Tuesday, 28 April 2020

Corona Resolution #1: Learn stuff

Stallone, Sylvester [Cliffhanger] photo
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,


  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

Tuesday, 21 April 2020

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, PhD1,2, Hamish Anderson3,4, 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,