Splinting in the Management of Proximal Interphalangeal Joint Flexion Contracture

Transcription

1 Splinting in th Managmnt of Poximal Intphalangal Joint Flxion Contactu Romay Po, BApSc(Phyiothapy), GadDipApSc(ExSpSc), CHT(USA), MSc(OT) Sydny Hand Thapy and Rhabilitation Cnt, St. Luk' Hopital Hand Unit Sydny, Autalia ABSTRACT: Poximal intphalangal (PIP) flxion contactu i a common complication following hand injui and condition. Thi tudy invtigatd th tatmnt outcom of 20 ubjct with PIP flxion contactu who followd a dynamic plinting pogam uing ith a Capn o low-pofil outigg. Th plint applid a 250-g foc to th dital nd of th middl phalanx. Each patint wa intuctd to wa th plint fo 8 to 12 hou p 24 hou fo 8 wk followd by a 2- to 3-wk waning piod. Paiv xtnion wa valuatd objctivly uing toqu ang-of-motion maumnt. Th avag ptatmnt flxion contactu wa 39. Final xtnion dficit avagd 21, an impovmnt of 18. Th wa no tatitically ignificant ffct on final ult bad on joint tiffn (a xpd by th lop of th toqu angl cuv). Total nd-ang tim (TERT) avagd 10 hou p 24 hou, fo an avag piod of 4.3 month. Statitical analyi howd that plinting tim wa th only tatitically ignificant facto affcting outcom. Th colation cofficint howd that th long th contactu wa pnt, th tiff th joint and th l th contactu olvd. Dynamic plinting wa an ffctiv fom of tatmnt fo PIP flxion contactu. J HAND THER 9: , T h poximal intphalangal (PIP) joint and it motion a among th mot impotant facto in hand function. Without PIP joint motion, a functional gip cannot b mad. Th PIP joint i ponibl fo 85% of total ncompamnt whn gaping an objct compad with th dital intphalangal (DIP) joint, which i ponibl fo only 15%.1 If th PIP joint cannot flx thn activiti involving handling and maintaining gip on mdium to mall objct, paticulaly cylindical objct, i vy difficult. If th PIP joint cannot fully xtnd, thn xtnion in ppaation fo gap i limitd, and lag objct cannot b gippd. Lack of PIP xtnion can alo hind oth functional activiti, uch a wahing th fac and putting th hand in a pockt. A PIP joint flxion contactu i dcibd a th inability to paivly xtnd th joint to nutal. Without paiv xtnion, activ xtnion cannot b achivd, cauing th functional dficit dcibd. A fqunt complication following PIP joint tauma i PIP joint flxion contactu. PIP flxion contactu may alo occu a a conqunc of Thi pap wa pat of a Mat' dg pogam in hand and upp-limb managmnt. Th autho acknowldg th aitanc Judith Wilton (Cutin Univity), who upvid thi ach pojct, and Jugn Somm (Cutin Univity) fo th tatitical analyi of th data. Copondnc and pint qut to Romay Po, CHT, Sydny Hand Thapy and Rhabilitation Cnt, 13/187 Macquai Stt, Sydny, NSW, 2000 Autalia. 378 JOURNAL OF HAND THERAPY poo poitioning of th joint duing immobilization? Injuy to th PIP joint oftn involv uptu of th joint' tabilizing tuctu, mot commonly th vola plat (VP) and collatal ligamnt. Akon t av hav potd on th chang in th tiu a a flxion contactu dvlop. Th long th joint i flxd, th mo matu i th fibou tuctu of th haling tiu. A th collagn matu and fom mo anomalou co link, th functional gliding of th tiu dca. Th long th co link and adhion a pnt, th mo matu and l mallabl thy bcom, and th long th contactu i pnt, th tiff th joint. Tatmnt fo PIP flxion contactu can b convativ, uing xci and lintag alon, o it can b ugical. Many autho z - 7 hav dcibd convativ managmnt uing plinting fo thi joint poblm, including tatic digit o hand-bad plint, a wll a dynamic digit, hand-, o foam-bad outigg plint. Mot tudi do not giv complt dciption of th plint ud and th xact plinting pogam. Z,5 Callahan and Mc Ent 7 pot on th citia fo plint uag; howv, thy do not dcib plint uag in a ubjct population o thi ult. Kolumban 4 do pot on th outcom of tatic and dynamic plinting with objctiv joint tiffn mau of 13 ubjct in an Indian population in whom PIP flxion contactu wa du to lpoy. Th litatu do not dcib th quality of joint tiffn, objctiv maumnt of paiv xtnion in PIP flxion contactu conday to tauma, and how thi i altd with a pcific plinting pogam in a clinical tting. Thi tudy attmptd to look at th paamt.

