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Recently, the wide-awake local anesthesia no tourniquet (WALANT) technique and relative motion extension (RME) splint changed practice in extensor tendon reconstruction and therapy. We wanted to share our approach for zones 5 to 8 extensor tendon management following the up-to-date developments. The impacts of surgery under WALANT and early active motion therapy with RME splinting were explained frankly and shown in several videos throughout the article.

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On-orbit servicing using a space robot is gaining popularity among the space community for both economic and safety aspects. In particular, the estimation of the relative motion of a noncooperative target is a challenging problem. This study presents a relative motion estimation scheme based on stereovision for noncooperative targets considering multiple solutions of rotational parameters. Specifically, the mass distribution of the target is identified based on the least-square method and the principle of conservation of angular momentum. Then, the determination of a unique principal axis coordinate frame of the target is employed to resolve the multiple-solution problem. In addition, an EKF (extended Kalman filter)-based filter with global observability is designed to estimate the full motion states and inertia parameters of the target. The convergence performance of the proposed method is verified by numerical simulation. The results also demonstrate that the method is robust to occlusion.

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BACKGROUND: The metacarpophalangeal joint blocking orthosis (MCPJ-BO) is one of the first-line orthotic treatment for patients with trigger finger (TF). Relative motion extension orthosis (RME-O) has recently emerged as a treatment option for various hand disorders involving TF. PURPOSE: The primary objective of this study was to compare the effectiveness of 6 weeks of orthotic treatment with the MCPJ-BO and the RME-O for pain relief. Function and satisfaction with the orthosis were assessed as secondary objectives. STUDY DESIGN: Randomized clinical study. METHODS: Thirty patients with an average age of 50 years with Froimson stage 1-3 A1 pulley triggering participated in the study. They were randomly assigned to either the MCPJ-BO (n = 15; 10 females, five males) or the RME-O group (n = 15; 12 females, three males). The orthoses were worn full time for 6 weeks. All patients received patient education, activity modification, and flexor tendon gliding exercises as part of the rehabilitation program. Pre- and post-assessments included Numeric Pain Rating Scale, Disability of the Arm, Shoulder, and Hand questionnaire, and Quebec User Evaluation of Satisfaction with Assistive Technology questionnaire. The Mann-Whitney U test was conducted to analyze the difference between the two groups. RESULTS: There were no significant differences between the two groups in pain and function before treatment (p < 0.05). Within-group comparisons indicated that both orthoses relieved pain, but the MCPJ-BO group achieved greater pain relief (p = 0.001). There was a significant improvement in function in the MCPJ-BO group, with a mean change of 12.7 (p = 0.0001). The overall success rates for the MCPJ-BO group and RME-O group were 60% and 27%, respectively. Patients in both groups had high satisfaction with the orthosis. CONCLUSIONS: MCPJ-BO and RME-O could be used for pain relief in the treatment of TF. The MCPJ-BO appears to be more effective than the RME-O in improving function.

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BACKGROUND: Evidence supports use of the relative motion extension (RME) approach following extensor tendon repairs in zones V-VI yielding good or excellent outcomes. PURPOSE: To demonstrate how a 3-year internal audit and regular review of emerging evidence guided our change in practice from our longstanding use of the Norwich Regimen to the RME approach using implementation research methods. We compared the outcomes of both approaches prior to the formal adoption of the RME approach. STUDY DESIGN: Prospective clinical audit. METHODS: A prospective audit of all consecutive adult finger extensor tendon repairs in zones IV-VII rehabilitated in our tertiary public health hand centre was undertaken between November 2014 and December 2017. Each audit year, outcomes were reviewed regarding the Norwich regimen and the RME early active motion approaches. As new evidence emerged, adjustments were made to our audit protocol for the RME approach. Discharge measurements of the range of motion of the affected and contralateral fingers and complications were recorded. RESULTS: During the 3-year audit, data was available on 79 patients (56 RME group including 59 fingers with 71 tendon repairs; 23 Norwich group including 28 fingers with 34 tendon repairs) with simple (n = 68) and complex (n = 11) finger extensor tendon zones IV-VI repairs (no zone VII presented during this time). Over time, the practice pattern shifted from the Norwich Regimen approach to the RME approach (and with the use of the RME plus [n = 33] and RME only [n = 23] approaches utilized). All approaches yielded similar good to excellent outcomes per total active motion and Miller's classification, with no tendon ruptures or need for secondary surgery. CONCLUSIONS: An internal audit of practice provided the necessary information regarding implementation to support a shift in hand therapy practice and to gain therapist or surgeon confidence in adopting the RME approach as another option for the rehabilitation of zone IV-VI finger extensor tendon repairs.

