Journal of Hand Therapy xxx (2020) 1e17

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Journal of Hand Therapy

journal homepage: www.jhandtherapy.org

Postoperative hand therapy management of zones V and VI

extensor tendon repairs of the fingers: An international inquiry of
current practice
Melissa J. Hirth B (OT), MSc (Hand & Upper Limb Rehab) a, b, c, *, Julianne W. Howell PT, MS, CHT d,
Lynne M. Feehan BScPT, MSc, PhD e, Ted Brown PhD, MSc, MPA, BScOT(Hons), GCHPE, OT(C),
OTR, MRCOT, FOTARA, FAOTA c, Lisa O’Brien PhD, B App Sci (OT), M Clin Sci (Hand & Upper Limb Rehab),
Grad Dip Ergonomics, Grad Cert Clinical Research Methods c
a
Occupational Therapy Department, Austin Health, Heidelberg, Victoria, Australia
b
Malvern Hand Therapy, Malvern, Victoria, Australia
c
Department of Occupational Therapy, Faculty of Medicine, Nursing and Health Sciences, Monash University e Peninsula Campus, Frankston, Victoria, Australia
d
Saint Joseph (Self-employed), MI, USA
e
Faculty of Medicine, Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Study Design: Electronic Web-based survey.

Received 30 August 2019 Introduction: Evidence supports early motion over immobilization for postoperative extensor tendon repair
Received in revised form management. Various early motion programs and orthoses are used, with no single approach recognized as
27 November 2019
superior. It remains unknown if and how early motion is used by hand therapists worldwide.
Accepted 31 December 2019
Available online xxx
Purpose of the Study: The purpose of this study was to determine if there is a preferred approach and
identify practice patterns for constituents of International Federation of Societies for Hand Therapy full-
member countries.
Keywords:
Extensor tendon
Methods: Participation in this English-language survey required respondents to have postoperatively
Hand therapy managed at least one extensor tendon repair within the previous year. Approaches surveyed included
Relative motion programs of immobilization, early passive (EPM), and early active (EAM) with motion delivered by resting
Orthosis hand, dynamic, palmar/interphalangeal joints (IPJs) free, or relative motion extension (RME) orthoses.
Splint Survey flow depended on the respondent’s answer to their “most used” approach in the previous year.
Survey Results: There were 992 individual responses from 28 International Federation of Societies for Hand
Therapy member countries including 887 eligible responses with an 81% completion rate. The order of
most used program was EAM (83%), EPM (8%), and immobilization (7%). The two most used orthoses for
delivery of EAM were RME (43%) and palmar/IPJs free (25%). The RME orthosis was preferred for earlier
recovery of hand function and motion. Barriers to therapists wanting to use the RME/EAM approach
related to preference of surgeon (70%) and clinic (24%).
Discussion: In practice, many therapists select from multiple approaches to manage zone V and VI
extensor tendon repairs. Therapists believed TAM achieved with the RME/EAM approach was superior to
the other approaches. Contrary to the literature, in practice, many therapists modify forearm-based
palmar/IPJs free orthosis to exclude the wrist to manage this diagnosis.
Conclusions: The RME/EAM approach was identified as the favored approach. Practice patterns and ev-
idence did not always align.
Ó 2020 Published by Elsevier Inc. on behalf of Hanley & Belfus, an imprint of Elsevier Inc.

Introduction

Numerous approaches1-3 have been described for therapy

Conflicts of interest: None.
* Corresponding author. Occupational Therapy Department, Austin Health, 145
Studley Road, Heidelberg, Victoria 3084, Australia.
E-mail address: melissa.hirth@monash.edu (M.J. Hirth).
management of postoperative extensor tendon repairs in zones V
and VI as delineated by Kleinert and Verdan.4 All aim to optimize
patient outcomes, accomplishing this with various orthoses and
types of motion. Five systematic reviews have identified four

0894-1130/$ e see front matter Ó 2020 Published by Elsevier Inc. on behalf of Hanley & Belfus, an imprint of Elsevier Inc.
https://doi.org/10.1016/j.jht.2019.12.019
2 M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e17
separate motion programs (immobilization, early controlled
mobilization, early active mobilization, early passive motion) and
two types of orthosis (static and dynamic).5-9 These motion pro-
grams, when combined with either type of orthosis become a
specific “approach” to guide therapists’ postoperative management
of tendon repair. The orthoses and type of motion used in the ap-
proaches are quite similar; however, the different names are
confusing. To aid clarity, the approaches can be grouped into five
main combinations of orthosis and motion: resting hand orthosis
with interphalangeal joints (IPJs) included [immobilization];
resting hand orthosis with IPJs included [early active motion];
palmar resting orthosis with IPJs free [early active motion]; dy-
namic orthosis [early controlled or early passive motion]; and
relative motion extension (RME) orthosis [early active motion].6-8
There is general consensus that early motion is likely to result in
quicker recovery of mobility than immobilization,6-9 and that early
active motion (EAM) is likely superior to all the other programs;
however, which is the best orthosis to facilitate active motion is still
unclear.9 Given the lack of a clearly superior EAM approach, it is
likely that hand therapists are using factors other than high-quality
evidence to guide their choice of therapy program and the type of
motion delivered or permitted by the orthosis.
To further improve our understanding of what choices thera-
pists are making, we conducted an international survey. Our aim
was to describe current practice patterns of therapists from IFSHT
full-member countries who have managed postoperative finger
extensor tendon repairs in zones V and VI (Fig. 1) in the previous 12
months. Specifically, we intended to

identify whether there is a preferred postoperative management
approach (therapy program þ orthosis);

investigate how reported practices align with current evidence;

compare how the preferred orthosis design, perceived level of
skill and amount of time to fabricate the orthosis, duration of
Fig. 1. Extensor tendon zones (Rights retained by the illustrator, Craig Hirth).
orthosis wear, and level of hand function and therapeutic exer-
cises were recommended when the orthosis worn varies across
different management approaches;

compare therapist-reported outcomes for the different ap-
proaches used;

explore therapist perceptions regarding the advantages and
disadvantages of the various approaches;

explore the factors that influence the selection of a postoperative
approach;

identify barriers to implementing therapists’ preferred approach;

describe variations in the return to work process, such as who
provides the return to work guidelines, usual timing for return to
work, and common reasons for delayed return to work.
Methods
Survey planning and administration was undertaken as per the
guidelines by Jones et al10 and planned and reported as per the
“Checklist for Reporting Results of Internet E-Surveys” (CHER-
RIES).11 Ethics approval was obtained from the Monash University
Human Research Ethics Committee, Victoria, Australia (13583). We
created a Web-based survey using the Qualtrics platform (Qualtrics,
Provo, UT). Our aim was to include all therapist members from
International Federation of Societies for Hand Therapy (IFSHT) full-
member countries.
Each country’s IFSHT representative was contacted by email (up
to three times) by the primary author (MH) to invite membership
participation in the survey. Each representative was sent a copy of
the survey for review and a consent to participate form and asked
to provide the total number of therapist members in their organi-
zation. If the original invitation emails were not answered, the
contact details were confirmed with the Secretary General of the
IFSHT. It was the responsibility of each national organization to
distribute the email invitation to their membership. Outlined in the
invitation was the purpose of the study, information about consent
and voluntary participation, and the online link to the survey. After
the initial email was sent out by the national organizations, each
representative was sent a second email to distribute to their
membership as a reminder to complete the survey. To encourage
participation, respondents were informed that a small donation for
each survey completed would be made by the authors to the IFSHT
Triennial Congress Travel grant fund.
The informed consent process on the initial page of the survey
consisted of an introduction to the investigating team, an estimate
of the time required to complete the survey, assurance that all
answers and data would be nonidentifiable, partial responses may
be included in the analysis, and completion of the survey implied
consent to participate. To qualify for participation in the survey,
each therapist had to answer “yes” to the initial screening question
in the survey stating they had postoperatively managed at least one
zone V-VI extensor tendon repair within the previous 12 months.
Survey instrument
The survey (see Appendix 1) was designed by the authors of this
study. Authors MH, JH, LF, and LO’B each having over 20 years of
practical experience in hand therapy and authors LF, TB, and LO’B
have extensive experience in survey design and implementation.
The survey items were constructed to obtain information about
current preferences and practice in the postoperative management
of extensor tendons in finger zones V and VI based on the ap-
proaches shown in Figures 2A-2F, along with an option to select
“other”. Survey flow varied depending on the respondent’s answer
to their most used postoperative therapy approach in the previous
12 months. As the relative motion extension (RME)/EAM approach
 M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e17 3

Fig. 2. A-F. Orthosis/program examplesd(A) resting hand orthosis [immobilization], (B) resting hand orthosis [EAM], (C) palmar resting orthosis with IPJs free [EAM], (D) dynamic
orthosis [EPM], (E) RME plus [EAM], and (F) RME only [EAM].