2 METHOD Th tudy aivd at th following hypoth: 1. Th i no aociation btwn plintag tim and final xtnion (i.., olution of contactu). 2. Th i no aociation btwn tim of contactu bfo tatmnt to plintag tim and final xtnion (i.., olution of contactu). 3. Th i no aociation btwn initial tiffn to plintag tim and final paiv xtnion (i.., olution of contactu). 4. Th i no aociation btwn initial tiffn and final tiffn. SUBJECTS Twnty ubjct with PIP flxion contactu of 25 o mo w ad and tatd popctivly. All ubjct w fd to th Sydny Hand Thapy and Rhabilitation Cnt pcifically fo plintag of th PIP joint fo flxion contactu. Subjct with flxion contactu of mo than 6 month' duation, with mo than two PIP joint involvd, with th diagnoi of an inflammatoy joint condition uch a athiti, o ad by th ugon and thapit a quiing ugy, w xcludd. Th tudy goup compid fiv fmal and 15 mal. Th avag ag wa 35 ya (SD: 13). Th contactu wa pnt fo 12.8 wk (SD: 7.9) on avag. Th ubjct w allocatd into on of two goup. Ethical conidation in th light of th pnt litatu by Callahan and McEnt 7 influncd th autho to allocat ubjct with a contactu gat than 45 to goup 2. Thi wa an thical containt and limitd th tudy. All oth ubjct w andomly allocatd to ith goup. Elvn digit w tatd with a Capn plint (goup 1), and 11 oth w tatd with a low-pofil outigg plint (goup 2). DATA COLLECTION Ag, gnd, hand dominanc, injud hand, diagnoi, typ of injuy, lngth of tim of flxion contactu, th numb of digit affctd, and th tiu dmd to b involvd w codd fom ubjct intviw and phyician fal. Paiv xtnidn wa ad with toqu ang of motion (ROM) a dcibd by Band and Hollit 8 and by oth. 9,10 Toqu ROM pocdu fo thi tudy involvd maintaining th wit in th nutal poition and th mtacapophalangal (MCP) joint in flxion. A foc of 800 g wa applid at ight angl to th middl phalanx 3 cm fom th PIP joint, and th ultant ROM wa maud (Fig. 1). All maumnt w don by th autho. Th ubjct w ad bfo th plint wa applid and thn again at 2, 4, 8, and 12 wk. FIGURE 1. Toqu ROM maumnt. Th foc i applid via Haldx gaug 3 m fom th joint, and th ultant ang ofxtnion i maud. FIGURE 2. A Capn plint applid to th PIP joint li on th pincipl ofth-point fixation. Th latal ping coil povid th xtnion foc. Futh maumnt w mad at 16, 20, and 24 wk if it wa dmd ncay to continu plintag fo long than 8 wk. Th data w tatically analyzd with Paon' poduct momnt colation cofficint, multipl gion analyi of vaianc, and patd mau multivaiat analyi of vaianc (MANOVA). SPLINTAGE PROGRAM A Capn plint wa cutom mad fo ach of tn ubjct. Th digit-bad Capn plint ha two coil ping on ith id of th joint. Th poduc th xtnion foc illutatd in Figu 2. Th maining tn ubjct had a cutommad, low-pofil, hand- o wit-bad outigg plint with ubb band taction,1l,12 a illutatd in Figu 3. Thi plint i fd to a th outigg plint. Both plint w adjutd to apply a foc of 250 g at th dital nd of th middl phalanx to th joint with th PIP flxion contactu. Th plint foc wa chckd and adjutd if ncay at ach amnt ion. Th foc applid by th Ca- Octob-Dcmb

3 th plint wa won. Aft 8 wk, th ubjct wa wand fom th plint ov a 2- to 3-wk piod. Thi tim wa includd in th total plint-waing tim. If th ubjct potd a lo of mo than 5 in xtnion whn th plint wa not won, thn th tim of plintag in wk wa xtndd until xtnion could b maintaind without plintag. All ubjct w intuctd to pfom activ flxion and xtnion of th PIP joint (10 ptition) and blockd PIP xtnion (10 ptition) fou tim p day (24 hou). ASSUMPTIONS FIGURE 3. A hand-bad, low pofil, outigg plint u ubb-band taction a th xtnion foc acting on th PIP joint. Th poximal mtacapophalangal joint i tabilizd by th thmoplatic componnt. pn plint wa maud by uing a mthod