Hand Therapy & the “No Pain, No Gain” Fallacy

Even after many years of practicing as an occupational therapist specializing in hand and upper extremity rehabilitation, I’m continually surprised when our clients arrive at their initial visit assuming that therapists will cause them pain.  Before I even sit down with them for the first time, clients may already in a state of emotional distress that interferes with the therapeutic process: overly medicated with either prescription or non-prescription drugs or alcohol; overly angry or anxious or tearful; or with an entourage of friends and relatives and significant others surrounding them for support and protection.

Each time this happens, I tell myself that I shouldn’t be too shocked as our culture does tend to support the philosophies of “No Pain, No Gain” and “More is Always Better”.   And our clients’ reports of previous encounters with healthcare personnel demonstrate that these philosophies are alive and thriving in our medical community.  One common complaint I hear is of experiences with heavy-handed therapists resulting in physical bruising and actual nausea-inducing pain.  Several clients have shared discussions they have had with a physician who instructs them to wear splints that stretch a stiff joint “to the point that it brings you to tears”.   And recently, I’ve heard reports of a physician assistant who tells patients with repetitive strain injuries that they should have more pain following an exercise session or they are not performing the exercises correctly. 

To be fair, some joints do require a more forceful approach as do more established joint contractures.  Patients undergoing therapy for knee and shoulder injuries will often joke of seeing their physical or occupational “terrorist”.  But these joints often tolerate the trauma and the swelling caused by an aggressive approach much better than the hand does.  The hand has so many structures that are so perfectly aligned that any increase in trauma or swelling seems to impact the perfect balance of function.

I won’t lie and say that hand therapy is or should be completely pain-free.  As much as we don’t like pain, it does serve a purpose: pain serves as a warning system that something is wrong; pain helps us know how far to push our limits; pain encourages us to rest an injured body part for healing purposes.  As therapists, we are often dealing with recent injuries, wounds, swelling, trauma.  We often see people within the first few weeks of an injury.  Occasionally we will see people the day after a surgery.  In our quest to establish the best possible outcome for recovery, we may have clients performing activities or exercises in a controlled way that may intuitively seem wrong (yet we know will not compromise healing).  So it is normal that we do treat people who are in pain.  However, our goal with therapy should be to minimize and control pain while promoting healing.

If my expectation and purpose with therapy is to ignore or to actually promote pain, I will likely find that my treatment backfires.  If I’m “cranking” on a swollen and recently injured joint, I’m going to potentially create more stress to the injury, create more swelling, generate more scar formation, possibly promote a pain-syndrome that goes beyond the bounds of a normal pain response for that particular injury.  If a tendon is inflamed from overwork or a nerve is compressed and I have someone exercise to the point of pain, I’ve done nothing but further the damage by increasing stress on tissues that were already breaking down.

In my opinion, a program of gentle persistence will always trump aggression.  And we have good results following this philosophy.  For example, take a stiff joint to the end of the range of motion and then nudge into the tightness; perform that motion for 2-3 minutes every hour and you will create tissue change without creating an increase in physical stress to the injured structures.  When wearing a splint to stretch a tight joint, going for a lighter tension for a longer period of time will yield results more effectively than than a short, painful stretch.  And when dealing with inflamed tissues, performing gentle stretches and nerve glides for the irritated tissues while promoting muscular balance by exercising the opposing muscle groups and strengthening postural muscles will promote healing.

In spite of common belief, hand therapy does not necessarily need to be painful.  Hand therapists should not be feared.  We can achieve good results in the clinic with persistence rather than aggressiveness.  The relief people feel is palpable when they realize that we are here to listen, collaborate, sympathize, share and educate rather than to “crank” on them.

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Happy New Year! (In Spite of PQRS)

Happy New Year to all of our social media friends!  I took the holiday time to clean and organize the clinic.  It always feels good to go into the new year feeling prepared.  I wish all of our Facebook and Twitter followers a year of health, adventure, learning, and good memories.

One issue I dealt with over the weekend was the pending PQRS (Physican Quality Reporting System) changes required by Medicare as of January 1, 2015.  In March, we switched from paper charts to an electronic medical record system.  I am so glad that we did.  I can not imagine how a paper chart could ever fulfill Medicare’s document requirements at this time.   (Thank you, WebPT, for guiding us through this and making the charting manageable!)

In an attempt to improve quality of care, Medicare is now requiring that all of our patient encounters address nine aspects of care (the PQRS measures that pertain to occupational therapy).  This is a huge change from the three that were required last year.  While I certainly agree that quality of care can be enhanced by addressing such medical issues as obesity, alcohol abuse, nicotine use, depression, risk of falls and elder abuse, I do question whether an outpatient occupational therapy clinic focused on upper extremity rehabilitation is the correct place to bring up some of these issues.

