A study to determine the practices, attitudes and experiences of public sector physiotherapists and occupational therapists in the post operative rehabilitation of flexor tendons of the hand.

Abstract

The management of flexor tendon injuries in the hand is complex and requires skill not only on the part of the surgeon but also the rehabilitation therapists and compliance on the part of the patient. Anecdotally it is clear that therapists (occupational therapists and physiotherapists) gain their skills and knowledge as practitioners through hands-on experience, since very little specialized training is available in the field of hand therapy. Therapists should equip themselves with the knowledge of the surgical management of the patient, since post-operative rehabilitation depends on it. Ideally the hand surgeons should advise the therapists or dictate the post-operative management based on the surgical technique performed. The actual practices, attitudes and experiences of South African therapists in the management of flexor tendons are not known. The purpose of this study was to determine the practices, attitudes and experiences of the public sector physiotherapists and occupational therapists in the postoperative rehabilitation of patients post repair of flexor tendons surgery in the hand. The first part of the study consisted of a cross sectional survey which explored the postoperative rehabilitation practices, attitudes, and experiences regarding flexor tendon rehabilitation. The second part which was a focus group discussion sought in depth information on the attitudes and experiences of the therapists. Sixty three therapists from different public hospital settings in two districts of KwaZulu-Natal completed a validated questionnaire. The therapists were accessed from randomly selected hospitals located in two conveniently selected health districts in KwaZulu- Natal. The findings suggest that the use of the Kleinert-type and immobilisation protocols is widely used. Overall there was no significant differences in the choice of rehabilitation protocol, but this differed by hospital setting. Therapists in the tertiary hospital preferred the Duran protocol (53.6%, p = 0.003). Regional hospitals utilized the immobilization protocol (74.1%, p=0.045) and district hospitals treated presenting postoperative symptoms mostly (20% p=0.75).There was no statistical (p=0.196) difference on the decision to initiate therapy amongst different hospital settings. Frequency of therapy visits varied, but was not statistically different (p=0.16) amongst different hospital settings. More respondents (29.2%) reported typically initiating active ROM exercises on the fourth post-operative week. There was a significant difference (p=0.002) in the initiation of active range of movement amongst different hospital settings. Approximately 37% of the respondents discontinue protective splinting at five weeks. There was a significant difference (p=0.004) by hospital setting regarding when the protective splinting should be discontinued. Initiation of resistance exercises varied between four and six weeks. Nearly half (49%) of the therapists reported that they are sometimes apprehensive about how to progress patients through rehabilitation. The focus group revealed that there is poor communication between therapists and surgeons, lack of protocol guidance, lack of knowledge of the flexor tendon protocols of the newly qualified therapists and doctors. During the focus group discussion therapist’s attitudes and experiences were revealed through the eight themes that emerged namely challenges experienced during flexor tendon (FT) rehabilitation, the patient's socio-economic background, patient’s home environment, compliance with flexor tendon rehabilitation protocol, multidisciplinary team approach, clinical experience, university undergraduate curriculum on flexor tendon rehabilitation, outcomes of flexor tendon postoperative rehabilitation. Conclusion. The rehabilitation protocols that are commonly used include the Kleinert -type and the immobilisation protocols. Duran type protocol was used less frequently, only when it was the best option for that particular patient according to the surgeon or the surgical management of that patient. The focus group discussion revealed that rural hospital therapists modify the protocols, due to lack of resources and the poor compliance of the patients. rehabilitation practices, flexor tendon experiences, hospital settings