Hands-on Experience

Subscribe | Advertise | About Us | Contact Us | Home

October 2004

By Deborah A. Rider, OTR/L, CHT

The population is living longer and struggling to maintain independence and quality of life. In a changing world where their needs are often overlooked, older people who encounter hand conditions face a potentially life-altering experience.

Current research strongly supports the belief that a majority of decline in occupational performance is due to disuse.¹ Disuse or inactivity can lead to decrease in work tolerance, endurance, strength, lift capacity, coordination, mental health, cognitive function, and socialization. An aging person cannot risk being inactive for very long. It is important to minimize the effects of a hand condition. The terms "aging hands" and "older population" are used in this article to avoid the term geriatric. The term geriatric is popularly defined by an age of 65 or older. Consideration should be given to the idea that it is not age that places one into the geriatric category, but what is associated with advanced years. It is true that the population is aging. Current demographic trends indicate that an increasing proportion of the population is more than 65 years of age. By the year 2030, the number of people over 65 will reach 70 million in the United States alone. People in the 85-plus group will be the fastest-growing portion of the population.² However, the members of this select group are doing more than growing old. Their roles and activities have changed considerably. Many are employed. Others volunteer, provide care for grandchildren, work out, play golf, garden, or search the Internet. Yes, once largely written off as a lost cause, older people are now coming into their own as Internet users.³

Keep in mind though that the hands that operate the mouse and keyboard are more likely to be stiffened by arthritis, numbed by carpal tunnel syndrome, swollen from lymphedema, or painful from a lifetime of cumulative trauma. Older people face some unique challenges. Physiologically, they experience decreased ability to heal. There is decreased blood flow and decreased cellular activity needed for tissue repair.⁴ Dryness and loss of skin turgor diminish the strength of the wound. There is a higher rate of dehiscence. Nutrition is a key factor in wound healing. Older people are often malnourished. This further compromises the rate of healing. Steroid use for arthritic conditions also delays the healing rate.⁵ With aging comes a change in muscle. Strength is usually stable until age 50. An average of 15% decline per decade is anticipated between ages 50 and 70, and 30% decline from 70 to 80. Eighty year olds have lost 50% motor neurons, motor units, muscle fibers, and muscle strength.^6,7 Muscle atrophy in the hand tends to affect the interosseous and thenar muscles.⁸ Protective fat is absorbed from hands, which makes them more vulnerable to injury.⁹ Nerves are less capable of accommodating movements and forces during activity. This sets up the potential for injury and cumulative trauma.

CARPAL TUNNEL SYNDROME
Carpal tunnel syndrome in this population can often be severe. Compression of the median nerve as it crosses the wrist can lead to pain, numbness in the thumb and index and middle fingers, and the diminished ability to hold onto items. The ability to sleep, perform ADL tasks, or sense danger from heat and sharp objects can be affected. Walking aids such as canes and walkers can further damage the nerve as it passes through the palm. Due to diminished sensation, overgripping is a common behavior. This also damages tissues.

Conservative treatment involves activity modification, splinting the wrist in neutral, and tendon and nerve mobilization. If indicated, surgical release of the transverse carpal ligament is performed to decompress the median nerve. Occasionally, a Camitz procedure is performed to compensate for poor thumb abduction and opposition due to muscle atrophy. This procedure is considered a tendon transfer that requires immobilization of the thumb for 4 to 6 weeks.¹⁰ Depending on the severity of the compression, sensation may not fully be restored after release of the nerve. It is important to teach compensatory techniques and safety measures, and, if needed, to recommend some adaptive equipment to assure a quick return to desired roles.

TRIGGER FINGER
Trigger finger or stenosing tenosynovitis is often associated with carpal tunnel syndrome and other cumulative trauma disorders. The swollen tendon is unable to glide under the flexor pulley system and causes diminished ability to grasp items and proximal interphalangeal contractures. There is usually pain over the volar aspect of the metacarpal head (location of the A-1 pulley). Conservative treatment involves limiting tendon glide by blocking the metacarpal from full flexion. This can be achieved through splinting, activity modification, or tools with built-up handles. When indicated, surgical release of the entrapping pulley is performed. Often, multiple trigger releases are performed along with the carpal tunnel release. Restoring function by improving tendon glide, managing edema, and mobilizing scar tissue is the goal. Education on the prevention of future trigger fingers is highly recommended.

