The Egyptian Journal of Hospital Medicine (October 2022) Vol.

89 (2), Page 6617- 6621

Relative Motion Protocol Versus Place and Hold Protocol After

Hand Zone II Flexor Tendon Repair: A Prospective Randomized Controlled Trial
Ahmed M. Zarraa1, Emad T. Ahmed1, 2, Ashraf A. Khalil3, and Amal M. Abd El Baky1
1
Department of Physical Therapy for Surgery, Faculty of Physical Therapy, Cairo University; 2Faculty of Physical
Therapy, Heliopolis University; and 3Department of Plastic Surgery, Faculty of Medicine, Cairo University
*Corresponding author: Ahmed Mahmoud Ali Gabr Zarraa, Mobile: (+20) 01007580084, E-Mail: [email protected]

ABSTRACT
Background: Flexor tendon injuries in zone II are very challenging and till now there no consensus on a particular therapy
protocol to provide the best outcomes postoperatively.
Aim: The present study was introduced to explore the effect of a relative motion protocol and compare it to those of a place
and hold protocol on the outcomes after zone II flexor tendon repair.
Patients and Methods: Sixty patients who underwent zone II flexor tendon repair participated in this study. Their ages
were between 20 to 35 years. They were collected from Cairo University Hospitals and distributed randomly into two
groups: Group (A) contained 30 patients who received a relative motion protocol, and Group (B) contained 30 patients
who received place and hold protocol. At 12th postoperative week, finger goniometer; hand dynamometer; and Michigan
Hand Questionnaire (MHQ) were used to evaluate outcomes.
Results: Relative motion protocol showed significant improvement over place and hold protocol in terms of IP joints active
ROM of the operated fingers, operated hand grip strength, and all scales of MHQ.
Conclusion: Relative motion protocol is superior to place and hold protocol in improving the outcomes after zone II flexor
tendon repair.
Key words: Relative motion, Place and hold, Flexor tendon repair.

INTRODUCTION
A formidable challenge faces hand surgeons and
therapists in repair and rehabilitation of tendons in zone AIM OF THE STUDY
II. Adhesions are highly anticipated to occur there leading The need for this study has been developed to be, up
to limited tendon excursion that causes a limitation in the to our knowledge, the first prospective study to
ROM and a reduction in hand strength and function (1, 2). investigate the effect of a relative motion protocol post
One of the major purposes in rehabilitation is to flexor tendon repair.
achieve better tendon gliding by inhibiting the adhesions
and an Early Active Mobilization (EAM) protocol can PATIENTS AND METHODS
clearly achieve that (1-3). Participants:
Relative motion protocol is firstly described for Sixty patients, who underwent zone II flexor tendon
rehabilitation after extensor tendon repair. Its concept is primary direct four-strand repair with ages between 20 to
simple, it depends on the presence of a single muscle that 35 years, participated in this study. They were collected
has multiple tendons through which it transmits its force from Cairo University Hospitals. Participants were
to the four medial fingers. By placement of the digits with excluded if they had more than one operated finger,
repaired tendons in 15-20° differential concurrent major vascular injuries, crush injuries, nerve
Metacarpophalangeal (MCP) joints angle than the injuries, fractures, tendon injuries in other zones or the
adjacent digits, the repaired tendons will receive less force other hand, flexor pollicis longus repair, previous post-
from the muscle which encourages immediate repair tendon rupture, or reduced cognitive capacity.
postoperative active fingers movement resulting in earlier
use of the hands in the Activities of Daily Living (ADL) Ethical Approval:
without risk of tendon rupture (4-6). After explanation of the all rights, an informed
Place and hold protocol is one of the most evident consent was signed by each patient before participation in
protocols but seeking for better outcomes, a start to study this study. Before conducting the study, an ethical
relative motion protocols post flexor tendon repair has approval (No. P.T. REC/012/002689) was provided by
been recently developed due to their advantageous nature the Institutional Review Board of Faculty of Physical
and promising effects (7,8). Therapy at Cairo University. The conduction of the
Depending on the conclusions of recently published current study was matched with the Declaration of
studies, it was recommended to prospectively investigate Helsinki Guidelines for Human Research (Ref).
the effects of a relative motion protocol (4,9).