dcibd by F. 13 A Haldx gaug wa applid to th dital thmoplatic band of th plint; pu wa thn applid though th Haldx gaug to th plint until th thmoplatic band touchd th middl phalanx. Th foc hown on th Haldx mt, bing th foc applid by th plint, wa thn codd. If th ultant foc wa gat than 250 g, th lv am w adjutd into nough flxion to duc th foc to 250 g. Th foc of th low-pofil outigg wa maud uing a Haldx gaug applid to th nd of th ubb band taction. Th ubjct w intuctd to wa th plint fo 8 to 12 hou vy day fo 8 wk. Th ubjct w ncouagd to wa th plint whil lping and fo val hou whil awak. Thi fd th hand fo functional u fo mot of th day. Each ubjct codd a log ht of th tim 50 D 40 g Total Initial mm Final GRAPH 1. Th dg of flxion contactu in tm of man paiv xtnion (0.24 Nm), initial and final. 380 JOURNAL OF HAND THERAPY An accptabl liability in joint ROM maumnt wa aumd. Th maumnt w undtakn by th am thapit, who wa xpincd in thi mthod of maumnt. Flow and LaStayo14 and oth 15 pot good intaat liability fo an xpincd thapit. Th ubjct' plint-wa tim pot w aumd to b hont and accuat. RESULTS All patint with PIP flxion contactu tatd with plintag (ith Capn o outigg) impovd. No flxion contactu compltly olvd; that i, complt xtnion wa not achivd. Th outcom of tatmnt wa valuatd clinically and tatitically with Paon' poduct momnt colation cofficint, multipl gion analyi of vaianc, and patd mau MANOVA with initial xtnion and plint wa a covaiat. Th two plint typ w not ignificantly diffnt in thi pfomanc accoding to a patd mau MANOVA with initial xtnion and plint wa a covaiat. In viw of thi, data w analyd fo th total ampl only. TOTAL SAMPLE RESULTS: CLINICAL RESULTS Chaactitic of Subjct Th total ampl iz wa 20: fiv fmal and 15 mal ubjct, with 22 digit bing tatd. Elvn ubjct had flxion contactu of th dominant hand and nin ubjct of th nondominant hand. Th littl and ing fing w pdominantly affctd: tn ubjct had a littl-fing flxion contactu, tn had a ing-fing flxion contactu, only on had middl-fing flxion contactu and on indx fing flxion contactu. Th mot common injuy cauing th contactu wa a joint injuy: 11 digit. Joint and tndon injuy wa th nxt mot common: ight digit, ix involving xtno tndon and two flxo tndon. Joint, tndon and bon, and joint and bon injui accountd fo th digit.

4 Extnion Outcom: Final Paiv Extnion Dficit Th initial and final paiv xtnion 0.24 Nm (800 g at 3 m) can b n in Gaph 1. Th avag ptatmnt contactu wa 39 (SD: 10) paivly at 0.24 Nm. Maximum xtnion ang achivabl with plintag wa dmd to hav occud whn th xtnion toqu ROM cuv maind unaltd ov 4 wk. No ubjct' flxion contactu compltly olvd. Th final paiv xtnion achivd avagd 21 (SD: 10). Th avag impovmnt in paiv xtnion can b n in Gaph 2. Aft 2 wk of plinting, th wa an avag impovmnt of 14 (SD: 11). Final avag impovmnt wa 18 (SD: 9). Toqu ROM Stiffn a indicatd by th lop of th toqu cuv (Gaph 3) did not appa to hav any influnc on th final outcom. Th avag toqu ROM wa 11 p 800 g (SD: 6) pplintag and 9 p 800 g (SD: 4) potplintag. Complianc and Splinting Tim (TERT): Splint Wa and Splint Duation All ubjct quid plintag long than 8 wk to nu that paiv xtnion had plataud. Complianc to waing tim in vy 24 hou angd fom 6 to 14 hou. Svn ubjct wo thi plint 6 to 7 hou on avag in vy 24 hou. Elvn wo thi plint fo an avag of 8 to 12 hou p 24 hou. Fou ubjct wo thi plint fo an avag of 13 to 14 hou p 24 D g o~=- Total Two wk mi Final GRAPH 2. Man paiv xtnion impovmnt. (0.24 Nm) wa 14 at 2 wk; final impovmnt wa 18 fo th total goup. 0.3 F 0.28 o 024 c N O. 1 m o Man Stiffn/ Toqu ROM Diffnc 2 ~ ~ ~.