DE QUERVAIN'S TENDONITIS
De Quervain's tendonitis is inflammation of the tendons that run through the first dorsal compartment. This includes the abductor pollicus longus and abductor pollicus brevis. These muscles are responsible for repositioning the thumb following flexion and opposition. They are aggravated by wrist rotation, extreme ulnar deviation, and thumb/wrist overactivity. Examples of these activities include picking up a child, walking a pet on a leash, opening a jar, and squeezing out wash. Conservative treatment involves activity modification and splinting to rest the inflamed tendon.

CMC ARTHRITIS
Carpal metacarpal (CMC) arthritis is a painful and debilitating condition caused by wearing out the joint at the base of the thumb. Pain increases with activities that require pinch. Examples of such activities are turning a key, holding a book, opening packages, and writing. Conservative treatment involves resting the involved joint. A hand-based or forearm-based splint that supports the base of the thumb is helpful. Caution must be used to prevent pressure areas to fragile skin over bony areas. The splint should allow pain-free use of the thumb by stabilizing the CMC joint. Activity and/or tool modification is recommended. Built-up handles can be placed on keys and writing and food utensils. Scissors are recommended for opening packages. If elected, an arthroplasty or fusion may be performed. This requires immobilization in a thumb spica cast or splint. In the older population, it is important to prevent finger contractures or shoulder adhesive capsulitis due to disuse and a guarded arm posture.

DUPUYTREN'S DISEASE
Dupuytren's disease is genetic and usually appears in the fifth decade of life. It involves the development of nodules, pits, and cords that lead to contractures when the fascia thickens and shortens. Because it is not painful, it is often tolerated until the hand is so deformed that it interferes with activities of daily living. Conservative treatment is limited. If surgical intervention is not indicated, compensatory techniques and adaptive equipment will help maintain independence. Postoperative management requires wound care, splinting, edema control, and restoration of motion. Roselyn Evans has introduced a no-tension protocol. The premise is that no-tension prevents ischemia and the return of the diseased fascia.¹¹ Caution must be directed to fragile skin and bony areas. Due to the prevalence of delayed healing in this population, facilitating wound healing is a priority, especially when an open or McCash¹¹ procedure is performed. In 1964, McCash found that transverse incisions in the palm could be left unsutured to heal secondarily, resulting in cosmetically acceptable scars with little or no morbidity. This procedure has become known as the open-palm method.

FRACTURES
The older population is very prone to fractures due to decreased bone mass (osteopenia), prevalence of falls, and elder abuse. Elder abuse is estimated at 500,000 incidents per year. Spiral, transverse, or oblique midshaft digital fractures might raise suspicion of physical abuse.¹² A common fracture is the distal radius that is often sustained after a fall. Depending on length of immobilization required, the need for internal or external fixation, and the involvement of the distal radial ulnar joint, recovery can take up to a year. This may progress to general declines in health.

The older population may face other challenges that interfere with therapeutic intervention. Lack of transportation, other medical appointments (dialysis, radiation), and fixed funds for co-pays may limit ability to attend outpatient therapy. Medical complications such as cancer, arthritis, diabetes, hypertension, or lymphedema may prevent implementation of preparatory agents (ultrasound, iontophoresis) or therapeutic exercises. Dementia or memory loss may limit the ability to follow a home exercise program or activity modification. Therapy would best be conducted in a familiar context and relevant time. This means that Mrs Jones should work on making breakfast in her own kitchen in the morning when her hands give her the most symptoms. The treatment becomes more real when it has personal or symbolic value to the individual.¹³ Unfortunately, most of the time this cannot happen. Often the best therapists can do is interview the patient to identify problem tasks and then simulate the task in the clinic. Patient-specific goals can also be identified with an outcome tool. The Canadian Occupational Performance Measure¹⁴ is an appropriate tool widely used by occupational therapists.

