April 2006

A Handful of Hope

By Randy Wolfe, OTR/L, CHT

Individual evaluation of hand injuries and conditions is crucial when determining a suitable patient rehabilitation program.

Randy Wolfe, OTR/L, CHT, supervises a patient performing one of the 100 exercises provided by the work simulator for wrist flexion and extension.

People use them all day, every day. From waking hours until nighttime slumber, their hands play an essential role in getting through life. People begin the day with them, turning off the dreaded alarm clock with the push of a button, and beginning their day's journey. They brush their teeth, rub shampoo into their hair, dress themselves, tie their shoes, cook and eat breakfast, lock the doors to their house, step into their car, and off they go. Their hands have been through so much, and the sun has barely risen above the trees.

These are things people take for granted; being able to use both hands as freely and often as they like. But then something happens: an accident or trauma, placing a hand on a hot stove, a flare-up of arthritis, a ligament strain on the left hand during a pickup game of basketball with friends, or, worse, a stroke. All of a sudden, life's simple tasks—zipping a jacket, taking out the garbage, or tying those brand-new sneakers—are not easy as they used to be. There is no need for people to throw away those sneakers and replace them with penny loafers, thanks to advances in hand therapy that can help restore motion, strength, coordination, and mastery of tasks.

EVALUATION: THE FIRST STEP TO A PATIENT'S THERAPY
While most patients are eager to jump into any therapy that will restore normal hand movement and ability, the hand therapists at Good Shepherd Rehabilitation Network, Allentown, Pa, agree that a personal evaluation of patients and their conditions is crucial in determining the most suitable rehabilitation program. Individualization is key for every patient. We get to know the patient and tailor our approach to their needs, not just implement programs straight from the rehabilitation books. "You need to take the time to make your customer feel at ease," says Karen Vasilik, MS, OTR/L. "Patients need a customized and tangible snapshot of what is going on, and we use our computerized evaluation and various questions to help demonstrate a holistic approach."

Randy Wolfe, OTR/L, CHT, uses a hand evaluation system to assess the patient’s grip strength.

The chief tool used is a computerized hand evaluation system, which provides valid and repeatable results on range of motion. Good Shepherd was one of only six centers in the world to adopt this technology back in 1991. Because of its usefulness, others have incorporated this computer-based system into their clinics. This evaluation system has devices capable of measuring a person's range of motion, grip strength, pinch strength, muscle strength, and coefficients of variation. The software can be used to graphically display the injury sites and the sensation patterns of the patient. It generates a professional report for patients and their physicians to view, and makes documentation much easier to perform and understand.

Good Shepherd sees patients with a wide range of hand-related injuries, including carpal tunnel syndrome, fractures, tendon injuries, burn injuries, amputations, strokes, and spinal cord and brain injuries. Fortunately, the computerized hand evaluation system can be incorporated when evaluating all of these conditions. Another unique quality of the system is the ability to generate progress graphs following reevaluation. Patients often go back to this device once they have begun a therapy program to measure their progress using a reliable and valid approach. The initial therapy orders are received from a physician and—once an occupational therapist has evaluated the patient—a treatment plan is outlined that is specific to that particular patient and their status. The next step is generally a warm-up phase before the actual hands-on therapy begins.

MODALITIES: EASING A PATIENT INTO THE THERAPY
In preparation for a patient's hand therapy program, Good Shepherd's therapists implement preconditioning modalities. Specific modalities are used on patients, depending on the severity of their condition. Examples of modalities include hot packs, paraffin dips, and fluid therapy, and all are considered very effective.

Hot packs are placed on patients' hands to provide penetrating warmth to soften and loosen the tissues. Taking it a step further, therapists use the paraffin dips, in which patients place their hands in heated wax to generate circumferential warmth. This is ideal for arthritis sufferers. Liked by most patients, fluidized therapy is a 30-year-old modality that has patients place their hands into a large box filled with fine cellulose material. As hot air circulates the cellulose, the patients receive a desensitizing massage. "In addition, it allows for more dynamic active range of motion," says Stacie Feil, COTA/L. "Because the patient is able to move freely, it maximizes the effects of heat and exercise simultaneously."

HAND THERAPY TECHNOLOGIES AND TECHNIQUES
With the evaluation and modalities complete, patients are now ready to begin their assigned therapy programs. The extent of the therapy program, what devices and techniques are used, and their frequency of use depend highly on the time frames surrounding their injury, their healing, the severity of the patient's injury, and the level of the patient's understanding.

Good Shepherd uses state-of-the art technologies, fundamental activities, and hands-on manual therapy with its patients. Four essential, cutting-edge devices are used: a system equipped with a comprehensive collection of attachments and objective documentation that duplicates hundreds of real world job and daily living functions; two electrical stimulation devices that detect low levels of neuron activity produced by weak muscles; and a portable, noninvasive, hand-wrist orthosis that controls the function of the hand with strategically placed electrodes, coordinating stimulation of nerves and muscles.