}. \ \ 1\ 6 \ \ 2 \ \ 8 \. \ Dg \, - Final - Initial GRAPH 3. Stiffn did not chang ignificantly fom ptatmnt initial toqu ROM (11 p 800 g) to pottatmnt final toqu ROM (9 p 800 g). hou. Man TERT in tm of plint waing tim wa 10 hou p 24 (SD: 3). Th avag TERT in tm of plintag duation wa 4.3 month (SD: 1.8). Tiu Injud Th wa no clinical diffnc among tho who w dmd to hav joint injui alon (11 ubjct), tho with joint and tndon injui (ight ubjct), and tho with joint and bon injui (th ubjct). It i not poibl du to th mall ampl iz to mak any tatitically ignificant tatmnt with gad to th ffct of th tiu injud on th final xtnion achivd. Howv, ubjct with joint injui alon had an avag paiv impovmnt of 19 (SD: 8). Joint and tndon injui avag paiv impovmnt wa 17 (SD: 10); joint and bon, and joint, tndon, and bon injui had 15 (SD: 12) avag paiv impovmnt. All tuctu aound th joint a cloly latd, a wa dcibd pviouly. It i thfo difficult to ay if th tndon w o w not involvd via adhion, flxo hath injuy, o ORL injuy in th joint-only g{}up. TOTAL SAMPLE RESULTS: STATISTICAL ANALYSIS Aociation btwn Vaiabl Th colation cofficint matix howd that th wa om intaction btwn th vaiabl (Tabl 1). Th mot ignificant colation (L., p = 0.01 w: 1. Th initial xtnion wa latd to th final xtnion. Th high th initial xtnion, th high th final xtnion dficit. 2. Th initial tiffn wa latd to th final xtnion. Th tiff th joint, th gat th final xtnion dficit. 30 Octob-Dcmb

5 3. Th initial tiffn wa latd to th final tiffn. Th joint that w tiff initially w alo tiff aft tatmnt. Significant colation at th low p lvl (L., p = 0.05) w: 1. Initial tiffn wa latd to initial xtnion. Th gat th flxion contactu, th tiff th joint. 2. Final tiffn wa latd to plinting duation. Th gat th tiffn, th long th duation of plintag. 3. Contactu tim wa latd to initial tiffn. Th long th contactu tim, th tiff th joint. Multipl gion analyi of vaianc wa don uing th following vaiabl: final paiv xtnion, plint waing tim p. 24 hou and plinting duation (TERT), initial paiv xtnion, contactu tim, final tiffn and initial tiffn. Whn final paiv xtnion i th dpndnt vaiabl and all oth a indpndnt vaiabl, initial xtnion dficit and plinting tim (TERT) in tm of plinting duation a th only vaiabl influncing final xtnion. Whn final tiffn i th dpndnt vaiabl and all oth indpndnt, th i a ignificant lina lationhip btwn final tiffn and initial tiffn. Initial paiv xtnion alo had an influnc on final tiffn. Whn plinting tim (TERT) i th dpndnt vaiabl and all oth a indpndnt vaiabl, th long th duation of plintag~, th gat th final tiffn. No oth vaiabl, including contactu tim and initial tiffn, influncd plinting tim (TERT). DISCUSSION Aociation btwn Splintag Tim (TERT) and Final Extnion Th tatitical analyi howd that th i an aociation btwn plintag tim (TERT) and final xtnion. Following 3 to 5 month of plintag fo both goup, th contactu olvd paivly fom 39 0 to 21 0 on avag, an inca in xtnion of 18. Thi compa favoably with Kolumban' 1969 ult." H pot an avag inca in xtnion of 10.3 with tatic plinting, and an avag inca of 7.9 with dynamic outigg plinting (pofil not pcifid) of 6 wk' duation fo flxion contactu du to lpoy. Kolumban 4 did not pot on long tm follow-up o th xtnt to which th impovmnt potd wa maintaind. In thi tudy, th minimum follow-up wa 3 month; maximum follow-up wa 14 month. Kolumban 4 alo pot om injuy to th ubjct fom outigg plintag. Th w no injui du to ith plint typ in th pnt tudy. Sval patint lot xtnion onc thy toppd plintag. Tho who applid thi plint gaind th lot xtnion and w abl to maintain it with a gat plinting duation. Paiv xtnion cannot b maintaind if th i inadquat activ xtnion. It ha alady bn tablihd that th joint tiu pond to th tnion placd on thm. 3 If th i inadquat