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Received: 7/7/2022
Accepted: 12/9/2022
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Study Design: avoidance of strenuous lifting or squeezing. The patients

The current study was designed to be a prospective, took off the relative motion splint and re-wear the cast
randomized, single-blind, controlled trial. The study was during sleep.
conducted from April 2020 to May 2022.
Randomization:
Participants were allocated randomly to either Group
A or B by using sealed opaque envelope procedures.
Usage of block randomization ensured equal number of
patients in each group. No subject was dropped out after
randomization.
Assessment Procedures:
At 12th postoperative week, active IP joints ROM of
each involved digit was measured using finger
goniometer (Baseline 12-1011 Finger Goniometer, Metal,
180 Degree - 6" Deluxe) (1). Hand grip strength of each
patient both hands was measured using hand
dynamometer (Takei Analog Hand Grip Strength (A)
Dynamometer T.k.k.5001 GRIP-A General Type, Made (B)
in Japan). The percentage of the operated hand grip Fig. (1): A relative motion splint. (A) Dorsal blocking
strength from the normal hand one was calculated. In case part. (B) Relative motion part.
of the operated hand was the non-dominant, 10% of the
dominant hand strength value was discounted before Stage 2: From 4th to 6th week. In the 2nd visit, the
dividing the grip strength of the operated hand on it as the relative motion splint was modified by cutting the relative
dominant hand is normally about 10% stronger (10- 12). An motion part with the MCPs block off the dorsal blocking
Arabic version of MHQ was provided for each patient to part. Patients wore both separate parts during daytime and
answer the questions of its 6 scales. The raw scale score continued to move their fingers actively in flexion and
was normalized to a scale score ranges from 0 to 100 extension throughout the day. The patients were permitted
according to MHQ scoring algorithm (13,14). to use their operated hands in light ADL and still not to
Therapeutic Procedures: use them in strenuous lifting or squeezing. Out of the
All patients were discharged postoperatively with a splint, patients continued performing the previous stage
dorsal blocking cast to place wrist in 0º extension, MCPs exercises in addition to active tenodesis exercises for 15
of the 4 medial digits in 60º flexion, and IPs in extension repetions 3 times/day. The patients continued to wear the
with the thumb free (15). Patients in group A received cast during sleep.
relative motion protocol while patients in group B Stage 3: From 6th to 8th week. In the 3rd visit, patients
received place and hold protocol. discontinued wearing the remaining of the dorsal
Relative motion protocol: blocking part and continued to only wear the relative
The protocol consisted of 4 stages (4,7,9,16): motion part with the MCPs block for full time and to
Stage 1: From 3rd day till 4th week. In the 1st visit, the move their fingers actively in flexion and extension
cast was removed and a relative motion splint (Fig. 1) was throughout the day. The hand use was more progressed to
fabricated which consisted of; A dorsal blocking part be described as bilateral lift weighing no more than 3.5
(Fig. 1. A) designed to place the wrist at 0º extension and Kg. The cast was discontinued at all. Out of the splint,
MCPs at 30º flexion with IPs and thumb free, and a patients continued performing the previous stages
relative motion part (Fig. 1. B) designed to keep the exercises in addition to flexor tendon gliding and blocking
operated digit in 30º more MCP flexion than the non- exercises for 15 repetions 3 times/day.
operated digits. This part was then attached to the back of Stage 4: From 8th to 12th week. In the 4th visit, the
the first part across the MCPs block. Out of splint, while patients discontinued wearing the splints at all. The
wrist was rested on neutral extension and MCPs were held patients continued performing the previous stages
on flexion, the patient performed passive composite IPs exercises in addition to progressive composite stretching
flexion and extension for 15 repetions 3 times/day. Then exercises for the extrinsic flexors (3 stretch cycles of 30
the patient performed gentle active wrist extension and seconds stretch then relax for 30 seconds then repeat, 3
passive wrist flexion also for 15 repetions 3 times/day. times/day) and progressive intrinsic and extrinsic finger
The patients wore the relative motion splint during flexion muscles strengthening exercises by squeezing
daytime and moved their fingers actively in flexion and therapy putty for 5 seconds, relax then repeat (3 sets of 15
extension throughout the day. They were asked also to squeezes with 30-60 seconds rest between each set for 3
utilize the operated hand in very light function with
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times/day). At this stage, patients were allowed to instructions in stage (4) of group A were followed by
progressively use their affected hands in resistive and patients in this group.
heavier hand functions and ADL. They were also allowed Patients in this group received 3 sessions/week.
to return to their work progressively.
Ethical approval:
Place and hold protocol: The study was approved by the Ethics Board of
The protocol consisted of 4 stages (1,2,15,17,18): Faculty of Physical Therapy, Cairo University and
Stage 1: From 3rd day till 4th week. With the cast in an informed written consent was taken from each
place, the subsequent exercises were done within the cast participant in the study. This work has been carried
limits; Passive Distal Interphalangeal (DIP) flexion and out in accordance with The Code of Ethics of the
extension, passive Proximal Interphalangeal (PIP) flexion World Medical Association (Declaration of Helsinki)
and extension, passive composite finger flexion and for studies involving humans.
extension, and place and hold exercises.
Stage 2: From 4th to 6th week. In addition to stage 1 Statistical Analysis
exercises, the cast was taken off for the following Comparison of age between groups was done
exercises; Active IPs flexion with MCPs extension through unpaired t test. Chi- squared test was used for
followed by full digits extension all from neutral wrist comparison of gender, dominant hand, injured hand and
extension and active tenodesis exercises. At this stage, the operated finger distribution between groups. Unpaired t
dorsal blocking cast was only placed during sleeping or test was used for comparison of IP joints active ROM of
out of home. operated digits, operated hand grip strength and MHQ
Stage 3: From 6th to 8th week. The cast was totally scales scores at 12th postoperative week between groups.
discontinued. In addition to the earlier stages exercises, The level of significance for all statistical tests was set at
the patient performed flexor tendon gliding and blocking p < 0.05. All statistics were done via Statistical Package
exercises. During this phase, patients started to use their for Social Sciences version 25 for windows.
affected hands in non-resistive and light hand functions
and ADL. RESULTS
Each previous exercise in each stage was performed Subjects’ baseline data were demonstrated in Table 1.
15 times/session and same per each 2 waking hours. There was no significant difference between groups in
Stage 4: From 8th to 12th week. In addition to the age, gender, dominant hand, injured hand and operated
previous stages exercises, the same exercises and finger distribution.