has been described with a wrist orthosis as ‘RME plus’ and without the analyses.12 This included MH and JH becoming familiar with the
a wrist orthosis as ‘RME only’, data for each was collected raw data in the Excel spreadsheet, peer debriefing on initial codes,
separately. diagramming to make sense of theme connections, reaching a
Before survey dissemination, technical functionality was tested consensus on themes, and debriefing and review by therapy col-
by authors MH, JH, and LF, each moving through the survey several leagues.12 Given the large amount of information collected in this
times, changing their responses to fit the various possible combi- survey, we have chosen to report selected descriptive quantitative
nations. Additional technical functionality and field testing for and summary thematic analyses for the main findings of this
content relevancy and utility was undertaken with experienced survey.
hand therapy colleagues (Occupational Therapists and Physical
Therapists) in Australia (n ¼ 12) and the United States of America
(n ¼ 11).10 Minor word and phrase revisions were made to clarify Results
questions and “time” intervals were added to time-based questions.
The final survey questions included closed (forced choice) and Survey response
open-ended (free text) answer options.10
While there were 262 questions in the final survey, participants The same survey was used across all participating national hand
answered between 39 and 60 questions because adaptive ques- therapy organizations, opening on the 3rd of July 2018 and closing
tioning with branches, skip logics, and display logics were used (see on the 11th February 2019. All 36 IFSHT full-member countries
Appendix 2).11 The survey was also designed to group-related were invited to participate and 28 participated. Reasons for
questions, such as details of orthosis fabrication, separately from nonparticipation included inability to use the organization’s data-
questions surrounding return to work details. Consequently, the base for nonsociety matters, limited English comprehension by
number of items per page varied and, with adaptive questions, the their members, and failure to return a willingness to participate
number of survey pages varied for each participant. Whenever the form. No response was received from four organizations, and two
survey branched, answers to the questions were mandatory to organizations chose to send the survey only to selected members.
ensure appropriate survey flow. If there was no branching, answers
to questions were optional. Hence, not all questions were answered
by all participants. A “back” button was available for the purpose of
returning to review previous questions and responses; however, a
check for completeness was not an option provided before the final
survey submission.
The use of the word “usual” was added to many questions to be
sensitive to the fact that various factors impact clinical reasoning,
and hence therapy interventions can and do vary between patients.
Similarly, therapists were asked questions related to their “most
used approach during the previous 12 months” to acknowledge
that many respondents use more than one approach. The term
“splint” was selected over “orthosis” for survey questions, as
currently “splint” is more widely used globally than “orthosis”.
Responses to closed questions were analyzed descriptively
while thematic analysis was utilized for open-ended questions and
was completed by authors MH. and JH. To establish trustworthiness
and rigor of the thematic analysis, several phases were involved in Fig. 3. Number of adult extensor tendon zone V-VI repairs managed in the past year.
4 M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e17

Table 1
Participating countries and eligible respondents

Participating countries (Hand Therapy Association/Society membership) grouped into 8 global regionsa
Eligible respondents/number of email requests sent to participate in the survey
Asia Middle East, North Africa, Europe North America Central America, South America Sub-Sahara Africa Australia, Oceania
Hong Kong Greater Arabia Austria Canada Caribbean Argentina Kenya Australia
Turkey Belgium The United States Guatemala Brazil South Africa New Zealand
Denmark Chile
France Columbia
Germany Uruguay
Ireland
The Netherlands
Norway
Portugal
Slovenia
Spain
Sweden
Switzerland
The United Kingdom
4/50 4/65 272/3643 136/3598 1/16 44/336 11/110 184/1074

Bold is responses received from those who were send the survey for each region.
The 8 global regions are in italics.
a
One therapist from a non-participating national hand therapy organization completed the survey, for a total of 29 represented countries.

The survey was sent to a total of 8892 therapists across the 28
participating organizations. The overall survey response rate was
11% with 997 therapists responding and 887 satisfying the eligi-
bility criteria of managing one or more zone V-VI extensor tendon
repairs in the past year. Of those who commenced the survey, the
completion rate was 81% (n ¼ 722).
Respondent demographics
Figure 3 details the number of ETs managed over the previous
year by the respondents and Table 1 identifies countries and
number of participating therapists. English was chosen by 71% as
their primary language. The occupational to physical therapy ratio
was 3:1, which included 762 females, 12 males, and two other. The
number of respondents distributed across each age category was 20
to 29 years, 68; 30 to 39 years, 269; 40 to 49 years, 240; 50 to 59
years, 208; and 60þ years, 88. Table 2 describes specific profes-
sional qualifications and experience of the respondents.
Extensor tendon orthosis/program approaches used in the previous
12 months (select 1 or more)
Many respondents indicated they had used more than one
approach in the previous 12 months, for a total of 1793 responses
(see Fig. 4). The most commonly reported approach was RME/EAM
(65%), followed by the palmar resting orthosis with IPJs free/EAM
approach (50%).
Extensor tendon orthosis/program “most used” approach in the
previous 12 months (select 1 only)
There were 853 responses to the questions. The most used
approach (Fig. 5) was the RME/EAM (43%), followed in descending
 M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e17 5

Table 2
Professional qualifications and clinical experience of respondents (n ¼ 887b)

Post-secondary rehabilitation or research qualification(s) (select ALL that apply)

Entry levela diploma/bachelors/ Postgrad. Diploma (hand Postgrad. Diploma Postgrad. Masters: Postgrad. Masters: Postgrada Postgrad. PhD: Other
masters/clinical doctorate therapy focus) (other) Coursework or research Coursework or Clinical research
(hand therapy focus) research (other) Doctorate
788 138 43 82 74 26 14 54

Number of years practicing in hand therapy specialty

<1 1-4 1-4 10-14 15-19 20þ
7 (<1%) 114 (13%) 114 (13%) 157 (18%) 145 (17%) 264 (30%)

Number of years working as a rehabilitation professional

<1 1-4 5-9 10-14 15-19 20þ
1 (0.2%) 57 (6.5%) 129 (15%) 139 (16%) 147 (17%) 395 (45.5%)

Do you have added specific credentials in hand therapy?

Yes No
497 (58%) 361 (42%)

If yes, hand therapy credentials (select ALL that apply)

Accredited hand therapist Certified hand therapist Other
112 (23%) 364 (73%) 62 (12%)

Postgrad ¼ Postgraduate.
a
In occupational therapy or physical therapy.
b
Total does not always add to 887 as responses to many questions were not mandatory.

order by the palmar resting orthosis with IPJs free/EAM (25%),
resting hand orthosis/EAM (15%), dynamic orthosis/EPM (8%),
resting hand orthosis/immobilization (7%), and “other” (2%). Table 3
details the most commonly used approach by country.
Skill level to fabricate the orthosis/es
There were 725 responses to this question. The dynamic
orthosis was rated as needing the most skill to fabricate (mean
difficulty: 7.3/10), followed by RME plus (mean difficulty: 6.0/10),
with the remaining options reported as having a similar level of
skill needed for fabrication (mean difficulty: 4.9-5.6/10) (see
Table 4).
Time required to fabricate the orthosis/es
There were 730 responses to this question. Of these responses, it
was reported that a dynamic orthosis took the longest to fabricate
(45-60 min) with the RME only orthosis taking the least amount of
time, 38% of RME only users reporting less than 10 min for fabri-
cation, and 50% reporting 10 to 19 min for fabrication (see Table 4).
Therapeutic exercise prescription
Most therapists (n ¼ 681 of 702 responses) routinely prescribe
exercises (see Table 4) except the resting hand orthosis/immobili-
zation approach which avoids motion during the postoperative

Fig. 4. Approaches used in the previous 12 months [more than one option could be selected] (n ¼ 1796).
6 M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e17

Fig. 5. Most used approach during the previous 12 months [one option only selected] (n ¼ 853, no response n ¼ 34).

phase of orthosis wear. Exercises were mostly performed while
wearing the orthosis (61%-83%). Depending on the orthosis/pro-
gram used, most of the 753 respondents (varying from 39% to 75%)
waited to commence “out of orthosis” composite active finger
flexion (MCP þ PIP þ DIP joints) until 4-6 weeks after repair (see
Table 4).
Orthosis design preferencedPalmar resting orthosis with IPJs free
[early active motion]
Of 202 therapists who selected the palmar resting orthosis with
IPJs free/EAM as their preferred approach, 61% reported they did
not use an attachment overnight to extend the IPJs and 31% stated
they usually did add an attachment.
Orthosis design preferenceddynamic orthosis [early passive motion]
Of 60 therapists using a dynamic orthosis, 69% restricted MCP
joint flexion either using a palmar block attachment (47%), or a stop
bead (22%). When asked how many fingers were included in the
dynamics of the orthosis, 26 indicated all four fingers, 23 only the
injured and adjacent fingers, and 19 the injured finger only. Thirty-
three of the dynamic orthosis/EPM approach users issued a second
overnight resting hand orthosis, 22 advised patients to wear the

