Following the Black Line

Of the three disciplines in Triathlon, swimming is the one I like the least. I've already mentioned that I was the 4th last person out of the water in my first tri. In my most recent one, I was mid-pack in my age group so not quite as bad! But it's swimming you say, surely your hands are safe in the water? And you'd be mostly right.

The vast majority of upper limb injuries in swimming are to the shoulder. More than 90%. Then the elbow, then the wrist, and then the finger. Usually wrist injuries are due to overuse or poor technique. Finger injuries occur when hands get smacked against the edge of the pool or hyper-extended in that last desperate lunge to the wall. The trick comes in how to manage these, especially in someone who needs to swim regularly.

It all starts, as it always should and especially with overuse injuries, with a detailed history. If a swimmer is compensating for shoulder pain, extra strain can be felt through the wrist. If a swimmer has had a different injury like a fractured distal radius, then her return to the pool can be compromised not necessarily just by a loss of motion, but more likely due to a loss of forearm strength. A lack of strength can then be exacerbated when swimming equipment like hand paddles are utilised, and wrist stability is compromised. Having said that, if you are sensible, the training aids like fins or paddles can actually help offload an injury. There is almost always a way 

to stay in the water.

Consider different strokes. It is obvious, or at least should be once you stop and think about it, that breaststroke utilises different muscles to free style. Just have a look at the body shapes of Olympic swimmers. The demands the strokes place on the wrist will change as shoulder position changes. Feathering of the hand through the water will also alter. Use this to your advantage. If one style is inflammatory, can you integrate another so that swimming fitness is maintained throughout recovery? There will be a way.

If you have been told to wear a splint or brace, can you swim with the splint on without posing a risk to how that injury will heal. Paddles can actually help protect a hand fracture, but need to be got used to. I have seen a couple of mallet finger injuries of late caused by hitting the wall too hard. One patient opted not to swim and COVID-19 closing the pool helped with that. The other was a keen open water swimmer. Stupidity personified given it is winter here and the bay sits at around 14 degrees Celsius. However, I'm not judging, really.

The answer here was working out a solid taping protocol both over and under the splint. We also spent some time discussing skin care as the risk of maceration and subsequent skin breakdown was high. Finally, we practiced donning and doffing the splint in the clinic until it could be done confidently without me saying a word.

Water exercise is important for so many reasons. The act of immersion itself can be healing, offering pressure differentials and sensory stimulation, that can reduce oedema, sensitivity, and pain. If you need to get back in the swim, I'm pretty confident that with the right advice, you can.

Look after those fingers,

Hamish 

Iso's in Iso: Beyond the Ball

If this isn't the best title for a blog piece on grip strengthening this year then I'll give it all up. I actually don't have much more than the title actually. Sorry. I've spent most of the morning thinking about how I help patients regain hand strength. What special tools do I utilise and what is the science behind these unique methods? Sorry again. I've got nothing for you beyond gut although I'm sure there is some science out there. 

When we talk grip strength, much of the conversation is based around differentiating between power grip and precision grip. Both types then get torn up into even more specifics. Power grip has 4 forms apparently. There's cylindrical grasp, ball grasp, hook grip and lateral prehension (thumb adduction). Pinch also has 4 forms, precision, oppositional, key pinch and chuck grip (1,2). So when I get a patient referred for rehab with the suggestion that "maybe a stress ball would help", it's hard not to feel a little superior. 

We can do better than a stress ball because rebuilding a functional hand requires more than 10 repetitions of a ball grasp 3 times a day. In fact, if I'm speaking plainly, I almost never prescribe stress ball squeezes. I find that often this type of grasp neglects to include the long flexors and the ulnar digits. Instead, I'll find strengthening exercises that replicate most what that patient needs to do and then build from there. If that's swinging a hammer, the initial focus may be on cylindrical grip. If that's holding a football, then working on a more open, ball grasp with its emphasis on intrinsic stability. If it's climbing a wall, then hook grips and flat pinch come into play. 