xtnion foc, th tiu will pond by tightning and ultimatly hotning. Thu, onc th plintag i dicontinud, xtnion nd to b maintaind in th long tm by activ motion. Aociation btwn Tim of Contactu and Final Extnion Th hypothi that th i no aociation btwn tim of contactu bfo tatmnt to plintag tim and final xtnion i uppotd by th multipl gion analyi of vaianc, but it i not uppotd by th colation cofficint. Tim of contactu did colat with initial tiffn (p = 0.05). Th long th contactu wa pnt, th tiff th joint bcam. A tiff joint initially wa aociatd with a gat xtnion dficit. Th conflict in tatitical data may b confoundd by th mall ampl iz and th lack of a homognou population. Th colation cofficint how an aociation btwn th initial flxion contactu and final x- TABLE 1. Paon' Poduct Momnt Colation Cofficint Splint Initial Final Contactu Initial Vaiabl Duation Extnion Extnion Tim Stiffn Splint duation Inihal xtnion ** * Final xtnion ** ** Contactu tim * Initial tiffn * ** * Final tiffn * ** Splint wa *Significant at th p = 0.05 lvl. **Significant at th p = 0.01 lvl. Initial xtnion = initial paiv xtnion (0.24 Nm). Final xtnion = final paiv xtnion (0.24 Nm). Contactu tim = contactu tim bfo plintag. Splint wa = plint waing tim p 24 hou. 382 JOURNAL OF HAND THERAPY Final Stiffn ** Splint Wa

6 tnion dficit. Thi can b n in Gaph 4, in which initial xtnion i plottd againt final xtnion. It alo uppot th clinical obvation that a mo contactd joint do not impov a much a a joint with a l contactu. Akon t ap hav potd on th chang in th tiu a a flxion contactu dvlop. Co link and adhion bcom mo matu and l mallabl th long thy a pnt. Th long th contactu i pnt, th tiff th joint. It could b agud that, whn th joint ha a gat contactu, mo tiu a involvd, and thi may qui mo foc than can b afly placd on th oft tiu in od fo th tiu to alt thi tuctu and longat. Th may alo hav bn tuctual chang in th tiu that will not pond to a af xtnion foc (0.24 Nm in thi tudy). Aociation btwn Splinting Tim (TERT), Complianc and Extnion Flow and LaStayoI4 pot that th amount of inca in paiv ROM in a tiff joint i in popotion to th amount of tim th joint i hld at it nd ang o TERT. In a goup of 20 ubjct with flxion contactu tatd with plat cylind cat, Flow and LaStayoI4 pot that TERT wa th mot ignificant facto in incaing paiv xtnion. In tm of plinting duation, TERT wa th mot tatitically ignificant facto in incaing xtnion in thi tudy. All ubjct quid polongd plinting to both achiv and maintain th xtnion gain. All quid a waning off piod, anging fom 2 to 8 wk. Th polongd plintag quimnt uppot th ational that th tiu nd to b und tnion long nough fo ynthi of nw collagn and covalnt bond. Pviou autho hav uggtd a daily plint waing tim of 8 to 11 hou in vy 24 hou ov an xtndd tim. Avag plinting tim in hou fo th total goup wa 10 p 24 (SO: 3); th Capn goup wa 11 p 24 (SO: 3), and th outigg goup wa 8 p 24 (SO: 2). Mot of tho ubjct who wo th outigg did pot that, ubjctivly, thy found it difficult to wa th outigg duing th day bcau it intfd with thi hand function. Complianc with day wa and plinting duation fo th Capn goup wa btt; mot ubjct potd that thy did not ally mind waing th plint in th daytim. A Capn plint i much mall and do not cov a much of th hand a an outigg plint do. It i th autho' clinical impion that plint iz i a tong facto in gad to complianc. Waton and Tukitaub I7 and Snll and ConollyIS commnd, fom clinical xpinc alon, a plinting duation of 3 month. Rult fom thi clinical invtigation uggt that a plinting duation of 4.3 month on avag hould b commndd. Splinting duation angd fom 2.5 to 10 month. Th colation cofficint uggt that th gat th plintag