Effect of Adding Shoulder Stabilization Exercises to the Rehabilitation of Postoperative Hand Injuries in Young Adult Patients

Abstract

Background
Hand injuries are common and could have an impact on all upper limb functions. Engaging shoulder muscle training during the rehabilitation protocol postoperatively could have a significant impact on regaining all upper limb function. The purpose of this study was to assess the effect of adding shoulder stabilization exercise to hand rehabilitation postoperatively.

Methods
Forty patients were randomly assigned to 2 equal groups. Group A received a standard physical therapy program plus shoulder exercise protocol and group B received only a standard physical therapy protocol for hand rehabilitation. Outcome measures were pain intensity; grip strength; Arabic modified Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire; and range of motion (ROM). All outcome measures were assessed before and after treatment.

Results
Statistical analysis revealed that both groups, the experimental and control, showed significant improvement in all outcome measures, but experimental group A showed significant improvement than the control group B posttreatment for hand grip strength, ROM, and QuickDASH questioners ( P < .001).

Conclusion
Adding shoulder stabilizer muscle training to the hand rehabilitation protocol postoperatively has a significant impact on hand function outcomes.

Full text

https://doi.org/10.1177/15589447241232017
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Original Manuscript
Introduction
Hand injury is encountered in 20% of all reported injuries in
emergency departments. It is a cause of debility and impair-
ment for the population.1,2 Optimum surgical intervention
within a good time window associated with a proper reha-
bilitation protocol could enable patients to restore their nor-
mal hand function.
Because the maintarget of hand physical therapy after
surgery is to perform and achieve maximum potential func-
tional level, we need a well-constructed rehabilitation pro-
tocol that depends on whole upper limb approach that could
enable the patient to avoid postoperative hand stiffness,
weakness, and deformities.3,4
Hand injuries and its surgery have been associated with
poor upper limb functional outcomes ranging from 20% to
80% and are linked to a series of postoperative complica-
tions.5 Accordingly, performing hand range of motion
(ROM) exercises, hand grip training, and implementing
shoulder stabilizer training act as the most prevalent phys-
iotherapy strategy designed to reduce such complications,
reduce pain, keep joint and soft tissue mobility, minimize
disability, and promote activity.6
Although shoulder muscle stabilizers are related to all
hand functions and affected with hand injury, there were
no studies to the authors’ knowledge that include a clear
1232017HANXXX10.1177/15589447241232017HANDAbdallah et al
research-article2024
1Department of Orthopedic Physical Therapy, Faculty of Physical
Therapy, Horus University, Damietta, Egypt
2Department of Basic Science for Physical Therapy, Faculty of Physical
Therapy, Cairo University, Giza, Egypt
3Department of Physical Therapy, Faculty of Applied Medical Sciences,
University of Tabuk, Saudi Arabia
4Department of Basic Science for Physical Therapy, Faculty of Physical
Therapy, Suez Canal University, Ismailia, Egypt
5Department of Orthopedic Physical Therapy, Faculty of Physical
Therapy, Cairo University, Giza, Egypt
Supplemental material is available in the online version of the article.
Corresponding Author:
Joseph W. Saweres, Department of Basic Science for Physical Therapy,
Faculty of Physical Therapy, Suez Canal University, Ismailia, Egypt.
Email: josephwageeh83@gmail.com
Effect of Adding Shoulder Stabilization
Exercises to the Rehabilitation of
Postoperative Hand Injuries in Young
Adult Patients
Ehab A. Abdallah1, Mohamed T. Eldesoky2,3, Joseph W. Saweres4,
and Mahmoud D. Abdelhaleem5
Abstract
Background: Hand injuries are common and could have an impact on all upper limb functions. Engaging shoulder muscle
training during the rehabilitation protocol postoperatively could have a significant impact on regaining all upper limb
function. The purpose of this study was to assess the effect of adding shoulder stabilization exercise to hand rehabilitation
postoperatively. Methods: Forty patients were randomly assigned to 2 equal groups. Group A received a standard
physical therapy program plus shoulder exercise protocol and group B received only a standard physical therapy protocol
for hand rehabilitation. Outcome measures were pain intensity; grip strength; Arabic modified Disabilities of the Arm,
Shoulder, and Hand (QuickDASH) questionnaire; and range of motion (ROM). All outcome measures were assessed
before and after treatment. Results: Statistical analysis revealed that both groups, the experimental and control, showed
significant improvement in all outcome measures, but experimental group A showed significant improvement than the
control group B posttreatment for hand grip strength, ROM, and QuickDASH questioners (P < .001). Conclusion:
Adding shoulder stabilizer muscle training to the hand rehabilitation protocol postoperatively has a significant impact on
hand function outcomes.
Keywords: hand, injuries, shoulder, exercises, function