My current favourite is the rice bath. It encourages composite wrist and hand movement, it facilitates all grip and pinch types, and there's a sensory component to it as well which may assist with proprioceptive feedback. The key is variation regardless of what you prefer. Use a ball, but also use a rope, or encourage wringing of a wet towel. Isometric holds of a barbell will build hook grip strength, but hanging from a chin up bar will encourage cylindrical grip. Remember that there is a clear correlation between grip strength and shoulder stability(3). Work in pronation and supination, sitting and standing, shoulder abduction and flexion. 

So, no science, but some sense. Have a look at how your patient grips. Use a rolled up bandage instead of a ball. Use a pillow or a handle. Empty 5 kilos of rice into a bucket. Look at what's not working, at what they need to do, and go from there. "Isos in iso", brilliant. Should have been in advertising! 

Look after those fingers,

Hamish

(1) Duncan S. et al. Biomechanics of the Hand, Hand Clinics 29 (2013) 483-92
(2) Landsmeer J. Power Grip and Precision Handling, Ann Rheum Dis 21 (1962) 164                                                          (3) Horsley I. Do changes in hand grip strength correlate with rotator cuff function? Shoulder Elbow 8-2 (2016) 124-9

Ways around a problem. Getting into Hands.

Greetings from lock down. Over the past couple of weeks I have listened to a number of webinars and participated in two. A quick shout out to the team at HandSpark, Beth and Ngaire for their initiative in creating the hand therapy summit with 9 speakers over 3 days. It has been well worth tuning in to. 

Beth & Ngaire from HandSPARK

I have also been involved with an Introduction to Hands webinar that the Australian Hand Therapy Association did last weekend, and also one on Hand Injuries to the musician and Athlete that I did with Karen Fitt from Melbourne Hand Rehab for the students group at the Australian Physiotherapy Association. Whilst both presentations provoked a range of questions from the participants, a common one was "how do I get into hands?". 

It's a tricky question to give an answer to as there is no consistently direct pathway. We no longer have a post graduate course in Australia due principally to bean counters at the universities, not due to lack of support from potential teachers or students. Several private groups have stepped into the breach, and alongside the education offered by the AHTA, there are now private graduate fellowships and workshops available. Travelling overseas was how I found my way in, but will that be an option for others? Maybe not for a while. What else... 

Lots of great courses here...

In a flash of laziness, I remembered the podcast I did with Jack Williams some months ago now in pre-COVID days. He  had followed up with a summary of our conversation with an emphasis on that very question that I always intended to publish, but never did.

Here then is a guest piece by Jack Williams. Please do have a listen to his podcast especially if you are a young therapist on the cusp of, or just starting your career because he talks a lot about opportunity and how you can shape your direction and path. Thank you Jack...

Hello Sporting Hands readers...

I first came across Hamish's blog in 2017 as a student physiotherapist and thought it was a great learning resource which really helped me whilst I was on a hospital orthopaedic / hand therapy placement. 

Hard to find a photo of Jack

I really enjoyed our chat and I promised Hamish to make a contribution to the blog which has proved very helpful over the years! I thought I would leave the sporting injuries to the experts and write about getting experience in hand therapy as I recently hosted a podcast with Hamish talking about this very subject...

You can listen in to the podcast here...

https://linktr.ee/Healthlinkd

I am fascinated with Hand Therapy for many reasons...

• Did you know Brian Mulligan’s “apple on the head” moment for the development of his mobilisation with movement manual therapy techniques occurred when he was working with a stiff PIPJ?
• Splinting is widely considered the defining factor of a hand therapist - but as Hamish says - splinting skills constitute a very small proportion of the job!
• Hand therapists have a specialised knowledge of physiology, anatomy, neuroscience and orthopaedic knowledge which is unrivalled by other spheres of OT and physio.

