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.

The Wrist & Repetitive Strain Injuries

The wrist joins the hand to the forearm. It is able to move forward and back, side-to-side, and in circular movements. This variety of motion allows the hand to reach objects and function in a wide range of motion. In addition, a strong and stable wrist is important during grip activities.The wrist is a complex joint where the two long bones of the forearm meet the eight small carpal bones of the wrist. These carpal bones are essentially arranged in two rows of 4 bones. The eight small wrist bones then meet the five long finger bones in the palm of the hand. Most of the muscles that move the wrist, fingers and thumb are located in the forearm. The tendons (the cords that connect muscle to bone) that bend and straighten the wrist and the fingers must cross through the wrist joint on their way from the elbow towards the hand.Many of the repetitive strain injuries associated with computer work occur at the wrist. In fact, according to the National Occupation Research Agenda for Musculoskeletal Disorders, the most frequently reported upper-extremity musculoskeletal disorders affect the hand and wrist region.

Carpal Tunnel Syndrome is the most commonly diagnosed nerve injury in the arm. The nerves are the power cords for the arms, providing strength to the muscles and sensation to areas of skin. Carpal tunnel syndrome is the compression of the median nerve as the wrist as it passes from the neck to the fingers. Carpal Tunnel Syndrome can cause pain at the base of the hand and in the bulky muscles in the palm right below where the thumb meets the palm. Also, people often say they feel as if they have a tight band around their wrists. Numbness in the thumb, index and middle fingers is common. The pain may feel as if it is traveling up the arm and into the shoulder and neck

Pain where the thumb meets the wrist may be caused by a tendinitis of the muscles that pull the thumb back (as if you were hitchhiking). People who type tensely are prone to developing this tendinitis as they hold their thumbs over the keyboard with tension. Pain at the base of the thumb can also be caused by arthritis in the joint where the long palm bone meets one of the tiny wrist bones of the thumb.

Tendinitis of the wrist and finger flexors (the bending/closing muscles) and extensors (the straightning muscles) and benign ganglion cysts also occur fairly frequently at the wrist.

RSI Prevention

  • Maintain a neutral wrist position.
    • The wrist should be flat in relationship to the forearm; it should not be bent forward or back.
    • For each 15 degrees that the wrist is out of alignment, the pressure on the median nerve increases.
    • The middle finger should be in alignment with the forearm, not angled toward the thumb or the small finger.
    • Wrist supports can provide proper positioning during the night.
    • Do not fight against a wrist support. It is better to remove the brace and perform activities carefully than to wear a brace that prevents necessary movement.
    • Softer, neoprene braces without the rigidity provide support but also allow for some movement and may be a better choice is the task requires wrist movement.
    • Using a wrist brace can cause the body to compensate for loss of motion by moving the elbows differently. Monitor for a shift in pain symptoms in other body areas.
  • Ergonomics
    • Using a split keyboard can align the wrists into a more neutral position.
    • Try a negative tilt of the keyboard where the row of keys closest to you is slightly higher than the row farthest away.
    • The keyboard height should allow the wrists to be neutral while the shoulders are relaxed and the elbows are open slightly greater than 90 degrees.
    • Use the upper arm to manipulate the mouse. Do not activate the mouse by using side-to-side movements of the wrist.
    • The mouse should be located by the keyboard. Do not reach forward to activate the mouse positioned on a different level than the keyboard or positioned out of easy reach.
    • Keep the fingers and thumb relaxed on the keyboard. Use only the minimum necessary force to activate the keys. Do not float the fingers stiffly over the keyboard.