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BACKGROUND: The design and efficacy of orthotic intervention to non-surgically manage adult and pediatric trigger finger vary widely. PURPOSE: To identify types of orthoses (including relative motion), effectiveness, and outcome measurements used to non-surgically manage adult and pediatric trigger finger. STUDY DESIGN: Systematic review. METHODS: The study was undertaken according to The Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 Statement and registered with the International Prospective Register of Systematic Reviews Registry, number CRD42022322515. Two independent authors electronically and manually searched, and screened 4 databases; selected articles following pre-set eligibility criteria; assessed the quality of the evidence using the Structured Effectiveness for Quality Evaluation of Study; and extracted the data. RESULTS: Of the 11 articles included, 2 involved pediatric trigger finger and 9 adult trigger finger. Orthoses for pediatric trigger finger positioned finger(s), hand, and/or wrist of children in neutral extension. In adults, a single joint was immobilized by the orthosis, blocking either the metacarpophalangeal joint or the proximal or distal interphalangeal joint. All studies reported positive results with statistically significant improvements and medium to large effect size to almost every outcome measure, including the Number of Triggering Events in Ten Active Fist 1.37, Frequency of Triggering from 2.07 to 2.54, Quick Disabilities of the Arm, Shoulder and Hand Outcome Measure from 0.46 to 1.88, Visual Analogue Pain Scale from 0.92 to 2.00, and Numeric Rating Pain Scale from 0.49 to 1.31. Severity tools and patient-rated outcome measures were used with the validity and reliability of some unknown. CONCLUSIONS: Orthoses are effective for non-surgical management of pediatric and adult trigger finger using various orthotic options. Although used in practice, evidence for the use of relative motion orthosis is absent. High-quality studies based on sound research questions and design using reliable and valid outcome measures are needed.

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BACKGROUND: The relative motion (RM) orthosis was introduced over 40 years ago for extensor tendon rehabilitation and more recently applied to flexor tendon repairs. PURPOSE: We systematically reviewed the evidence for RM orthoses following surgical repair of finger extensor and flexor tendon injuries including indications for use, configuration and schedule of orthosis wear, and clinical outcomes. STUDY DESIGN: Systematic review. METHODS: A PRISMA-compliant systematic review searched eight databases and five trial registries, from database inception to January 7, 2022. The protocol was registered prospectively (CRD42020211579). We identified studies describing patients undergoing rehabilitation using RM orthoses after surgical repair of acute tendon injuries of the finger and hand. RESULTS: For extensor tendon repairs, ten studies, one trial registry and five conference abstracts met inclusion criteria, reporting outcomes of 521 patients with injuries in zones IV-VII. Miller's criteria were predominantly used to report range of motion; with 89.6% and 86.9% reporting good or excellent outcomes for extension lag and flexion deficit, respectively. For flexor tendon repairs, one retrospective case series was included reporting outcomes in eight patients following zones I-II repairs. Mean total active motion was 86%. No tendon ruptures were reported due to the orthosis not protecting the repair for either the RME or RMF approaches. DISCUSSION: Variation was seen in use of RME plus or only, use of night orthoses and orthotic wear schedules, which may be the result of evolution of the RM approach. Since Hirth et al's 2016 scoping review, there are five additional studies, including two RCTs reporting the use of the RM orthosis in extensor tendon rehabilitation. CONCLUSIONS: There is now good evidence that the RM approach is safe in zones V-VI extensor tendon repairs. Limited evidence currently exists for zones IV and VII extensor and for flexor tendon repairs. Further high-quality clinical studies are needed to demonstrate its safety and efficacy.

