The role of hand therapy in facilitating participation in rock wall climbing: A case report of a woman with cerebral palsy.

STUDY DESIGN: This is a case report. BACKGROUND: A woman with hemiplegic cerebral palsy and limited right upper extremity motion, strength, and control was referred to hand therapy to enable participation in adaptive climbing. PURPOSE: The purpose of this case is to describe the role of hand therapy in identifying and addressing barriers to participation in adaptive climbing. Description of the patient's wrist flexion/extension, grip strength, and functional use over the course of eleven months is also included. METHODS: Activity analysis, iterative problem solving, activity simulation, activity modification, and targeted therapeutic exercises were used over the course of eleven sessions. RESULTS: The patient conveyed successful participation in adaptive climbing with reported improvements in overall strength, motion, ability to shift weight, ability to manage digit spasticity, spontaneous right upper extremity use, and body awareness. Active right wrist flexion, wrist extension, and grip strength improved by 33 degrees, eight degrees, and 35 lbs, respectively. CONCLUSIONS: This case highlights an unconventional treatment scenario where outpatient hand therapy was entirely focused on targeting and facilitating the patient's participation in a specific activity-adaptive climbing. Rehabilitation professionals, uniquely suited to helping individuals explore interests, determine "good fit", identify barriers, and navigate obstacles, can advance the promotion of participation in activities that are both meaningful and physically engaging.

Reliability and agreement between two wearable inertial sensor devices for measurement of arm activity during walking and running gait.

STUDY DESIGN: This is a validation study. BACKGROUND: Tracking limb movement with body worn sensors allows clinicians to measure limb dynamics to guide treatment for patients with movement disorders. The current gold standard, 3-dimensional optical motion capture, is costly, time-consuming, requires specific training, and is conducted in specialized laboratories. PURPOSE: The purpose of our study was to a compare consumer-grade inertial sensor to a laboratory-grade sensor to provide additional methods for capturing limb dynamics. METHODS: The participants wore an Apple Watch and a laboratory-grade Xsens sensor on each wrist during 3 conditions: walk, fast-walk, and run. Acceleration data were collected simultaneously on each device per wrist for all conditions. Intraclass correlation coefficients and Bland-Altman plots were calculated to measure intra-/interdevice reliability, evaluate bias, and limits of agreement. RESULTS: Intradevice ICCs showed good reliability during walk and fast-walk (0.79-0.87) and excellent reliability during run (0.94-0.97) conditions. Inter-device ICCs yielded moderate reliability during walk (0.52 ± 0.22) and excellent reliability in fast-walk and run (0.93 ± 0.02, 1.00 ± 0.01) conditions. Bland-Altman plots showed small biases with 90% or more of the data contained within the limits of agreement. DISCUSSION: Our study demonstrates reliability and agreement between the two devices, suggesting that both can reliably capture upper extremity motion data during gait trials. CONCLUSION: Our findings support further study of consumer-grade motion trackers to measure arm activity for clinical use. These devices are inexpensive, user-friendly, and allow for data collection outside of the laboratory.

The forgotten radial nerve: A conceptual framework for treatment of lateral elbow pain.

BACKGROUND: Lateral elbow pain is a prevalent musculoskeletal overuse disorder that has serious consequences for musculoskeletal health, occupational performance, and overall healthcare burden. Available treatment options (traditional therapy and steroid injections) have been studied rigorously, yet supporting evidence is weak. The majority of treatment options available are targeted at the local pathology of the common extensor tendon as the apparent source of pain, and do not adequately address the cause, the source of overuse, and mechanism of injury. PURPOSE: The purpose of this paper is to describe a novel approach, a regional interdependence model, to reduce symptoms of upper extremity musculoskeletal overuse in populations at risk by addressing a broader systematic approach versus a localized symptom driven approach for the assessment and treatment of lateral elbow pain. METHODS: The proposed framework - Think in nerve length and layers (TINLL)- accounts for nerve tension and muscle balance in the entire extremity. In this paper we describe the application of the TINLL model for assessment and treatment of SRSN irritation in individuals with lateral elbow pain and propose a method for treatment and for further studies. The proposed treatment approach combines mobilization with movement, elastic taping, and isometric exercises to address impairment at each level: joint alignment, neural tension, and the superficial sensory nervous system. RESULTS: Our findings of reduced pain with a relatively small number of therapy sessions in a small retrospective cohort of patients using the TINLL framework for assessment and treatment supports further formal study of this approach in a larger cohort with longer follow-up to determine effectiveness compared to current treatments. CONCLUSION: Future studies will test and compare the efficacy of the TINLL framework and model of treatment on the short- and long-term outcomes in individuals with chronic lateral elbow pain compared to traditional therapy.