Maybe this is why getting a position in hand therapy is so competitive... these skills are not taught at university and private practise educators and mentors are hard pressed for time to impart such knowledge...

Which brings me to the point of this article…

What are some things a student or new graduate OT/PT can do to get a training position in Hand Therapy?

The AHTA runs a number of special interest groups in each state, getting along to as many of these as possible is a fantastic learning opportunity and also good for networking... as a student it is recommended that you find out where your nearest SIG group is and get along!

Approaching a private practise as a student and doing some observation is a good way to get your foot in the door and learning about what is required for a private practise role. If you are volunteering for a period of time - this should not exceed more than a few months and be sure to make yourself a part of the team’s professional development in-services and other learning opportunities.

There are also a lot of overseas training in hand therapy available in the UK. Hamish first started working in NYC as a hand therapist and also notes that many early career and experienced OT / PT's are able to find hand therapy training positions and work in London and other parts of the UK.

The AHTA also runs a number of courses for OT/PT's who are interested in training in hands - they are for people looking for professional development in hand and upper limb MSK and students and new graduates are welcome to attend - even without much experience in hands... getting started early with one of these courses will stand out on your resume - particularly with the new pathways for 'Accredited Hand Therapist' come into play and both private practise and public employers value this certification for leadership positions for hand therapists.

The are many exciting prospects in the future for Hand and it is certain that this area will remain distinct moving into the future... Hamish also talked about what is in store for hand therapy on the podcast as well as 3D printing of splints and places for hand therapists in professional sports... You can listen in here...

@Healthlinkd | Linktree

It was great to visit the Heidelberg Repatriation Hospital and put a face to a familiar blog...

Thanks again for coming on the podcast Hamish!

Jack

Just When I Think I'm Out...

So close. There was always talk about a second wave, but we all thought we'd be right. Well I did. So did, obviously, those who started to flout sensible advice like washing hands and social distancing. The result is that the city I live in has gone back into lockdown. I can't escape to the beach for a surf this time either. It's a hardcore lockdown. Not that the idiots running around the park this morning in packs of 4 to 8 seemed to think anything of it. I didn't say anything; just crawled into my little car and screamed at the world. 

Raynauds, keep it simple.

It's hard to build back into the mindset I had for the initial lockdown. I was pretty productive then. Updated website, updated protocols, video consults, research paper, a bit of learning. Even made a street library and stocked it with old books. The patients that did come through got extra attention and great results. Numbers started to climb and so did my confidence in myself and my clinics. Then everything stopped again. Just, like, that.

A full session yesterday was cut by 75%. I was so cranky. Then Carol bought me a croissant. Then Antonio walked past the clinic with wave and a ridiculously big grin on his face. He does that every day at 9:15am. He said his hands were cold. I couldn't understand much else given the mask and his Italian English, but the fact that his fingers were white meant he was probably a bit uncomfortable. I grabbed a pair of arthritis gloves, put them on him and sent him on his way back down the road with his wheely walker and his smile. 

And then I had a young patient who had never had any help following a traumatic elbow fracture dislocation whilst playing footy ten months ago. He'd regained full movement, but it was a bit clumsy, his strength was off and his sensation was messed up. All he wanted to do was to play footy again, and get ready for the cricket season. Given the fact that he was pretty much an open book, the question was where to start. 

Thank you Alison #walkadifferentdirection

We did a lot of talking. He asked a lot of questions, I offered reassurance and something different for me, Kinesiotape. Now, I'm not going to say that Alison Taylor is a genius, even if she wanted me to and even though it may be true. I missed her presentation at the Asian Pacific Hand conference due to COVID so have been looking at and trying to work out some of her treatment methods online. I must admit, much of it I don't yet understand. I do understand and appreciate her primary message though. That message is that she gives us all as clinicians, the power to say "I'm going to have a crack at that", even if we haven't tried it before and even if it's not at the top of our usual toolbox of techniques. So I taped.

