Postoperative management of zones V-VI extensor tendon repairs: A survey of practice in Malaysia and comparison to IFSHT member countries

Abstract

Introduction

A survey of International Federation of Societies for Hand Therapy (IFSHT) member countries identified relative motion extension as the preferred approach to management of zones V-VI extensor tendon repairs. The aims of this survey were to identify and compare hand therapy practice patterns in Malaysia (a non-IFSHT member country) with findings of the IFSHT survey including an IFSHT subset of Asia-Pacific therapists and to investigate if membership status of the Malaysian Society for Hand Therapists (MSHT) influenced therapy practice patterns.

Methods

An online English-language survey was distributed to 90 occupational therapists and physiotherapists including MSHT members and non-members. Participation required management of at least one extensor tendon repair in the preceding year. Five approaches were surveyed: immobilisation, early passive motion (EPM) with dynamic splinting, and early active motion (EAM) delivered by resting hand (RH), palmar resting interphalangeal joints free (PR), and relative motion extension (RME) splints.

Results

Thirty-seven of the 53 therapists (68%) who commenced the survey completed it. The most used approach was dynamic/EPM (28%), followed by RH/immobilisation (22%) and RH/EAM (22%). A preference for RME/EAM was identified with implementation barriers being surgeon preference and hand therapist confidence.

Discussion

Approach selection for Malaysian therapists differed from the combined IFSHT and Asia-Pacific respondents, with the former using dynamic/EPM and RH/immobilisation compared to IFSHT respondents who predominately used RME/EAM and PR/EAM. This survey provides valuable insights into Malaysian hand therapists’ practices. If implementation barriers and therapist confidence are addressed, Malaysian practice patterns may change to better align with current evidence.

Introduction

A survey of individual members of the International Federation of Societies for Hand Therapy (IFSHT) full-member countries determined relative motion splints with early active motion as the most used approach in the postoperative management of zones V-VI extensor tendon repairs of the fingers. ¹ To gain a more inclusive global perspective of therapists’ practice patterns, the authors recommended surveying therapists from non-IFSHT member countries. ¹ In 2019, this opportunity presented itself, after author JWH was invited by the Malaysian Society for Hand Therapists (MSHT) to deliver a symposium on the topic of Relative Motion. The MSHT was established in 2014, has 62 members, and is a member of the Asia Pacific Federation of Societies for Hand Therapy, an IFSHT regional liaison organisation. Because it is not yet a full-member IFSHT country, it was not included in the international survey. Hand therapy in Malaysia is provided by occupational therapists and physiotherapists, with patients able to access both public and private health care systems for surgery and therapy. ²

Since 2012, work-related hand injuries in Malaysia have increased with industrialisation ³ , and in 2019 the prediction was made that more surgeons and therapists would need to upskill to the specialty of hand surgery and hand therapy. ⁴ Malaysian surgeons and therapists have prepared for this need by forming professional organisations devoted to hand care including the MSHT and the Malaysian Society for Surgery of the Hand. Approximately 25% of industrial injuries in Malaysia affect the hand or wrist, and nearly half are classified as severe. ³ Of these severe injuries, 62% involve the fingers, mostly caught in machinery, and 69% of the non-severe injuries involved the forearm or hand mostly caused by a sharp tool, a smash or strike. ³ The specific structures involved in these injuries are unknown, so the incidence of extensor tendon injury in Malaysia has not been formally documented.

The primary aim of this study was to report on the practice patterns for postoperative management of zones V-VI extensor tendon repairs by therapists who are MSHT members or have previously attended a hand therapy symposium organized by the MSHT. The secondary aim was to compare the results of this Malaysian extensor tendon survey with that of the IFSHT member countries including a subset of Asia-Pacific respondents.

Methods

Design

A survey was selected as the approach to address our research aim as it is a convenient and inexpensive way to investigate the sample population. ⁵ Planning and administration of the survey was done according to the recommendations of Jones et al. ⁵ The “Checklist for Reporting Results of Internet E-Surveys” (CHERRIES) ⁶ was consulted during planning and for guidance in reporting the survey results. Ethics approval was obtained from the Monash University Human Research Ethics Committee, Australia (13583). The web-based survey was administered using the Qualtrics platform (Qualtrics, Provo, UT).

Participants

The original English-language survey administered to therapists of countries with full membership in the IFSHT ¹ was sent to Malaysian therapists whose national language is Malay. To undertake the survey, therapists had to have postoperatively managed one or more zone V or VI finger extensor tendon repair(s) within the previous year and have either been a member of the MSHT or have attended a MSHT-sponsored symposium.