Table 3
Most used approach by country

Country Number of therapists Resting hand Resting orthosis, Palmar orthosis, Dynamic Relative motion “Other”
responding to this orthosis, IPJs included IPJs included [EAM] IPJs free [EAM] orthosis extension An alternative
question [IMMOBILE] [EPM] orthosis [EAM] approach selected
Argentina 23 4 - 8 6 3 2
Australia 139 5 23 18 2 90 1
Austria 11 - 1 2 6 2 -
Belgium 2 - - 1 - 1 -
Brazil 11 1 2 2 1 5 -
Canada 46 2 1 17 - 22 4
Chile 2 - - - 1 - 1
Columbia 3 - - 1 1 1 -
Denmark 20 4 2 7 - 2 5
Germany 20 3 1 - 13 1 2
Guatemala 1 1 - - - - -
Hong Kong 4 - - - 3 1 -
Ireland 19 - 12 1 - 6 -
Kenya 9 - 3 3 2 1 -
The Netherlands 43 1 4 2 - 36 -
New Zealand 44 1 14 3 1 25 -
Norway 5 - - 3 - 2 -
Portugal 1 1 - - - - -
Slovenia 3 - - - 3 - -
South Africa 12 - 2 6 1 3 -
South Korea 1 1 - - - - -
Spain 6 1 1 1 2 1 -
Sweden 40 15 5 17 1 1 1
Switzerland 18 1 1 1 1 14 -
Turkey 4 1 - 1 2 - -
The United Kingdom 88 2 42 6 - 37 1
The United States 275 14 14 110 19 114 4
Uruguay 3 3 - - - - -
Total 853 61 128 210 65 368 21

IMMOBILE ¼ immobilization; EAM ¼ early active motion; EPM ¼ early passive motion; IPJs ¼ interphalangeal joints.
Table 4
Orthosis/program comparison based on percentage of total responses (for questions see Appendix 1)

Variable Resting hand orthosis, IPJs Resting hand orthosis, Palmar resting orthosis, Dynamic orthosis RME plus wrist RME only orthosis
included (IMMOBILE) IPJs included (EAM) IPJs free [EAM] [EPM] orthoses [EAM] [EAM]

Orthosis examples

Skill 0-10 mean 5.63 4.92 5.30 7.34 6.02 5.45

SD/Var. 2.32/5.39 2.33/5.42 2.16/4.65 2.11/4.65 1.89/3.55 2.15/4.61
Number of responses 59 106 202 61 220 77
Time to fabricate (minutes) <10 7% <10 19% <10 4% <10 0 <10 2% <10 38%
10-19 35% 10-19 57% 10-19 35% 10-19 7% 10-19 25% 10-19 50%
20-29 39% 20-29 21% 20-29 39% 20-29 17% 20-29 41% 20-29 10%
30-44 14% 30-44 3% 30-44 21% 30-44 24% 30-44 26% 30-44 2%
45-60 2% 45-60 <1% 45-60 1% 45-60 41% 45-60 5% 45-60 0
60þ 3% 60þ 0 60þ 0 60þ 11% 60þ <1% 60þ 0

M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e17

Number of responses 59 106 201 59 225 80
Exercises during the phase of full-time Not applicable Yes 100% Yes 99.5% Yes 95% Yes 96.5% Yes 90%
orthotic wear No n ¼ 1 0.5% No n ¼ 3 5% No n ¼ 9 3.5% No n ¼ 8 10%
Number of responses 106 201 61 256 78
Composite finger flexion out of orthosis 0-13 7% 0-13 6% 0-13 1% 0-13 0 0-13 1% 0-13 0
(days) 14-27 26% 14-27 3% 14-27 16.5% 14-27 14% 14-27 9.5% 14-27 9%
28-41 39% 28-41 68% 28-41 64% 28-41 55% 28-41 56% 28-41 76%
42-55 24% 42-55 23% 42-55 17.5% 42-55 28% 42-55 31.5% 42-55 13%
56-69 0 56-69 <1% 56-69 1% 56-69 1.5% 56-69 2% 56-69 1%
70þ 4% 70þ 0 70þ 0 70þ 1.5% 70þ 0 70þ 1%
Number of responses 54 106 198 58 258 79
Exercises during full-time phase of Not applicable In 83% In 68% In 61% In either 83% In 76%
orthotic wear (in/out or both of the Out 9% Out 6% Out 14% Out either 2% Out 15%
orthosis) Both 8% Both 27% Both 25% Both 15% Both 9%
Number of responses 106 200 56 249 89
Full to part-time step-down phase of Yes 85% Yes 91% Yes 88% Yes 57% Yes 79% Yes 87%
orthotic wear No 15% No 9% No 12% No 43% No 21% No 13%
Number of responses 52 106 198 58 258 79
Change from full to part-time orthotic 2-4 24% 2-4 2% 2-4 7% 2-4 16% 0-2: 1% 2-4: 5% 2-4 7.5%
wear (weeks) 4-6 44% 4-6 72% 4-6 60% 4-6 56% 4-6 52% 4-6 67%
6-8 30% 6-8 24% 6-8 32% 6-8 25% 6-8 25% 6-8 2%
8-10 2% 8-10 2% 8-10 1% 8-10 3% 8-10 3% 8-10 4.5%
Number of responses 43 96 173 32 196 67
Stop orthosis completely [after step- 4-6 19% 4-6 4% 4-6 10% 4-6 16% 4-6 11% 4-6 18%
down phase of orthotic wear] 6-8 38% 6-8 63% 6-8 56% 6-8 59% 6-8 49% 6-8 54%
(weeks) 8-10 33% 8-10 30% 8-10 28% 8-10 19% 8-10 37% 8-10 22%
10þ 10% 10þ 3% 10þ 6% 10þ 6% 10þ 3% 10þ 6%
Number of responses 42 95 174 32 196 67
Stop orthosis completely [no step- 2-4 25% 2-4 0 2-4 0 2-4 8% 2-4 2% 2-4 0
down phase of orthotic wear] 4-6 38% 4-6 40% 4-6 46% 4-6 20% 4-6 20% 4-6 60%
(weeks) 6-8 25% 6-8 60% 6-8 54% 6-8 68% 6-8 72% 6-8 40%
8-10 12% 8-10 0 8-10 0 8-10: 0 10þ: 4% 8-10 6% 8-10 0
Number of responses 8 10 24 25 54 10

IMMOBILE ¼ immobilization; EAM ¼ early active motion; EPM ¼ early passive motion; RME ¼ relative motion extension; SD ¼ standard deviation; Var. ¼ variance.

7
8 M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e17

dynamic orthosis full-time, and six reported a variety of alternatives
including removing the dynamics at night and use of an overnight
palmar resting orthosis with the IPJs free. The arc of MCP joint
motion permitted during the postoperative phase of orthosis wear
was between 30 and 45 in most patients (n ¼ 29), followed by an
arc of motion between 46 and 60 (n ¼ 12), then an arc of less than
30 (n ¼ 5). A single respondent allowed a 61 to 75 arc of motion.
Orthosis design preferencedRelative motion orthoses [early active
motion]
Of the 353 respondents who used the RME approach, most
chose RME plus (47%) or a combination of RME plus and RME only
(44%). Only 9% exclusively chose RME only. When users of “both”
were asked to select their single most used RME approach over the
past 6 months, most (67%) used RME plus.
Orthotic wear time
Independent of the type of orthosis used, a large percentage
(82% of 751 responses) of therapists reported a “weaning” or
“step-down” phase from full to part-time orthosis wear. Those
more likely to not wean orthosis wear were the dynamic orthosis
users (43% of 58 responses) (see Table 4). The timing for transition
from full- to part-time wear most commonly occurred during the
4 to 6 weeks postoperative period, varying from 44% to 72%
depending on the orthosis used. However, transition from part-
time to nonwear occurred between 6 and 8 weeks with the per-
centage varying between 38% and 63% depending on orthosis
used. For those that did not use a step-down phase (n ¼ 131), the
orthosis was stopped slightly earlier, between 4 and 6 weeks (20%-
75%) (see Table 4).
Hand functional usedDuring orthotic wear
Ratings of patient ability to use the hand when wearing the
orthosis varied widely between the mean ability of 1.54 and
6.77/10 (see Table 5). Therapists who used RME orthoses gave the
highest means for functional ability while wearing the orthosis
(RME plus mean ability: 6.6/10, RME only mean ability: 6.77/10) in
contrast to therapists who used a resting hand orthosis (immo-
bilization mean ability: 2.63/10, EAM mean ability: 1.54/10) (see
Table 5).
Of the 735 responses assessing the level of safe hand use while
wearing the orthosis, 91% to 100% reported light-level tasks were
safe in any of the orthotic choices offered. Fewer felt it was safe to
perform medium-level tasks (varying from 3% to 17%) and heavy-
level tasks (varying from <1%-4%) when wearing the orthosis.
Those more likely to advise it was safe to use the hand during
orthosis wear for medium-level tasks were the RME plus users
(11%) and RME only (17%).
More than one answer could be chosen about showering/
bathing orthosis recommendations, which included “keep it dry”,
“remove it for washing”, and “ok to get it wet”, consequently there
were 731 responses (see Table 5). For all approaches, removal of the
orthosis for washing was chosen the most, varying between 57%
and 71%, with 229 RME/EAM approach users endorsing removal.
Keep it dry was selected most when dynamic (47%) and palmar
resting IPJs free (42%) orthoses were used. Removal of the orthosis
for hand hygiene was reported by more RME orthosis users, RME
only (38% of n ¼ 78) and RME plus (36% of n ¼ 248) and least likely
by those using immobilization (10% of n ¼ 48) and dynamic/EPM
(12% of n ¼ 57) approaches.
Hand functional usedAfter orthosis wear
Therapists were asked to select one answer to the question,
“once the orthosis has been stopped what is the heaviest 2-handed
activity you would recommend to at least ninety percent of your
patients?” There were 735 of responses to this question (see
Table 4). The most common response was medium 2-handed ac-
tivity (up to 25 pounds/11 kg) with percentages varying between
48.5% and 79% across all approaches. Next selected was light 2-
hand activity (up to 10 pounds/4.5 kg), varying between 13 and

