1. Efficacy of LLLT and Exesices After Hand Flexor Tendon Repair

2. Ahmed Barakat, PhD lecturer of orthopedic physical therapy

3. Introduction
Flexor tendon injury has long been recognized as a difficult problem in hand surgery.
Muscle atrophy, joint stiffness, osteoarthritis, infection, skin necrosis, ulceration of joint cartilage and tendocutaneous adhesion are familiar complications produced by prolonged immobilization of surgically repaired tendon ruptures.
Loss of active motion in the digits results in significant morbidity.

4. Introduction
These problems become more pronounced in zone II where the tendons travel through a fibro-osseous canal along the palmar aspect of the digits.
Zone II is located between the origin of the flexor sheath in the palm (distal palmar crease) and the insertion of the flexor digitorum superficialis tendon on the middle phalanx ).

5. Introduction
Unfortunately injuries in zone II are the most frequent injuries in the hand and carry the most severe prognosis.
The functional outcome is poorer and the complication rate is greater than that associated with injury in other zones.
It has been termed no man’s land because the healing tendon tends to adhere to its fibro-osseous tunnel.

6. Introduction
Tendon repair and subsequent immobilization is frequently complicated by postoperative stiffness secondary to inflammation and peritendinous adhesions and tissue edema.
Restoration of normal hand function following flexor tendon repair requires reestablishment
not only the continuity of the tendon fibers, but
also of the gliding mechanism between the tendon
and its surrounding structures

8. Modulation of the tendon healing process remains a challenging problem
Modulation of the tendon healing process remains a challenging problem. Despite remodeling, biochemical and mechanical properties of healed tendon tissue, it never matches those of intact tendon .
Low Level Laser Therapy (LLLT) has gained a considerable attention for enhancing tissue repair in a wide spectrum of applications.

9. Tissue healing
is a complicated series of processes which consists of three overlapping processes:
a. Inflammation
b. proliferative stage
c. Remodelling. .

10. A. Inflammation characterized by vasodilatation and oedema formation.
A variety of cells arrive at the wound site e.g. Neutrophils, Macrophages, Lymphocytes, Platelets
bio-chemical mediators are important:
a. Heparin → prevent occlusion of capillary blood flow
b. Histamine → vasodilatation → heat and redness
c. Bradykinin, Serotonin , and Prostaglandin → increase capillary membrane permeability → pain and swelling

11. B. proliferative stage C. Remodelling
is the proliferative stage of repair, also comprising fibroplasia and angiogenesis
C. Remodelling
is the establishment of an equilibrium between collagen formation and lysis, resulting in the constant reshaping of the scar over several months.

12. Laser physics Electromagnetic spectrum
LLLT = a range of electromagnetic radiation of various wave lengths from nm including both visible (red) radiation at the lower end of the visible range and invisible (near infrared) radiation.

13. wavelengths associated with:
Visible red laser (He-Ne) = nm
is recommended for superficial conditions,
Infrared (Ga-As) = 904 nm for deeper musculoskeletal structure

14. Assessment procedures
Maximum grip strength
Was measured 3 weeks and 3 months postoperatively by the hand dynamometer.

15. Assessment procedures
2. ROM Was measured 3 weeks and 3 months postoperatively
TAM = active PIP + DIP flex. – ext. lag

16. Treatment procedures:
1. accelerates inflammation,
2. promotes fibroblast proliferation,
3. quicken bone repair and remodeling,
4. encourages revascularization of wounds and
5.increased tensile strength during wound healing
6. stimulate DNA in damaged cell tissue.
7. kill the pain.
overall accelerates tissue repair
1- Laser therapy

17. 2- therapeutic exercises
All the patients will be treated by therapeutic exercises 3 sessions weekly for 12 weeks for total of (36) sessions.
All exercises done for three sets of 10 repetitions.
Patients will be instructed to do exercises at home, three times daily till three weeks

18. First 2 weeks The hand will be splinted with posterior plaster slab
30º wrist flexion,
45º MCP joint flexion,
full IP joint extension
Hand kept elevated by a shoulder sling until the slab was removed at three weeks

19. 5th day postoperatively
Splint was removed every session
passive fingers flexion and active extension for all fingers together
Passive flexion and extension for PIP and DIP joints separately

20. 3rd and 4th week Active assisted finger flexion exercises
Active wrist flexion and extension while fingers are flexed
Active fingers flexion up to 1/3 of the range while wrist in neutral position

21. 5th week Active finger flexion to ½ of the range
Active wrist flexion and extension while fingers extended
Passive finger full extension

22. 6th week 7th and 8th week Full active free fingers flexion
Active fingers flexion up to 2/3 of the range
7th and 8th week
Full active free fingers flexion
Isolated active finger flexion

23. 9th to 10th week
Isolated active finger flexion against mild to moderate resistance

24. 11th to 12th week Tendon gliding exercises: Hook fist Straight fist
Full fist

25. Thank You