Introduction
cumulative trauma prevention
Exercise for dysphagic patients
desensornation
Rehabilitation after free flap for breast reconstruction
Rehabilitation after breast implantation
 

The hand center accords with the hand surgeon and the hand therapist first for Taiwan, established in 1989 by Dr. Fu-Chan Wei and Ms. Hae-Shya Ma, OTR. Our 7 OTs and 8 PTs have extensive experience in hand and microsurgery.
Because in the eighties, the export processing industry of Taiwan was very vigorous , quite a lot of patients weighed wounded in the hand , so patient of the service is mostly of the hand traumatism the beginning of establishment,
Now, our hand therapists help the more kind of the patient with:

- extremities injuries
- brachial plexus injuries
- burn injuries
- head and neck reconstructions
- breast reconstructions
- congenital deformities
We also provide job accommodation, vocational evaluation, and vocational consultation for the disabled.
We are willing to share the experience with the colleagues and have many fellows from the Taiwan and many international observers from around the world complete their training under our therapist.
The aim of the center is to help the patients get the best functional cosmetic result.

1. Understand the early symptoms of inflammation, and treat as soon as possible.
2. Take a break at work as you can, and take gentle stretch exercises frequently.
3. Take warm-up and gentle stretch exercises before engaging in tasks especially which would reproduce symptoms.
4. Arm close to the body and elbow flex about 100˘X(hand slightly below elbow) is the optimal posture of upper extremity at work. An adjustable footrest should be used when needed.
5. Keep your wrist at neutral position and avoid hyperflexion or hyperextension for a long period of time.
6. Avoid lowering your head over long periods of time. Please place manuscript at eye level when you need to type accordingly.
7. Avoid carrying objects at full forearm pronation (palm downward) or supination (palm upward).
8. Manipulate tools such as spanner, screwdriver by larger muscles and joints as possible.
9. Avoid pulling, twisting or striking suddenly.
10. Use elastic protective brace (ex. wrist support, elbow support) to provide tissue against resistance and prevent hyper-mobility.
11. Use larger joints and more powerful muscles instead of placing excessive force on small joints over long periods of time.

Exercises for head control:
- Head against gravity in a diagonal , rotational pattern
- Utilizes proprioceptive input , ask the patient to hold the head in midline
   
Exercises for facial expression
- Raise the eyebrows
- Wrinkle the nose
- Pucker the mouth
 
Exercises for the lips
- Smile , show the top teeth
- Hold something steadily between the lips
- Alternating movements , kiss and smile , say ˇ§Oˇ¨and ˇ§Eˇ¨
- Blow through a straw at ping pong balls
- Blow out matches
- Blow whistle
   
Exercises to increasing sucking
- Use a straw to suck , grading for Straw length , Liquid thickness , resistance
   
Exercises for cheek control
- Ask the patient himself to massage or push the cheek from the outside
- Suck in the cheeks , blow them out, move an objects from one cheek to the other
- Apply resistance exercise for obicularis oris
   
Exercises for jaw control
- Mandible depression
- Mandible elevation
- Mandible lateral deviationˇ]both sidesˇ^
- Mandible protraction
- Mandible retraction
   
Exercises for a hyperactive gag
- Patient desensitizing himself, using fingers or tongue blades walk back on the tongue slowly with firm pressure
   

Exercises for a hypoactive gag

- Use tongue blade to quickly tap or stretch the arch of the soft palate in an upward and outward direction
- Facilitate soft palate elevation by having the patient say a sustained ˇ§ahˇ¨ sound
- Good positioning and cough are far more important than gag
   
Exercises for tongue control
-

Protrude , retract and lateralize the tongue with or without resistance

- Lick the palate as far back as possible
- Move the tongue into the cheek as far back as possible
- Lick lips , upper to lower , in a circle , in both directions
- Lick around the inside and outside of the teeth , from back to front and back to the other side
- To encourage humping , use a tongue blade to press down on the back of the tongue , and ask the patient to push it up against the palate
- Gently rub a tongue blade on its side along the midline of the tongue to increase grooving
   
Exercises for the soft palate
- Stroke the palate
- Stroke the palate
- Manually close off the nose and ask the patient to blow
   
Reference
1. Jeri A.Logemann. Evaluation and treatment of swallowing disorders. PRO-ED, 1998
2. Nadine Oˇ¦sullivan , OTR. Rehab style Dysphagia care Team approach with acute and long term patients , 2nd-ED, 1995