Leveraging implementation science to prevent and reduce musculoskeletal overuse injury in musicians: A proposal for the study of a conceptual framework.

BACKGROUND: Musician health and wellness, a fundamental requirement for safe, effective and optimal musical performance, is not guaranteed. Performance related musculoskeletal disorders (PRMD) affect between 60% and 90% of all musicians, and have serious consequences on musculoskeletal health, performance ability and the overall healthcare burden of musculoskeletal injury. The high prevalence of PRMD in musicians can be prevented and reduced via health-education programs designed to address risk factors and practice habits. Multiple studies demonstrate the efficacy of education and instructional exercises in reducing PRMD symptoms in musicians. Despite the awareness of risk and the substantial consequence of non-adherence, implementation of health-education programs is complex and challenging and is rarely offered in music institutions. For successful adoption of musculoskeletal health programs, it is important to identify system level barriers and facilitators and it is important to develop and pilot effective strategies to guide successful implementation of musculoskeletal health programs for musicians. PURPOSE: This paper proposes a conceptual framework using implementation science methodology to study the factors that influence adoption of musician health education programs to prevent performance related injury. The overall goal of this methodology is to identify determinants of implementation by engaging key stakeholders, developing strategies for adoption of injury prevention programs and generate hypotheses for future studies. METHODS: The research plan is designed to accomplish the specific aims of this study. Through a mixed-method study we will use qualitative and quantitative methods to address potential barriers, and design and test implementation feasibility of health-education programs for musicians. RESULTS/CONCLUSIONS: Our findings will inform the development of a large-scale participant randomized hybrid trial to assess effectiveness and implementation outcomes of health education programs and ultimately reduce injury and promote musculoskeletal longevity and performance in musicians.

Feasibility and impact of a musculoskeletal health for musicians (MHM) program for musician students: A randomized controlled pilot study.

BACKGROUND: There is a high incidence of performance-related musculoskeletal disorders in musicians that may be reduced via education programs. However, the efficacy of formalized injury prevention programs has not been rigorously studied. PURPOSE: To assess the feasibility and effect of a formalized injury prevention education workshop on incidence and severity of musculoskeletal pain in a cohort of musician-students attending an intensive summer music festival compared to controls. STUDY DESIGN: Randomized-controlled-pilot trial. METHODS: Musicians at an 8-week long intensive summer festival were randomized to an intervention (workshop) or control group. Workshop attendees participated in a 90-minute session of injury prevention strategies. Musculoskeletal outcome data were collected at the start and end of the festival. Outcomes included presence of musculoskeletal pain, adherence level, and sub-scales of the Musculoskeletal Pain Intensity and Interference Questionnaire for Musicians. RESULTS: A total of 57 musician-students (ages 17-30, 23 females) participated in the study, and 48(84%) completed the study. Seventy-five percent of workshop participants reported adherence over 8 weeks. At baseline, 84% of participants reported a history of playing-related pain, and 47% recent or current pain. Participants played a range of instruments (50% string, 34% piano, 16% woodwind/brass). At baseline, average weekly reported playing time was 39 hours (±11). At follow-up, reported pain decreased by 32% in the intervention group and increased by 8% in controls (P < .01). Pain interference scores were lower (Post - Pre = -4.58, 95% CI -9.26 to 0.11, P = .055). There was no statistically significant difference between groups for pain intensity. CONCLUSIONS: The high compliance and willingness to participate suggests that injury prevention education implementation is feasible. Our preliminary findings suggest a positive effect on pain incidence and pain interference in the intervention group. Future studies will examine the relationship between adherence levels and injury rates in a larger cohort and identify obstacles to implementation.

Self-identified functional limitations improve in patients with degenerative wrist arthritis after surgery.

