Lack of information on recovery
I had surgery on my right hand last week (not as bad as I had thought!)
Have read previous posts on recovery times, and it seems I am not the only one who does not know what to expect. Since every case is different you would think that your surgeon would explain what you should be doing to help your hand to recover as soon as possible. How long should we be resting, and when and how should we be moving? I asked for information before leaving the hospital, but was not given anything satisfactory.
Bearing in mind that my case has been described as severe,(although I have no figures regarding the nerve conduction tests, other than what the doctor said at the time) I am not expecting immediate results. However I do want to know how to prevent my nerve from being permanently damaged. My fingers are still stiff at the moment, and my thumb a bit worse.
Also as I can't use my right hand I am in danger of overusing my left, and am worried that it may not have the chance to recover at all, depending on how long it is before I can have surgery on it. I wonder whether GPs and surgeons forget how important it is to be able to use your hands. Apart from that there seems little point in spending NHS money on operations when no-one offers aftercare advice! Any further thoughts?
OK, I have a bit more time to reply now. There have been a couple of attempts to look at whether the hand should be splinted/immobilised/rested after surgery. These studies are pretty much impossible to carry out as double blind trials but for what they are worth they suggest that immobilising the hand is not a good idea.
(Cook 1995) - compared 2 weeks of splinting after surgery with range of motion exercises beginning on the second post-operative day in 50 patients. The splinted patients had more pain and scar tenderness in the first month after surgery but there were no other differences between the two groups.
(Finsen 1999) - compared 4 weeks of immobilisation with no immobilisation in 82 operations and found no detectable difference in outcome between the two groups.
... so we can say that the evidence does not favour immobilising the hand after surgery. One other study is worthy of attention (Pomerance 2007) and I will give the whole abstract here....
Purpose: To assess if a formal 2-week hand therapy improves outcomes and justifies its expense.
Methods: A prospective randomized study was completed using a contemporary short incision and a 2-week program of therapy. Patients were randomized into 2 treatment groups: one group received instruction on home therapy exercises to be followed after carpal tunnel release, and a second group received the home program in addition to a therapist-directed program for 2 weeks. Variables measured were patient age, gender, preoperative and postoperative pain scores, grip and pinch strengths, return to modified and regular work, insurance coverage, and job category. Both groups were followed for 6 months postoperatively.
Results: One hundred fifty patients (110 women and 40 men) entered and completed the study. The average age was 46 years (range, 29–70 years). The average age, gender distribution, insurance coverage, and breakdown of job categories between groups was not statistically significant. There was no difference in return to work times between those with and without postoperative therapy; however, patients covered by workers’ compensation insurance were slower to return to both modified and regular work compared with the other groups. The postoperative grip and pinch strengths, pain and Disabilities of the Arm, Shoulder, and Hand scores did not show statistical differences between groups at any of the measured time periods. Depending on insurance carrier, directed therapy added $600 to $900 to the cost of care.
Conclusions: The current randomized study failed to show benefit in a 2-week course of hand therapy after carpal tunnel release using a short incision. The cost of supervised therapy for an uncomplicated carpal tunnel release seems unjustified.
.... The hand therapy is described as 6 sessions of 'nerve glide exercises, range of motion and strengthening'. Considering the expense and inconvenience of this regime of hand therapy intervention it seems fairly clear that it cannot be justified in unselected patients. All of these patients were given the same instructions for self care however after surgery. They were instructed preoperatively that there would not be any restrictions to motion of the operated hand and wrist and no splints would be used after surgery. They were also instructed preoperatively in differential tendon gliding exercises and scar massage to be done without direct hand therapy supervision.
This is obviously a topic which warrants further exploration and once I have had a chance to discuss it with the surgeons in my own area I will probably expand this answer into a dedicated page in the surgery section of the website.
Our current instructions for patients having surgery are here - is that better or worse than the advice you received? JB
Thank you - your info is more detailed than I have received, and info on exercises at least gives people the option of doing them if they want. I asked my surgeon whether it should be in a splint afterwards, and he said no. He did advise wiggling the fingers, but I could hardly move my fingers at all until the end of operation day (mine was done by 10 am). Due to the big bandage I couldn't do very much, (couldn't have made a full fist) and mine didn't get changed to a small dressing until five days afterwards, following the bank holiday.
It is now 15 days after surgery, I have had the stitches out (this and the change of dressing done at the GPs) and am supposed to be leaving it uncovered, but the wound does not look properly closed at one end, so I have been very careful with it and covered it when outside. I am hoping this will improve. It does not bleed, so presumably it will mend properly. However this adds more confusion to exactly how much I should be trying to do. At the moment my fingers move O.K. individually, e.g. to type, although the ends are still tender, as they were before, but they are very tight when trying to make a fist.
I presume the best thing is to try to move them a bit more each day, and not to carry any weight for a while (this confirmed by the nurse at my GP) I see the surgeon again in 4 weeks, so I intend to be careful with it until then, and see what he says. Is it usual to do another nerve conduction test at a suitable time after surgery to see whether the nerve has repaired? Since I lost most symptoms, presumably when the nerve went effectively dead, I may not be able to feel any difference, but I am hoping that recovery of the nerve is possible, and the hand regains strength. As mentioned before I am concerned about overuse of the other hand, and the fact that it may not recover at all, whether I have surgery on it or not. I will want to make sure the first hand is fully useable before entertaining the idea of having the second one done, so I would guess that will take a few months.
It is interesting to see how post-operative care varies. At the most minimal end of the spectrum we see surgeons who use absorbable sutures and never see their patients again after the operation unless there are problems. Elsewhere we see varying degrees of post-operative physio, stitch removal, telephone follow-up clinics and, in your case, a review appointment at 4 weeks apparently. No-one that I know of does routine follow-up nerve conduction studies outside the context of a research study. You are normally only sent back for more NCS if there is a problem.
If you had significant numbness (loss of sensation) before surgery it may take a long time to recover and may or may not recover fully. JB
A part of the problem is that there is very little good quality scientific evidence to support any particular regimen of post-surgical care. I have a few papers written by individual surgeons who feel that their particular regime of physiotherapy/rest/exercise or whatever is 'obviously the right thing to do' - but I am aware of no good randomised trials. Our general advice is to try and keep the hand elevated for the first 24-48 hours until the bulky dressing comes off to reduce swelling and then to avoid strenuous hand-grip until the scar has had time to knit together at about 2 weeks or so but to keep the fingers moving to prevent the development of adhesions between the tendons. A little skin care around the scar with oils and such also seems to help sometimes but we tend to reserve more specific physiotherapy approaches for those patients who seem to have a problem - relatively few. I'll come back to the topic later. JB