2 HAND 00(0)
exercise that targets shoulder stabilizers during hand reha-
bilitation after surgery. Reducing the likelihood of devel-
oping complications, improving recovery, restoring
functional ability, and improving patients’ outcomes are
the primary goals of physical therapy after hand surgery.
For this purpose, the authors performed this study to assess
the effect of adding shoulder stabilization exercise to hand
rehabilitation postoperatively.
Materials and Methods
Participants
Forty patients who had a bone, tendon, or peripheral nerve
injury in the hand or wrist with impaired hand function or
an isolated hand injury were referred by an orthopedic sur-
geon. At least 6 weeks (about 1.5 months) after surgery was
the healing time frame for most of the cases.
Patient ages ranged from 25 to 35 years. All patients with
grip strength data were included. Patients were excluded
from the study if they had bilateral injury, brachial plexus
lesion, shoulder or elbow problems, polytrauma, multiple
injuries that involve multiple organs or systems, rheumato-
logic diseases involving the hand, complex regional pain
syndrome, solely ring and small finger lesions, burned
hands or crush injuries of the hand involving damage to
multiple structures within the hand, loss of tissue, devascu-
larization, and amputation of digits.
Patients provided an informed consent to be able to par-
ticipate in the study and were refrained from using any
topical or nonsteroidal anti-inflammatory drugs during the
study.
Design
Before enrolling at this study, all patients were instructed
about all the procedures and were recommended to sign a
consent form which was taken as approved by Cairo Uni-
versity’s Supreme Council for Postgraduate Studies and
Research and Human Research Ethics Committee.
In addition, this study followed all pertinent national
regulations, institutional policies, and the principles of the
Declaration of Helsinki. After we receive informed consent,
the patients will be randomized into 2 groups. Group A
included 20 patients, and group B included 20 patients. To
ensure group equality, each group had an equal number of
patients from each diagnosis. For example, each group had
the same number of patients from each diagnosis such as
nerve injury, tendon injury, and fracture.
A computer-generated randomization table was used to
implement randomization using the Statistical Package for
Social Sciences (SPSS) program (version 25 for Windows).
Each patient was assigned a unique identification number,
which was used to divide the patients into 2 equal groups.
The number index cards were then sealed in opaque enve-
lopes and a blinded researcher opened the sealed envelopes
and assigned the patients to their groups.
Evaluation
All outcome measures were assessed twice, before and after
6 weeks (about 1.5 months). Hand grip strength, ROM, and
functional performance were assessed before and after
treatment. Patients’ demographic data including age, sex,
weight, height, pain intensity, grip strength, Arabic modi-
fied Disabilities of the Arm, Shoulder, and Hand (Quick-
DASH) questionnaire, and ROM were collected from each
patient. A researcher who was blinded to group assignment
measured pain intensity, grip strength, Arabic modified
QuickDASH questionnaire, and ROM before and after
treatment (6 weeks).
Outcome Measures
Grip strength. Grip strength testing is a maximally resistive
test. To evaluate the grip strength, a dynamometer (Jamar,
Jackson, Michigan) was used.7 The patients were in the sit-
ting position, shoulder in adduction, elbow in flexion, and
wrist in neutral. They were asked to grip the device with full
strength. First, a test measurement was applied to become
familiar with the test, and then, the test was applied 3 times
with an interval of 15 seconds. The mean of 3 evaluations
was used in analyses. Testing is contraindicated before full
healing following a fracture, ligament repair, tendon lacera-
tion, or tendon transfer of the forearm, wrist, or hand, or as
decided by the referring physician.
Range of motion
1. The range of opposition was evaluated by measur-
ing the distance between the pulps of the first and
the fifth fingers.
2. The range of abduction was calculated as the sum of
the distances between the pulps of the fingers except
for the first.
Arabic Modified QuickDASH Questionnaire. The Arabic
modified QuickDASH–9 consisted of the following: (1)
brief instructions that informed the patients about how to
do the questionnaire; (2) the point number (1-6) that are
about the degree of hardness in doing various physical
activities related to the arm, shoulder, or hand problems;
(3) the 2 points (7 and 8) are about the impact of upper
extremity problems in the social activities; (4) point num-
ber 9 as about arm, shoulder, or hand pain; (5) each point
as 5 response scores, ranging from no problem to unable to
perform activity (0-4) Likert scale; and (6) the Arabic

