Hand therapy in nerve transfer rehabilitation

Lorna Kahn, BSPT, CHT, is a renowned hand therapist and subject matter expert in nerve transfer rehabilitation

by Michele Berhorst • April 5, 2024

Kahn performs shoulder stabilization exercises on a patient with an accessory nerve injury.

Lorna Kahn, BSPT, CHT, is a renowned hand therapist and subject matter expert in nerve transfer rehabilitation. She is the co-author of research papers and book chapters and presents at national and international conferences. Kahn is a frequent guest lecturer and panelist at hand society meetings and medical universities. Her nearly 40-year career is built on her professional relationships with prestigious plastic surgeons who consider Kahn a vital part of their patients’ recovery.

Certified hand therapist

Kahn was born in Brooklyn, N.Y., one of five children, to Ingrid and Edgar Canavan. Her mother was a nurse before becoming one of the first physician assistants in the state. Kahn and her sister, Lydia, shared their mother’s interest in the health professions. Lydia went to medical school, while Kahn was interested in physical therapy (PT). “In my senior year of high school, I spent a semester shadowing a physical therapist at Rusk Institute in New York. Then, I started looking at colleges based on which ones offered the best PT programs in the country – I chose Washington University,” Kahn recalls.

At that time, a five-year bachelor’s was the entry-level degree for PT, and there was only one lecture in the curriculum on hand therapy. It wasn’t something Kahn thought she’d be interested in. Following graduation in 1984, she moved to Oregon for three years, got married, then moved back to St. Louis where her husband, Randy, had what was supposed to be a two-year appointment. “I wanted to be back at WashU, and there was an opening at the Orthopedic Center for Upper Extremity Rehabilitation (OCUER),” Kahn explains. “OCUER provided hand therapy for the orthopedic surgeons, and Milliken Hand Rehabilitation Center provided it for the plastic surgeons. I was in the clinic with Dr. Paul Manske, who was the head of orthopedic surgery, Dr. Robert Strecker and other surgeons. We used one of their treatment rooms as our satellite clinic so that patients who just came out of a cast or had a large wound didn’t have to leave the physician’s clinic without proper splinting. We also took carts to see inpatients in their rooms.” Kahn eventually became board-certified as a hand therapist within two years of the establishment of the national certification process.

Eventually, OCUER merged into Milliken, so there was one hand center serving both orthopedic and plastic hand surgeons and their patients. After the birth of their first child, Kahn worked part-time at several hand clinics, including Milliken, for the next 10 years. From 2000-06, she stepped away from hand therapy to support her husband’s new business and raise their three children until she felt it was time to return. “I was a little hesitant to come back, but I fell right back into it,” Kahn says. “Soon after that, I met Dr. Mackinnon, and that changed everything.”

Physician-therapist relationships

Susan Mackinnon, MD, the Minot Packer Fryer Chair of Plastic Surgery, is described as a “groundbreaking scientist and nerve surgeon” who is widely recognized as an international authority on peripheral nerves with a focus on nerve transfer surgery. “When I returned to Milliken, she had had a rift with one of the former therapists and wasn’t referring to our clinic even though we were right next door,” Kahn remembers. “I’d been back for a week or two, and the manager told me, ‘I want you to take this walk-in from Dr. Mackinnon.’ I was unfamiliar with nerve transfers, and the patient had to catch a bus back to Indiana. So, I taught him some exercises, but I felt terrible that I didn’t know anything about nerve transfers. I started asking questions, and Dr. Mackinnon appreciated my inquisitiveness. The more my interest grew, the more patients she’d send me. Then, one day, she asked, ‘What would it take for me to have you in my clinic?’”

Thus began Kahn’s 18-year (and counting) relationship with Mackinnon. “She is an incredible mentor. She challenged me, and that’s what I needed at that point in my career to grow,” Kahn says. “I became her rehab liaison and started creating the postoperative protocols for her surgeries. She has a great appreciation for the therapist's perspective, which is different from a medical perspective. I am also there to provide input with evaluations (because I ask different questions) and develop and coordinate postoperative care. It’s a wonderful collaborative experience.” In 2016, Dr. Mackinnon invited Kahn to write a chapter in the Hand Clinics edition she co-edited with Dr. Amy Moore on the subject of nerve transfers. The publication of this chapter helped therapists around the world better understand how to manage and improve functional outcomes for individuals with muscle paralysis who have undergone nerve transfers, and it gained Kahn some notoriety.

