Most nerve expansion studies involve animal models. At 18 months after nerve expansion, no differences in nerve conduction velocity (NCV) and muscle contraction force between nerve grafting and nerve expansion/repair procedures were found, although muscle weight was significantly greater with grafting133; in skin that was expanded 110%, no change in nerve function was noted.134 Expanded/repair nerve compares favorably with traditional nerve repair results.119 Using electron microscope evaluation, although degenerative changes were present beginning at 8% limb lengthening up to 33% of limb lengthening, nerves in an animal model recovered normal

»References 4, 5, 63, 70, 73, 79, 106, 109, 115. References 4, 5, 78, 79, 106, 115.

structure within 2 months postexpansion.69 Another electron microscopic study found that nerves elongated by 88% retained their intraneural cytoskeleton components despite some loss of myelin.47 Expanded Wallerian degenerated nerve exhibits increased Schwann cell proliferation and increased vascularity at the expander site.57,100,101


Most vascular volume and/or lengthening procedures involve acute intraoperative expansion. Studies on the affects of intravascular volume expansion with stents indicate that adaptive vessel remodeling occurs after stent placement with endothelial and smooth muscle cell hyperplasia taking place. Expanders have been used intraoperatively to increase arterial length.56 Studies involving influences of tissue expansion on the lymphatic system are rare. Ercocen found that the expander itself reduces lymphatic flow.


Soft tissue expansion devices may be two-dimensional or three-dimensional depending on the direction(s) of applied force. Surgery is required to insert nonin-flatable or inflatable force-transducing devices or to incorporate bone pins/screws as links to distraction frames.72 Producing more dermal thickening than three-dimensional expanders,1 two-dimensional expanders operate in one plane by pulling wound boundaries together.1 This type of expander stimulates biological tissue gain, maintains mechanical creep, prevents stretchback.1,98 Three-dimensional expanders push/compress tissue away from fixed boundaries, stretching tissues in all directions.1 Tissue gain is five times more than that for two-dimensional expanders.1 Tissue deformation, via biologic creep, assumes the configuration of the expansion device.

In contrast, splints apply noninvasive mobilization forces that are unidirectional, or sometimes bidirectional, to in vivo soft tissues surrounding three-dimensional bone and joint structures that comprise a multiarticulated open kinematic chain. Mobilization splinting to remodel soft tissues limited by adhesion, stiffness, or contracture is efficacious because splintgenerated biologic creep or tissue remodeling occurs in the plane(s) of normal joint function. It is important to remember that associated normal and abnormal anatomical structures also apply remodeling forces in addition to those applied by splints. Knowing how to effectively control and harness these multiple forces is a key factor to successful splinting outcomes (Fig. 3-26).


Soft tissue remodeling is inherent to life. As we move from infancy to adulthood our soft tissue structures continuously adapt to keep pace with our lengthening skeletal frames. Through pregnancy, weight changes, skeletal pathology, disease, or injury our soft tissues continue to adapt, sometimes for the better and sometimes for the worse. It is only when life leaves that tissue remodeling ceases.

The remodeling process can be positively influenced to correct deformity caused by disease or injury through the judicious use of externally or internally applied devices that apply prolonged, sustained, controlled, gentle forces. Understanding the biomechani-cal and biochemical processes involved in tissue remodeling allows therapists and surgeons to better treat their patients. Extensive investigation into the causative factors underlying cellular growth is already well underway. We all need to be a part of this exciting and challenging frontier. Knowledge derived from other disciplines provides therapists with an important step up into the future. Splints apply forces externally and expanders apply forces internally. Each is used to affect tissue remodeling. Although an assumption of parallel influences and results is self evident, considerable splinting research is needed to conclusively connect the bridge between splinting and tissue expansion frames of knowledge.

Fig. 3-26 Index-small finger DIP extension and flexion torque transmission splint, type 3 (13)

As described by Brand in the 1950s, joints beyond the physical boundaries of a splint may be remodeled over time by controlling secondary joints and allowing active motion at primary joints. This splint encourages DIP active motion by controlling the secondary wrist, MP, and PIP joints.


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Fig. 3-26 Index-small finger DIP extension and flexion torque transmission splint, type 3 (13)

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Arthritis Joint Pain

Arthritis Joint Pain

Arthritis is a general term which is commonly associated with a number of painful conditions affecting the joints and bones. The term arthritis literally translates to joint inflammation.

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