Our hand therapy clinic is not the first line of defense in medical care.  By the time our patients reach us, they have had possible encounters with ER or urgent care personnel, their primary care physicians, rheumatologists, upper extremity or orthopedic specialists, imaging and radiology personnel.  Our patients are already overwhelmed with all of the paperwork that is required at each of these facilities (intake forms, health history, notice of privacy practices, notices of patient’s right and responsibilities, functional assessment forms).  And now we are being told that we, as occupational therapists, need to take height and weight for a Body Mass Index, ask about alcohol and tobacco use, ask about history of falls, and administer a depression screen and an elder abuse screen before we can even begin to address the reason that our patient was originally referred to our hand therapy clinic.  I anticipate that these screenings will be a time-consuming and frustrating process for the therapist as well as for the patient who just wants to focus on what they can do to make their upper extremity injury better.

I spent many hours over the weekend reviewing the PQRS measures and developing a checklist that will hopefully meet Medicare requirements while not being overwhelming for either the therapists or the patient.  However, I would love to hear how other clinics are addressing the issues.  Or how clients feel about these changes.  Any tips?  Advice?  Stories of how addressing these issues made a positive change (as I’m trying to keep an open mind)?  Any thoughts on how to best handle the counseling or referral process if any of the measures requires intervention?

It will be interesting to check back in a year, to see the impact of PQRS on our small clinic.  At best, I’m hoping to discover opportunities for growth and expansion.  At worst, we will just survive the additional paperwork.    In the meantime, I’m looking forward to hearing from you.

Best wishes for a happy and healthy year!

Marji

The Use of Compression Gloves for Hand Swelling

Compression gloves are often recommended for a swollen hand or finger.  The blend of nylon and lycra provides a comfortable, gentle squeeze that helps reduce swelling.  These gloves are thin and unlined so that they move with the hand and do not get in the way of hand use.  You can often purchase the gloves without tips (3/4 finger length) so that you have sensation and better purchase at the ends of the fingers for easier hand  use.  The seams of these gloves are deliberately placed on the outside of the glove to provide a smooth and even fit, to increase comfort, and to prevent pressure areas and friction.  The gloves also provide a low-level warmth that can be comforting to painful and stiff finger joints.

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Preventing Frostbite in the Hands

The hands can be at risk for frostbite when temperatures drop below 20 degrees Fahrenheit. With the sub-zero temperatures many are experiencing this week across the nation, here are a few tips to help you prevent a cold-related hand injury.
1. Wear appropriate clothing for the weather. Wool or a wool synthetic is warmer than cotton. Mittens are more protective than gloves. Insulate with several thinner layers of clothing rather than only one or two thicker layers. Top with a waterproof outer layer. Carry extra pairs of gloves with you in case the ones you are wearing become wet.
2. Check to be sure that no area of skin is exposed (for example, where the glove and the arm sleeve meet).
3. Check the fingers for signs of frostbite on a regular basis if you need to be out in the weather for any length of time.
4. Avoid use of alcohol or cigarettes. Both increase susceptibility to developing frostbite. Certain medical conditions (for example, neuropathy, diabetes, peripheral vascular disease, Raynaud’s) and medications can also increase risk of developing frostbite. Take extra precautions if you have a condition that puts you at higher risk.
Be aware. Be safe.

Self-Adhering Bandage & It’s Many Uses for Hand Injury Recovery

Self-Adhering Bandage & It’s Many Uses for Hand Injury Recovery

Self-adhering bandages can be a wonderful way to hold dressings in place or to cover an open wound in a hand injury.  Because the bandage sticks to itself and not to the skin, it is an ideal choice for those who are allergic to adhesive or whose skin tears easily.

In addition to the obvious use as wound coverage, self-adhering bandages can also be used to accomplish a variety of goals during the recovery of a hand injury.

The self-adhering bandage can be used to buddy-tape an injured finger to an adjacent finger.  This provides protection for the injured finger.  Buddy-taping can also be used to mobilize an injured finger that is at risk of becoming stiff (of course, only use it in this manner if the injury has healed to the point that motion is allowed).

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When used as a spiral wrap moving around the finger from the tip towards the wrist, a light compression can help reduce swelling in the finger or a finger joint.  Be careful not to put the wrap on too tightly.  Just lightly take up the tension as the wrap is applied.  Remove the wrap if it appears to be compromising the circulation of the finger in any manner (for example, if the finger tip turns cool or purplish or if the wrap causes pain).

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Self-adhering bandage can  be used to create a stretch for stiff fingers.  Wrap the fingers that need to improve motion into a gentle bend.  Keep the bandage on for 20-30 minutes, 3-4 times a day.  Remove immediately, however, if pain increases dramatically.

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Self-adhering wrap can be used to correct for a rotational misalignment by gently spiraling the wrap into the corrected position and strapping the injured finger to the adjacent finger.

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Self-adhereing bandages come in a variety of sizes and colors.  It can be purchased through medical supply companies, pharmacies, and even veterinary supply outlets.