Survey instrument

The survey instrument (Supplementary File 1) was designed by Occupational Therapists MJH and LO’B and Physiotherapists JWH and Lynne Feehan, each with more than 20-years practical experience in hand therapy. ¹ Proficiency in survey design and implementation was contributed by Lynne Feehan, LO’B and TB. ¹ Questions were constructed to investigate current preferences and practice relating to the postoperative management of zones V-VI finger extensor tendon repair, specifically to the five approaches (splint/motion program) shown in Figure 1(a) to (e). ¹ Respondents were provided with the option of ‘other’, if their preferred approach was not among the five shown. Survey flow depended on responses to the ‘most used’ postoperative therapy approach during the past 12 months. ¹ As the relative motion extension (RME)/early active motion (EAM) approach has been described as RME plus (with a wrist splint) and RME only (without a wrist splint) data for these options were collected separately. ¹ As previously described by Hirth et al. ¹ the survey was field-tested prior to distribution for technical functionality, respondent utility, clarity of wording and phrasing, and content relevancy by qualified American and Australian hand therapists. The final survey consisted of 262 questions, with respondents answering between 39 and 60 questions due to adapting questions with branches, skip logic, and display logics (Supplementary File 1). When the survey branched, questions were mandatory to improve survey flow; when there was no branching, answers were optional, resulting in not all participants answering all questions.

Figure 1.

(a–e) Approaches used in the management of extensor tendon repair: a. resting hand splint/immobilisation (RH/immobilisation), b) resting hand splint/early active motion (RH/EAM), c. palmar resting interphalangeal joints (IPJs) free splint/early active motion (PR/EAM), d. dynamic splint/early passive motion (dynamic/EPM), and e. relative motion extension/early active motion (RME/EAM; RME plus in combination with a wrist splint, or RME only without a wrist splint).

The word ‘usual’ was used in the survey to recognise the many factors considered by therapists in patient management are taken into consideration, asking therapists to select the practice that ‘best’ represented them. ¹ Therapists were asked to select their ‘most used’ approach, to imply we recognise more than one approach is often used.

Data management and analysis

Closed questions were analysed descriptively, and responses to open-ended questions were grouped into themes. Thematic analysis was performed independently by JWH and MJH on MS excel spreadsheets and any differences discussed until consensus achieved. Malaysian survey responses were compared to those of the IFSHT survey ¹ and the Asia-Pacific region subset. The MS Excel database for the IFSHT survey enabled us to filter the data for the IFSHT member countries from the Asia-Pacific region, namely Australia (n = 141), Hong Kong (n = 4) and New Zealand (n = 44), allowing us to run a report on these neighbouring countries for additional comparison in this study.

Procedures

A representative of the MSHT was contacted by email to inquire about the Society’s interest in participating; the Board of the MSHT approved and signed the survey consent form. After editorial review of the email lists, MSHT provided author SCC with the addresses for therapist members and non-members. The survey link was emailed to all 90 clinicians on the Society’s database, comprised of 39 therapists who had attended a symposium on ‘Relative Motion Splints in Hand Therapy’, and 51 additional members and non-members, some who had attended a previous MSHT-sponsored symposium. After September 18, 2019 initial email distribution of the survey, a second emailing followed three weeks later, and a third and final email reminder was sent October 23, 2019. To encourage participation, a small contribution to the MSHT educational fund was made by the authors for each returned survey.

Prior to taking the online survey, potential respondents were provided with an estimate of survey completion time and informed their responses would be non-identifiable, partial responses could be included, and that starting the survey implied consent to participate.

Results

Fifty-three commenced the survey and 37 respondents met the single inclusion criterion of managing a minimum of one zone V and/or VI extensor tendon repair over the past year for a response rate of 59%. One participant dropped out early, and our survey completion rate was 68%. Twenty-five therapists managed five or less zones V-VI extensor tendon repairs over the past 12 months (n = 11 MSHT members; n = 14 non-members). More MSHT members (n = 9) than non-members (n = 2) managed more than five repairs during the previous year.

Of the 36 respondents, 20 identified as MSHT members. Twenty-two reported that English was not their first language. Table 1 shows most respondents were female (n = 29), and 30 were occupational therapists, five physiotherapists, and one identified as ‘hand rehab’. Twenty-nine (80%) of the therapists were aged less than 40 years old, and most respondents had 1–9 years of hand therapy experience, all had an entry level diploma (43%) and/or degree (60%), and none held formal credentials in Hand Therapy (Table 2).

Table 1.

Demographics, professional experience, and credentials (n = 36^a).

