hand injuries are very common in china . based on the epidemiological studies of hand injuries , approximately 2354% of all emergency department visits were for hand injuries from 1994 to 2005 in china . moreover , the increased hand injuries were also due to low - level consciousness and self - protection . the fingertip skin defect , often accompanied by tendon or bone exposure , is one of the most common hand injuries . when the tendon , bone , or nail bed is exposed , flap reconstruction is necessary to preserve finger function after treatment of fingertip skin defects . the goal of fingertip reconstruction is to preserve functional length and sensitivity , restore joint flexibility , prevent the development of joint stiffness or neuroma , minimize aesthetic deformities , and provide a quick return to work . various treatment options include the random - pattern abdominal flap , fascial pedicle dorsal flap of the finger , advanced skin flap , and cross - finger flap [ 68 ] . numerous studies have reported satisfactory results in the reconstruction of fingertip skin defects with abdominal skin flaps . previous studies focused on skin flap survival and sensory recovery of the flaps and showed that the abdominal skin flap technique was effective for the treatment of fingertip skin defects . flap pedicle division is often performed 3 or more weeks after the first stage of fingertip reconstruction surgery . however , some shoulder diseases , including joint pain and stiffness , muscular soreness , and even joint inflammation , that occur in many patients are often overlooked . , we generally perform several shoulder - conservative management procedures , including massage of the muscles around the joint , active and passive mobilization exercises , physical therapy practice , and pulsed electromagnetic field ( pemf ) . to date , although the effectiveness of rehabilitation in the treatment of shoulder diseases has been proven in many published studies , the outcomes in patient who receive treatment after the first stage of fingertip reconstruction remain unknown . in addition , there is no standardized rehabilitation protocol for those patients . therefore , the aim of this study was to investigate the clinical effectiveness of shoulder management strategies for stage i of fingertip skin defect repair with a random - pattern abdominal skin flap . this study is retrospective , and the first hospital of hebei medical university institutional review board and the third hospital of hebei medical university institutional review board approved this study . a total of 95 patients who underwent fingertip skin reconstruction with a random - pattern abdominal skin flap between march 2007 and february 2013 were enrolled in the study . all patients presented with a traumatic fingertip skin defect accompanied by tendon or bone exposure , as well as a completely or partially missing nail . patients with finger injuries that were managed with a combination of abdominal flaps and other local flaps and those with clinical diseases were excluded from the study . according to the rehabilitation method employed after the first stage , 32 patients underwent active exercise ( group a ) , 29 patients underwent passive exercise ( group b ) , and 34 patients underwent a combination of active exercise and pemf . the mean age at the time of operation was 30.2 years in group a ( range , 1846 years ) , 29.6 years in group b ( range , 1949 years ) , and 31.8 years in group c ( range , 1850 years ) . there were no significant differences in the preoperative demographic data among groups ( table 1 ) . follow - up data were obtained from hospital charts with a minimum of 6 months of follow - up . all patients underwent fingertip skin reconstruction with random - pattern abdominal skin flap , as recommended by kleinman and dustman . the random - pattern abdominal flap was constructed based on the shapes and sizes of the wounds . the skin flap area was 1520% larger than the actual wound area to avoid excessive tension . the flap pedicle division of the second stage was performed 3 weeks later after the first step . before performing the flap pedicle division , all patients underwent rehabilitation according to instructions from the same supervising physiotherapist . after the second - stage surgery was performed , all patients continued with the home exercise program , including the home exercises , and received advice on sleep , posture , and pain relief . the patients began to undergo active exercise 1 day postoperatively and were showed demonstrations of each exercise by a supervising physiotherapist . the exercises included shrugs , lowering the shoulder , moving the joint backwards , forward extension , clockwise rotation , and counter - clockwise rotation . continuous passive exercise was performed by a physiotherapist twice a day for 30 minutes each session , starting on the first postoperative day . the shoulder joint exercise included forward and side elevation of the upper extremities , and internal and external rotation of the shoulder . after baseline evaluations , the outcome measures were assessed at 1 , 3 , and 6 months . the constant   and university of california / los angeles ( ucla )   scales were used to measure joint function . quantitative muscle strength measurements of the rotator cuff were assessed with use of a portable handheld nottingham mecmesin myometer ( mecmesin co. , nottingham , uk ) . elevation strength was tested with the patient in the seated position with the arm flexed to 90 in the scapular plane . external and internal rotation was measured with the shoulder in a neutral position and the elbow in 90 of flexion . range of motion ( rom ) included forward flexion , external rotation , internal rotation , and abduction . patients were also asked to evaluate the clinical outcome as excellent , good , fair , or poor . descriptive statistics for the demographic data and all outcome measures are expressed as averages and sds with a normal curve . an independent t test was used to compare the outcomes between groups a and b and groups a and c. pearson  test was also performed to compare the satisfaction levels . a total of 95 patients who underwent fingertip skin reconstruction with a random - pattern abdominal skin flap between