Ulnar to radial dorsal glide just distal to Guyon's canal. It worked. Not exactly sure why, but I think I know, and I know I'll work it out. I'll definitely try it again. Thank you Ali, thank you www.handtherapyed.com Tape may not be the answer next time, but something else will be. The sun will come up tomorrow everyone. Keep trying new things, keep smiling and eating croissants, because being cranky helps no one.

Stay safe and look after those fingers,

Hamish

Corona Resolution #1: Learn stuff

One cannot climb in isolation...

My big Corona virus resolution was to formalise my ulnar sided wrist pain rehab progression. As I worked on this, much like a lot of my thinking, the initial concept I had morphed into something much bigger and more unwieldy. So often as hand therapists we talk about the need to assess and treat the whole arm, not just the end of it. There is no good having a wrist that works if the shoulder that is designed to put it into space can't do that. But, there is no point in having a shoulder that works beautifully, if the wrist lacks coordination and stability. The problem with realising this, is that assessment of upper limb issues typically is done by examining each part individually, not as a whole. So are there measures that look at whole arm movement and function, not just bits? 

Nice guns Rafa, shame about your wrists...

Screening tools used in elite sport include the 9+, the United States Tennis Association High Performance Profile, and the Functional Movement Screen. Unfortunately, these are all predominantly lower limb and balance related. The USTA one for example is made of of 10 tests. Three look at the shoulder in isolation. 6 look at the hip and legs, again mostly in isolation, and one assesses the core. There is no reference to anything elbow, wrist or hand related, and no way to even examine them even accidentally, in spite of the fact that injuries to these areas make up 10 to 24% of injuries within the sport(1,2). 

A bit more digging and I discovered some tests with potential. A bloke by the name of Matt Redshaw posted a presentation he had made that discusses assessment with a view to returning to play (thank you Matt)(3). Again, it is a shoulder heavy piece, but I couldn't help wondering if some of the tests could be used to look at whole arm performance. The two with the most promise are very similar in nature.

The single arm seated shot put, and the seated medicine ball throw both measure the ability to push a weighted ball through the air. Distance is measured, the results are compared to norms and, in the case of the shot put, to the non-involved arm with an expectation of 90% symmetry. The test requires an extended wrist and hand that flexes as the arm extends in order to propel the weighted ball. Simple, sort of functional, providing immediate and relevant feedback to the patient and therapist (4). 

Fibonacci in the hand

Its application made sense to me as I wondered why I am seeing so many rock climbers with trigger fingers. Ben Cunningham, a local hand therapist whose wisdom I respect, reasoned that this is probably due to an intrinsic vs extrinsic muscle imbalance, and therefore a dysfunction of the Fibonacci sequence. Also known as the Golden Ratio, this famous sequence occurs frequently in nature and mathematics. It refers to a sequencing of numbers where each number is the sum of the two numbers that preceded it eg 0,1,2,3,5,8 etc.

Whilst the ratio has been disproven with regard to bone length in the hand (5), it still seems relevant when applied to hand movement. Here, it describes how during finger flexion, the motion paths of the digits form an equiangular spiral. Ben's argument is that this predictable & balanced progression of angles, whilst applicable to full grasp, is disrupted during specific climbing holds like the crimp. This then exaggerates the forces, disrupts the relationship between muscle groups, and leads to overload and failure. 

Not true. Just keep doing this. Stay safe & well.

Now Ben is a very wise man, and whilst he possibly has something there, could it also be the result of a more proximal deficiency? Either way, hand and wrist pain in climbers is usually the result of overload causing poor technique, and subsequent biomechanical failure. Establishing a baseline of whole arm power might prove useful even if the assessment itself is not as obviously applicable as a timed hangboard test. My suggestion is that in addition to examining individual parts, we test muscle power and efficiency with whole arm active testing. Dynamic tests like the seated shot put or medicine ball throw might be part of the answer. I'll keep playing around with things, but in the meantime I would love to know what others are using. 