- Desensitization techniques are used to diminish symptoms of hypersensitivity and are designed to gradually increase the patientˇ¦s tolerance to be touched. The protocols include:
 
1. cotton
2. paper tissues
3. lambswool
4. felt
5. terrycloth towel
6. gauze
7. velcro loops
8. Velcro hook
9. sandpaper
   
- Immerse the affected hand into containers filled with particles ranging from the least irritating to the most:
 
1. cotton
2. sand
3. beans
4. Styrofoam pieces
5. popcorn
6. rice
7. macaroni
- Massage and tapping are the other methods.
- Functional use is the most important.
The 2nd day to 2 weeksˇG
- ExercisesˇG
  Initially 2 weeks after surgery, the shoulder joint should be immobilized to avoid stretching the anatomized vessels. You can massage over the neck or shoulder to prevent the muscle soreness or spasm. Deep breathing exercise is another kind of relaxing technique. Ipsilateral upper extremity exercise and ankle pumping are performed 10 times every one to two hours.
   
- ScarˇG
  Start to tape the donor wound to desensitize, and to put on a brassiere or a tunic while leaving out of the bed.
 
- Activities of daily living
  About 5 days after surgery, the patient should be bedridden. During these days, it is very important to compress abdomen while coughing and sneezing to prevent the donor wound rupture. Put on a brassiere without wires in the first month after surgery
 
2nd day to 2 weeksˇG
- ExercisesˇG
  Start to elevate the arm freely, gently and painless. Almost all patients could reach the normal range in one month.
   
- ScarˇG
  Start to tape and massage the wound, which can desensitize and soften the scar. It is recommended not to scrub on the scar, but gently compress it for 5 minutes every one to two hours.
 
- Activities of daily living
  At this period, most patients can get home and engage in light activities of daily living. It should be kept in mind to take adequate nutrition, spatially vitamin C and protein. It is strongly recommended to keep out of nicotine and caffeine.
 
After one monthˇG
- ExercisesˇG
  The shoulder joint range of motion exercise is performed every one to two hours. Besides, the strengthening and endurance exercises are gradually started.
- ScarˇG
  Scar massage should be performed regularly up to one year at least.
- Activities of daily living
  At this period, most patients can return to the normal activities of daily living. A brassiere with wires is requested. Avoid heavy lifting or carrying.
- Precaution should be taken to against lymphedema. As it develops, look for help from your therapist.
   
Post operation 2 days ~6 weeks:
- ExercisesˇG
  Initially 2 weeks after surgery, the shoulder joint should be immobilized to avoid stretching the anatomized vessels. You can massage over the neck or shoulder to prevent the muscle soreness or spasm. Deep breathing exercise is another kind of relaxing technique. Ipsilateral upper extremity exercise and ankle pumping are performed 10 times every one to two hours.
- ScarˇG
  Start to tape the donor wound to desensitize, and to put on a brassiere or a tunic while leaving out of the bed.
- Activities of daily living
  About 5 days after surgery, the patient should be bedridden. During these days, it is very important to compress abdomen while coughing and sneezing to prevent the donor wound rupture. Put on a brassiere without wires in the first month after surgery
   
2nd day to 2 weeksˇG
- ExercisesˇG
 
1. Avoid elevation over 90˘X frequently
2. Gentle massage over affected shoulder and back
3. Total flexion and extension exercises of hand and elbow are recommended. 10 times ever hour during day time
- Exercises for the implant:ˇG
 
1. While pain and edema are subsiding, push the implant in downward, left and right side for 10 seconds, once ever1 ~2 hours.
2. Post operation 3 ~7 days, use ice pack to reduce pain and edema.
3. Alternately use bandage and bra ˇ]ever 2 hoursˇ^can enhance cosmetics and soften chest wall.
4. Tapping over surgical wound helps to reduce sensitivity of the wound.
   
Post operation 6 weeks ~3 months:
- ExercisesˇG
 
1. Avoid elevation over 90˘X frequently
2. Gentle massage over affected shoulder and back
3. Total flexion and extension exercises of hand and elbow are recommended. 10 times ever hour during day time
- Exercises for shoulder:
  According to clinical performance, therapist will decide the exercises and range of the motion of the shoulder.
- Exercises for the implant: Keep exercises of the implant