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BACKGROUND: Relative motion (RM) orthoses have gained popularity with therapists as their versatility lends to "protective," "exercise," and "adaptive" uses. PURPOSE OF THE STUDY: To ask for comments from patients wearing RM orthoses for protective or exercise reasons. STUDY DESIGN: Interpretive descriptive qualitative study. METHODS: Semi-structured face-to-face interviews comprised of nine open-ended questions were conducted with 20 hand injured patients who were advised to wear a protective or exercise RM orthosis for at least 4 weeks. RESULTS: Twenty patients participated in the interviews. Thirteen patients wore the protective RM orthoses had a mean age of 28 years (range,16-54) and the mean age was 34 years (range, 20-51) for 7 patients using exercise RM orthoses. Interviews generated 4 major themes: physical characteristics of the orthoses, challenges in daily living activities, emotional response to orthotic wear, and impact of social environment. DISCUSSION: Comments from both groups of patients suggested the small size of the orthosis contributed to wearing the orthosis as advised. Most found the orthosis comfortable, when not, comments were related to rubbing of the orthosis causing pain and rigidity of the orthosis resulting in finger swelling. A few were impacted by the orthosis drawing attention to their injured hand. Those wearing the exercise RM orthosis often removed it instead of using it for nonintentional exercise. CONCLUSIONS: Comments obtained from the limited structured interview of 20 patients wearing protective or exercise RM orthosis may offer therapists with some understanding from the patient's perspective. Additional study is worthwhile.

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STUDY DESIGN: Case report INTRODUCTION: Relative motion flexion (RMF) orthoses are emerging as an option for early active motion (EAM) postoperatively. PURPOSE OF THE STUDY: To describe the rationale and implementation of an RMF orthosis to manage a patient after partial zone II epitendinous flexor tendon repairs. METHODS: This case involves a female who sustained partial flexor tendon lacerations to her middle finger in zone II, 60% flexor digitorum superficialis (FDS) and 90% flexor digitorum profundus (FDP). After epitendinous repair she was referred to therapy for EAM with a no orthosis request. The unusual circumstances prompted the therapist, concerned about the risk of tendon rupture to engage in discussion with the surgeon. Following discussion, a decision was made to use an RMF orthosis for controlled EAM to protect the epitendinous zone II FDS and FDP repairs. Outcomes of range of motion (ROM), total active motion (TAM), %TAM, grip, and quickDASH are reported. RESULTS: Neither the FDP or FDS tendons ruptured, nor were there any joint contractures. "Good" %TAM outcomes were achieved at 12-week postoperatively. Quick DASH scores improved 61 points indicating a clinically meaningful difference of improved function. DISCUSSION: The lack of a multi-strand core suture repair is unusual in combination with EAM. The positive outcomes reported in this single patient have raised questions about the protective benefit of the RMF orthosis when used with a zone II epitendinous repair of a 90% FDP laceration. Epitendinous repair of a partial (60%) FDS injury, however, is not uncommon and often not repaired at all. CONCLUSIONS: In this single case report the epitendinous repairs of zone II 90% FDP and 60% FDS with digital nerve involvement were successfully managed with an RMF only orthosis. The use of EAM with an epitendinous repair is in conflict to the current surgical and therapy literature.