Mackinnon’s associates, fellows and residents observed this multidisciplinary collaboration and saw how beneficial it was to a patient’s recovery. Kahn naturally developed relationships with the doctors who came through the clinic over the years, whom she now sees at meetings and conferences. Some even invite her to speak or present at their institutions on nerve transfer rehabilitation.

Through Dr. Mackinnon, Kahn began working with Ida Fox, MD, professor of surgery in the Division of Plastic and Reconstructive Surgery. Fox also performs nerve transfer surgery but also specializes in nerve transfers in spinal cord injury patients to help them regain some volitional movement in their hands. Kahn worked closely with Fox for 15 years to develop a therapy program to optimize patient outcomes following surgery. They published a paper in May 2022 in Springer Nature’s Spinal Cord Cases and Series to give therapists a framework for motor reeducation after nerve transfers.

Kahn expanded her peripheral nerve practice into a third population through Alison Snyder-Warwick, MD, associate professor of surgery in the Division of Plastic and Reconstructive Surgery. “She was a former resident of Dr. Mackinnon who returned to WashU to start a facial nerve practice. She wanted me to see her patients, but, at the time, I didn’t know anything about facial paralysis. In 2013, she invited me to attend an international facial paralysis conference with her,” Kahn says. “Aside from palsies and facial nerve injuries, she sees children with Moebius syndrome. Sadly, they are born without facial nerve function and are unable to make facial expressions. By grafting a leg muscle to the cheek and transferring a working nerve to it, the child can potentially smile for the first time in their life.”

Subject matter expert

Because of her expertise in nerve transfers, Kahn has taken on another role as an educator in multiple capacities. For years, she was a lab assistant in the Program in Physical Therapy at WashU for their hand and upper extremity units and guest lectured on nerve transfers to the third-year students. She is a guest lecturer, presenter and/or panelist for the American Society of Hand Therapists and the American Association for Hand Surgery. Kahn has taught and developed courses for the Hand Therapy Certification Commission. In 2023, she traveled to Italy to present at the Federation of European Societies for Surgery of the Hand. She delivered a Grand Rounds presentation on nerve transfer rehabilitation to Yale University’s Department of Plastic and Reconstructive Surgery last March and spent a day lecturing to the hand therapists there.

Kahn is the co-author of numerous papers and book chapters. She is the first author on the recent publication, “Key Concepts for Nerve Transfer Rehabilitation After Surgical Reconstruction for Brachial Plexus and Peripheral Nerve Injuries,” in the Journal of Hand Surgery (November 2023).

Currently, she is writing and editing a book with hand therapists at eight other academic nerve centers around the country on the subject of nerve transfer rehabilitation.

Changing lives

When asked what she is most proud of in her career, Kahn doesn’t respond with a speaking engagement, a publication or a physician collaboration. It’s a patient – a nine-year-old girl who regained use of her hand.

“A psychiatrist had referred her to our clinic because she was diagnosed with clenched fist syndrome, a mental illness where a patient refuses to open their hand. A colleague was trying to treat her, but she was in distress and screaming. I asked if I could look at her because her reaction was so extreme,” Kahn shares. “I evaluated her and thought, ‘She has a nerve injury.’ She had had a blood draw in that area, near the median nerve, and the problems started soon after. I asked Dr. Mackinnon to look at it, and she agreed. It took a couple of months to convince her parents and other providers she needed surgery.”

Kahn was worried on the day of the surgery. She thought – What if I’m wrong? What if she didn’t need surgery? What if the psychiatrist was right all along? She went into the clinic nervous the next day and asked Dr. Mackinnon how it went. “She said, ‘Go see her. Go up to her room.’ I did, and she was batting a balloon back and forth with her dad using that hand,” Kahn says. “The nerve had abnormal scarring sitting on it. As soon as the nerve was released, she felt better. By the end of the year, she regained 100% of function and was playing golf. We published a paper so it can inform other doctors that a nerve injury could, in some cases, be the cause of clenched fist syndrome, not a mental illness. It was a life-changing moment I’ll never forget.”