Look after those fingers,

Hamish

1. Targett, S. Periodic medical assessment of athletes. In Brukner & Khan, Clinical Sports Medicine Ch 46. 5th Ed. 2017. McGraw-Hill.
2. Abrams,G. Epidemiology of musculoskeletal injury in the tennis player BrJSpMed 2012
3. Redshaw, M. https://www.manchester.edu/docs/default-source/fort-wayne-docs/neisms/2017docs/matt-redshaw.pdf?sfvrsn=2
4. Riemann, B.L., A bilateral comparison of the underlying mechanics contributing to the seated single-arm shot-put functional performance test. Journal of Athletic Training 2018;53(10):976–98
5. Park, A.E.,The fibonacci sequence: Relationship to the human hand JHand Surgery, 2003  https://doi.org/10.1053/jhsu.2003.50000

Telehealth; the New Normal?

Lauren Miller, amazing what a deadline can do!

Telehealth can be awesome but has inherent limitations. Like so much of what I do, it requires practice and it also requires a buy in from both therapist and patient. I spent a bit of time helping Lauren Miller out with a review paper on telehealth and hand therapy she punched out for the AHTA. I've pasted the introduction below. The paper demonstrated that there is established proof that telehealth can be a viable and effective treatment modality. I would agree with this, albeit we need to recognise that it does have limitations. I'll let you read Lozza's work first, then I'll add my 5 cents. 

Evidence of clinical effectiveness of telehealth consultations by Hand Therapists: for the consideration of Private Healthcare Australia, Lauren Miller, PhD^1,2, Hamish Anderson^3,4, Andrea Bialocerkowski, PhD ^5,6

Hand Therapy and Coronavirus (COVID-19)

Hand Therapy is the science and art of rehabilitation of the upper limb from the shoulder to the hand. It involves the assessment, using standardised tests, of the injured limb from which a specific treatment program is designed (Australian Hand Therapy Association, 2020). A variety of specialised treatment techniques are used to achieve client goals. Hand Therapy is practiced by occupational therapists and physiotherapists, and traditionally occurs in the face-to-face delivery mode.

However, in the wake of the coronavirus (COVID-19) pandemic, measures aimed at controlling the spread of the virus within our community have been introduced. These include social distancing of at least 1.5 metres between individuals, advice for people to stay at home (particularly those aged over 70, or over 65 with pre-existing conditions, or Indigenous people aged over 50 with pre-existing conditions) and self-isolation for those who have recently returned from overseas, tested positive, or been in contact with someone who has (Australian Government, 2020).

These important measures present significant challenges to the traditional face-to-face model of care. Telehealth consultation provides an alternative and in many cases adjunct option that enables continued access to Hand Therapy services and prevents unnecessary delays in receiving care while minimising risk of coronavirus (COVID-19) disease transmission. Telehealth consultation may become even more crucial in the event of more restrictive lockdowns, such as those being enforced in other countries.

Fortunately, the Australian Hand Therapy community is well placed to introduce safe and effective telehealth consultations. The use of telehealth has been repeatedly shown to be efficient, cost-effective, and able to deliver the results that Australian Hand Therapy consumers demand, and deserve. It is the strident view of the Australian Hand Therapy Association that to enable privately insured patients to access appropriate and effective health care during the restrictions of this pandemic, hand therapists need to be able to bill private health insurers for teleconsultations.

Ordinary meme, but pickings were slim

The issues I have faced are mostly addressed in the article. They include poor display quality that means I can't tell if a wound is infected or just angry, reluctance on behalf of patients to actually pay for my time, and the inability to repair a splint over the internet. The evidence does exist to justify telehealth as a modality. My immediate problems are twofold. 