march 2007 and february 2013 were enrolled in the study . all patients presented with a traumatic fingertip skin defect accompanied by tendon or bone exposure , as well as a completely or partially missing nail . patients with finger injuries that were managed with a combination of abdominal flaps and other local flaps and those with clinical diseases were excluded from the study . according to the rehabilitation method employed after the first stage , 32 patients underwent active exercise ( group a ) , 29 patients underwent passive exercise ( group b ) , and 34 patients underwent a combination of active exercise and pemf . the mean age at the time of operation was 30.2 years in group a ( range , 1846 years ) , 29.6 years in group b ( range , 1949 years ) , and 31.8 years in group c ( range , 1850 years ) . there were no significant differences in the preoperative demographic data among groups ( table 1 ) . follow - up data were obtained from hospital charts with a minimum of 6 months of follow - up . all of the operations were performed by the same surgeon . all patients underwent fingertip skin reconstruction with random - pattern abdominal skin flap , as recommended by kleinman and dustman . the random - pattern abdominal flap was constructed based on the shapes and sizes of the wounds . the skin flap area was 1520% larger than the actual wound area to avoid excessive tension . the flap pedicle division of the second stage was performed 3 weeks later after the first step . before performing the flap pedicle division , all patients underwent rehabilitation according to instructions from the same supervising physiotherapist . after the second - stage surgery was performed , all patients continued with the home exercise program , including the home exercises , and received advice on sleep , posture , and pain relief . the patients began to undergo active exercise 1 day postoperatively and were showed demonstrations of each exercise by a supervising physiotherapist . the exercises included shrugs , lowering the shoulder , moving the joint backwards , forward extension , clockwise rotation , and counter - clockwise rotation . the patients began to undergo active exercise 1 day postoperatively and were showed demonstrations of each exercise by a supervising physiotherapist . the exercises included shrugs , lowering the shoulder , moving the joint backwards , forward extension , clockwise rotation , and counter - clockwise rotation . continuous passive exercise was performed by a physiotherapist twice a day for 30 minutes each session , starting on the first postoperative day . the shoulder joint exercise included forward and side elevation of the upper extremities , and internal and external rotation of the shoulder . after baseline evaluations , the outcome measures were assessed at 1 , 3 , and 6 months . the constant   and university of california / los angeles ( ucla )   scales were used to measure joint function . quantitative muscle strength measurements of the rotator cuff were assessed with use of a portable handheld nottingham mecmesin myometer ( mecmesin co. , nottingham , uk ) . elevation strength was tested with the patient in the seated position with the arm flexed to 90 in the scapular plane . external and internal rotation was measured with the shoulder in a neutral position and the elbow in 90 of flexion . range of motion ( rom ) included forward flexion , external rotation , internal rotation , and abduction . patients were also asked to evaluate the clinical outcome as excellent , good , fair , or poor . descriptive statistics for the demographic data and all outcome measures are expressed as averages and sds with a normal curve . an independent t test was used to compare the outcomes between groups a and b and groups a and c. pearson  test was also performed to compare the satisfaction levels . all patients in the 3 groups were followed up at a mean time of 8.0 months . all groups were homogeneous for age , sex , and body mass index ( bmi ) . all of the clinical evaluations at the final follow - up are listed in table 2 . a higher constant score was observed in group c ( p=0.023 ) compared with group a. however , the patients who received passive exercise exhibited the lowest constant score among the 3 groups , and a significant difference was observed between groups a and b ( p=0.001 ) . there was no significant difference in the ucla score between groups a and b or between group a and c. the pain scores on the vas were lowest in group c. however , no difference was found between groups a and c. there was a significant difference in vas between groups a and b ( p=0.047 ) . additionally , although relatively higher rom was achieved in group c , there was no statistically significant difference between groups a and c. however , there was a significant difference between groups a and b in rom in terms of forward flexion ( p=0.049 ) . regarding muscle strength , there were significant differences in forward flexion and external rotation between groups a and b ( p=0.049 and p=0.042 , respectively ) . of the 12 patients who judged the treatment as fair or poor , 5 patients exhibited shoulder stiffness , 5 felt shoulder pain , and 2 experienced muscular atrophy . most of these 12 patients were discontent with the treatment as a result of the ineffective rehabilitation procedure . all of the clinical evaluations at the final follow - up are listed in table 2 . a higher constant score was observed in group c ( p=0.023 ) compared with group a. however , the patients who received passive exercise exhibited the lowest constant score among the 3 groups , and a significant difference was observed between groups a and b ( p=0.001 ) . there was no significant difference in the ucla score between groups a and b or between group a and c. the pain scores on the vas were lowest in group c. however , no difference was found between groups a and c. there was a significant difference in vas between groups a and b ( p=0.047 ) . additionally , although relatively higher rom was achieved in group c , there was no statistically significant difference between groups a and c. however , there was a significant difference between groups a and b in rom in terms of forward flexion ( p=0.049 ) . regarding muscle strength , there were significant