The Effectiveness of Early Active Mobilization in Zone II Flexor Tendon Repair Rehabilitation: A Systematic Review

PURPOSE: Zone II flexor tendons are notorious for developing adhesions and ruptures because the fibrous pulley system surrounding the tendons influences scarring adhesions (Kasch & Walsh, 2013), which may lead to additional surgical repairs and decreased dexterity (Kasch & Walsh, 2013). Ultimately, the decreased nimbleness leads to decreased use and difficulty in performing daily occupations. Current practice trends include passive mobilization, Kleinert method, and delayed active mobilization. Immediate active and passive protocols have both been described as early mobilization approaches in an attempt to minimize complications due to adhesions (Klein, 2014). Early active mobilization (EAM) is a newly developed intervention that is usually directed by experienced surgeons and therapists (Kasch & Walsh, 2013). This systematic review assessed the effect of EAM on the return of hand function specifically in repaired Zone II flexor tendons.

DESIGN: A systematic review was conducted to critically appraise this topic. Articles were included if they were in English, assessed functional outcomes of people with Zone II flexor tendon injuries, and included EAM protocols in the intervention.

METHOD: Nine databases were searched in October 2015. The primary author reviewed titles and abstracts and identified 16 studies that matched the identified criteria. Information regarding intervention, outcomes, limitations, and implications for occupational therapy was recorded in an evidence table. Next, the results were aggregated and hand analyzed to determine evidence strength and implications for occupational therapy practice. After duplicate studies were removed, six articles remained for full-text review.

RESULTS: Overall, the studies indicated good to excellent return of hand function. At 4 wk postrepair, there was a significant difference in increased function for those treated with controlled active motion when compared to those treated with early passive mobilization, but no difference by Week 12. Increased function included total active range of motion and grip strength. Fair to poor functional return occurred most often when the lacerated tendon had frayed ends, whereas clean, sharp lacerated edges tended to receive good to excellent return of hand function. No studies specifically assessed return of function though a subjective or self-report functional measure.

CONCLUSION: Moderate evidence exists to support immediate use of EAM as a primary intervention to improve hand function for people who had a Zone II flexor tendon repair. As occupational therapists seek to increase functional use in occupations, EAM protocols used as intervention for Zone II flexor tendon injuries are a viable treatment. Although entry-level therapists may provide EAM, it is recommended that therapists seek additional training.

IMPACT STATEMENT: The use of EAM protocols for Zone II flexor tendon repair should be the preferred intervention used by occupational therapists to influence functional return of the affected upper extremity.

References

Kasch, M. C., & Walsh, J. M. (2013). Hand and upper extremity injuries. In H. M. Pendleton & W. Schultz-Krohn (Eds.), Pedretti’s occupational therapy: Practice skills for physical dysfunction (7th ed., pp. 1037–1073). St. Louis, MO: Mosby.

Klein, L. J. (2014). Flexor tendon injury. In C. Cooper (Ed.), Fundamentals of hand therapy: Clinical reasoning and treatment guidelines for common diagnoses of the upper extremity (2nd ed., pp. 412–425). St. Louis, MO: Mosby.