STUDY DESIGN: This is a prospective cohort pilot study. BACKGROUND: Degenerative wrist arthritis leads to pain, loss of strength, mobility, function, and impairments in psychological well-being. Accurate assessment of functional limitations that are unique to the individual is essential for successful treatment that best meets those specific needs. PURPOSE OF THE STUDY: To identify and determine if self-identified functional limitations improve in patients who underwent surgery for degenerative wrist arthritis. METHODS: Patients with degenerative wrist arthritis who were scheduled for surgery were prospectively recruited (n = 14, mean age + SD = 42 + 16, 10 males, 4 females) into a pilot study that measured self-identified functional limitations and outcomes. Inclusion criteria included a diagnosis of scapholunate advanced collapse, scaphoid nonunion advanced collapse, scapholunate interosseous ligament tear, or Kienböck disease. Exclusion criteria included a history of neuromuscular disease or concomitant ipsilateral musculoskeletal injury. Data were collected during two 20-minute sessions, preoperatively and one year postoperatively, utilizing the Patient-Rated Wrist Evaluation and the Canadian Occupational Performance Measure. RESULTS: All patients reported significant decreases (P < .001) in total pain (mean change = 17.6, SD = 8.5) and total disability (mean = 17.8, SD = 9.1) on the Patient-Rated Wrist Evaluation from presurgery to postsurgery, with a large effect size of d > 0.8. Patients also reported significant improvements (P < .001) in mean performance (mean = 3.5, SD = 1.5) and mean satisfaction (mean = 4.0, SD = 2.1) with self-identified activities on the Canadian Occupational Performance Measure, with an effect size of d > 0.8. CONCLUSION: Patients with degenerative wrist arthritis reported significant postoperative improvement in both performance and satisfaction in self-identified activities. Consideration of patient-specified goals can inform both patients and clinicians during the surgical decision-making process and allow for more individualized care.

Elbow Kinematics During Gait Improve With Age in Children With Hemiplegic Cerebral Palsy.

BACKGROUND: Children with hemiplegic cerebral palsy (hCP) exhibit a typical posture of elbow flexion during gait. However, the change in elbow kinematics and symmetry during gait across age span in both hCP and typically developing (TD) children is not well described. The aim of this study was to quantify the change in elbow kinematics and symmetry across age span in hCP children compared with TD children. METHODS: Upper extremity kinematic data were extracted and analyzed from a database for gait studies performed between 2009 and 2015. A total of 35 hCP and 51 TD children between the ages of 4 and 18 (mean age: TD=11.2±0.6, hCP=9.8±0.5) met inclusionary criteria. The groups were further subdivided into 3 age categories: 4 to 7, 8 to 11, 12+ years old. Elbow angles were extracted and peak elbow flexion, overall range of motion during gait, and asymmetry indices were calculated. A 1-way analysis of variance was performed on each group with post hoc Tukey honestly significant difference pairwise comparisons. RESULTS: Peak elbow flexion during gait increased with age in TD children (P<0.05) and decreased with age in hCP children on the affected side (P<0.05). There was no change on the less affected side of hCP children. TD children demonstrated significantly less elbow flexion (mean=51.9±2.1 deg.) compared with the affected side in hCP (mean=82.1±3.8 deg.) across all age categories (P<0.05). There was no change in elbow asymmetry index (0=perfect symmetry) across age in either controls or hCP children; however, there were differences between hCP and TD groups in younger age groups (TD=28, hCP=62, P<0.05) that resolved by adolescence (TD=32, hCP=40). CONCLUSIONS: During gait, hCP children have greater peak elbow flexion on the affected side than do TD children. Peak elbow flexion angle converged between the 2 groups with age, decreasing in hCP children and increasing in TD children. Furthermore, elbow symmetry during gait improves with age in hCP children, approximating symmetry of TD children by adolescence. These findings have implications for both consideration and optimal timing of surgical intervention to improve elbow flexion in children with hCP. LEVEL OF EVIDENCE: Level III-retrospective case-control study.

Anatomical and biomechanical framework for shoulder arthroplasty rehabilitation.

This article provides an anatomical and biomechanical framework for the postoperative management and progression of treatment for shoulder arthroplasty. The clinical relevance of normal shoulder anatomy, biomechanics, and pathomechanics related to this surgery is emphasized to provide the reader with an understanding of the rationale for treatment. We review the rehabilitation implications of surgical indications and technique for both traditional total shoulder arthroplasty and reverse total shoulder arthroplasty procedures with an emphasis on biomechanical considerations. Relevant factors that affect rehabilitation outcomes are discussed along with supporting evidence from the literature. Principles to guide and progress treatment are highlighted with a discussion on return to sports with the ultimate objective of providing a comprehensive approach for successful rehabilitation.

