EFFECT OF ULTRASONIC THERAPY IN PATIENTS POST FLEXOR

TENDON REPAIR SURGERY- A PROSPECTIVE STUDY

Chawla. S. Nistara, PG student; Saini. S. Sandeep, Principal, COP, CMC Ludhiana; Pargal Pinki, Professor,
Department of Plastic Surgery, CMC Ludhiana; Gill S. Amarjot, Assistant Professor, COP, CMC Ludhiana.

Abstract:
Injuries to the flexor tendons of hand may not seem to be very complicated, but the
rehabilitation of a patient who has sustained such an injury requires sincere commitment and
hard work of the surgeon, the physical therapist and the compliance of the patient with the
treatment. [1] The process of repair of the tendons can take very long time, even after surgical
suturing. By adjunction of the rehabilitation process with electrotherapeutic agents, the rate of
recovery can be accelerated. [2] The high incidences of these injuries indicate the need for
further studies in this area to help in reducing the recovery time. The existing protocols of
rehabilitation in patients with flexor tendon repair consist of varying intervals of
immobilization which have been shown to yielding suboptimal results mostly due to non-
compliance of the patients. [1] Some studies also highlight the importance of therapeutic
ultrasound with early mobilization in the treatment of such cases. Ultrasound therapy is used
for tendon repair during the later phase of recovery as an adjunct to mobilization to assist
tendon gliding. [1] However, we propose to include the modality during the earlier phase of
tendon healing. But, there is no ideal intensity, frequency and duration of treatment with
ultrasound therapy been chalked out for stat reference. Also, ultrasound therapy has also been
considered as a strong placebo [3].

Keywords: Ultrasound, Flexor tendon injuries, Tendinopathy, Tendon healing, Hand Injury,
Therapeutic ultrasound.

Introduction:
Flexor tendon injuries lead to limitation of adequate range and strength to perform various
activities by hand. [1] Hand is a crucial part of the body as it is a source of bread earning, art,
expression, and needful activities. It takes years of practice that makes the hand so skilful that
our lives depend on that. Its limitation also affects the psychology of a person. Depression is
highly being associated with it. [14] After an injury, patients have various questions in their
mind related to its recovery and pain settlement. The field of hand physiotherapy has
witnessed a lot of changes in trends and progressed a lot so far. The main focus is on finding
various therapeutic ways which could promote recovery, make it fast so that that people
resume to their duties on time. Restoring the skills in hand needs lot of practice and
compliance from the patient side. However one of the most important steps in this regard is in
achieving the optimal range of motion of the wrist and phalangeal joints. [15] Something is
needed which would help, to lengthen the tendons at an early stage, without causing trauma
to the surgically sutured part. Various therapeutic heating modalities like wax and hot
fomentation are very helpful as it promotes circulation and help in tissue expansion. [16] Some
studies also highlight the importance of modalities such as ultrasound in increasing the
tendon microcirculation. [17] Along with these, early mobilisation has been shown to help in
preventing joint stiffness and increase the ROM, thus encouraging the patient to gain control
over hand movements. [18]

Hand injuries represent up to 20% of all the cases brought to the emergency departments of
hospitals in India. [4] Lacerations, contusion, fracture-dislocation, crush injury and amputation
are various types of hand injuries seen. Of the total reported cases of hand injuries
specifically in North India, 67.21% of injuries have associated laceration and incised wounds.
Of these, 74.4% patients sustain tendon injuries. The Prevalence of hand injuries is more in
males (88%) than in females (12%). The age group which is the most susceptible to
sustaining such an injury is 21-35 years of age. Although patients sustaining hand injuries
belong to various occupational backgrounds, it is most frequently seen in people engaged
with manual labor. Mode of injury most commonly includes factory accidents, assault, road
traffic accident, alcoholic rage and associated glass-cut injuries. [5] [6]

Injuries to the flexor tendons of hand may not seem very complicated, but the recovery may
take months. Despite continuous progress in understanding of the anatomy, biomechanics of
the flexor tendons of the human hand and the advances in post-op treatment, the recovery
results after flexor tendon repair surgeries typically have high failure rates, which indicate the
need for improvement of the rehabilitation protocols. [7] The high prevalence of these injuries
implies the need for further studies to adjunct the process of tendon repair by reducing
recovery time and the time to return to functional activities.

The existing protocols of rehabilitation in patients with flexor tendon repair consist of
varying intervals of immobilization which has shown suboptimal results mostly due to non-
compliance of the patients.[1] Ultrasound therapy is being used safely after tendon repair
surgeries, during the re-modelling phase (after three weeks) as an adjunct to mobilization to
improve the tendon gliding. [1] However studies have shown that therapeutic Ultrasound
generates response on mast cells and macrophages which occupies the wound site during
inflammatory phase, therefore therapeutic ultrasound helps in rapid transition from
inflammatory to proliferative phase. [2] This factor indicates its application to be enabled in
the early days following the surgery to fasten its recovery rate. In addition it has also been
considered a strong placebo [3] which gives a patient a sense of healing and overcoming initial
pains of surgery.

Despite all these factors which show us an accelerated recovery response, the therapeutic use
of ultrasound in the early or acute phase of post-surgical flexor tendon repair of hand needs to
be evaluated on the grounds of restoring hand mobility and bringing its strength back. This
can save a lot of time and may give a fruitful outcome.
Methodology:
This is a prospective study, completed over a period of 1 year from December 2018 to
December 2019. 50 patients with flexor tendon injuries of zone II were included. Ethical
approval for conducting the study was granted by the ethics committee of College of
Physiotherapy, CMC&H, Ludhiana. The patients were thoroughly briefed about the
procedure and written consents were obtained from them.