	N=	All	MSHT	Non-member MSHT
Gender	36
Male		7 (19%)	7 (19%)	0
Female		29 (81%)	13 (36%)	16 (45%)
Age	36
20–29		10 (28%)	3 (8%)	7 (20%)
30–39		19 (53%)	11(31%)	8 (20%)
40–49		4 (11%)	3 (8%)	1 (3%)
50–59		3 (8%)	3 (8%)	0
60+		0	0	0
Number of years practicing in hand therapy specialty	36
<1		3 (8%)	1 (3%)	2 (5%)
1–4		16 (45%)	6 (17%)	10 (28%)
5–9		9 (25%)	6 (17%)	3 (8%)
10–14		4 (11%)	4 (11%)	0
15–19		4 (11%)	3 (8%)	1 (3%)
20+		0	0	0
Number of years working as a rehabilitation professional	36
<1		0	0	0
1–4		8 (22%)	2 (5%)	6 (17%)
5–9		7 (19%)	1 (3%)	6 (17%)
10–14		11 (31%)	9 (25%)	2 (6%)
15–19		5 (14%)	4 (11%)	1 (3%)
+20		5 (14%)	4 (11%)	1 (3%)
Rehabilitation discipline (Select ALL that apply)	36
Occupational Therapy		30 (83%)	16 (44%)	14 (39%)
Physiotherapy		5 (14%)	4 (11%)	1 (3%)
Other		1 (3%)	0	1 (3%)b
Do you have added specific credentials in Hand Therapy?	35
Yes		3 (9%)	2 (6%)	1 (3%)
No		32 (91%)	17 (48%)	15 (43%)
If yes, what are the Hand Therapy credentials? (Select ALL that apply)	3
Accredited Hand Therapist		2 (67%)	2 (67%)	0
Certified Hand Therapist		0	0	0
Other		1 (33%)	0	1 (33%)

MSHT: member of the Malaysian Society for Hand Therapists; non-MSHT: non-member of the MSHT.

^aTotal does not always add to 36 as responses to these questions were not mandatory

^bHand therapy fellowship.

Table 2.

Post-secondary Rehabilitation or Research Qualification(s) (n = 35).

Post-secondary Rehabilitation or Research Qualification(s): (Select ALL that apply)
Entry level diplomaa	15 (43%)
Entry level bachelor’s degreea	21 (60%)
Entry level master’s degreea	0
Entry level clinical doctorate degreea	0
Postgraduate diploma- Hand Therapy	1 (3%)
Postgraduate Diploma- other	1 (3%)
Postgraduate master’s (coursework) degree - Hand Therapy focus	1 (3%)
Postgraduate master’s (coursework) degree - other	2 (6%)
Postgraduate master’s (research) degree - Hand Therapy focus	1 (3%)
Postgraduate master’s (research) degree - other	1 (3%)
Postgraduate clinical doctorate degreea	0
Postgraduate PhD (research)	1 (3%)
Other	0

^aOccupational Therapy or Physiotherapy.

Approaches used in the past 12 months

For the previous 12 months, therapists were asked to i) list ‘All’ approaches used (more than one could be selected), and ii) note their single ‘most used’ approach. Of 32 responses to this question, 12 reported using only one approach over the past year, while 20 used two or more (two approaches, n = 10; three approaches, n = 5; four approaches, n = 4; and six approaches, n = 1).

Over half of all respondents had in the past 12 months used resting hand (RH)/immobilisation (n = 19, 59%; n = 8 MSHT members, n = 11 non-members). A similar number of therapists used the following approaches: RH/EAM (n = 15, 47%; n = 9 MSHT members, n = 6 non-members), dynamic/early passive motion (EPM) (n = 15, 47%; n = 8 MSHT members, n = 7 non-members), and palmar resting interphalangeal joints free (PR)/EAM (n = 12, 38%; n = 8 MSHT members, n = 4 non-members). Whilst only five therapists had used the RME/EAM approach (7%; n = 4 MSHT members, n = 1 non-member) and three selected ‘other’ (9%, n = 2 MSHT members, n = 1 non-member).

The single ‘most used’ approach was dynamic/EPM (n = 9, 28%; n = 4 MSHT members, n = 5 non-members), followed by equal numbers (n = 7) using RH/immobilisation (22%; n = 3 MSHT members, n = 4 non-members) or RH/EAM (22%; n = 4 MSHT members, n = 3 non-members). There were three therapists in each group, using the PR/EAM (9%; n = 2 MSHT members; n = 1 non-member), RME/EAM (9%, n = 3 MSHT members), or ‘other’ (9%, n = 2 MSHT members, n = 1 non-member) approaches.

Specifics of ‘most used’ approach in the past 12 months

Key highlights of responses regarding the ‘most used’ approach are presented , with more detailed information presented in Supplementary File 2 – Tables S1–S3.