duation, th gat th F i n E Extnion Dficit n i o 7.5 n 2.5l!:;;;;;=~=;;;b;;;;=;;;!;;;;=;;;;b;=;;;b=;;;b=d=d=d (Jgl.'t'S) Initial Extnion (d~) GRAPH 4. Th colation btwn th initial flxion contactu (xtnion dficit) and final xtnion dficit i hown h. Th gat th initial flxion contactu, th l th contactu olvd. olution of th contactu (L., th low th final xtnion dficit). Thitn of th 22 digit (60%) tatd and valuatd in thi tudy quid plinting fo long than 3 month. Two ubjct quid plintag fo long than 5 month. On ubjct had a vy inflamd joint whn plinting wa commncd. Th polongd inflammatoy pha quid th tnion of th plint to b ducd to 100 g-150 g in od to pvnt aggavation and futh inflammation of th joint. Onc inflammation wa contolld, th plintag foc wa incad to 250 g. Th polongd inflammatoy pha influncd tim to modling and collagn tiu modling itlf. Th oth ubjct had a long-tanding contactu, a did val oth ubjct. Som of th ubjct impovd in a lativly hot tim (3 month). (Phap th natu of th haling tiu and th ca of ach individual govn how quickly th oft tiu pond). Th fibou tiu ticting th joint may b mo matu and l fiboplatic, with mo fibin tand and covalnt bond quiing a gat tim fo,i: tiu lngthning. Aociation btwn Rat of Extnion Impovmnt, Initial Extnion and Splinting Tim (TERT) Clinical obvation of at of impovmnt fo th two goup wa diffnt (Gaph 5). Fo th Capn goup, in whom initial paiv xtnion dficit angd fom 22 to 43, avag impovmnt at 2 wk wa vy imila to th final impovmnt achivd (at lat 90% of final avag impovmnt). Fo th outigg goup, in whom initial paiv xtnion dficit angd fom 24 to 65, th wa a 65% avag impovmnt at 2 wk compad with th final avag impovmnt. No concluion can b dawn fom th data; th two goup could not b compad tatitically du to th diffnc in initial flxion contactu. Thi obvation on at of impovmnt i intting. Th diffnc in contactu vity o Octob-Dcmb

7 o g 20 30, , 10 0'-================ Total Capn Outigg GRAPH 5. Man paiv xtnion impovmnt (0.24 Nm) wa 14 at 2 wk; final impovmnt wa 18 fo th total goup. Clinically, th Capn goup' impovmnt at 2 wk wa imila to th final impovmnt achivd fo thi goup. Th outigg goup' impovmnt at 2 wk wa appoximatly 65% of th final impovmnt achivd fo thi goup of patint. TERT ath than diffnc in plint typ may b th mot impotant facto affcting at of impovmnt. Both plint povidd a 250-g xtnion foc at 90 to th dital nd of th middl phalanx. In thi tudy, th Capn plint goup clinically had a btt TERT tim than th outigg goup did (Gaph 6, 7), uggting that a Capn plint may b mo ffctiv in th clinical ituation than th outigg plint. Futh ach with two goup matchd in flxion contactu and andomly allocatd to ith Capn o outigg plint goup nd to b undtakn bfo any concluion can b dawn gading at of impovmnt, plint typ, TERT, and complianc. Aociation btwn Initial Joint Stiffn, Splinting Tim, Final Extnion, and Final Joint Stiffn Multipl gion analyi of vaianc uggt joint tiffn, a maud by toqu ROM cuv lop, did not affct th final paiv xtnion achivd (Gaph 3) o th plinting tim. Th thid hypothi of thi tudy, that th i no aociation btwn initial tiffn to plintag tim and final paiv xtnion, i uppotd by th m,ultipl gion analyi but not by th colation cofficint. Th colation cofficint how an aociation btwn initial tiffn and final xtnion at th p = 0.01 lvl. Th gat th initial tiffn, th gat th initial contactu and contactu tim. Th conflict in tatitical ult may b again du to th mall ampl iz, o to oth unidntifid vaiabl uch a tiu pathology. Clinically, coniding th hitologic poc of matuing fibou tiu, on would xpct that a vy tiff, long-tanding contactu would not olv a wll a on that wa not a tiff fo a long. 384 JOURNAL