differences in forward flexion and external rotation between groups a and b ( p=0.049 and p=0.042 , respectively ) . of the 12 patients who judged the treatment as fair or poor , 5 patients exhibited shoulder stiffness , 5 felt shoulder pain , and 2 experienced muscular atrophy . most of these 12 patients were discontent with the treatment as a result of the ineffective rehabilitation procedure . to the best of our knowledge , this is the first study to compare various shoulder management strategies for stage i of fingertip skin defect repair with a random - pattern abdominal skin flap . in our study , the combination of active exercise and peme provided better clinical outcomes compared to only active or only passive exercise . the major strengths of our study are that a single fully trained surgeon conducted all of the operations using a well - established technique , and the follow - up evaluations were performed by an independent physiotherapist . fingertip injuries are common and are the result of sharp lacerations and crush or avulsed injuries . although often initially cosmetically unappealing to the patient , a good repair or reconstruction can provide a sensitive , durable fingertip with excellent results . different regions of the body have different skin sensations because of the diverse receptors and the varying density of the nerve fibers in these parts . numerous previous studies have evaluated fingertip reconstruction with the random - pattern abdominal skin flap and reported good results . shoulder immobilization results in those patients symptoms beyond the first stage of the surgery . in general , 3 weeks are required to stabilize the flaps and skin grafts before performing the flap pedicle division . although several authors suggested active and passive finger mobilization exercises during stabilization of the flaps however , the findings of this study support and provide substantial evidence for the use of active exercise , and in particular physiotherapy , in the treatment of patients after stage 1 of fingertip reconstruction . pemf is commonly was described as  bioelectromagnetic therapy ,  and is based on the principle of the interaction between non - ionizing electromagnetic fields and biological systems . previous studies [ 2426 ] have suggested therapeutic effects in various pathologic conditions , including pseudoarthrosis , osteoarthritis , and acute and chronic pain from different musculoskeletal conditions , as well as tendon injuries . the results of the study confirmed that patients receiving in a combination of active exercise and peme , supervised by a physiotherapist , had better patient - reported outcomes than patients in the only - active or only - passive exercise groups . the group that received pemf and performed active exercises showed better results regarding forward flexion and external rotation muscle strength in contrast to the only - active or passive exercise groups . a recent trial by freitas et al .   showed that the combination of pemf and shoulder exercises is effective for improving function and muscle strength and decreasing pain . therefore , pemf treatment was effective in increasing shoulder function with good to excellent results . in this study , lower vas was observed in patients who performed only active exercise or those in the combination of active exercise and peme group . however , there was no difference between groups a and c. the findings in the present study suggest that peme had no role in relieving pain some previous studies   showed that that electromagnetic therapy can be a useful tool for relieving pain , but other studies suggested no effects of peme . the effects of pemf in patients with shoulder pain are still controversial . in the absence of scientific evidence regarding the effectiveness of the multimodal rehabilitation programs after stage 1 of fingertip reconstruction , our research sought to provide some useful reference for other studies the number of patients included was small , and the period of follow - up was relatively short . finally , the selection of the rehabilitation procedure was based on the physiotherapist s preference , and some bias may therefore exist in those selections . this is the first study to evaluate the effectiveness of multimodal rehabilitation after the first stage of fingertip reconstruction . the most important findings in our study is that compared to passive exercise , active exercise can provide satisfying results and higher functional scores as part of a combination of active exercise and peme . further well - designed studies with longer - term follow - up and involving a larger group of patients are needed .
backgroundin the absence of scientific evidence regarding the effectiveness of shoulder management strategies after stage i of fingertip reconstruction , the purpose of this study was to compare the clinical outcomes of various rehabilitation procedures.material/methodspatients who underwent fingertip reconstruction with a random - pattern abdominal skin flap between march 2007 and february 2013 were enrolled in the study ( n=95 ) . 
 thirty performed only active exercise ( group a ) , 29 performed only passive exercise ( group b ) , and 32 received a combination of active exercise and pulsed electromagnetic field ( pemf ) ( group c ) . 
 the mean age at the time of treatment was 30.2 years in group a , 29.6 years in group b , and 31.8 years in group c.resultsat the final follow - up , there were significant differences between group a and b in terms of constant score ( p=.001 ) , vas ( p=.047 ) , forward flexion of the shoulder ( p=0.049 ) , and muscle strength with forward flexion and external rotation ( p=0.049 and p=0.042 , respectively ) . 
 a higher constant score was observed in group c compared to group a , and although there were no differences in the other evaluations between groups a and c , a trend toward better function of the shoulder was demonstrated in group c.conclusionsthe most important findings in our study are that a combination of active exercise and peme produces superior patient - reported outcomes regarding relief of shoulder signs and symptoms . given the limitations of this study , better - designed studies with large sample sizes and long - term follow - up 
 are required .