Splint fabrication skill level was rated between 0–10 (0= basic skill/new graduate could make, 10= advanced skill/highly experienced therapist could make) by 27 therapists with the RH splint fabrication requiring the least amount of skill (n = 14, mean 4.7), followed by the RME splint (n = 2, mean 6.0), with the PR splint requiring the most skill level to fabricate (n = 2, mean 7.0).

Twenty-six therapists estimated the time to make their ‘most used’ splint with dynamic taking the longest (7/9 therapists > 30 minutes). For the remainder of splint designs, the majority were completed in < 30 minutes (n = 16) with only three taking 30–44 minutes.

With the exception of RH/immobilisation, exercises were prescribed during the full-time phase of splint wear, with varying guidelines of exercises to be performed ‘in’ (n = 7) or ‘out’ (n = 2) or ‘both’ in and out of the splint (n = 10). For all approaches, most therapists (54%, n = 14) initiated composite finger flexion out of the splint between 42–55 days postoperatively.

Twenty-three of 26 respondents affirmed a step-down/weaning phase of splint wear, with the most common time of transition between 4–6 weeks (n = 10) and 6–8 weeks (n = 11).

Splint design preference

The most preferred splint was a RH (EAM, n = 7; immobilisation, n = 7), followed by dynamic (n = 9), PR (n = 2), and RME (n = 2, one with [plus] and one without [only] a wrist splint). Six of nine users of the dynamic splint added features to limit metacarpophalangeal joint (MCPJ) motion such as a palmar block (n = 5), or a stop bead (n = 1). The dynamic splint permitted an arc of MCPJ flexion of 30–45° (n = 5), <30° (n = 2), and 61–75° (n = 1). The splint dynamics included all fingers (n = 5) or the injured and adjacent fingers (n = 4). The dynamic splint was worn full-time (n = 3), or an additional overnight splint was provided (n = 5). Neither respondent using the PR splint added a night attachment. Both respondents who used RME fabricated the splint with 15–20° relative MCPJ extension for the involved digit and the respondent using the wrist splint positioned the wrist in 15° extension. The respondent using RME plus/EAM reported adding a resting hand splint at night and if an extensor lag developed whilst the RME only/EAM user did not add splints.

Functional hand use

The ability to use the hand in the splint during the phase of full-time splint wear was rated between 0–10 (0 = unable to use hand in splint; 10 = full use of hand in splint). Therapists reported the most restrictive design to be the RH/immobilisation splint (n = 6, mean 2.8), whilst the least restrictive was the RME only splint (n = 1, mean 6.0) (Supplementary File 2, Table S4).

Twenty-five therapists responded to recommendations for safe hand hygiene, 16 thought it safe to wash and ten advised to keep the involved hand dry. Nearly all responses (n = 25/28) suggested light two-handed activity compared to medium or heavy during the protective phase of splint wear, and after splint cessation, most responses (n = 18/25) advised medium-level hand use. Twenty-four commented on unrestricted hand use without a splint, most commencing between 6–8 weeks (n = 5), 8–10 weeks (n = 7), or >12 weeks (n = 8) (Supplementary File 2, Table S4).

Therapist-reported outcomes

Across all approaches there were no ruptures reported by any of the 25 respondents. Usual discharge from therapy was >12 weeks after surgery, Total Active Motion (TAM) grades were mostly ‘good’ (n = 21/24) and patient satisfaction was rated as positive. The ability of patients to return to work in a pre-injury capacity was chosen by most therapists (n = 20/24), and most often return to work was a combined surgeon-therapist decision (Supplementary File 2, Table S5).

Advantages and disadvantages of the usual approach

Twenty-three respondents commenting only on their ‘most used’ approach selected advantages and disadvantages related to splint design, therapy program, function, return to work, and outcomes (multiple selections possible).

The primary advantage of the RH and PR splints was that these were quick to make, could be made by a junior therapist, materials cost less, are readily available, and hand function is supported. An advantage of RH/EAM, PR/EAM and RME only/EAM was an earlier return to work. Respondents said all approaches supported the outcomes of fewer complications, fewer secondary surgeries, and overall better results (Supplementary File 2, Table S6).

Disadvantages of the RH and PR splints were the cost of materials, the dynamic splint found to be cumbersome, and hand use was restricted by both RH and PR splints, while the RME plus splint permitted too much hand use. The disadvantage of the RH/immobilisation approach was length of time to instruct, and that the RH/EAM, Dynamic/EPM and RME/EAM approaches were not for non-adherent patients. Additionally, use of the RH/immobilisation, PR/EAM and RME plus/EAM approaches delayed return to work more than 6 weeks (Supplementary File 2, Table S7).