Table 5
Orthosis/program functional hand use (for questions see Appendix 1)

Variable Resting hand orthosis, Resting hand orthosis, Palmar resting orthosis, Dynamic orthosis RME plus wrist RME only
IPJs included (IMMOBILE) IPJs included (EAM) IPJs free [EAM] [EPM] orthoses [EAM] orthosis [EAM]
Hand use in orthosis 0-10a 2.63 1.54 3.73 3.63 6.25 6.77
mean
SD/Var. 2.36/5.57 1.63/2.67 1.59/2.54 2.31/5.52 1.54/2.38 1.41/1.99
Number of responses 48 105 199 57 246 75
Showering/bathing KD: 18 37.5% KD: 37 35% KD: 63 42% KD: 27 47% KD: 59 24% KD: 17 22%
recommendations SW: 30 2.5% SW: 69 66% SW: 135 69% SW: 34 60% SW: 177 71% SW: 52 67%
Keep dry, Safe washing, OK wet OK: 5 10% OK: 27 26% OK: 56 29% OK: 7 12% OK: 89 36% OK: 30 38%
Can select >1 response Number 48 105 195 57 248 78
of responses
Safe tasks with orthosis on L: 41 91% L: 82 98% L: 182 99% L: 51 98% L: 243 100% L: 75 96%
M: 4 9% M: 2 2% M: 5 3% M: 5 3% M: 28 11% M: 13 17%
Light, Medium, Heavy H: 0 H: 0 H: 0 H: 0 H: 1 <1% H: 3 3%
Can select >1 response Number 45 84 184 52 244 78
of responses
Heaviest tasks when orthosis L: 22 46% L: 51 48.5% L: 65 32.5% L: 28 49% L: 64 26% L: 10 13%
stopped M: 25 52% M: 51 48.5% M: 121 61% M: 28 49% M: 165 66% M: 62 79%
Light, Medium, Heavy H: 1 2% H: 3 3% H: 3 6.5% H: 1 2% H: 19 8% H: 6 8%
Number of responses 48 105 199 57 248 78
Return to unrestricted hand use 4-6 8% 4-6 1% 4-6 1% 2-4: 2% 4-6: 3% 4-6 <1% <2: 1% 4-6: 1%
without orthosis (weeks) 6-8 13% 6-8 11% 6-8 9% 6-8 11% 6-8 13% 6-8 7%
8-10 32% 8-10 22% 8-10 33% 8-10 24% 8-10 30% 8-10 33%
10-12 25% 10-12 32% 10-12 31% 10-12 30% 10-12 32% 10-12 37%
12þ 23% 12þ 34% 12þ 26% 12þ 30% 12þ 24% 12þ 21%
Number of responses 48 105 198 57 249 78

IMMOBILE ¼ immobilization; EAM ¼ early active motion; EPM ¼ early passive motion; RME ¼ relative motion extension; IPJs ¼ interphalangeal joints; KD ¼ keep dry; SW ¼
safe washing; OK ¼ okay to wet; L ¼ light; M ¼ medium; H ¼ heavy.
a
0 ¼ Unable to use hand in the orthosis; 10 ¼ Full use of hand in the orthosis.
 M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e17 9

Table 6
Orthosis/program outcomes based on percentage of total responses (for questions see Appendix 1)

Variable Resting hand orthosis, Resting hand orthosis, Palmar resting orthosis, Dynamic orthosis RME plus wrist RME only
IPJs included (IMMOBILE) IPJs included (EAM) IPJs free (EAM) (EPM) orthoses (EAM) orthosis (EAM)

Orthosis examples

Tendon rupture Yes: n ¼ 2 4% Yes: n ¼ 8 8% Yes: n ¼ 9 5% Yes: n ¼ 8 15% Yes: n ¼ 14 6% Yes: n ¼ 2 3%

No 96% No 92% No 95% No 85% No 94% No 97%
Number of responses 47 104 197 55 246 77

Usual discharge from <4 2% <4 0 <4 <1% <4 0 <4 <1% <4 1%
therapy (weeks) 4-6 4% 4-6 0 4-6 0 4-6 4% 4-6 0 4-6 3%
6-8 6% 6-8 3% 6-8 7% 6-8 11% 6-8 13% 6-8 22%
8-12 47% 8-12 57% 8-12 60% 8-12 46% 8-12 60% 8-12 60%
>12 41% >12 40% >12 32% >12 39% >12 27% >12 14%
Number of responses 47 105 197 56 248 77

TAM on discharge
Exc: equal or 100% Exc 6.5% Exc 21% Exc 19% Exc 12% Exc 23.5% Exc 22%
Good: 75%-99% Good 85% Good 77% Good 80% Good 79% Good 75.5% Good 78%
Fair: 50%-74% Fair 6.5% Fair 2% Fair 1% Fair 9% Fair 1% Fair 0%
Poor: <50% Poor 2% Poor 0% Poor 0% Poor 0% Poor 0% Poor 0%
Number of responses 47 103 196 57 248 74

Satisfaction on discharge
Yes: my opinion 28% 47% 51% 32% 66% 65%
Yes: patient opinion 68% 82% 79% 72% 81% 79%
Yes: satisfaction 13% 19% 27% 32% 18% 29%
survey
No: my opinion 2% <1% 1.5% 5% 0 0
No: patient opinion 6% 2% 1% 5% <1% 0
No: satisfaction 0 2% 1% 3.5% <1% 0
survey
Unsure 4% 2% 3.5% 9% 1% 0
Number of responsesa 47 105 197 57 247 78

RTW pre-injury Yes 94% Yes 98% Yes 96% Yes 93% Yes 98% Yes 97%
capacity No 6% No 2% No 4% No 7% No 2% No 3%
Number of responses 47 105 197 55 248 77

RTW in any capacity Yes 50% Yes 50% Yes 85% Yes 50% Yes 100% Yes 50%
No 50% No 50% No 15% No 50% No 0 No 50%
Number of responses 2 2 7 4 5 2

RTW guidelines set by

No one 2% 2% 1% 0 1% 0
Surgeon 38% 20% 49% 40% 30% 25%
Surgical team 0 2% 2% 0 2% 1%
Therapist 22% 28% 10% 8% 19% 25%
Combination 31% 48% 35% 50% 46% 46%
Other 7% <1% 3% 2% 2% 3%
Number of responses 45 105 194 52 247 75

IMMOBILE ¼ immobilization; EAM ¼ early active motion; EPM ¼ early passive motion; RME ¼ relative motion extension; IPJs ¼ interphalangeal joints; TAM ¼ total active
motion; Exc ¼ excellent; RTW ¼ return to work.
a
Percentage amounts add to >100% as more than one option could be selected.