Rehabilitation for scapholunate injury: Application of scientific and clinical evidence to practice.

In this article, the development of a rehabilitation approach is describe using scapholunate injury as a model. We demonstrate how scientific and clinical evidence is applied to a treatment paradigm and modified based on emerging evidence. Role of the scapholunate interosseous ligament within the pathomechanics of the carpus, along with the progression of pathology, and specific rehabilitation algorithms tailored to the stage of injury. We review the recent and current evidence on the kinematics of wrist motion during functional activity, role of the muscles in providing dynamic stability of the carpus, and basic science of proprioception. Key relevant findings in each of these inter-related areas are highlighted to demonstrate how together they form the basis for current wrist rehabilitation. Finally, we make recommendations for future research to further test the efficacy of these approaches in improving functional outcomes.

Surgical Treatments for Scapholunate Advanced Collapse Wrist: Kinematics and Functional Performance.

PURPOSE: The purpose of this investigation was to compare kinematic motion and functional performance during 2 tasks in patients following 4-corner fusion (4CF) or proximal row carpectomy (PRC) and to compare these data with those from healthy asymptomatic individuals. METHODS: Twenty men (10 4CFs and 10 PRCs, ages, 43-82 y) were recruited for 3-dimensional wrist motion analysis testing. Kinematic coupling (the ratio of wrist flexion/extension to radial-ulnar deviation), kinematic path length (a measure of total angle distance), clinical measures, and performance measures were collected during 2 tasks: dart throwing and hammering. For each outcome, between-group comparisons employed a 1-way analysis of variance with post hoc analysis using the Fisher least significant difference test. RESULTS: All clinical measures (flexion-extension, radial-ulnar deviation, and grip strength) were decreased for 4CF and PRC patients compared with healthy subjects. Coupling, kinematic path length, and performance were all significantly reduced in 4CF and PRC patients compared with healthy subjects during both tasks. Reduced coupling and a shorter kinematic path length are indicative of less global and combined wrist motion. There were no differences identified in coupling patterns or performance between the surgical groups for the dart-throwing task. However, in hammering, the kinematic path length and performance (time and total strikes) were worse in 4CF than in PRC. CONCLUSIONS: Differences in wrist kinematics and performance were identified between the groups. PRC subjects performed better on kinematic and performance variables. As expected, both groups demonstrated decreased wrist kinematic motion and functional performance compared with individuals with normal wrists. These results require confirmation and while they cannot be used to determine the benefits of one procedure over the other, they are an important step in quantifying differences in motion and function between procedures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Responsiveness of three Patient Report Outcome (PRO) measures in patients with hand fractures: A preliminary cohort study.

STUDY DESIGN: Clinical measurement. INTRODUCTION: Few studies describe the responsiveness of functional outcomes measures in patients sustaining hand fractures. PURPOSE: 1--To explore the responsiveness of three function-oriented Patient Report Outcome (PRO) measures with a cohort of hand fracture patients. 2--To examine patients' PRO preference. METHODS: 60 participants with 74 hand fractures at an outpatient hospital-based hand therapy clinic consented to participate in this study. They completed the Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH), Michigan Hand Outcomes Questionnaire (MHQ), and Patient-Rated Wrist/Hand Evaluation (PRWHE) at three trials: T1 (evaluation), T2 (one month later), and T3 (two months later). Participants also identified which PRO they felt best reflected their hand use and which was easiest to complete. Descriptive statistics, analyses of variance (ANOVA), effect size, and standardized response mean (SRM) were employed to describe participants, determine functional change between trials, and examine and compare PRO responsiveness. Questionnaire preference at T1 was reported. RESULTS: Participants demonstrated functional improvement, as measured by the DASH, PRWHE, and MHQ. T1 scores: DASH = 41.85 (SD ± 22.78), MHQ = 50.13 (SD ± 18.36), and PRWHE = 48.18 (SD ± 22.07). T2 scores: DASH = 22.11 (SD ± 18.18), MHQ = 69.89 (SD ± 15.93), and PRWHE = 22.62 (SD ± 18.15). T3 scores: DASH = 17.56 (SD ± 18.01), MHQ = 75.37 (SD ± 19.19), and PRWHE = 22.40 (SD ± 19.04). Each PRO demonstrated significant test score differences between trials (p < .001). Large responsiveness (≥.80) was noted between T1 and T2: (effect size: .98-1.23; SRM: 1.31-1.49) and T1 and T3 (effect size: 1.21-1.54; SRM 1.49-1.84). Smaller responsiveness effects were noted between T2 and T3 (effect size: .35-.64, SRM: .38-.81). No significant differences between questionnaire responsiveness were found. Patients reported PRWHE easiest to complete and MHQ best reflecting their hand use. CONCLUSIONS: DASH, MHQ, and PRWHE were each able to describe functional limitations in this cohort of patients with hand fractures. In capturing improvement over time they demonstrated comparable responsiveness in assessing change in patients with hand fractures. LEVEL OF EVIDENCE: 2c.