OF HAND THERAPY Accoding to th colation cofficint, gat initial tiffn wa aociatd with gat final tiffn. Th joint that w th tifft bfo tatmnt w alo th tifft aft tatmnt. Thi do flct th clinical ituation. Th fouth hypothi, that th i no aociation btwn initial and final tiffn, i thfo jctd. Subjct with a tp toqu cuv lop (l than 10 p 800 g) w claifid a having nonpingy joint, th joint bing th tiff on. Tho with a flatt toqu cuv lop (lao o gat p 800 g) w claifid a pingy o not a tiff a non-pingy joint. Som of th tiff joint howd a flattning of thi cuv within 2 wk of plintag, indicating that th joint wa bcoming mo pingy. Th aly flattning and impovmnt of th toqu cuv lop uggt that th fibin tand in th haling injud oft tiu may b in a fiboplatic pha, wh thy could b modld by altation in wat contnt and th xtacllula matix to poduc a long tuctu. Data fom thi clinical tudy do not uppot Callahan and McEnt'7 pmi, bad on clinical xpinc alon, gading pingy and nonpingy joint. Callahan and McEnt 7 uggt that th joint i pingy if it impov 10 to 15 in th fit wk of plintag and non-pingy if it only impov 5 to 10 in that tim. Of th ubjct with tiff joint (i.., toqu cuv lop of l than 10 p 800 g), om impovd l than 10 and oth impovd mo than 10 in th fit 2 wk of plinting. No facto xplaind o idntifid th aon fo thi diffnc. RECOMMENDATIONS FOR FURTHER RESEARCH Thi tudy indicatd that th i an aociation btwn plinting tim and final xtnion dficit and th i an aociation btwn initial and final tiffn. Futh invtigation with a lag, mo homognou ampl i ncay to confim th finding of thi clinical tudy. Th two aociation in which th tatitical data w conflicting alo H a 18 II P Total Capll Outigg GRAPH 6. Th TERT in tm ofman plint waing tim in hou p 24 fo th total ampl, Capn and outigg goup. Th Capn goup had th gatt plint waing tim.

8 waant futh invtigation o that th aociation can b confimd o jctd. Thi tudy indicatd that th gat th initial xtnion dficit, th l th flxion contactu olvd. If thi i th ca, futh invtigation into thi lationhip and what it impli clinically i ncay. Th at of impovmnt a a clinical indicato of outcom i a vy intting notion. Thi tudy howd that, fo flxion contactu btwn 25 and 65, on avag mo than 50% impovmnt can b xpctd in th fit 2 wk of plinting. If at of impovmnt can b ud a a pdicto of final avag outcom, tatmnt xpctation and indication fo ugical la may alt. Anoth intting clinical qution ha bn aid in th cou of th tudy: I TERT (plint wa tim and plinting duation) th mot impotant facto in olving a flxion contactu? If it i, thn futh ach i ncay to actain th mot clinically ffctiv plint-waing tim and plinting duation. Thi tudy uggt that plinting duation nd to b continud fo at lat 4 month on avag. Th qution of complianc i alo impotant. If TERT i dictly latd to complianc, phap th patint hould b mo involvd in making th plint choic. Th ffct of complianc on TERT alo nd to b valuatd. Callahan and McEnt 7 and Colditz 2 pot fom clinical xpinc that pingy and nonpingy joint pond diffntly. Th autho uggt that th joint pingin hould b conidd whn chooing th typ of plint to b ud in tatmnt. Data fom thi tudy do not uppot thi. Th citia fo chooing a plint may qui -valuation. Futh ach i ncay to dtmin if th i an aociation btwn joint pingin (toqu cuv) and pon to plinting. Thi tudy would alo uggt that caution i quid in intpting and adhing to clinical pincipl that hav not bn cintifically invtigatd. Many of th xit in th aa of plinting. Thi tudy i a tat on cintific invtigation in thi aa. It idntifi many of th difficulti of clinical ach on uch iu but alo idntifi th ugncy fo knowldg bad on ach ath than clinical infnc. CONCLUSION Th qution of appopiat