49%, and least often selected heavy 2-hand activities (up to 50
pounds/22.5 kg) varying between 2% and 8%. Those that used
immobilization, resting hand/EAM, and dynamic/EPM approaches
selected light and medium 2-handed activity nearly equally, with
medium 2-handed activity selected by more respondents using the
palmar resting orthosis with IPJs free/EAM and both RME/EAM
approaches.
There was great variability in the 735 responses to “at what
week post-repair do you usually recommend patients can return to
unrestricted hand use without the orthosis?” The breakdown by
week before unrestricted use was allowed: >12 weeks (26%), 10 to
12 weeks (32%), 8 to 10 weeks (29%), 4 to 6 weeks (11%), and 2 to 4
weeks (2%) (see Table 5).
Therapist-reported outcomes
Tendon ruptures
Of the 726 responses to this question, most reported no ruptures
(varying from 85 to 100%) (see Table 6). For the 43 respondents who
reported ruptures, the highest rates (15%) where when dynamic
orthoses/EPM were used, followed by 8% for resting hand/EAM
approach. Remaining approaches reported rates of 6% or less.
Usual timeframe for discharge from therapy
Of the 730 responses to this question, most therapists dis-
charged their patients between 8 and 12 weeks after surgery (57%),
followed by 31% beyond 12 weeks (see Table 6). The RME only/EAM
10 M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e17
approach had the smallest percentage (14% of n ¼ 77) of patients
discharged after 12 weeks compared with all other approaches.
Total active motion (TAM) on discharge
Of the 725 responses estimating total active motion on
discharge from therapy, most therapists selected “good” TAM
(75.5%-85%) at discharge, followed by “excellent” (6.5%-23.5%),
“fair” (1%-9%) and “poor” (0%-2%). The greatest percentage of
“excellent” TAM were reported by users of RME only/EAM (78% of
n ¼ 74) and RME plus/EAM (75.5% of n ¼ 248) approaches (see
Table 6).
Satisfaction on discharge
Respondents (n ¼ 731) were asked whether more than 90% of
patients were satisfied with their hand function at the time of
therapy discharge; choices included therapist opinion, patient
report, or a satisfaction survey (see Table 6). Therapists generally
deemed patients to be satisfied, derived mostly from therapist’s
opinion (54%) and patient report (79%), as few therapists used a
formal survey to determine satisfaction (22%).
Returning to work
Of the 729 responses, percentages varied from 93% to 98% for
the question “on therapy discharge do almost all (>90%) patients
who have paid employment return to their PRE-INJURY work ca-
pacity?” across all approaches (see Table 6). If the answer was “no”
to this question (n ¼ 23), respondents were asked if the worker
could return to work in any capacity, with the percentages for a
“yes” answer varying from 50% to 100% and percentages for “no”
varying from 17% to 50%.
Of the 718 responses to the inquiry on who usually provides the
return to work guidelines/restrictions, similar percentages were
reported across approaches with the answer “surgeon” varying
from 20% to 49%, an answer of a “combination” varying from 31% to
50%, and the answer “therapist” varying from 8% to 28% (see
Table 6). The same top three reasons for delayed return to work
were reported for all approaches: the workplace does not have any
light or modified duties, the worker cannot return to full duty until
there are no restrictions, and the worker cannot return to work
wearing an orthosis.
Advantages of usual approach
Therapists could select from a list of advantages related to or-
thotic design, therapy program, function, return to work, and out-
comes. Specific response percentages of the 708 respondents to this
question are detailed in Table 7.
Orthosis design
RME plus and RME only had the highest percentages of re-
spondents who believed that these orthoses had a small and low-
profile design (>92% of n ¼ 321). However, the RME only also had
a high percentage of users reporting it is quick to make (84% of
n ¼ 75), and that materials cost less (75%). Forty percent of re-
spondents (n ¼ 104) using a resting hand orthosis/EAM felt that the
orthosis could be made by a junior therapist, followed by RME only
orthosis users (32% of n ¼ 75), and palmar resting orthosis with IPJs
free users (22% of n ¼ 193). Only 8% of those using a dynamic
orthosis believed it could be made by a junior therapist.
Therapy program/approach
Program instruction was considered “quick” by most re-
spondents of RME only/EAM (60% of n ¼ 75), RME plus/EAM (59% of
n ¼ 246), palmar resting orthosis with IPJs free/EAM (56% of
n ¼ 193), and resting hand orthosis/EAM (55% of n ¼ 609).
When asked whether the usual approach was suitable for less
adherent patients, the most likely to agree were users of the resting
hand orthosis/immobilization (50% of n ¼ 40), and the least likely
were the dynamic orthosis/EPM (20% of n ¼ 50) users. Sixty percent
or more of all users felt any of the approaches could be used for
almost all (>90%) of patients.
Function
Eighty-six percent of therapists using RME/EAM approaches (of
n ¼ 321) reported the ability to use the hand while in the orthosis as
an advantage compared with less than 3% (of n ¼ 104) or 8% (of n ¼
40) of therapists using a resting hand orthosis for EAM or immo-
bilization, respectively.
Return to work
Eighty-one percent of therapists (of n ¼ 75) using RME only/
EAM reported this approach allowed earlier return to work, fol-
lowed by RME plus/EAM (63% of n ¼ 246). Conversely, 15% (of
n ¼ 193) therapists using a palmar resting with IPJs free/EAM felt
this approach allowed earlier return to work, followed by resting
hand orthosis/immobilization (10% of n ¼ 40), and resting hand
orthosis/EAM (6% of n ¼ 104).
Outcomes
Eighty-eight percent of therapists (of n ¼ 75) using the RME
only/EAM reported this approach yields better outcomes than other
approaches, followed in descending order by RME plus/EAM (82% of
n ¼ 246), dynamic/EPM (56% of n ¼ 50), palmar resting IPJs free/
EAM (55% of n ¼ 193), immobilization (48% of n ¼ 40), and resting
hand/EAM (38% of n ¼ 104).
Disadvantages of usual approach
Therapists could select from a list of disadvantages related to
orthotic design, therapy program, function, return to work, and
outcomes, as well as the choice to say there were no disadvantages.
Specific response percentages for the 691 respondents are detailed
in Table 7. More than a third of RME/EAM users responded that
there were no disadvantages (36% of 312 responses).
Orthosis design
From the 691 responses, the most common disadvantage iden-
tified was the perception of the orthosis design being “cumber-
some”, varying from 4% (of n ¼ 238) for the RME plus orthosis
reporting this as a disadvantage compared with 69% (of n ¼ 102)
resting hand orthosis/EAM users. Forty-one percent of n ¼ 49
fabricators of the dynamic orthosis reporting it as “taking too much
time to make”. While 20% (of n ¼ 49) dynamic orthosis users and
16% (of n ¼ 102) resting hand orthosis/EAM users identified “ma-
terial costs too much” as a disadvantage.
Therapy program and approach
Six therapists (12% of n ¼ 49) using the dynamic/EPM approach
identified “instructions taking too much time” as a disadvantage,
which was the highest rating for all approaches. As well, 18% of
therapists using this approach also reported the program as un-
suitable for a junior therapist. The approaches, more likely to be
identified as “not suitable for nonadherent patients”, were by users
of the RME/EAM approaches (RME plus 42% of n ¼ 238, RME only
39% of n ¼ 74) and dynamic/EPM approach (33%). Very few thera-
pists identified “cannot be used for 90% of patients” as a potential
disadvantage for any approach.
 M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e17 11

Table 7
Orthosis/program advantages and disadvantages (for questions see Appendix 1)

Advantages and Resting hand orthosis, Resting hand orthosis, Palmar resting Dynamic orthosis RME plus wrist RME only orthosis
disadvantages IPJs included (IMMOBILE) IPJs included (EAM) orthosis, IPJs free (EAM) (EPM) orthoses (EAM) (EAM)

Orthosis examples

Advantages (Percentage of total respondents)

Orthotic design
Small & low profile 13 16 42 14 92 100
Larger & more 28 25 9 6 <1 0
limiting
Quick to make 53 69 56 14 53 84
Junior therapist can 20 40 22 8 19 32
make
Materials cost less 5 12 14 6 33 75
Materials are 35 44 34 32 44 60
available
Therapy program
Instruction is quick 30 55 56 28 59 60
Instruction junior 20 35 16 14 21 25
therapist
Use less adherent 50 42 44 20 26 31
patients
Used for >90% of 68 81 77 70 68 63
patients
Function in orthosis
Able to use hand 8 3 36 18 85 91
for usual ADLs in
orthosis
Cannot use hand in 35 41 11 4 2 0
orthosis
Return to work
Allows for earlier 10 6 15 10 63 81
RTW
Outcomes
Fewer 50 49 57 64 62 68
complications
Fewer 2 surgeries 28 29 26 44 36 45
Better clinical 48 38 55 56 82 88
outcomes
Number of 40 104 193 50 246 75
responses
Disadvantages (Percentage of total respondents)
Orthotic design
Cumbersome 40 69 29 65 4 7
Too small & less 0 0 3 0 8 18
limiting
Too much time to 5 3 3 41 3 0
make
Junior therapist 3 0 1 0 1 0
cannot make
Materials cost too 5 16 6 20 3 3
much
Materials are 5 1 1 4 1 1
unavailable
Therapy program
Instruction too 3 5 2 12 <1 1
much time
Instruction cannot 5 3 4 18 8 9
be done by junior
therapist
Not suitable for less 5 23 23 33 42 39
adherent patients
Cannot be used 5 0 <1 0 3 0
>90% of patients
Function in orthosis
Not able to use 58 78 41 41 3 1
hand for usual ADLs
Allows too much 3 4 19 8 33 43
hand use
Return to work
Not allowed until 33 48 28 37 3 3
>6 weeks
(continued on next page)
12 M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e17

Table 7 (continued )

Advantages and Resting hand orthosis, Resting hand orthosis, Palmar resting Dynamic orthosis RME plus wrist RME only orthosis
disadvantages IPJs included (IMMOBILE) IPJs included (EAM) orthosis, IPJs free (EAM) (EPM) orthoses (EAM) (EAM)
Outcomes
Higher risk of 5 4 3 6 2 4
complications
Higher risk 8 8 6 8 0 0
secondary surgery
Poor clinical 8 3 3 4 <1 1
outcomes
No disadvantages 15 9 19 2 36 36
Number of 40 102 188 49 238 74
responses

IMMOBILE ¼ immobilization; EAM ¼ early active motion; EPM ¼ early passive motion; RME ¼ relative motion extension; IPJs ¼ interphalangeal joints.