Number one is that with no one playing sport or doing risky things, with no elective surgery, and with no one visiting a GP for anything other than a fearful sniffle, I don't have patients knocking on my door at the moment. I do want to utilise telehealth but I don't currently have a patient population to use it on. Bigger practices, those associated with trauma surgeons, and those who pre-pandemic had established exercise classes may be different. Good luck to you all. Also what can't be effectively addressed is a perceived inability on my part to translate what the patient needs to do without being able to physically put my hands on them. I'll learn that if I get the chance to persist, perhaps in the  post COVID-19 world. Ultimately, the valuable lesson for us all is that it is an option, and is likely one that should be be added to most therapy tool kits from here on. So well done Lozza, and thank you.

Look after those fingers,

H

Madness in the Time of Corona

Hates a microphone!

Six weeks ago, I wrote about how things change. I was diving back into private practice after 3 years of mostly working at a public hospital. The Corona virus was on the radar then, but it didn't appear to be influencing anybodies plans unless they lived in Wuhan, and it certainly wasn't shaping mine. For me it was full steam ahead. Loving being back at the Hawthorn footy club, and relishing the challenges associated with working with the Carlton AFLW team. I was also at the pointy end of having been the co-convenor for the, wait for it, triennial combined meeting of the Asia Pacific Society for Surgery of the Hand, and the Asia Pacific Federation of Hand Therapists here in Melbourne. 

Do they miss me as much as I miss them?

We were expecting well over a thousand registrants for this conference. As we got closer to the event date of March the 10th, those numbers started dropping. First the Chinese delegation pulled out, then Singapore, Korea, and much of Japan. When the Grand Prix wasn't cancelled, we took this as a green light to continue. At the same time, we spent a lot of time arranging video presentations, and the schedule took a massive hit. 

The conference went extremely well. Minimal contact, but not nearly to the extent we have now. A challenging program amidst a backdrop of impending doom. The call to cancel the final day was made at three o'clock on Friday the 13th. Apt perhaps. There was disappointment, but no complaints that I was aware of, and I can only thank the delegates for that. The gala dinner went ahead, and as Alison Taylor said, it was kind of like the last party on the Titanic. It was certainly the last party I'll be at for a while. 

Ripping tune

I've now lost my contract at the footy clubs and my practice has shrunk to half of what it was. I still have people coming through the door, but I'm restricting that as much as possible to post-operative cases. I've read comments about how we should shut our doors completely or just offer tele-health, and I can appreciate where they are coming from. However closing the door on a person just after surgery and having them rely on surgical advice to "just start moving when you feel like it" is likely condemning them to a crap result. Tele-health is great for some and I've used it to reinforce & adjust programs, but it can't work for everyone. So I'm still open. 

But it's weird isn't it? It's surreal. Streets are empty. Toilet paper has made a return, but you can't buy more then two tins of vegetables even if you mix the types, and there's nothing in bulk. Spotify is chockers with Corona Isolation playlists. The memes that are flying around are mostly hilarious, although I get the impression that the edge to them is getting darker and nastier.

For a positive sporting fix

When I'm not working on the business I'm watching anything on Netflix I can that's sport related. Just finished "The English Game". Acting was ordinary, but the story was fascinating. There's a series of ESPN documentaries called "30 on 30" that I'd love to work through, and I've found several podcasts one of which, "The Howie Games" is a surprising stand out. I'll do some exercise, go for a run, hit the lonely speed ball, and have a kick with my son. I'm also working on a passable version of "I Useta Love Her" by the Saw Doctors. Classic happy space song. It could be worse, and so it's not me I'm worried about. 

Here's where a blog that is determinedly light-hearted and irreverent becomes sombre. I worry for those who don't have my resources. I worry for Mum and Dad. I worry for the mental health of so many. I worry for the long term implications of this virus: socially, financially, and physically. I worry for my friends working on the front-line in public health both here and overseas. I don't worry for the dickheads who think they are above it all and can do whatever they want. Karma will get them.

So stay safe, look after your fingers, and I'll see you on the other side of this madness. 

H