Continue approach or use another

When asked if therapists would like to continue using their selected approach, or if they would like to start using another, only the two RME/EAM users chose to continue with their current approach. For the other 23 respondents using the alternative approaches, nine selected they would continue with their current approach, whilst 14 would like to try another. Of these 14 therapists, 13 responded to the question ‘what approach would you like to start using’, with nine (69%) selecting the RME/EAM approach (Supplementary File 2, Table S8).

Barriers to using another approach

Thirteen respondents identified barriers to implementing a different approach (Supplementary File 2, Table S9). The single largest barrier irrespective of approach, was ‘surgeon preference’ for nine respondents (69%). For the nine respondents who would like to start using the RME/EAM approach, five (56%) noted barriers of the splint affording too little protection, and four (44%) lacked confidence to progress the program.

Responses to open-text comments

Ten open text comments were made by eight respondents with three themes identified:

Theme 1 - Therapist’s choice of approach is constrained by the Surgeon’s preferences:

“My approach was different according to (the) surgeon. Some surgeon(s) prefer dynamic splint, some prefer to immobilize it in splint, and some even did not even immobilize. Each patient's intervention was made based on therapist discussion with the surgeon and also (the) patient (patient's needs and expectation).”

“Most of (the) surgeon(s) in Malaysia are still conservative, they prefer to immobilize or put in (a) dynamic splint.”

“Most Doctors in Malaysia did not know/aware about relative motion, that is why many therapists were not confident in practicing relative motion splint.”

Theme 2 - Lack of confidence in the patient’s ability to adhere to post-operative guidelines:

“Postoperative management approach usually selected according to (the) patient's educational level and adherence to the program.”

Theme 3 - Tendency for therapists to stick with what they know (or were taught in school) rather than try new approaches which may seem too risky:

“Most of OTs in Malaysia were taught to use this regime for extensor tendon cut in schools making this regime is popular technique for extensor tendon cut.”

Comparison of responses among Malaysian, IFSHT respondents and the IFSHT Asia-Pacific region subset

In Tables 3 to 5 responses among the Malaysian, the IFSHT respondents and the IFSHT Asia-Pacific respondent subset (Australia, Hong Kong, and New Zealand) are compared.

Table 3.

Demographic and professional qualification comparison.

Survey Question	Malaysian respondents	International respondents (total IFSHT survey)	Asia-Pacific respondents (within IFSHT survey)
English as primary language	YES: 63%	YES: 71%	YES: 96%
Female to Male ratio	6:1	7:1	10:1
OT/PT respondent ratio	6:1	3:1	2:1
Age	Most: 30–39 years	Most: 30–39 years	Most: 30–39 years
	Next: 20–29 years	Next: 40–49 years	Next: 40–49 years
Years as rehabilitation professional	Most:10–14	Most: 20+	Most: 20+
	Next: 1–4	Next: 15–19	Next: 10–14
Years in hand therapy	Most:1–4	Most: 20+	Most: 5–9
	Next: 5–9	Next: 1–14	Next: 10–14
Education level	Entry levela 82%	Entry levela 88%	Entry levela 78%
Hand Therapy credentials	NO: 91%	YES: 58%	YES: 50%

IFSHT: International Federation of Societies for Hand Therapy.

^aDiploma/bachelors/masters/clinical doctorate in Occupational or Physiotherapy.

Table 4.

Comparison between Malaysian and International ET survey responses to splint design and wear questions.