Function poor clinical outcomes. Users of both RME/EAM approaches were

Eighty therapist users of resting hand orthosis/EAM (78% of
n ¼ 102) and 23 therapists (58% of n ¼ 40) of resting hand orthosis/
immobilization users identified “not able to perform ADLs with
orthosis on” as a disadvantage. Conversely, users of RME only/EAM
approach (43% of n ¼ 74), followed by RME plus/EAM approach (33%
of n ¼ 238) identified “able to use the hand too much” as a potential
disadvantage to these approaches.
Return to work
When asked which approach “does not allow return to work
until after 6 weeks” response percentagesvaried from a high of 48%
(of n ¼ 102) for users of the resting hand orthosis/EAM to a low of
3% for each RME approach (of n ¼ 238 RME plus; n ¼ 74 RME only).
Outcomes
Across all approaches, therapists generally reported low rates
(<10% of n ¼ 691) of complications, need for secondary surgery, and
least likely (36% each of n ¼ 238 RME plus; n ¼ 74 RME only) to
report any of these complications.
Continue approach or use another
All therapists who used the RME only/EAM (n ¼ 76) approach
reported they would continue with their approach (see Table 7). Of
those RME users who added a wrist orthosis (n ¼ 245), only seven
indicated they would like to start using another approach; these
included two who selected RME only/EAM, two users a resting hand
orthosis with IPJs included/EAM, and three who selected “other”
with details of the preferred approach unspecified. By contrast, 55%
of the 401 therapists not using an RME/EAM approach wanted to
continue with their current approach, whereas the remaining 45%
said they would like to start using another approach. Notably, 85%
of 184 these respondents wanting to use another approach selected
“relative motion extension” (see Table 8 and Fig. 6). The reasons

Table 8
Continue using preferred approach or use another approach: Percentage of total responses (for questions see Appendix 1)

Continue using or use Resting hand Resting hand Palmar resting Dynamic orthosis RME plus wrist RME only “Other”
another approach orthosis, IPJs orthosis, IPJs orthosis, IPJs (EAM) orthoses orthosis
included (IMMOBILE) included (EAM) free (EPM) (EAM) (EAM)

An alternative
approach
Orthosis examples
was selected
by respondent

Continue or use another Continue 56% Continue 53% Continue 56% Continue 51% Continue 97% Continue 100% Continue 71%
Another 44% Another 47% Another 44% Another 49% Another 3% Another 19%
Number of responses
41 104 193 49 245 76 14
Would like to start using
Resting hand orthosis, -
IPJs included 0 1 0 0 0 0
(IMMOBILE) 1%
Resting hand orthosis, -
IPJs included (EAM) 2 3 2 2 0 0
11% 4% 9% 28.5%
Palmar resting orthosis, -
IPJs free (EAM) 5 3 1 0 0 1
28% 4% 4% 25%
Dynamic orthosis (EPM)
0 2 0 1 0 0 0
4% 4%
RME (EAM)
11 45 76 19 2 - 3
61% 92% 94% 79% 28.5% 75%
Other
0 0 1 1 3 0 0
1% 4% 43%
Number of responses
18 49 81 24 7 0 4

IMMOBILE ¼ immobilization; EAM ¼ early active motion; EPM ¼ early passive motion; RME ¼ relative motion extension; IPJs ¼ interphalangeal joints.
 M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e17 13

Fig. 6. Preference for approach therapists would like to start using (n ¼ 183).

these 156 therapists desired use of RME included achievement of
functional hand use (83%), sooner recovery of motion (82%), smaller
and lower profile of the orthosis (76%), earlier functional hand use
reported by the literature (62%), and earlier return to work (58%).
Importantly, these same therapists (n ¼ 156) reported the single
largest barrier to using another approach was surgeon preference
(70%), followed by therapy department preference (24%) (see
Table 9). Surgeon preference was also reported as the single largest
barrier for the 27 therapists who did not select RME but would like to
start using another approach. Two other barriers to implementing an
RME/EAM approach was the concern that the orthosis does not
provide enough protection (22%, n ¼ 35) and concerns about lack of
adherence by the therapist’s patient population (19%, n ¼ 29).
Summary of respondent open-text comments
Therapists were invited to comment within the open-text
fields about select therapy approaches, extensor tendon post-
operative management, and the survey structure. Overall, 318
open-text comments were received from 260 therapists or 29% of

Table 9
Barriers for therapists in implementing their preferred approach (see Appendix 1, question 50)

Barriers for Resting hand orthosis, Resting hand orthosis, Palmar resting orthosis, Dynamic orthosis RME (with or “Other”
implementing another IPJs included IPJs included (EAM) IPJs free (EPM) (EAM) without wrist
approach (IMMOBILE) orthosis) (EAM)

An alternative
Orthosis examples approach
was selected
by respondent

Orthotic design
Time to make the 1 11% 2 67% 7 4% 1 20%
orthosis is too much
Cost of orthosis is too 2 22% 1 11% 1 33% 1 <1% 1 20%
much
Orthotic materials are 2 22% 2 22% 1 33%
not available
Does not provide 1 11% 35 22% 1 20%
enough protection
Preference
Surgeon preference 1 100% 6 67% 6 67% 1 33% 109 70% 4 80%
Therapy department 5 56% 3 33% 1 33% 37 24%
preference
Other
Lack of evidence for 2 22% 1 11% 17 11% 2 40%
orthosis/program
Lack of confidence to 1 33% 23 15%
make the orthosis
Lack of confidence to 1 11% 1 33% 23 15% 1 20%
progress program
Lack of adherence by 1 100% 1 11% 29 19% 1 20%
my pt. population
Other 3 33% 1 11% 14 9%
Number of responses 1 9 9 3 156 5

IMMOBILE ¼ immobilization; EAM ¼ early active motion; EPM ¼ early passive motion; RME ¼ relative motion extension; IPJs ¼ interphalangeal joints.
14 M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e17
Table 10
Coding of therapists (n ¼ 318) open-text comments
Theme RME discussion Comments on approach
Subtheme
Prefer RME
Adaptation to

Reasons for not approach
doing RME

Advantages of RME
Number of comments 155 138
RME ¼ relative motion extension.
all respondents. Responses have been blended for thematic
analysis as many responses crossed over between two open-text
fields.
For these analyses, comments were first coded into five themes
as outlined in Table 10 and then similar threads were categorized
into subthemes. When possible, themes and subthemes are sup-
ported by direct quotes.
Theme 1: Relative motion extension discussion
Discussion on relative motion was the most prevalent topic,
with 155 comments (49% of all respondents) in the open-text fields
with several subthemes emerging. The subthemes identified were a
preference for the RME orthosis/EAM approach although not sup-
ported by the practice setting, reasons for not implementing an
RME approach, and reasons why patients and therapists liked the
approach.
Subtheme: “Prefer RME”. Several therapists wrote that their pref-
erence would be to use RME; however, their practice setting did not
allow for implementation of an RME/EAM approach. An example
comment was
“I prefer the I-CAM (RME) regime as patients return to full work
and ADLs much quicker, however the new department I work in
state [another] regimen is their protocol and not open to
adopting an alternative.”
Subtheme: “Reasons for not using RME”. There were 55 comments
(17%) by therapists citing reasons for not using RME/EAM ap-
proaches, these largely related to not being able to use RME or-
thoses for all patients. Some noted the RME/EAM approach could
not be used when all four fingers were injured, or restricted use to
when the injury involved only one finger, or two fingers, whereas
others did not believe RME/EAM approaches could be used if two
adjacent fingers were injured. This comment offered by a therapist
who identified preference for use of a resting hand orthosis/EAM
used the following rationale:
“Can be used for multiple tendon repairs whereas the Relative
Motion protocol is suitable for 1-2 tendons only”
Others stated that RME orthoses/EAM approaches could not be
used with patients referred late to therapy.
Subtheme: “Advantages of RME”. Both therapist users and nonusers
highlighted advantages of the RME program in 42 comments,
frequently citing, ease of use, adherence to instructions, improved
clinical outcomes, and early return to work. The most often cited
advantages of RME orthoses/EAM approaches are reflected in these
quotes:
“I love this program! Patients have much fewer issues with scar
adherence and incorporate regular activity more quickly versus
the dynamic programs we’ve previously used.”
Patient-centered Surgeon preference Compliments and
therapist management
The surgeon decides complaints
required the postoperative approach