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INTRODUCTION: An international survey of therapists cited 2 barriers (physician preference and departmental policy) to the implementation of a relative motion extension (RME) orthosis/early active motion (EAM) approach. STUDY DESIGN: e-survey PURPOSE: To glean insight from hand surgeons and hand therapists regarding their awareness and experiences in implementing or not implementing an RME orthosis/EAM approach for management of finger zones V-VI extensor tendon repairs. METHODS: Two e-surveys, one to hand surgeons and the other to hand therapists were distributed. Participants were asked 8-open ended questions with the opportunity for additional comment. RESULTS: Nine of 11 surgeons and 10 of 11 therapists (clinicians/educators/administrators) who were surveyed, participated. All respondents from 7 countries were aware of the RME/EAM approach, with only 1 surgeon and 2 therapists not implementing. Surgeons once aware, quickly implement; therapists in this survey implemented about 2.5 years after learning of the approach. Surgeon use was influenced more by their peers than the evidence while therapist knowledge came from professional meetings. Therapists teaching at university-level and continuing education integrate the approach. DISCUSSION: Although the RME orthosis/EAM approach has been around for 4 decades, awareness for the hand surgeons and therapists surveyed has only been over the past 20 years. Surveyed surgeons like to visualize how the RME concept works and therapists depend more on the evidence. To overcome barriers to RME/EAM implementation, several strategies are outlined. CONCLUSION: Although a small survey, valuable comments provide insight for addressing the previously cited barriers. Strategies for increasing awareness and fostering implementation of an RME orthosis/EAM approach are offered by international hand surgeons and therapists surveyed regarding the commonly cited barriers of surgeon preference and department procedures.

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STUDY DESIGN: Case report. INTRODUCTION: Despite better disease control with more effective medications, people with rheumatoid arthritis (RA) continue to experience persistent and fluctuating levels of pain, swelling and functional limitations in their hands. PURPOSE: To describe therapists and people living with RA working together to understand what could be occurring in their hands because of the RA and how relative motion (RM) orthoses may be used to self-manage common hand RA related problems. METHODS: Case reports are used to demonstrate how patient self-report, clinical exam, and observation of hand movement and function are integrated into the design of RM orthoses for individuals with RA. The cases are supported by photos and videos, including a personal narrative video exploring 1 persons' personal perspective on their use of RM orthoses. RESULTS: Case reports illustrate adaptive and/or protective RME orthoses use for RA related finger malalignment, tendon subluxation, joint pain and instability in the hand. The narrative video also introduces a person living with RA, who speaks candidly about her multiple RM orthoses and how she decides which orthosis is "best" for a given activity and the current level of RA related problems in her hands. DISCUSSION: It is not unusual for individuals with RA to have multiple RM orthoses, made for different purposes and fabricated from different materials. Mulitple RM orthosis options allows a person to select what is "best" for them, depending on the context of use and priorities or needs. CONCLUSION: Partnering with people living with RA to understand how to use simple, low-profile, adaptive and protective RM orthoses may be an effective way to support self-management of common RA related hand problems.

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STUDY DESIGN: Retrospective. INTRODUCTION: Boutonniere deformity (BD) is a troublesome injury occurring from rupture of tissue connecting the extrinsic to intrinsic tendon systems. This causes loss of interphalangeal joint balance, and immobilization often results in adherence and difficulty restoring balance. PURPOSES: Review of relative motion flexion (RMF) orthotic use for safe healing during functional activity in 23 patients, and explanation of the rationale. METHODS: Anatomic rationale and clinical experience is reviewed in 8 acute BD patients utilizing RMF orthoses for 6 weeks, and for chronic BD patients, 3 months after serial casting. RESULTS: All patients met the Strickland and Steichen criteria for "excellent" results following treatment, with an average of 35° increase in ROM. DISCUSSION: The anatomic rationale for relative motion recognizes that altering relative positioning between adjacent metacarpophalangeal (MCP) joints produces a protective favorable impact on interphalangeal forces during hand function using 15°-20° greater MCP joint flexion. This provides dorsal and volar protective benefits because the extensor digitorum communis (EDC), a single-muscle-four-tendon system, attaches to the intrinsic lateral band (LB) tendons. With greater MCP flexion, dorsal EDC force is increased, pulling lateral bands medially, while on the volar surface the downward pull of the lumbrical on LB is relaxed due to origin from the flexor digitorum profundus tendon of the injured digit, also a single-muscle-four-tendon system. The RMF orthosis permits protected active motion during functional activity with acute BD. In patients with chronic BD and adequate passive extension, an RMF orthosis for 3 months also produced encouraging results. CONCLUSION: Management of acute BD with RMF orthoses provided earlier recovery of motion and hand function. Similar results occurred for chronic BD using serial casting for adequate extension followed by 3 months of RMF orthotic use and should be attempted prior to surgical intervention, with surgery remaining an alternative.