The work simulator is a magnetic-controlled exercise head that provides torque resistance activities for the patients. With this device, patients can exercise the entire upper extremity through full ranges of motion at varied resistances, heights, durations, and distances. This technology provides patients with more than 100 exercises, including gripping, pinching, rope pull, pushing, and pulling, and simulates the use of certain tools such as wrenches, screwdrivers, and even a shovel. Patients receive immediate feedback from the device through real-time graphic display. Progress reports are provided with percentages and graphs, showing an increase or decrease in improvement from previous therapy sessions.

Good Shepherd's therapists like the work simulator because of its broad therapy spectrum; it can be helpful in treating patients suffering from hand injuries related to fractures, carpal tunnel syndrome, burns, spinal cord injuries, head injuries, and stroke.

The high-tech electrical stimulation devices are for patients recovering from stroke. Both are biofeedback devices that provide visual feedback displays and auditory cues to improve patients' coordinated motion. Therapists agree that these two technologies are a good way to help patients learn how to move again. Good Shepherd was an early adopter of this technology, with six devices available for use by hand therapy patients, as well as other outpatients and inpatients within our extensive rehabilitation network.

These electrical stimulation devices have received FDA approval for treating stroke patients, but our therapists frequently use them on patients with brain injuries, spinal cord injuries, and nerve and tendon injuries, as an enhanced form of basic electric stimulation.

The portable, noninvasive, hand-wrist orthosis that controls the function of the hand with electrodes by a coordinated stimulation of nerves and muscles is designed to help patients with neurological hand deficits related to stroke and spinal cord injuries. Introduced to the market in 2004, this device serves as a neuroprosthetic and rehabilitation system. Electrodes built into the product are placed against the patient's hand and forearm muscles. The device has preset programs and can be customized to enable patients to do various types of extension and flexion exercises, including composite digit and thumb motions. This exercise helps patients reorganize the cortical areas of their brains so they can relearn hand movement patterns.

In order to place patients in more lifelike situations, therapists emphasize the importance of performing basic activities along with using the equipment. Some exercises are as fundamental as tying knots with rope or shoelaces, which helps patients improve their pinching and dexterity. Clothespin exercises and therapy putty are used for the same reason. Other finger exercises include turning knobs, handling clasps, and playing a modified game of checkers. A velcro checkerboard is set up in which little blocks are velcroed to the checkerboard. Patients pinch and pull the blocks off to build strength, dexterity, and fine motor coordination.

"We incorporate gross motor and fine motor tasks in addition to the technologies," says Diane Clause, COTA/L, "This helps patients develop more functional gains in their activities of daily living (ADLs)."

Although technology and fundamental activities contribute very much to the improvement of a patient's condition, Good Shepherd's therapists regard manual therapy as one of the most necessary and effective tools for a patient's overall recovery. Therapists use their own hands when working with patients to massage for edema and scarring, to desensitize, and to stretch and bring comfort to the affected tissues. Through this manual therapy, therapists can perform wound care, isolate the patient's range of motion, isolate individual muscles for strengthening, and mold custom-made splints for patients, if necessary. Manual therapy is individualized and comprehensive, enabling Good Shepherd to treat not just the injury, but the whole patient.

Because therapists cannot be with their patients 24 hours a day, they use this one-on-one manual therapy time to guide and educate the patients. Once patients gain an understanding of their condition, it is easier for them to work through and eventually wean off the therapy program. As patients improve, they need professional therapy less and less, and they transition to an independent home therapy program.

HOME THERAPY PROGRAM
This process actually begins on evaluation day when therapists create a home program that enables them to continue their therapy outside the rehabilitation facility. It is continually monitored and upgraded or downgraded to help patients make progress toward their goals. Therapists emphasize the importance of doing self-exercise once they finish a session at Good Shepherd and return home. Hand rehabilitation has to become integral in patients' lives for the most effective results. Therapists assign their patients functional activities at home such as baking cookies, doing laundry, and cleaning dishes. Such tasks are a great way for patients to measure improvements in their grip and pinch strength, flexibility, and coordination. "Folding laundry is the ultimate task," according to Suzanne Williams, COTA/L. "They use both arms with gross motor and fine motor coordination, and by returning to their ADLs, they feel like they are contributing back to the household."

Giving patients these routine chores helps them better determine their progress. Once they start to feel comfortable doing their daily tasks, they know that they are on the right path to recovery. Further, it reintroduces a level of normalcy to their lives. As mundane as dishes or laundry may seem, therapy patients welcome a return to their lives as they knew it.

Wolfe uses an electrical stimulation device on a patient for wrist and finger extension exercises.

Two of the things I like most about my job here at Good Shepherd is the relationship I build with every patient I work with, and the individual attention I am able to give to my patients, even as a manager. Their success is personal to them and me. It is so much more than just setting patients up on tasks and doing our daily documentation. We try to manage their cases and communicate with their doctors and families, and we answer a multitude of questions. We provide them with realistic hopes and expectations because we take the time that is needed to help them improve. I think that is what sets us apart the most from other rehabilitation providers.

Randy Wolfe, OTR/L, CHT, is an occupational therapist and certified hand therapist at Good Shepherd Rehabilitation Network, Allentown, Pa.

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