Therapist preferred
approach is limited by
surgeon preference
49 40 33
“The patients love the freedom of movement that this splint and
protocol allow as well as the prospect of earlier return to work.”
Theme 2: Comments on selected approach
Therapists made 138 comments (43%) regarding the program
selected as their most used approach in the previous 12 months.
These comments varied greatly with one emergent subtheme:
orthosis/program adaption. Other comments included specific
merits of their most used approach, how to manage adhesions, the
level of skill needed to fabricate the orthosis, and a few on third-
party pay or insurance issues.
Subtheme: “Adaptation to orthosis/approach program”.
Comments related to adapting their most used orthosis/approach
came mostly from (28/40) therapists who used the palmar orthosis
with IPJs free/EAM approach. Several therapists wrote that they
made a patient-centered change for example adding an orthosis if
the patient developed an active PIP joint extension lag or modified
the orthosis design from forearm to a hand-based orthosis.
Theme 3: Patient-centered management required
Factors related specifically to the patient were cited by 49
therapists to effect selection of the approaches. Ideally, many sug-
gested having a variety of approaches from which to select is better,
as supported by the following comment:
“I think it is better for a hand therapy service to have all the
methods at their disposal and choose based on sound clinical
reasoning, such as anticipation of serious adhesion, as described,
or based on surgeon feedback concerning the integrity of the
repair. It is the therapist’s responsibility to weigh up the risks
and benefits of the chosen regimen and also ensure that it fits
with the capacity of the patient to comply. I don’t think we will
ever have ‘one size fits all’ clinical guidelines for this injury.”
Theme 4: Surgeon preference
Subtheme: “The surgeon decides the postoperative therapy approach”.
Interestingly, 40 therapists said that the surgeon decided which
postoperative approach was to be used, further commenting
“The hand surgeons in my area almost all specify the type of
splint they want, usually the palmar/IPs free style, so the deci-
sion is theirs not mine.”
“Unfortunately, I have almost no participation in the decision
process about which splint the patient is going to get. It is al-
ways decided by the surgeon.”
Subtheme: “My preferred approach is limited by surgeon preference”.
Over half of the comments indicated a preference for the RME or-
thoses/EAM approach, with surgeon preference the limitation or
barrier. Comments such as
 M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e17
“Personally, I like the relative motion orthosis more. It has a
better outcome. BUT the doctors that refer want me to follow
this protocol.”
“I would choose to use relative motion splinting more if sur-
geons were on board. We have several referral sources who
refuse to try it with their patients.”
Theme 5: Compliments and complaints
Congratulations and well wishes were extended by 21 thera-
pists to the researchers with many interested in the survey re-
sults. A few therapists commented that the survey fell short in
collecting information about confounding factors that may in-
fluence the therapist’s choice of approach as noted in the
following comment:
“Survey does not account for straight forward laceration vs
complex fracture/crush. Surgeon repair timing/technique. Pa-
tient comprehension/compliance factors. All of these play into
decision of postoperative management strategy.”
Discussion
To our knowledge, this study is the first to globally investigate
current practice patterns in hand therapy and specifically for the
postoperative management of finger zones V and VI extensor
tendon repairs. We received responses from 28 of 36 IFSHT full-
member countries and our sample was mostly female occupa-
tional therapists who had 10 or more years of hand therapy expe-
rience, with >50% holding additional credentials in hand therapy.
Our sample closely matches the typical demographics of therapist
members from IFSHT full-member countries reported in a 2015
IFSHT survey https://www.ifsht.org/page/ifsht-reports. As such, we
have confidence that the findings from our survey are likely
representative of postoperative practice patterns in the manage-
ment of extensor tendon zones V and VI of the fingers by English-
speaking hand therapists working in countries that have a national
hand therapy organization with full-membership in the IFSHT.
Survey responses inform us that therapists worldwide use or
have used a variety of postoperative approaches after extensor
tendon zone V-VI repair. While many were familiar with all five of
the best-known approaches, the data suggests that RME orthoses
with EAM is the most used or “preferred” approach. Moreover, in
this survey, the RME orthosis/EAM approach was chosen by most
therapists who are not currently using it but wanted to use it.
Regarding the “most used approach in the previous 12 months”
regional influence was evident, with high uptake of the RME/EAM
approach in Australia, the Netherlands, New Zealand, and
Switzerland. High usage of the resting orthosis IPJs included/EAM,
also known as the “Norwich regimen”,13 was in Ireland and in
nearly half of all United Kingdom respondents (the origin of the
Norwich regimen program), with the RME/EAM approach a close
second. The United States and Canada almost equally used the RME
and palmar orthosis with IPJs free EAM approaches. Sweden’s usage
was almost equal between immobilization and a palmar orthosis
with IPJs free/EAM, while German therapists primarily used a dy-
namic/EPM approach. The remaining participating countries had a
more equal spread of approaches selected or had too few survey
participants to identify a trend.
Early motion rehabilitation programs are known to yield earlier
and better TAM than immobilization after extensor tendon repair.7-
9
Although there have been many studies that have not found
appreciable difference between early active and early passive mo-
tion approaches,1,3,14-16 there are recognized disadvantages of dy-
namic orthoses including poor patient acceptance and orthosis
15
malfunction,9 and more skill and time is required to fabricate a
dynamic orthosis compared with a resting hand orthosis.14 The
practical disadvantages, specifically skill level and fabrication time
were identified by survey respondents, and may be why dynamic
orthosis/EPM was ranked as the approach least used, and perceived
to have the lowest patient satisfaction.
Survey respondents elected to use the RME and palmar IPJs free
orthoses as their number one and two, respectively, “most used”
orthoses to deliver EAM, aligning with the conclusions from several
systematic reviews which cautiously recommended the RME
approach despite the lack of high-level evidence.5,9 The opinions of
the review authors have since been supported by a recent ran-
domized controlled trial that compared EAM with palmar orthosis/
IPJs free to EAM with RME only orthosis/EAM.17 This trial also re-
ported similar advantages to those reported by respondents in our
study, in that RME orthoses achieved earlier functional hand use
and TAM, and greater patient satisfaction than the palmar orthosis
with IPJs free/EAM.17
Given respondents reported similar recovery timelines across
approaches, with most reporting good to excellent TAM and return
to work outcomes, we wondered why the RME/EAM was the “most
used” approach as well as the approach the vast majority of non-
RME users would like to use. Literature published to date lists the
advantages of the RME orthosis such as its small size, low profile,
and low cost2,17-21 all of which align with the survey findings.
Survey responses suggest another advantage might be the differ-
ence in the degree of difficulty to fabricate and, therefore, time to
fabricate, especially when compared with dynamic orthoses. Our
survey was constructed in such a way that it did not take into
consideration the time required to instruct the patient or if the
amount of time available to the therapists for fabrication of the
orthosis affected orthotic choice. Our results, however, suggest a
hierarchy to skill level required for orthosis fabrication, further
supported by responses to a separate question asking if a “junior
therapist” could fabricate the orthosis. If this is true, then the
easiest to fabricate orthoses is more likely be selected by therapists
with less skill, unless influenced by implementation barriers
recognized in this survey.
Although there is some evidence that earlier recovery of TAM
and hand function occurs when an RME only orthosis/EAM is used
compared with use of a palmar orthosis with IPJs free/EAM,17 there
are no published trials comparing different EAM approaches. We
recommend studies with EAM in both groups but comparing either
RME only with RME plus or either RME orthosis/EAM approach to
the Norwich/EAM Regimen (resting hand orthosis). Survey re-
sponses indicate therapists believe that TAM outcomes are superior
with either RME orthosis/EAM approaches compared with all other
approaches surveyed, but there is no level 1 or 2 evidence to sup-
port this.
Responses to the question regarding approaches allowing the
greatest/earliest hand function resulted in selection of the RME
orthosis with and without the wrist component with EAM. This is
supported by the functional hand use (Sollerman test) results of
Collocott et al17 and the observations of others.2,18,20,21 An inter-
esting observation is that although the palmar IPJs free and dy-
namic orthoses allow for IP joint motion, the respondents
perceived the RME plus orthoses to be more functional for hand
use; the only difference being that the RME plus orthoses permits
both IP and MCP joint active motion. Another finding of interest is
that survey respondents report modifying the palmar orthosis IPJs
free to permit wrist motion, which differs from the orthosis
description in the literature.22
The question about patient satisfaction after extensor tendon
repair has only recently been explored in the literature by Svens
et al21 and Collocott et al,17 who used questions from some sections
16 M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e17
of the Patient Evaluation Measure. Collocott17 also added their own
orthosis satisfaction questions to compare EAM using RME only
orthoses to EAM with a palmar orthoses/IPJs free. In brief, at 8