Abdallah et al 3
modified QuickDASH–9 allows for 1 missing response.
The Arabic modified QuickDASH–9 score = ([sum] *
1.1) * 5/2, a missing response is added as the average of
the remaining.8
Interventions
In control group (B), patients had the following therapeutic
exercises:
1. Early passive exercise, within the pain-free range,
for the affected hand that included passively moving
all hand joints for 3 to 5 minutes.
2. Active-assistive exercise, and active ROM exercise
for all hand and finger joints.
3. Strengthening exercises for wrist flexors and exten-
sors with gradual increase of weights using dumb-
bells.
4. Hand grip strengthening exercise with specific tools
with different resistance strength started from light
to heavy. The session lasted 30 minutes, 3 times a
week for 6 weeks.
In the experimental group (A), patients (n = 20) had
physical therapy and the same exercise program with group
(B) plus Cools exercises (for shoulder; Cools exercises are
designed for patients with an imbalance in the scapular
muscles. Selective activation of the weaker muscle parts
with minimal activity in the hyperactive muscles is an
important component in the reduction of the imbalance).9
We have advised the patients in both groups to maintain
performing home exercise program to ensure maximum
achievement (see Supplemental 1).
Cools Shoulder Exercise
1. Side-lying external: Patient side-lying with the
shoulder in the neutral position and the elbow flexed
90°; patient rotation performs external rotation of
the shoulder (with towel between trunk and elbow
to avoid compensatory movements).9
2. Prone shoulder abduction: Patient prone with the
shoulder in the neutral position; patient performs
shoulder abduction to 90° with external rotation in a
horizontal plane.
3. Forward flexion: Patient standing with shoulder in
the neutral position; patient performs maximal for-
ward flexion in a sagittal plane.
4. Forward flexion from side-lying: Patient in the side-
lying position, shoulder in the neutral position;
patient performs forward side-lying position flexion
in a horizontal plane to 135°.
5. Prone extension: patient prone with the shoulders
resting in 90° forward flexion; Patient performs
extension to the neutral position with the shoulder in
the neutral rotational position.
Statistical Analysis
A priori sample size for variance between 2 independent
means was calculated based on visual analog scale data col-
lected in a pilot study conducted on 10 patients, 5 patients
in each group, using G*power (version 3.1.9.2, Franz Faul,
Universitat Kiel, Germany). So the required sample size
was 20 patients in each group with the α level set at 5%,
type II error set at 90%, and effect size set at 0.86.
The IBM SPSS statistics 22 software was used for sta-
tistical analysis. The analysis of data for this study was
performed using descriptive statistics and a 2 × 2 mixed
model analysis of variance (ANOVA) with 2 groups
(experimental vs control) as the between-patients factor
and 2 times for measuring the dependent variables (pre-
treatment and posttreatment) as the within-patients factor.
The P value was set at .05. Before data analysis, Shapiro-
Wilk and Levene tests were used to test the data’s normal-
ity and the equality of variances, respectively. The
differences in demographic characteristics for both groups
were assessed using unpaired t tests.
Results
There were 20 participants in each group, and their demo-
graphic data are presented in Table 1. There was no statisti-
cally significant difference between both groups in
demographic data (age, weight, height, sex, kind of injuries,
and time for therapy after injury/surgery). The Shapiro-
Wilk test and Levene test revealed no violations of the
assumptions of normality and homogeneity of variance for
any of the dependent variables.
Descriptive statistics of hand grip strength, ROM,
and functional performance are presented in Table 2.
All pretreatment dependent variables showed no sig-
nificant difference between the 2 groups (P > .05). All
the participants complete measurements of hand grip
strength, ROM, and functional performance pretreat-
ment and posttreatment.
The 2 × 2 mixed model ANOVA analysis demon-
strated significant improvements in the hand grip strength
for both groups after treatment as the main effect of time
was statistically significant (P < .0001), but the experi-
mental group showed significant improvement than the
control group posttreatment as the main effect of group
was statistically significant (P < .001) and time × group
interaction effect was also significant (P < .0001) as
shown in Table 3.

