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.