for data collection/scoring, andinstruction for calibration of instru-ments. Data were collected both pre-and post-treatment, and some testedagain on three month follow-up.Tools used included the hand symp-tom diagram, symptom severity andfunction scales, satisfaction and qual-ity of life surveys, and Short Form-12Health Survey. Detailed instructionwas given for the method of datacollection and interpretation of thedata. Examinationmethods included:Tinel’s sign, Phalen’s test, manualnerve compression, vibration,Semmes Weinstein monofilaments,static two-point discrimination, mod-ified upper limb tension test, gripand pinch, and observation of thenaratrophy. Clinicians were encouragedto communicate via e-mail with theproject mentor. Routine bulk e-mailswere sent to the participants to reportchanges in the project, helpful hints,and to offer moral support during thesix-month project.

Results: The general objective of theproject was to have 20 therapistsattend the two-hour instructionalcourse; 55 attended. The majority oftherapists in attendance had neverdone clinical research. Fewer thanhalf of the attendees reported man-aging people with CTS nonsurgically.After instruction in use of the tem-plate, one-third of the group electedto participate; the remaining two-thirds felt they did not have a referralsource for subjects. However, manyin this last group had no doubt theycould use this template as a guide forfuture research on other topics. Fourof the 16 clinicians who started datacollection completed the project. Theresults of their data collection will beincluded in the results.

Conclusion: The template proved tobe an effective tool for mentoringclinical research and data collectionin this pilot study. Interestingly, twoyears ago this group of certified handtherapists reported that nonsurgicalmanagement of CTS was not often

included in their scope of practice.Within the last year a consensus froma recent American Society for Sur-gery of the Hand/American Associ-ation for Hand Surgery (ASSH/AAHS) symposium on cumulativetrauma supports the idea of anorganized approach to evaluate theoutcomes of nonsurgical manage-ment of CTS.

Management of Raynaud’s Syn-

drome: Our Twenty-year Experi-

ence. Jonathan Isaacs, MD, WyndellH. Merritt, MD, Julianne W. Howell,PT, MS, CHT

Purpose: 1) To review the long-termoutcomes of a large group of patientswho have undergone periarterialsympathectomy of the hand and 2)to describe the role of hand therapyin the evaluation and treatment ofpatients with Raynaud’s syndrome.

Method: We reviewed results onpatients who had undergone periar-terial sympathectomy (PAS) of thehand for recalcitrant ischemic pain,ulceration, and gangrene of digitsfrom 1982 to the present. Data collec-tion consisted of chart and operativereview, and when possible follow-uptelephone interview. Twenty-one (31hands) had from two to 20 years offollow-up, ages at the time of initialprocedure ranged from 21 to 87years. Of these patients, three hadsuffered blunt trauma to the hand,four had mixed connective tissuedisease, one had lupus, four hadCREST (Calcinosis, Raynaud’s phe-nomenon, esophageal involvement,sclerodactyly, and telangiectasia) orscleroderma, and the rest were idio-pathic. Three main criteria—pain,ischemic ulceration, tissue loss (am-putation)—were used to evaluate thesuccess of treatment. We consideredthe initial procedure a success if thepatient improved in one of the threemain criteria. Patient satisfaction andchanges in cold induced or Ray-naud’s attacks were also noted. The

initial procedure was considereda failure if any of the criteria wors-ened or the patient required revisionsurgery or surgical amputation.When the resultwas rated as a failure,a critical review regarding the possi-ble role of the surgical technique,disease progression, or both wasconsidered. Not all Raynaud’s syn-drome patients require surgical in-tervention. A functional assessmentsalgorithm aided our clinical decision-making regarding the choice of med-ical and/or surgical intervention.Evaluation baselines taken by thehand therapist included measure-ment of digital temperatures, coldrecovery, tissue necrosis, sensibility,range of motion, and function. Re-peat measures were used to evaluatethe outcome of medical managementor PAS. To complement medicalmanagement, the therapist discussedmodification of risk factors, methodsto reduce vasospastic episodes suchas behavior and biofeedback techni-ques, and organized patient supportgroups.

Results: Our first four patients hadPAS of only the common volarvessels. To meet one of the threemain criteria, all subsequent caseshad PAS of the entire palmar arch,common volar digital arteries beyondthe bifurcation into the digit, ulnarand radial artery. When necessary,vein grafts for arterial occlusion andprimary amputation to the level ofgangrenous tissue were performed.

Conclusion: Treatment of severedigital ischemia can be a frustratingand unrewarding experience. In our20-year experience we have foundthat a collaborative relationship be-tween hand surgeon and hand ther-apist helps us to best serve ourpatients with Raynaud’s syndrome.Information obtained in this orga-nized approach aided our decision-making regarding medical andsurgical management of this chal-lenging group of patients.

January–March 2004 87