4 HAND 00(0)
The opposition ROM significantly improved following
treatment in both groups as the main effect of time was
statistically significant (P < .0001). Also, the experimental
group showed significant improvement in the opposition
ROM than the control group at posttreatment as the main
effect of group was statistically significant (P < .0001) and
time × group interaction effect was also significant (P <
.0001) as shown in Table 3.
Furthermore, abduction ROM was significantly
improved following treatment in both groups as the main
effect of time was statistically significant (P < .0001). Also,
the experimental group was superior to the control group at
posttreatment as the main effect of group was statistically
significant (P < .004) and time × group interaction effect
was also significant (P < .0001) as shown in Table 3.
Arabic modified QuickDASH questionnaire showed sig-
nificant improvements in both groups after treatment as the
main effect of time was statistically significant (P < .0001)
and also, the experimental group showed significant
improvement than the control group at posttreatment as the
main effect of group was statistically significant (P < .002)
and time × group interaction effect was also significant (P
< .0001) as shown in Table 3.
Table 1. Demographic Characteristics of the Participants.
Characteristics Experimental group, mean ± SD Control group, mean ± SD P value*
Age, y 35.55 ± 8.66 34.3 ± 10.01 .67
Weight, kg 84.75 ± 8.59 82.4 ± 9.22 .41
Height, cm 175.05 ± 4.82 176.1 ± 6.69 .57
Time for therapy after injury/surgery, d 57.15 ± 8.02 56.6 ± 7.76 .82
Characteristics n (%) n (%) P value*
Sex
Male 14 (70) 12 (60) .74
Female 6 (30) 8 (40)
Kind of injuries
Ligament injuries 8 (40) 7 (35) .92
Nerve injuries 5 (25) 6 (30)
Fracture injuries 7 (35) 7 (35)
*Significant at α < .05.
Table 2. Descriptive Statistics of Hand Grip Strength, ROM, and Functional Performance for Both Groups Pretreatment and
Posttreatment.
Variables Group Pretreatment Posttreatment
Hand grip strength Experimental 36.15 ± 9.35 79.05 ± 10.68
Control 37.2 ± 9.32 59.2 ± 8.7
Opposition ROM Experimental 1.78 ± 0.41 0.73 ± 0.2
Control 1.82 ± 0.32 1.36 ± 0.27
Abduction ROM Experimental 6.53 ± 0.96 8.39 ± 0.46
Control 6.42 ± 0.75 7.13 ± 0.75
Arabic modified QuickDASH questionnaire Experimental 27.7 ± 3.79 14.5 ± 2.35
Control 27.35 ± 3.74 19.9 ± 1.61
Note. ROM = range of motion; DASH = Disabilities of the Arm, Shoulder, and Hand.
Table 3. Results of a 2 × 2 Mixed Model ANOVA.
Source of variance F value P value
Hand grip strength
Between-patients (group) 12.21 <.001*
Within-patients (time) 560.85 <.0001*
Time × Group 58.16 <.0001*
Opposition ROM
Between-patients (group) 14.81 <.0001*
Within-patients (time) 258.23 <.0001*
Time × Group 39.83 <.0001*
Abduction ROM
Between-patients (group) 9.49 <.004*
Within-patients (time) 201.48 <.0001*
Time × Group 40.13 <.0001*
Arabic modified QuickDASH
questionnaire
Between-patients (group) 10.75 <.002*
Within-patients (time) 330.59 <.0001*
Time × Group 25.63 <.0001*
Note. ANOVA = analysis of variance; ROM = range of motion; DASH
= Disabilities of the Arm, Shoulder, and Hand.
*Significant at α < .05.

