A rubber band that pro-vides enough additional tractionto position the MCPs in extensionwithout limiting flexion is thenapplied.

The authors report that there isno clinical data to support theeffectiveness of this splint, butthat they have used it in theirclinical practice. They do notreport on the length of time thesplint has been in use or on thenumber of patients, but theyconclude from their clinical expe-rience that it is effective in restor-ing functional extension andpreventing complications of

sagittal band injuries in rheuma-toid patients.

SUSAN MITCHELL, OTR/L, CHT