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INTRODUCTION: There is no comparative evidence for relative motion extension (RME) orthosis with dynamic wrist-hand-finger-orthosis (WHFO) management of zones V-VI extensor tendon repairs. PURPOSE OF THE STUDY: To determine if RME with wrist-hand-orthosis (RME plus) is noninferior to dynamic WHFO for these zones in clinical outcomes. STUDY DESIGN: Randomized controlled non-inferiority trial. METHODS: Skilled hand therapists managed 37 participants (95% male; mean age 39 years, SD 18) with repaired zones V-VI extensor tendons randomized to RME plus (n = 19) or dynamic WHFO (n = 18). The primary outcome of percentage of total active motion (%TAM) and secondary outcomes of satisfaction, function, and quality of life were measured at week-6 and -12 postoperatively; percentage grip strength (%Grip), complication rates, and cost data at week-12. Following the intention-to-treat principle non-inferiority was assessed using linear regression analysis (5% significance) and adjusted for injury complexity factors with an analysis of costs performed. RESULTS: RME plus was noninferior for %TAM at week-6 (adjusted estimates 2.5; 95% CI -9.0 to 14.0), %TAM at week-12 (0.3; -6.8 to 7.5), therapy satisfaction at week-6 and -12, and orthosis satisfaction, QuickDASH, and %Grip at week-12. Per protocol analysis yielded 2 tendon ruptures in the RME plus orthoses and 1 in the dynamic WHFO. There were no differences in health system and societal cost, or quality-adjusted life years. DISCUSSION: RME plus orthosis wearers had greater injury complexity than those in dynamic WHFOs, with overall rupture rate for both groups comparatively more than reported by others; however, percentage %TAM was comparable. The number of participants needed was underestimated, so risk of chance findings should be considered. CONCLUSIONS: RME plus management of finger zones V-VI extensor tendon repairs is non-inferior to dynamic WHFO in %TAM, therapy and orthotic satisfaction, QuickDASH, and %Grip. Major costs associated with this injury are related to lost work time.

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BACKGROUND: Proximal interphalangeal joint (PIPJ) contractures, zone III extensor tendon injuries and phalanx fractures are challenging to treat in isolation. In this case the patient presented with all 3 of these issues in a single digit, presenting a unique problem for the hand therapist. PURPOSE: A case report to examine the effectiveness of using single orthosis to treat an index finger following a combined zone III extension tendon repair, surgically stabilized second phalanx fracture and PIPJ flexion contracture. METHODS: A patient presented to therapy with a 40° PIPJ flexion contracture and minus 70° of active PIPJ extension (ICD10 M25.64) after left index surgical fixation of a middle phalanx fracture (ICD10 S62.621B) and zone III extensor tendon repair (ICD10 S66.321A). To correct the contracture, a distal elastic strap was added to a relative motion flexion orthosis with dorsal hood. This applied a gentle extension force to the PIPJ. Once the contracture resolved a short arc motion program (SAM) was initiated using the same orthosis. RESULTS: At 20 weeks post initial therapy evaluation, active range of motion (extension/flexion) of the PIPJ was 5°/100° and distal interphalangeal joint (DIPJ) 0°/60°. The Quick DASH score improved 50 points from an initial 59 points to 9 points. The patient reported good satisfaction and full function of the hand. CONCLUSION: Our case report demonstrated the effective use of a single relative motion flexion orthosis with a dorsal hood when treating a complex hand injury involving an open zone III injury, second phalanx fracture and 40-degree PIPJ contracture.