Abdallah et al 5
Discussion
One of the main goals of hand physical therapy was not
only to improve the strength and mobility of the hand but
also to restore all the functional level of the hand to practice
activities of daily living (ADL) without any limits. With the
injured hand, each lesion shows unique recovery course and
choice of proper treatment protocol is necessary and could
lead to significant results.10-12 On the same vein as hand and
shoulder joints are very connected anatomically and biome-
chanically, any kind of injury to the hand does not remain
limited to the hand function but could potentially affect the
shoulder function and mobility.10-13
According to literature, the hand is the most injured part
of the upper limit and most of these injuries are from work-
machine-use accidents. The average age of the affected
population of these injuries is 34 to 37 years with a higher
rate to occur at the dominant hand.14,15 Statistical analysis
revealed that all outcome measures (hand grip strength,
opposition ROM, and QuickDASH) showed significant
improvement following treatment in both groups as the
main effect of time was statistically significant (P < .0001).
Also, the experimental group showed significant improve-
ment in all outcome measures than the control group at
posttreatment and these results lead to the impact of adding
shoulder exercise training on management of patients after
hand surgery rehabilitation.
Hand function is complex and does not depend on a
complete and intact anatomical structure; thus, preserved
ROM of the joints and the strength of muscles alone might
not reflect the greatest functional ability of the hand.1,2,16 On
the same vein in this study, the authors performed assess-
ment for anatomical structures by ROM measurement and
hand grip strength and, they performed functional assess-
ment for the hand.12-17 The authors examined the hand func-
tion in daily living by using the DASH scale. The DASH is
a questionnaire used to assess upper limb function. Its reli-
ability and validity have been shown in measuring disabil-
ity of the upper limbs.18,19
Adhesions around joint capsules and tendons, joint stiff-
ness, shortening of muscles, and contracture of ligaments
are main causes of limitations in movements after hand
injury and subsequent surgery. Thus, well-constructed
physical therapy protocols after surgery will help patients
avoid all these complications, and implementing shoulder
stabilizer training early could result in achieving a maxi-
mum potential level postoperatively and accelerated the
recovery process and guide patient to restore their prior
functional level in shorter period compared with regular
rehabilitation protocols.20
Assessment of grip strength is indeed used within the
rehabilitation procedure to compare against normative
values, or to compare strength between dominant and
nondominant limbs.21 Alizadehkhaiyat et al reported that
performing hand grip tasks in neutral position activates
good function of shoulder stabilizers as supraspinatus and
infraspinatus, and this reflects how the position of the
task may lead or affect the shoulder stabilizer perfor-
mance and hence enhance the activity of the patient.22
The study by Balogun et al supports the correlation
between hand grip strength and strength of the upper limb
muscle, especially the shoulder muscles.23 Nascimento
et al found a statistically significant and positive relation-
ship between hand grip strength and the strength of the
shoulder stabilizing muscles. The correlation has been
reported as a consequence of the demand of a stable prox-
imal shoulder girdle to enhance optimal recruitment of
the hand grip muscles, and the force transmitted along the
myofascial pathways.24
The results of this study are agreed with those of the
study that was performed by Waheida et al. They aimed at
this study to compare the effect of activation of shoulder
girdle muscle exercises versus hand on wrist joint mechan-
ics of patients after intra-articular distal radius fracture sur-
geries. Waheida and her colleges included 50 patients in
their study and allocated them into 2 equal groups. They
concluded that shoulder muscle training, and elbow and
hand exercise training after intra-articular distal radius frac-
ture surgeries have been shown to improve wrist joint func-
tional abilities, ROM, and muscle strength more than hand
exercises only.25 Also this study’s findings go in parallel
with those of Horsley et al who showed that there was a
strong correlation between grip strength and lateral rotator
strength which was shown at all positions for both left and
right hands, suggesting that assessment of grip strength
could be used as a rotator cuff monitor of recruitment func-
tion.26 As the results of the experimental group in this study
are better than those of the other group, this reflected the
useful effects of adding shoulder stabilizer training in
regaining hand function and achieving optimum functional
level at ADL.
Limitations
This study had some limitation as it was a short-term fol-
low-up study performed postoperatively. Also, there were
different injuries that were included in this study and the
authors implemented 1 suggested protocol for all included
cases.
Conclusion
Adding shoulder stabilizer muscle training to hand rehabili-
tation protocol postoperatively could have significant
impact on hand function outcomes. The results of this study
provide a recommendation to clinicians who deal with post-
operative hand rehabilitation to give attention to shoulder
joint exercises to guide their patients to optimal recovery.

6 HAND 00(0)
Acknowledgments
The authors express their thankfulness to all the study members
for their cooperation.
Authors’ Contributions
All authors conceived and designed the study, conducted the data
collection, and analyzed and interpreted the data in addition to
reviewing the final draft and results. They read and approved the
final manuscript.
Ethical Approval
The ethical review board for the faculty of physical therapy at
Cairo University gave its approval for this study (No.
P.T.REC/012/003767), which is listed as a randomized controlled
trial with this number at the Pan African Clinical Trials Registry
(PACTR202108675488120).
Statement of Human and Animal Rights
The study was conducted in accordance with the Declaration of
Helsinki. In this study, we obtained informed consent from all par-
ticipants and protect their privacy and confidentiality, and respect
their autonomy and diversity. These universal rights are inherent
to us all, regardless of nationality, sex, national or ethnic origin,
color, religion, language, or any other status.
Statement of Informed Consent
All persons gave their informed written consent prior to inclusion
in the study. Details that might disclose the identity of the patients
in the study have been omitted.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Clinical Trial Registration
The identification number for registry at Pan African Clinical Tri-
als is PACTR202211899755437.
ORCID iDs
Ehab A. Abdallah https://orcid.org/0009-0003-3359-1046
Joseph W. Saweres https://orcid.org/0009-0006-1192-1720
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