Development of Useful Function in the Severely Paralyzed Hand
Nickel, V.L.; Perry, J.; Garrett, A.L.
Journal of Bone and Joint Surgery. American Volume 45: 933-952
1963
ISSN/ISBN: 0021-9355 PMID: 14047365 Document Number: 8690
Improvement of function of the severely paralyzed hand by splinting or by reconstructive surgery has been successful in an increasing percentage of patients as knowledge of these hands has increased and experience has been gained. Acceptance of these procedures is still a major psychological hurdle for some patients. The extent of their involvement and the absence of positive suggestions for a period of time, not infrequently extending into years, have led to a state of mind which makes it very difficult for these severely disabled patients to accept the apparatus and procedures that have been discussed in this paper. Such stagnation is best overcome by a graduated program of activities which assures successful performance. Simple tasks, well within the limitations of the remaining muscle power, are slowly made more complex. Hand splints and functional arm braces are prescribed for a particular purpose and the patient is made aware of that purpose. Time is allowed for the patient to become accustomed to the apparatus. Adjustments are made as frequently as necessary to assure comfort and effective function and to keep up with the progress of the patient. At the same time the therapist trains the patient in the optimum use of the device. Any external appliance presents an abnormal situation; effective control is not automatic. Only with guidance and practice can any but the most unusual patient learn to reap the advantages of the functional assists and to overcome the disadvantages of an external appliance. The therapist is in an excellent position to evaluate the effectiveness of the device and to advise appropriate modification. Only since we have rigidly included training, along with fitting, have these devices been well accepted. Surgery also is most difficult for these patients to accept. It obviates the possibility of eventual recovery of normal function, and the risk of failure suggests further loss. A matter-of-fact mention of various operative procedures as a means of eliminating bracing, during re-evaluation visits, has proved the most effective approach. No time is set; we try to time the suggestion of surgery so that it will not act as a reaffirmation of the patient's loss of physical integrity, but rather indicate progress. Willingness to accept surgical treatment is also encouraged if the patient sees successful results in others. The operative procedures must be selected most carefully. Goals have to be realistic and the technique must be exact. Above all, the surgeon must avoid the common fault of expecting, inferring, or promising results that are impossible to achieve with what has been left to the patient.
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