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BACKGROUND: For hand therapists and hand surgeons acute and chronic injuries of the extensor mechanism (EM) in zones III-IV are challenging to treat with satisfying results. INTRODUCTION: Early active motion combined with relative motion flexion (RMF) orthoses to manage EM zone III injuries and boutonnière deformity has renewed interest in the complex anatomy and biomechanics of the EM. PURPOSE: To provide an in-depth discussion of EM zones III-IV anatomy with emphasis on inter-tendinous structures, often omitted in simplified, model-wise illustrations which focus mostly on the tendinous structures. METHOD: In collaboration the authors combined on the one hand extensive clinical experience and knowledge of the EM literature and on the other hand decades of anatomical, biomechanical and kinesiology research of the EM with special interest for the spiral fibers, through gross anatomy and microdissection anatomy laboratory work, MRI and ultrasonography studies. RESULTS: The inter-tendinous tissues (i.e., spiral fibers) in zone III are of imminent importance for proper functioning of the EM and to prevent boutonnière deformity to develop after EM surgery or injury. DISCUSSION: Inter-tendinous links between the tendinous structures of the EM are necessary for balanced finger motion. The spiral fibers are described in more detail because of their role in controlling volar migration of the conjoined lateral bands and because their disruption makes development of boutonnière deformity more likely. Understanding the anatomy and biomechanics of the EM may assist in progress toward 'proof of concept' for use of RMF orthoses and controlled early active motion after EM injury or surgery. CONCLUSION: Hand surgery and hand therapy practice interventions, including use of RMF orthoses for management of non-surgical and surgical EM injuries may benefit from an in-depth look at the EM zone III and IV anatomy and biomechanics.

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BACKGROUND: Little is known about the patient experience of relative motion (RM) orthoses, or how they impact hand use and participation in occupational roles. PURPOSE: To explore the use of Photovoice methodology in hand-injured patients and the patient experience of wearing a RM orthosis. STUDY DESIGN: Photovoice methodology, Qualitative Participatory research, feasibility study METHODS: Purposive sampling was used to identify adult patients prescribed a RM orthosis as part of their therapy intervention for an acute hand injury. Over a 2-week period and using their personal camera device participants captured their experience of wearing a RM orthosis and its impact on their daily life. Participants shared 15-20 photos with the researchers. At a face-to-face semi-structured interview, 5 key photographs were selected by the participants with context and meaning explored. Interview data was transcribed, captions and context of images confirmed by member checking, and thematic analysis completed. RESULTS: Protocol fidelity was observed using our planned Photovoice methodology. Three participants (aged 22-46 years) shared 42 photos and completed individual interviews. All participants reported their involvement as a positive experience. Six themes were identified: adherence, orthosis factors, expectations and comparisons, impact on daily activities, emotions, and relationships. RM orthoses allowed freedom of movement enabling participation in a range of occupations. Challenges included water-based activities, computer use and kitchen tasks. Participants expectation of orthotic wear and recovery appeared to contribute to their overall experience, with RM orthoses viewed favourably when compared to other orthoses and immobilization methods. CONCLUSIONS: Photovoice methodology was a positive process for participant reflection and a larger study is recommended. Wearing a RM orthosis enabled functional hand use as well as providing challenges completing everyday activities. Participants had different demands, experiences, expectations, and emotions associated with wearing a RM orthosis, reinforcing the need for clinicians to take a client-centred approach.

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STUDY DESIGN: Systematic review INTRODUCTION: Early active mobilization (EAM) of tendon repairs is preferred to immobilization or passive mobilization. Several EAM approaches are available to therapists; however, the most efficacious for use after zone IV extensor tendon repairs has not been established. PURPOSE OF THE STUDY: To determine if an optimal EAM approach can be identified for use after zone IV extensor tendon repairs based on current available evidence. METHODS: Database searching was undertaken on May 25, 2022 using MEDLINE, Embase, and Emcare with further citation searching of published systematic/scoping reviews and searching of the Australian New Zealand Clinical Trials Registry, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials. Studies involving adults with repaired finger zone IV extensor tendons, managed with an EAM program, were included. Critical appraisal using the Structured Effectiveness Quality Evaluation Scale was performed. RESULTS: Eleven studies were included, two were of moderate methodological quality, and the remainder was low. Two studies reported results specific to zone IV repairs. Most studies utilized relative motion extension (RME) programs; two utilized a Norwich program, and two other programs were described. High proportions of "good" and "excellent" range of motion (ROM) outcomes were reported. There were no tendon ruptures in the RME or Norwich programs; small numbers of ruptures were reported in other programs. CONCLUSIONS: The included studies reported minimal data on outcomes specific to zone IV extensor tendon repairs. Most studies reported on the outcomes for RME programs which appeared to provide good ROM outcomes with low levels of complications. The evidence obtained in this review was insufficient to determine the optimal EAM program after zone IV extensor tendon repair. It is recommended that future research focus specifically on outcomes of zone IV extensor tendon repairs. LEVEL OF EVIDENCE: I.