Paraffin Bath – Good for Scars, Joint Pain

We often use heat as a modality in the hand therapy clinic to warm up the hands in preparation for therapy.  A paraffin bath is one of the more intense forms of applying heat.

During the hot wax treatment, the hand is immersed in a “spa” of melted paraffin mixed with mineral oil.  The oil lowers the melting point of the wax (to about 120 degrees) and makes it tolerable for the body part to be immersed.  The hand is dipped 4-5 times with a brief pause in-between dips to let the wax set.  This layering creates a thicker coating of wax.  After the last dip, a plastic bag is placed around the waxed hand; then towels are wrapped over the plastic to hold the heat in for 5-10 minutes.  Because of the oil in the paraffin, it slides off the hand smoothly when the treatment is complete, leaving the hands feeling soft, moisturized and warm.

The Paraffin Bath is useful for several conditions.  

  • The intense heat is good for circulation.  
  • The penetrating heat can ease aching.  
    • It is often used in arthritic conditions with good relief of joint pain.
    • Aching from chronic repetitive injuries may also respond well to the wax treatment. 
  • Stiff joints will feel more flexible after an application of wax.  
    • Good for arthritic stiffness.
    • Also works well with stiffness caused by fractures, dislocations and other trauma.
  • Scars respond well to the heat and the coating of mineral oil, making them softer and more pliable in preparation for scar massage techniques.

Do not use a paraffin bath in the following situations:

  • If there is numbness in the hand.  
  • If you have an open wound.
  • If you have an injury that is acute, hot, swollen, inflamed.

To keep the paraffin bath as clean as possible, wash your hands well and dry them thoroughly before immersing in the wax.  If you have purchased your own machine, you can re-use the wax (however, we do not re-use wax in the clinic).  

Paraffin Baths are easily available, both online and in local stores and pharmacies.  Simple and small home units are priced around $40.  A larger, more durable model can range in price from about $80 to close to $200.  

It is possible to make your own bath at home using an old pot in a double boiler or an old crock pot set on low.  This can take a bit of time each session for the wax to melt.  Once melted, turn off the heat and monitor the temperature until the correct temperature is achieved.  It is important to use a thermometer to make sure that the wax is not too hot in order to avoid burns. The temperature should be 120-125 degrees. 

Recipe:

  • 2-4 blocks of paraffin
  • 1 ounce of mineral oil for each block of paraffin
  • drops of essential or scented oils as desired (optional)

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The Proper Application of a Tennis Elbow Strap

Tennis Elbow Straps, or Counterforce Straps, can be very helpful in reducing the pain of lateral epicondylitis (tennis elbow) or medial epicondylitis (golfer’s elbow).
However, very rarely are people instructed in the proper technique to apply these straps.

The purpose of the counterforce strap is to reduce the tension on the tendinous origin of the muscles that start at the outside of the elbow for tennis elbow or the inside of the elbow for golfer’s elbow. These are the muscles that bend and straighten the wrist and the fingers. The strap helps distribute the tension that the tendon normally receives over a wider area. This allows the tendon to rest and become less inflamed.

To apply the strap for tennis elbow:

  • Rest your hand and forearm flat on the table, palm down.
  • Gently close the fingers.
  • Pull the wrist and fingers back off the table.
  • Do you see the muscle bulge out a bit in the forearm close to the elbow? (You may need to place your other palm over the muscles so you can feel the muscle contract.)
  • This muscle bulge is where the strap should be placed (normally about 2 finger widths from the elbow crease).
  • If the strap has a cushion or pillow, that cushion should be placed right over the muscle bulge.
  • Tighten the strap with just enough tension to feel the strap while the muscle is contracted.
  • When the muscle is not contracted, you should not feel any tension from the strap.

To apply the strap for golfer’s elbow:

  • Rest your hand and forearm flat on the table, palm up.
  • Gently close the fingers.
  • Pull the wrist forward off the table
  • Do you see the muscle bulge out a bit in the forearm close to the elbow? (You may need to place your other palm over the muscles so you can feel the muscle contract.)
  • This muscle bulge is where the strap should be placed (normally about 2 finger widths from the elbow crease).
  • If the strap has a cushion or pillow, that cushion should be placed right over the muscle bulge.
  • Tighten the strap with just enough tension to feel the strap while the muscle is contracted.
  • When the muscle is not contracted, you should not feel any tension from the strap.

Dos & Don’ts:

  • Do wear the strap only during activity.
  • Don’t wear the strap at night while sleeping.
  • Wearing the strap all the time places undue stress on tissues that are not used to the stress and can create new problems.
  • Do not wear the strap if you have numbness or tingling.
  • Do not wear the strap if you have nerve compressions such as carpal tunnel, cubital tunnel, or radial tunnel syndrome.  The tension can make these conditions worse.
  • If the strap seems to increase your pain level, do not wear it.