Survey Question	Malaysian Response	International response (total IFSHT survey)	Asia-Pacific response (within IFSHT survey)
Approaches used in the previous 12 months
‘Most used’ approach in previous 12 months	Most: Dynamic/EPM	Most: RME/EAM	Most: RME/EAM
	Next: RH (Immobilisation = EAM)	Next: PR/EAM	Next: RH/EAM
ALL approaches used in the previous 12 months (>1 selected)	Most: RH/Immobilisation	Most: RME/EAM	Most: RME/EAM
	Next: RH/EAM = Dynamic/EPM	Next: PR/EAM	Next: RH/EAM
	Least: RME/EAM	Least: Dynamic/EPM	Least: Dynamic
How many repairs managed in the previous 12 months	Most: 3–5 (38%)	Most: 3–5 (35%)	Most: > 10 (32%)
	Next: 6–10 (24%)	Next: 6–10 (24%)	Next: 3-5 (17%)
Splint design and exercise
Skill to make splint	Most: PR; Dynamic	Most: Dynamic; RME plus	Most: Dynamic; RME plus
	Least: RH	Least: RH	Least: RH
Time to make splint	Most: Dynamic	Most: Dynamic	Most: Dynamic
	Least: RH	Least: RME only	Least: RME only
Exercise in/out or both of splint	Most: BOTH in/out	Most: IN	Most: IN
Prescribe exercise in splint	Most: YES	Most: YES	Most: YES
Week composite finger flexion allowed out of splint	Most: 6–8	Most: 4–6	Most: 4–6
Night attachment PR splint	Majority NO; n = 2/2	Majority: NO	Majority: NO
MCPJ motion dynamic splint	Most: palmar block	Most: palmar block	Most: palmar block
	Next: no limit	Next: stop bead	Next: no limit
Fingers included in dynamics	Similar: all, injured/adjacent	Similar: all, injured/adjacent and injured only	Similar: all, injured/adjacent and injured only
Arc Dynamic MCPJ motion allowed	Most: 30–45°	Most: 30–45°	Most: 30–45°
	Next: <30° 25%	Next: 46–60°	Next: <30°
Relative MCPJ difference RME	Most: 15–20°	Most: 15–20°	Most: 15–20°
Wrist extension RME plus	Most: 15°	Equal: 30° and 15°	Most: 30°
RME plus v RME only	Equal: RME plus v RME only	Most: RME plus	Most: RME plus
		Next: Combination of RME plus & RME only	Next: Combination of RME plus & RME only
Additional splints for RME/EAM	Yes: resting hand splint overnight or if a lag develops	Yes: resting hand splint overnight or if a lag develops	Yes: resting hand splint overnight or if a lag develops
Splint wear-time
Splint step-down phase	Majority: YES	Majority: YES	Majority: YES
Step-down week	PR: 2–4 weeks; 4–6 weeks	Most: 4–6 weeks	Most: 4–6 weeks
	RH/Immobilisation; RH/EAM: 4–6 weeks	Next: 6–8 weeks	Next: 6–8 weeks
	All others: 6–8 weeks
Week no splint AFTER step-down	RH/EAM: 4–6 weeks	Most: 6–8 weeks	Most: 6–8 weeks
	RH/Immobilisation; PR: 6–8 weeks	Next: 8–10 weeks	Next: 8–10 weeks
	All others: 8–10 weeks
Week no splint NO step-down	Most: 6–8 weeks (n = 2)	Most: 6–8 weeks	Most: 6–8 weeks
	Next: 8–10 weeks (n = 1)	Next: 8–10 weeks	Next: 8–10 weeks

EAM: early active motion; EPM: early passive motion; PR: palmar resting hand splint interphalangeal joints free; RH: resting hand splint; RME plus: relative motion extension splint with wrist splint; RME only: relative motion extension splint without wrist splint; MCPJ: metacarpophalangeal joints; IFSHT: International Federation of Societies for Hand Therapy.

Table 5.

Comparison between Malaysian and International ET survey responses to return to function, work, and outcome questions.

Survey Questions	Malaysian Response	International response (total IFSHT survey)	Asia-Pacific response (within IFSHT survey)
Hand use in splint	Least: RH/Immobilisation; PR	Least: RH/EAM; RH/Immobilisation	Least: RH/EAM; RH/Immobilisation
	Most: RME only; Dynamic	Most: RME plus; RME only	Most: RME only; RME plus
Safe 2-handed activity wearing splint (light; medium, heavy)	Majority: Light	Majority Light	Majority: Light
Heaviest 2-hand activity when splint stopped (light; medium, heavy)a	Majority: Medium	Majority: Medium	Majority: Medium
Return to unrestricted hand use	Most: 8–10 weeks	Most: 8–10 weeks	Most: 10–12 weeks
	Next: >12 weeks	Next: 10–12 weeks	Next: >12 weeks
Hand Hygiene recommendations (full-time splint wear phase)	Most: Safe to wash carefully	Most: Safe to wash carefully	Most: Safe to wash carefully
	Next: Keep dry	Next: Keep dry	Next: OK to get splint & hand wet
RTW pre-injury capacity	Most: Yes	Most: Yes	Most: Yes
RTW guidelines set by	Most: Combination of surgeon, therapist, and patient	Most: Combination of surgeon, therapist, and patient	Most: Combination of surgeon, therapist, and patient
	Next: Therapist	Next: Surgeon	Next: Therapist
Usual discharge from therapy	Most: >12 weeks	Most: 8–12 weeks	Most: 8–12 weeks
	Next: 8–12 weeks	Next: >12 weeks	Next: > 12 weeks
TAM on discharge	Most: Good	Most: Good	Most: Good
	Next: Excellent	Next: Excellent	Next: Excellent
Satisfaction on discharge	Most: ‘Yes’ patient opinion	Most: ‘Yes’ patient opinion	Most: ‘Yes’ patient opinion
	Next: ‘Yes’ patient survey	Next: ‘Yes’ therapist opinion	Next: ‘Yes’ therapist opinion

EAM: early active motion; EPM: early passive motion; PR: palmar resting hand splint interphalangeal joints free; RH: resting hand splint; RME plus: relative motion extension splint with wrist splint; RME only: relative motion extension splint without wrist splint; MCPJ: metacarpophalangeal joints; IFSHT: International Federation of Societies for Hand Therapy. TAM: total active motion; Excellent: equal or 100% of contralateral; Good: 75–99% of contralateral.