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Relative Motion (RM) orthoses are an extremely important and beneficial intervention in hand rehabilitation. They can be used for a variety of hand conditions including for positioning, protection, alignment and exercise. In order to achieve the intended goals of this orthotic intervention, the clinician must pay attention to detail during its fabrication. The purpose of this manuscript is to offer some simple and practical fabrication tips for hand therapists who want to include the use of RM orthoses to manage these different clinical conditions. Photos are provided to reinforce some of the key concepts.

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The relative motion concept is simply recognition of the normal functional anatomic relationships that allow powerful extrinsic muscles, the extensor digitorum communis (EDC) and flexor digitorum profundus (FDP), to vary forces on individual finger joints and function in response to the relative position of adjacent metacarpophalangeal joints (MCPJs) in the hand, one to another. First identified as a cause of complications after surgery, a better understanding now allows us to harness these forces by way of differential metacarpophalangeal joint (MCPJ) positioning using an orthosis. This can reduce undesirable tension and allow immediate controlled active motion while permitting functional use of the hand. Tissue gliding with active motion prevents restrictive scarring, maintains joint mobility and avoids unnecessary limitations and stiffness on normal neighboring structures. The historical development of this concept is shared with explanation of the anatomic and biologic rationale for this approach. Acute and chronic hand conditions that may benefit from better understanding of relative motion are numerous and growing.

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INTRODUCTION: Movement is fundamental to the normal behaviour of the hand, not only for day-to-day activity, but also for fundamental processes like development, tissue homeostasis and repair. Controlled motion is a concept that hand therapists apply to their patients daily for functional gains, yet the scientific understanding of how this works is poorly understood. PURPOSE OF THE ARTICLE: To review the biology of the tissues in the hand that respond to movement and provide a basic science understanding of how it can be manipulated to facilitate better functionThe review outlines the concept of controlled motion and actions across the scales of tissue architecture, highlighting the the role of movement forces in tissue development, homeostasis and repair. The biophysical behaviour of mechanosensitve tissues of the hand such as skin, tendon, bone and cartilage are discussed. CONCLUSION: Controlled motion during early healing is a form of controlled stress and can be harnessed to generate appropriate reparative tissues. Understanding the temporal and spatial biology of tissue repair allows therapists to tailor therapies that allow optimal recovery based around progressive biophysical stimuli by movement.

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STUDY DESIGN: Narrative review and case series. INTRODUCTION: The relative motion approach has been applied to rehabilitation following flexor tendon repair. Positioning the affected finger(s) in relatively more metacarpophalangeal joint flexion is hypothesized to reduce the tension through the repaired flexor digitorum profundus by the quadriga effect. It is also hypothesized that altered patterns of co-contraction and co-inhibition may further reduce flexor digitorum profundus tension, and confer protection to flexor digitorum superficialis. METHODS: We reviewed the existing literature to explore the rationale for using relative motion flexion orthoses as an early active mobilization strategy for patients after zone I-III flexor tendon repairs. We used this approach within our own clinic for the rehabilitation of a series of patients presenting with zone I-II flexor tendon repair. We collected routine clinical and patient reported outcome data. RESULTS: We report published outcomes of the clinical use of relative motion flexion orthoses with early active motion, implemented as the primary rehabilitation approach after zone I-III flexor digitorum repairs. We also report novel outcome data from 18 patients. DISCUSSION: We discuss our own experience of using relative motion flexion as a rehabilitation strategy following flexor tendon repair. We explore orthosis fabrication, rehabilitation exercises and functional hand use. CONCLUSIONS: There is currently limited evidence informing use of relative motion flexion orthoses following flexor tendon repair. We highlight key areas for future research and describe a current pragmatic randomized controlled trial.

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