Table (1): Subjects’ baseline data.

Group A Group B p-value
Age, Mean ± SD (years) 26.26 ± 4.15 27.53±5.23 0.30
Females 10 (33.3%) 13 (43.3%)
Gender, n (%) 0.42
Males 20 (66.7%) 17 (56.7%)
Right 26 (86.7%) 24 (80%)
Dominant hand, n (%) 0.73
Left 4 (13.3%) 6 (20%)
Dominant hand 17 (56.7%) 19 (63.3%)
Injured hand, n (%) 0.59
Non-Dominant hand 13 (43.3%) 11 (36.7%)
Index 6 (20%) 9 (30%)
Little 4 (13.3%) 8 (26.7%)
Operated Finger, n (%) 0.32
Middle 11 (36.7%) 6 (20%)
Ring 9 (30%) 7 (23.3%)
SD: Standard deviation p-value: Probability Value

There was a significant increase in IP joints active ROM of operated fingers and operated hand grip strength (% of
normal hand) of group A compared with that of group B at 12th postoperative week (Table 2).

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Table (2): Mean IP joints active ROM of operated digits and operated hand grip strength (% of normal hand) at
12th postoperative week of group A and B:
Group A Group B
MD (95% CI) t- value p value
Mean ± SD Mean ± SD
Active ROM 150 ± 8.81 142.46 ± 10.96 7.54 (2.39: 12.67) 2.93 0.005
Grip strength (% of normal hand) 75.7 ± 5.38 69.33 ± 5.65 6.37 (3.51: 9.21) 4.46 0.001
SD: Standard Deviation; MD: Mean Difference; CI: Confidence Interval; p-value: Probability Value
There was a significant improvement in all MHQ scores of group A compared with that of group B at 12th
postoperative week (Table 3).