STUDY DESIGN: Prospective study

STUDY SETTING: College of Physiotherapy,CMC ,Christian Medical College and
Hospital, Ludhiana.
TARGET POPULATION: Patients with flexor tendon injury postsurgical repair, 1 week
post-op
SAMPLE SIZE: 50
SAMPLING METHOD: Simple random sampling.
RANDOMIZATION: Lottery method to assign the patients to control and
experimental groups.
PARAMETERS: Pulse ratio of 1:4, frequency of 1 MHz & intensity of 0.7wt/cm2
for a treatment period of 5 mins per session [1]
Inclusion Criteria:
 Both male and female.
 Zone 2 flexor tendon injury
 Age 21-35 years [5]
 Mode of injury-mechanical, traumatic, glass cut;
 1 week post-op [8]
Exclusion Criteria:
 Tendon injuries with tendon loss
 Crush injury
 De-gloving injury
 Burns
 Multiple level injuries of the flexor tendons
 Injury associated with or extending to extensor tendons
After surgery, patients were included in the study based on whether they fit the inclusion
criteria. Thereafter, baseline assessments were taken. The ROM was measured using a finger
goniometer and the grip strength was measured using hand held dynamometer. The readings
were recorded for all the patients in the same hand position and using the same devices. The
allocation of the patients was done into the control and the experimental groups using lottery
method of simple random sampling. The patients were asked to draw a card from a box
containing a pack of cards labelled as experimental or control. Thus the therapists had no
control over the allocation of patients to different groups.

Conventional Protocol:
Day 7 to 2 weeks-
• Dorsal Blocking splint for immobilization
• Hand elevation & gentle finger compression wrap.
 • Passive movements of the digit for warm up.
• Active IP joint extension with MP joint blocked in flexion
• True active flexion up to one third to half of a fist (active hook fist).
2 to 4 Weeks-
 Active synergistic exercise program in the Manchester short splint.
 Half to full active fist position and up to 45 degrees of wrist extension.
 IP joint extension through full ROM with MP in complete flexion.
Full fist position by 6 weeks. [8]

Ultrasound Parameters for experimental group:

 Pulse ratio of 1:4,
 Frequency of 1 MHz
 Intensity of 0.7wt/cm2
 Treatment period of 5 mins per session [1]

Further, the statistical analysis was done using the Chi Square test in the SPSS software.

Results:
The period of time between the initial and the final assessment ranged from 4 to 6 weeks.
Assessment included the measurement of active ROM at the PIP and DIP joints of the digits
using goniometer and the measurement of grip strength using a hand-held dynamometer.

In the control group, the mean change in ROM before and after the intervention came out to
be 14.4 for DIP joints and 30.2 for PIP joints. The mean change in grip strength came out to
be 2.8 kgs. In the experimental group, the mean change in ROM before and after the
intervention came out to be 20.1 for DIP joints and 57.4 for PIP joints. The mean change in
grip strength came out to be 4.1 kgs. The data was analysed using Chi square test in the SPSS
software. The P value for ROM comparison came out to be 0.0082 By conventional criteria,
this difference is very statistically significant. The P value for grip strength comparison
between the groups came out to be 0.238 the result of which is not significant at p < 0.05.

Discussion:
Therapeutic ultrasound uses a range of frequencies between 0.75 to 3 MHz. At these
particular frequencies, the ultrasound gives thermal and non-thermal physiological effects at
the tissue level. The non-thermal effects of ultrasound therapy are known to promote tissue
healing at cellular level by stimulating the release of histamine and mast cells. This helps in
soft tissue healing. Ultrasound is also known to be useful in scar tissue management and
preventing joint contractures. [9]

Advances in treatment of injuries to the flexor tendons of the hand over the last few years
have contributed to significant improvements in clinical outcomes. The main factors in
treatment of flexor tendon injuries are the surgical technique and the post-op physiotherapy
program which enhances tendon gliding without sacrificing the repair-site strength or
inhibiting healing. [10] The main aim was to achieve greater tendon strength while maintaining
the smooth tendon gliding at early phase.

There are many therapeutic effects ultrasound. Numerous studies have shown that ultrasound
enhances healing. Therapeutic ultrasound aids tendon-bone junction healing through
improved tissue function. It can safely be used to treat soft tissue injuries, and improve
outcomes for post-operative recovery in tendon repair surgeries. [11] Various studies have
shown that the use of therapeutic ultrasound improves the range of movement, helps in the
advancement of scar maturation and acts as pro-inflammatory. [1]

Ultrasound has been reported to benefit in the better organisation of the granulation tissue and
helps in maturation of the collagen fibres. Good fibroblastic proliferation, neovascularisation
and maturation collagen fibres at the healing site are few factors which advocate the use of
ultrasound in case of patients with post-op tendon repair. [13] Thus therapeutic ultrasound is
used for treating soft tissue injuries as the above mentioned morphological changes would be
manifested as biomechanical improvements of the tendons.[12]

From the perspective of the patient, the inability to use the hand is a debilitating issue.
Stiffness of fingers remains frustrating problem. Thus formulating a cost-effective and
clinically safe therapeutic model has been an effective outcome of this research. The study
provides a promising solution to deal with tendon gliding, finger mobility post tendon repair
surgery and preventing tendon rupture.

Conclusion:

The use of therapeutic ultrasound in tendon repair significantly helps to enhance the recovery
of active range of motion of the DIP and the PIP joints when administered at early stage.
However, no significant difference in the increase of grip strength was observed. Pulsed
mode of ultrasound at the given parameters effectively improves tendon gliding and aids with
active ROM exercises. Thus ultrasound therapy can be effectively and safely used in the early
phase of tendon healing after flexor tendon repair surgery.
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