^aLight= up to 10lbs/4.5 kg; Medium= up to 25lbs/11kgs; Heavy =up to 50lbs/22.5kgs.

Discussion

We were encouraged by the higher response rate for the Malaysian survey (59%) compared to that of the IFSHT survey (11%). ¹ Consequently we are confident the survey gives a representative snapshot of zone V-VI extensor tendon rehabilitation practice in Malaysia. Likewise, we have confidence in the Malaysian respondents’ comprehension of English, as all therapists must be competent in English as textbooks and medical communication are in English. Inclusion of both MSHT members and non-members assisted our ability to collect data on Malaysian practice patterns, with few differences noted in responses between the two groups.

While there were similar results for many questions, there were clear differences in demographic profile, selection of the ‘most used’ approach, exercise prescription during the splint protective phase, and the timing of splint step-down and return to unrestricted activity. Different from IFSHT responses and the evidence, Malaysian respondents felt that the RME splint would not be protective enough. Despite this belief, and somewhat contradictory, Malaysian therapists did express a desire to use relative motion, while indicating a lack of confidence to progress this approach. One of the most striking similarities between the groups surveyed was ‘surgeon preference’ as the number one barrier to implementing the therapist favoured RME/EAM approach. ⁷

Demographic profile

All groups varied in demographic profile, with the ratio of Malaysian occupational therapists to physiotherapists twice that of total IFSHT sample, and three times the Asia-Pacific subset; the years of hand therapy experience was considerably less for Malaysian therapists (1–4 years) and Asia-Pacific therapists (5–9 years) compared to 20+ years for IFSHT therapists. This experience gap is further highlighted with only 9% of Malaysians compared to 50% of Asia-Pacific and 58% of IFSHT respondents having additional hand therapy credentials. Whereas the demographics and professional qualifications of the IFSHT respondents matched the typical profile of therapists belonging to IFSHT full-member countries ¹ , the Malaysian therapists’ profile did not. Since MSHT is a relatively new organisation it is not surprising to see this younger therapist demographic managing hand injuries in a variety of clinical settings (and believe this may be true for other countries involved in upskilling hand therapy). Our intent was to learn about the practice patterns of Malaysian therapists managing these zone V-VI extensor tenorrhaphies, which also gave us insight into the frequency of extensor tendon repairs referred to therapists. Results from respondents of the Malaysian survey found that 38%, and from the IFSHT survey 35%, ¹ managed at least 1–2 repairs over the past year, whilst 32% of the Asia-Pacific respondents managed greater than 10 repairs in the past year.

‘Most used’ approach

Malaysian therapists selected their ‘most used’ approach as dynamic/EPM, while the IFSHT and Asia-Pacific therapists selected RME/EAM. ¹ Similar numbers of MSHT members compared to non-members selected the three ‘most used’ approaches (dynamic/EPM, RH/EAM and RH/immobilisation), whilst the three users of RME/EAM were all MSHT members. Despite some regional variation within the IFSHT survey, more therapists worldwide use early active motion approaches than Malaysian survey respondents. ¹ Overall the IFSHT responses reflect evidence consensus that early motion recovers movement better than immobilisation and early passive motion,^8–11 and that motion delivered by a RME only splint is superior to that achieved with a PR IPJs free splint. ¹²

Personal communication with author SCC, a local university lecturer informed us that the entry level occupational therapy curriculum includes an introduction to extensor tendon management, with time most spent on dynamic and static resting hand splint fabrication, and the physiotherapy curriculum focuses on extensor tendon anatomy and general rehabilitation. With many Malaysian respondents having four or less years of experience, it was no surprise these therapists were using approaches (immobilisation and dynamic/EPM approaches) that were taught or were following the advice of the attending surgeon or institution. This may in part explain why immobilisation was the equal second ‘most used’ approach selection. Additional contributing factors to selection of the ‘most used’ approach may include patient particulars such as living remotely without the ability to attend regular therapy appointments, manual handling demands at work, low education levels and language communication issues.