When hand conditions afflict an aging person, intervention methods should take into consideration specific hand structures and protocols, general health conditions, and the uniqueness of the individual. The Occupational Therapy Practice Framework identifies an occupational profile where the individual's needs, interests, values, and concern about performing occupational and daily life activities are identified. Performance skills, performance patterns, context, activity demands, and client factors should all be considered.¹⁵

TIPS WHEN WORKING WITH THE AGING

Obtain a thorough medical history
Identify the client's occupational profile
Be familiar with Medicare guidelines
Accommodate methods of transportation
Schedule during time when the patient is most oriented
Allow for extra time
Diminish distractions
Provide boldly written instructions
Simplify splint straps
Pad or relieve areas with boney surfaces
Suggest modifications that are easily learned
Focus on desired occupational performance (activities)

Deborah A. Rider, OTR/L, CHT, based in Mt Laurel, NJ, received her certification in 1997 and has been employed by Hand Surgery and Rehabilitation Center of New Jersey for 13 years.

REFERENCES

Fiatorone MA, Evans WJ. The etiology and reversibility of muscle dysfunction in the aged. J Gerontol. 1993;48:77-83.
Centers for Disease Control and Prevention. Healthy aging: preventing disease and improving quality of life among older Americans. Available at: www.cdc.gov. Accessed October 1, 2003.
Hapner K. Aging hands that cradle the mouse. International Herald Tribune. March 27, 2004.
Grove GL. Physiologic changes in older skin. Clin Geriatr Med. 1989;5:115.
Gerstein AD, Phillips TJ, Rogers GS, Gilchrest BA. Wound healing and aging. Dermatol Clin. 1993;11:749.
Booth FW, Weeden SH, Tseng BS. Effect of aging on human skeletal muscle and motor function. Med Sci Sports Exerc. 1994;26:556.
Buckwalter JA, Woo SL, Goldberg VM, et al. Soft tissue aging and musculoskeletal function. J Bone Joint Surg Am. 1993;75: 1533-48.
Morris JC, McManus DQ. The neurology of aging: normal versus pathological change. Geriatrics. 1991;46:47.
Keen DA, Yue GH, Enoka RM. Training-related enhancement in the control of motor output in elderly humans. J Appl Physiol. 1994;77:2648.
Cannon N. Diagnosis and Treatment Manual for Physicians and Therapists. 4th ed. Indianapolis: The Hand Rehabilitation Center of Indiana; 2001.
Hunter JM, Mackin EJ, Callahan AD. Rehabilitation of the Hand: Surgery and Therapy. Vol II, 4th ed. St Louis: Mosby; 1995:991, 996.
Hall GR, Weiler K. Elder abuse, neglect and mistreatment. In: Bradway CW, ed. Nursing Care of Geriatric Emergencies. New York: Springer; 1996.
Cooper C. OT Practice. August 4, 2003:17.
Law M, Baptiste S, Carswell A, McColl M, Polatajko H, Pollock N. Canadian Occupational Performance Measure. Ottawa: Canada CAOT Publications ACE; 2000.
American Occupational Therapy Association Occupational Therapy Practice Framework, domain and process. Am J Occupat Ther. 2002;56:609-639.

LOOKING FOR EXPERT ADVICE?

Experts here are available to answer all your questions!

Please contact us for more information about this feature, or to become an expert.

MEDIA CENTER

Interactive Media

Resources

	Classifieds
	Calendar
	Consumer Resources
	Media Kit
	Advertiser Index EAB Reprints Submit an Article

Featured Jobs

AUDIOLOGIST NEEDED
Boise, Idaho

Hospitalist & Locum Tenens Opportunities St Joseph Hospital, Saint Joesph East
Lexington, Kentucky

Hospitalist Chestertown Chester River Hospital
Chestertown, Maryland

More Jobs...

Find a Job

www.thejobcure.com

ADDITIONAL ONLINE RESOURCES

Allied Healthcare		Medical Education
24X7mag Chiropractic Products Magazine Clinical Lab Products (CLP) Orthodontic Products The Hearing Industry Resource HME Today Rehab Management	Physical Therapy Products Plastic Surgery Products Imaging Economics Medical Imaging RT Magazine Sleep Review	SynerMed Communications IMED Communications
		Practice Growth
		Practice Builders

Become a featured employer

Featured Employer

Eagle Hospital Physicians

Is Eagle's Hospitalist practice for you?

At Eagle Hospital Physicians, we are a growing force of excellent physicians creating a new specialty in hospitalist medicine. If you are seeking the intellectual stimulation and challenge of an inpatient care environment, one of our Hospitalist practice opportunities could be a match for you.

Learn More
See All Jobs

October 2004