Efficacy of LLLT and Exesices After Hand Flexor Tendon Repair

Ahmed Barakat, PhD lecturer of orthopedic physical therapy

Introduction Flexor tendon injury has long been recognized as a difficult problem in hand surgery. Muscle atrophy, joint stiffness, osteoarthritis, infection, skin necrosis, ulceration of joint cartilage and tendocutaneous adhesion are familiar complications produced by prolonged immobilization of surgically repaired tendon ruptures. Loss of active motion in the digits results in significant morbidity.

Introduction These problems become more pronounced in zone II where the tendons travel through a fibro-osseous canal along the palmar aspect of the digits. Zone II is located between the origin of the flexor sheath in the palm (distal palmar crease) and the insertion of the flexor digitorum superficialis tendon on the middle phalanx ).

Introduction Unfortunately injuries in zone II are the most frequent injuries in the hand and carry the most severe prognosis. The functional outcome is poorer and the complication rate is greater than that associated with injury in other zones. It has been termed no man’s land because the healing tendon tends to adhere to its fibro-osseous tunnel.

Introduction Tendon repair and subsequent immobilization is frequently complicated by postoperative stiffness secondary to inflammation and peritendinous adhesions and tissue edema. Restoration of normal hand function following flexor tendon repair requires reestablishment not only the continuity of the tendon fibers, but also of the gliding mechanism between the tendon and its surrounding structures

Modulation of the tendon healing process remains a challenging problem Modulation of the tendon healing process remains a challenging problem. Despite remodeling, biochemical and mechanical properties of healed tendon tissue, it never matches those of intact tendon . Low Level Laser Therapy (LLLT) has gained a considerable attention for enhancing tissue repair in a wide spectrum of applications.

Tissue healing is a complicated series of processes which consists of three overlapping processes: a. Inflammation b. proliferative stage c. Remodelling. .

A. Inflammation characterized by vasodilatation and oedema formation. A variety of cells arrive at the wound site e.g. Neutrophils, Macrophages, Lymphocytes, Platelets bio-chemical mediators are important: a. Heparin → prevent occlusion of capillary blood flow b. Histamine → vasodilatation → heat and redness c. Bradykinin, Serotonin , and Prostaglandin → increase capillary membrane permeability → pain and swelling

B. proliferative stage C. Remodelling is the proliferative stage of repair, also comprising fibroplasia and angiogenesis C. Remodelling is the establishment of an equilibrium between collagen formation and lysis, resulting in the constant reshaping of the scar over several months.

Laser physics Electromagnetic spectrum LLLT = a range of electromagnetic radiation of various wave lengths from 600- 1000 nm including both visible (red) radiation at the lower end of the visible range and invisible (near infrared) radiation.

wavelengths associated with: Visible red laser (He-Ne) = 632.8 nm is recommended for superficial conditions, Infrared (Ga-As) = 904 nm for deeper musculoskeletal structure

Assessment procedures Maximum grip strength Was measured 3 weeks and 3 months postoperatively by the hand dynamometer.

Assessment procedures 2. ROM Was measured 3 weeks and 3 months postoperatively TAM = active PIP + DIP flex. – ext. lag

Treatment procedures: 1. accelerates inflammation, 2. promotes fibroblast proliferation, 3. quicken bone repair and remodeling, 4. encourages revascularization of wounds and 5.increased tensile strength during wound healing 6. stimulate DNA in damaged cell tissue. 7. kill the pain. overall accelerates tissue repair 1- Laser therapy

2- therapeutic exercises All the patients will be treated by therapeutic exercises 3 sessions weekly for 12 weeks for total of (36) sessions. All exercises done for three sets of 10 repetitions. Patients will be instructed to do exercises at home, three times daily till three weeks

First 2 weeks The hand will be splinted with posterior plaster slab 30º wrist flexion, 45º MCP joint flexion, full IP joint extension Hand kept elevated by a shoulder sling until the slab was removed at three weeks

5th day postoperatively Splint was removed every session passive fingers flexion and active extension for all fingers together Passive flexion and extension for PIP and DIP joints separately

3rd and 4th week Active assisted finger flexion exercises Active wrist flexion and extension while fingers are flexed Active fingers flexion up to 1/3 of the range while wrist in neutral position

5th week Active finger flexion to ½ of the range Active wrist flexion and extension while fingers extended Passive finger full extension

6th week 7th and 8th week Full active free fingers flexion Active fingers flexion up to 2/3 of the range 7th and 8th week Full active free fingers flexion Isolated active finger flexion

9th to 10th week Isolated active finger flexion against mild to moderate resistance

11th to 12th week Tendon gliding exercises: Hook fist Straight fist Full fist

Thank You