Exercise in or out of the splint, timing of splint step-down and release to unrestricted activity

Malaysian respondents were more likely to have patients perform exercises both ‘in and out’ of the splint while the international and Asia-Pacific therapists kept the splint on. ¹ The difference between IFSHT and the Asia-Pacific managing these hand injuries was that both respondent groups reported more frequent use of RME and PR with EAM, implying exercises were done in the splint^13–15. Earlier commencement of composite finger flexion by the IFSHT and Asia-Pacific respondents (4–6 weeks) ¹ compared to most Malaysian respondents (6–8 weeks) may be explained by higher rates of EAM approaches. This is also more consistent with the evidence which recommends beginning this after week 4.^15–17

Most therapists from both surveys moved their patients from full to part-time splint wear before stopping the splint completely. The step-down timing was consistent and earlier for most IFSHT and Asia-Pacific respondents (4–6 weeks) ¹ compared to widely variable timing reported by Malaysian therapists. As most international and Asia-Pacific respondents used RME and PR splints with early active motion, ¹ this timing practice may be a result of following the published guidelines set out for these two approaches.^12–14 The reason for this variability in step-down timing among Malaysian therapists is unknown, perhaps reflective of a small sample size or following individual surgeons’ advice.

Discharge to unrestricted activity was highly variable among the IFSHT and Malaysian respondents, although more Malaysian therapists waited longer. This later discharge (after 12 weeks) to unrestricted activity may be a result of following early PR and dynamic splinting protocols or consideration of work demands.^15,16 There is no evidence in the literature guiding the ideal timeframe for safe hand use without restriction, as most authors generally report their protocol; hence variability in survey participant responses is not unexpected. Lastly, discharge may vary depending on the practice of the surgeon which would likely affect both groups surveyed.

Function

During the phase of full-time splint wear, both versions of the RME splint were selected by the IFSHT and Asia-Pacific respondents as permitting the most functional hand use, while Malaysian therapists selected both versions of RME and dynamic splints. Considering that Malaysian therapists selected the dynamic/EPM as their ‘most used’ approach followed by the RH splint with EAM or immobilisation, they may view motion allowed by the dynamics versus the static splints comparatively more functional.

Approach they would like to try and barriers to implementation

The single largest barrier to implementing an approach other than the ‘most used’ was ‘surgeon preference’ for both the IFSHT and Malaysian groups. This is important since a large portion of therapists in both groups not using RME/EAM expressed a desire to try it. Interestingly, alongside the desire to try RME/EAM, another barrier agreed on by more Malaysian than IFSHT therapists was the lack of confidence in progressing the RME program. This lack of confidence may be related to many things (other than their own lack of experience), such as having no local therapist RME/EAM mentors, accessibility to and understanding of the relative motion literature, or introducing a new idea that cannot be guided by the surgeon. Another barrier for more than half of the Malaysian and one quarter of the IFSHT respondents was the common concern that the RME splint offered too little protection for most of their patients, ¹ although the literature does not support this opinion.^{12–14,18–22}

Limitations

As with the international electronic survey, responses to this survey were generated from emailed invitations, so these findings may not be representative of all therapists managing hand injuries in Malaysia. The 59% response rate gives some confidence that a fair sample has been obtained, as this is larger than our international response rate. ¹ Although the survey was presented in English, we did not anticipate the large number (63%) of Malaysian therapists who use English as their primary language. We suspect whilst some with limited written English comprehension skills completed the survey, others may have underestimated their proficiency, and decided to not participate.

Future research recommendations

Malaysian practice patterns shown by this survey suggest that the RME/EAM approach is new to them, unlike many of their IFSHT peers who chose this as their usual or most desired to use approach. This survey highlights that barriers to RME/EAM use are similar across the world independent of being an IFSHT member country or not. Our combined survey findings can provide a platform for therapists to discuss rehabilitation options with their peers and surgeons and to reflect on their current interventions, as well as offer a pathway to change, if so desired. These discussions might include methods to upskill in the use of RME/EAM via professional supervision and attending hand surgeon and therapist continuing education seminars.

Conclusion

We report the practice patterns through an electronic online survey for a group of Malaysian therapists managing zones V-VI extensor tendon repairs and compared these to prior survey responses from therapists in countries with full-membership in the IFSHT, and an IFSHT subset of Asia-Pacific respondents. Shared commonalities across all groups were a desire to try the RME/EAM approach and the perception that surgeon preference was the single most mentioned barrier to implementation. Current practice patterns unique to most Malaysian therapists rehabilitating extensor tendon repairs is use of dynamic splints with EPM and RH splints with immobilisation or EAM, which reflects a disparity between the evidence and clinical practice.