weeks postoperatively orthosis satisfaction questions were found
to be significantly different, as well as better for those who wore
RME only orthoses.17 Clinical practice after extensor tendon repair
from this survey reflects the literature in that few respondents
measure outcome with a validated patient satisfaction question-
naire (see Table 6). However, therapist’s perceived satisfaction for
both themselves and their patients by far exceeded respondents
who perceived dissatisfaction with any approach. Furthermore,
perceived and measured satisfaction was greater for EAM and EPM
approaches than immobilization.
Tendon rupture is often used as an indicator for successful repair
and postoperative management. While no tendon ruptures have
been reported in RME clinical or cohort studies,2,17,18,20,21,23 survey
respondents reported experience with ruptures for all approaches,
including RME/EAM. Those with the greatest rupture experience
used dynamic orthosis/EPM and tendons were reported to ruptured
least with use of RME only orthosis/EAM. In addition, the need for
secondary surgical procedures was identified to be a greater “risk”
by respondents for all approaches except the RME/EAM
approaches.
RME users for the most part want to continue to use this
approach, whereas nearly half of those using other approaches
would like to use another. Of those wanting to make a change, 85%
would like to use RME but faced barriers to use. The top four bar-
riers to therapist use of RME are surgeon preference, clinic policies/
procedures, and a belief that RME orthoses afford less protection,
and RME orthoses are not indicated for nonadherent patients.
Regarding the first two barriers, to our knowledge, until this survey,
there has been no documentation to suggest that hand therapists
may be limited in their capacity to make patient-centered choices
after extensor tendon repair due to surgeon or clinic preferences. If
this is so, strategies to provide the necessary information to the
surgeon or those responsible for a clinic’s policy and procedure
should be considered. The last two barriers mentioned were also
singled out as disadvantages alongside some saying RME orthoses
allowed too much use of the injured hand. The idea that the RME/
EAM approach is not indicated for nonadherent patients and the
impression that the RME orthoses do not provide enough protec-
tion has not been substantiated. Given that users in this survey of
RME did experience tendon repair ruptures, this was less when
compared with the alternate approaches in this survey, and there
have been no ruptures with the RME orthosis/EAM approach re-
ported in the literature.
Exactly which approach (orthosis/program) best protects extensor
tendon repairs of the nonadherent patients has not been established.
There is no evidence, other than opinion circulated throughout the
literature that suggests immobilization as the best approach for
nonadherent patients.6,24 However, there is evidence to recommend
patient adherence after tendon repair can be improved when the
patient likes the appearance of the orthosis, is comfortable, has no
pain wearing the orthosis, can function safely in the orthosis, and is
able to perform hand hygiene.25 Correspondingly, many of these fac-
tors are supported by RME orthoses, as demonstrated by Collocott
et al17 and recognized by survey respondents. Hirth et al20 also com-
mented that the simplicity of the RME orthotic design, along with
early functional hand use, may yield improved adherence.
For all approaches, respondents reported nearly all patients
returned to their preinjury work capacity before therapy discharge,
and if not, most injured workers returned to work in some capacity.
Four of the five extensor tendon systematic reviews investigated
return to work time frames. The return to work for dynamic/EPM
and resting hand/EAM varied between 9 and 12 weeks.1,14,26-28 One
study separated return to light (4 weeks) and heavy (12 weeks)
duties for dynamic/EPM and resting hand/EAM,3 whereas another
separated simple (6.5 weeks) and complex (8.5 weeks) injuries for
those managed with a resting hand/EAM approach.13 RME has the
earliest report of return to work (18 days) after tendon repair.2
However, Collocott et al17 reported return to work time frames
were often limited by a driving restriction until 6 weeks after sur-
gery. As such, timeliness of return to work may not be a valid
measure of tendon repair outcome due to these extraneous vari-
ables. This was supported by the survey which explored various
barriers for return to work, and regardless of the approach used and
who provided the return to work guidelines (surgeon, therapist,
combination), the top three reasons for a delayed return to work
were variables controlled by the workplace.
Limitations
Respondents to this electronic survey came from a convenience
sample, which included only therapist members from IFSHT full-
member countries, and therefore may not be representative of all
hand therapists worldwide. While a large proportion of full-member
countries did participate, we acknowledge it was unknown if the
email lists of the national organizations were complete or accurate,
four full-member countries failed to respond, others did not follow
the participation protocol, two organizations did not send the survey
to their full membership, and there is limited data for several regions
surveyed. Translating the survey into multiple languages was not
feasible, so it was developed for those who read English, which could
have influenced participation because 70% of respondents affirmed
that English was their first language.
Overall survey participation rate was 11%; while low, this was
similar to a flexor tendon study29 conducted with American Society
for Surgery of the Hand members that recorded 15%, and less than
the 25% response rate recorded by Parish et al30 who surveyed
American Society of Hand Therapists members on practice patterns
for carpal tunnel syndrome. We suspect that targeting a larger
global population including countries for which English was not
their first language likely contributed to a lowered response rate.
We also acknowledge that a survey design that ultimately
required participants to answer anywhere from 39 to 69 questions
may have been a limitation. In support of our efforts to design the
instrument, an extensive English-language review was done,
approval of the ethics committee was given, and a pilot trial for
content review was done with 23 therapists from Australia and the
United States. Furthermore, while strong consideration was given
to the fact that not all respondents have English as a first language,
we cannot project to know if the content of all questions was fully
understood, even by the English first language respondents.
The authors fully appreciate that hand therapy intervention and
clinical reasoning is patient-centered and may vary more among
injuries of various complexity. Because the aim of the survey was to
learn about management after extensor tenorrhaphy, we did not
explore cases with concomitant fractures or multiple injuries such
as described in zone III-V case reports.31 To undertake this study
and gain a wider understanding of practice patterns, the term
“usually” was applied to many questions to manage these potential
variations of injury and therapeutic management to reduce survey
length. This may have resulted in presentation of data in a more
simplistic manner than what occurs in clinical practice.
It was consensus of the authors that our interest was to learn of
the practice patterns of hand therapists regardless of the number of
extensor tendon repairs managed over the past year. Some may
view the fact that therapists were made to choose and respond
regarding a single approach, their “most used” in the previous 12
months and respond accordingly as a limitation. We understand
 M.J. Hirth et al. / Journal of Hand Therapy xxx (2020) 1e17
that many therapists have experienced and do use multiple ap-
proaches; however, the survey structure did not allow for com-
parisons. The reasons for this were to limit the length of the survey
and minimize any possible bias respondents might have for or
against approaches that are not their “most used” approach.
Recommendations for the future
To capture a more comprehensive understanding of practice
patterns worldwide, future survey should also attempt to recruit
therapists from non-IFSHT member countries and be translated and
disbursed through IFSHT full-member countries to potential re-
spondents whom English is not their primary language.
Conclusions
This survey affords a better understanding of the global practice
patterns of therapists who manage zone V-VI extensor tendon re-
pairs of the fingers. For the most part, survey respondents preferred
early active motion approaches over EPM/immobilization, and
these approaches are used based on the perceived advantages in
terms of superior results and speed of recovery. It is notable,
however, that emerging evidence supporting the benefits of early
active motion and clinical practice did not always align.
Although there are many commonalities among the different
approaches, the most preferred method of early active motion
delivery was with RME orthoses. Unforeseen were the reported
barriers of surgeon and clinic preferences as a primary reason
preventing therapists from using their preferred or desired ap-
proaches. Future randomized clinical trials are warranted,
comparing the relative effectiveness of different early active motion
approaches conducted in real-world clinical settings.
Acknowledgments
Special recognition to Angela Chu, OT, for the fabrication of the
orthoses photographed for this survey, and to Luke Robinson, OT,
who assisted in the early development of the survey. Our appreci-
ation to the Australian and USA survey field testers who helped us
refine the questions. Many thanks to the IFSHT Secretary General,
Maureen Hardy, for providing participating country contact infor-
mation as well as the IFSHT Hand Therapy national society/asso-
ciation liaisons who kindly forwarded the survey link to their
membership. Most importantly, the authors thank each therapist
who devoted time to answer our questions! Through this collabo-
ration, the authors now have a better understanding of practice
patterns for the management of zone V-VI extensor tendon repairs
of the fingers.
Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.jht.2019.12.019.
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