and ffctiv plinting of th PIP joint intt all thapit daling with thi difficult poblm. Thi mall clinical tudy howd that th avag olution fo PIP joint flxion contactu btwn 25 and 65 wa 21. Statitically, th wa an aociation btwn plintag and final xtnion dficit. Th long th plinting duation, th low th final xtnion dficit. Thi impli that TERT i on of th majo facto in olving PIP flxion contactu. Statitical analyi alo confimd poitiv aociation btwn contactu tim, tiffn, and 9 8 M 7 o 6 ~ 5 h 4 3 IOI~ ---, 2 1 o Total GRAPH 7. Splint duation in month i alo a facto in TERT. Clinically, plint duation wa gatt fo th Capn plint goup than fo th outigg plint goup. Thi uggt that a Capn plint may b mo ffctiv in th clinical ituation than an outigg plint i. Futh ach nd to b undtakn. REFERENCES Capn Outigg final outcom; that i, th long th contactu wa pnt, th gat th final xtnion dficit. Futhmo, th gat th initial tiffn, th long th plinting tim and th gat th final xtnion dficit. Splinting tim in tm of plinting duation wa th mot ignificant facto in th olution of th flxion contactu. Th aociation of tiffn bfo and aft tatmnt wa uppotd. Th joint that w tiff bfo plintag maind th tiff joint aft plintag. Th tiff joint did, howv, mak om impovmnt in paiv xtnion. A dynamic plint applid with a toqu of 0.24 Nm i ffctiv in olving a flxion contactu fom 39 to 21 on avag. Th i a ound pmi fo th clinical application of a dynamic plint fo tating PIP flxion contactu, gadl of th vity of th contactu, th tim of contactu, o th tiffn of th joint, povidd adquat TERT i maintaind. 1. Libovic SJ, BowWH: Anatomy of th poximal intphalangal joint. Hand Clin 10: , Colditz JC: Sping-wi plinting of th poximal intphalangal joint. In Hunt JM, Schnid LH, Mackin EJ, Callahan AD (d.): Rhabilitation of th Hand, 3d d. St. Loui, Moby, 1990, pp Akon WH, Amil D, Woo SL-Y: Immobility ffct on ynovial joint: Th pathomchanic of joint contactu. Biohology 17:95-110, Kolumban SL: Th ol of tatic and dynamic plint, phyiothapy tchniqu and tim in taightning contactd intphalangal joint. Lpoy in India Octob 1969, pp Wk PM, Way RC, Kuxhau M: Th ult of non-opativ managmnt of tiff joint in th hand. Plat Rcont Sug 62:58-63, F E, Phillip C: Hand Splinting, 2nd d. St. Loui, Moby, Callahan AD, McEnt P: Splinting poximal intphalangal joint flxion contactu: a nw dign Am J Occup Th 40: , Band PW, Hollit A: Clinical Mchanic of th Hand, 2nd d. St. Loui, Moby, Octob-Dcmb

9 9. Bg-L D, Bll-Kotoki J, Bandma JW: Toqu ang of motion in th hand clinic. J Hand Th 3:7-13, Flow KR, Phaant SD: Th u of toqu angl cuv in th amnt of digital joint tiffn. J Hand Th 1: 69-74, Colditz JC: Low pofil dynamic plinting of th injud hand. Am J Occup Th 37: , Colditz JC: Dynamic plinting of th tiff hand. In Hunt JM, Schnid LH, Mackin EJ, Callahan AD (d.): Rhabilitation of th Hand, 3d d. St. Loui, Moby, 1990, pp F E: Foc magnitud of commcial ping-coil and ping-wi plint dignd to xtnd th poximal intphalangal joint. J Hand Th 1:86-90, Flow KR, LaStayo P: Effct of total nd ang tim on impoving paiv ang of motion. J Hand Th 7: , Bg-L D, Tomancik-Volk E, Giuintano D, Novick A, Bowd L: Rliability of toqu ang of motion. J Hand Th 6:29-34, Bochinn-Moin J, Davy V, Conolly WB: Th Hand: Fundamntal of Thapy, 2nd d. Oxfod, Buttwoth Hinmann, Waton K, Tukltaub S: Stiff Joint. In Gn D (d.): Opativ Hand Sugy. Nw Yok, Chuchill Livington, 1979, pp Snll EJ, Conolly WB: Pot-taumatic flxion contactu of th poximal intphalangal joint, ugical la and pot opativ thapy: A viw of 21 ubjct. In Pocding of Th Fit National Cong of th Intnational Fdation of Sociti of Hand Thapit. Tl Aviv, Ial, 1989, p JOURNAL OF HAND THERAPY