Table (3): Mean MHQ scales scores at 12th postoperative week of group A and B:
Group A Group B
MD (95% CI) t- value p value
Mean ± SD Mean ± SD
Overall hand function 82.83 ± 15.41 69.33 ± 14.74 13.5 (5.71: 21.29) 3.46 0.001
Activities of daily living 78.06 ± 10.21 71.5 ± 11.56 6.56 (0.92: 12.2) 2.33 0.02
Work 71 ± 7.12 62.33 ± 9.71 8.67 (4.26: 13.06) 3.94 0.001
Pain 29.5 ± 6.21 36.33 ± 7.87 -6.83 (-10.49: -3.16) -3.73 0.001
Aesthetics 68.96 ± 9.14 62.1 ± 9.58 6.86 (2.02: 11.71) 2.83 0.006
Satisfaction 70.46 ± 8.93 63.53 ± 9.79 6.93 (2.08: 11.78) 2.86 0.006
SD: Standard Deviation; MD: mean difference; CI: Confidence Interval; p-value: Probability Value

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DISCUSSION restoration and earlier return to work. The main pros of
Despite great evolution in approaches used in repair mRMS protocol were the small unsophisticated orthosis
or rehabilitation of flexor tendons, complications design, and direct patient instructions that facilitate earlier
continue to develop. Postoperative formation of motion, functional hand use and coming back to both
adhesions is still the most occurring complication that ADL and work.
restricts the active ROM which affects hand strength and Considering the current study relative motion
(19,20)
functions . protocol is an early dynamic active flexion postoperative
Postoperative therapy significantly affects the protocol in its core, the results of the current study would
outcomes of a flexor tendon repair. Up to now, there is no be mismatched with other studies which concluded
consensus on a single protocol to be optimal, however, equivalence in effectiveness of both early dynamic active
there is no doubt that EAM has the best outcomes (19,21). flexion and early static place and hold protocols post
In the present study, relative motion protocol showed flexor tendon repairs and that what found in studies of
significant improvement over place and hold protocol in Chevalley et al.(24) and Allam et al.(25).
terms of IP joints active ROM of the operated fingers, The contradiction between the results of Chevalley
operated hand grip strength, and all scales of MHQ. et al.(24) and Allam et al.(25) to the results of the current
The superiority of relative motion protocol in the study explains that early dynamic active flexion itself may
current study is matched with the results of the studies not be the key of superiority but the excellence, from our
which compared the relative motion protocols with others point of view, can be attributed to the following
following extensor tendon repairs and also concluded characteristics: Firstly, allowance of unlimited, but safe,
relative motion superiority in outcomes like what found early dynamic active flexion of the operated fingers
in studies of Collocott et al. (22) and Hirth et al. (23). throughout the day postoperatively; Secondary, a nearly
Collocott et al. (22) concluded that participants unrestricted early movement of the uninjured fingers;
managed using a relative motion extension protocol Thirdly, early controlled progressive usage of the
showed significantly better early hand function, total operated hand in ADL; and finally, replacement of
active motion, and splint satisfaction than those managed traditional form of many repetitions of exercises and
by the controlled active motion protocol post extensor multiple sessions by an early, free, safe, and unlimited
tendon repairs in zone V & VI. active motion, an early, safe, progressive engagement in
Hirth et al. (23) compared the outcomes of a modified hand functions, and following clear instructions with
Relative Motion Splinting (mRMS) protocol to those of performance of essential exercises by a reasonable
an immobilization splinting protocol following zone V number of repetitions. All the previous distinguished the
and VI extensor tendon repairs. The results showed a relative motion protocol in the current study.
privilege for the mRMS protocol in earlier ROM
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The current study was limited by the differences 11. Chan T, Ho C, Lee W et al. (2006): Functional outcome
between surgeons’ preferences, physical and of the hand following flexor tendon repair at the ‘No man's
psychological statuses of participants, individual land’. J Orthop Surg., 14(2): 178-183.
variations between participants, and possible human 12. Amin D, Hawari M, Hassan H et al. (2016): Effect of sex
and neck positions on hand grip strength in healthy normal
errors.
adults: A cross-sectional, observational study. Bull Facu
Phys Therapy, 21(1): 42-47.
CONCLUSION 13. Khaja A, Al-Roudhan M, Hanna S et al. (2020): Cross-
In conclusion, Relative motion protocol is superior cultural adaptation, validation, and reliability of the
to place and hold protocol in improving the outcomes Michigan hand outcomes questionnaire: Arabic version.
after zone II flexor tendon repair. Surgery: Curr Trends Innovations, 4(3): 1-6.
14. Chung K, Pillsbury M, Walters M et al. (1998):
Conflict of interest: Nil Reliability and validity testing of the Michigan hand
Source of funding: Nil outcomes questionnaire. J Hand Surg., 23(4): 575-587.
15. Formby M (2016): Flexor tendon repair. In R Saunders, R
Astifidis, S Burke et al. (Eds.), Hand and upper extremity
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