Wrist kinematic coupling and performance during functional tasks: effects of constrained motion.

PURPOSE: To quantify the coupled motion of the wrist during selected functional tasks and to determine the effects of constraining this coupled motion using a radial-ulnar deviation blocking splint on performance of these tasks. METHODS: Ten healthy, right-handed men performed 15 trials during selected functional tasks with and without a splint, blocking radial and ulnar deviation. The following tasks were performed: dart throwing, hammering, basketball free-throw, overhand baseball and football throwing, clubbing, and pouring. Kinematic coupling parameters (coupling, kinematic path length, flexion-extension range of motion, radial-ulnar deviation range of motion, flexion-extension offset, and radial-ulnar deviation offset) and performance were determined for each functional task. A generalized estimation equation model was used to determine whether each kinematic coupling parameter was significantly different across tasks. A repeated-measures generalized estimation equation model was used to test for differences in performance and kinematic coupling parameters between the free and splinted conditions. RESULTS: Wrist motion exhibited linear coupling between flexion-extension and radial-ulnar deviation, demonstrated by R(2) values from 0.70 to 0.99. Average wrist coupling and kinematic path lengths were significantly different among tasks. Coupling means and kinematic path lengths were different between free and splinted conditions across all tasks other than pouring. Performance was different between wrist conditions for dart throwing, hammering, basketball shooting, and pouring. CONCLUSIONS: Wrist kinematic coupling parameters are task specific in healthy individuals. Functional performance is decreased when wrist coupling is constrained by an external splint. CLINICAL RELEVANCE: Surgical procedures that restrict wrist coupling may have a detrimental effect on functional performance as defined in the study. Patients may benefit from surgical reconstructive procedures and wrist rehabilitation protocols designed to restore kinematic coupling.

SSc management--In person appointments and remote therapy (SMART): a framework for management of chronic hand conditions.

The changing health care climate poses unique challenges to managing a chronic and progressive disease like systemic sclerosis (SSc). At our institution, we employ a new model for SSc management that combines "in person" appointments and "remote" therapy (SMART). This program fosters an understanding of the disease process with the goal of improving skills and confidence for self-management and empowering individuals by providing a means of daily self-assessment. Technology is utilized as a means to remotely monitor and assess progress. We present our approach as a framework for long term management of chronic hand conditions. Evidence from a variety of disciplines is cited to support the design and parameters of this model.

Development of an anatomical wrist joint coordinate system to quantify motion during functional tasks.

The purpose of this study was to develop a three-dimensional (3D) motion analysis based anatomical wrist joint coordinate system for measurement of in-vivo wrist kinematics. The convergent validity and reliability of the 3D motion analysis implementation was quantified and compared with manual and electrogoniometry techniques on 10 cadaveric specimens. Fluoroscopic measurements were used as the reference. The 3D motion analysis measurements (mean absolute difference [MAD] = 3.6°) were significantly less different (P < .005) than manual goniometry (MAD = 5.7°) but not (P = .066, power = 0.45) electrogoniometry (MAD = 5.0°) compared with fluoroscopy. The intraclass correlation coefficient (ICC[2,1]) was highest for 3D motion analysis compared with manual and electrogoniometry, suggesting better reliability for this technique. To demonstrate the utility of this new wrist joint coordinate system, normative data from 10 healthy subjects was obtained while throwing a dart.

Children With Cerebral Palsy's Experiences With Adaptive Climbing: A Qualitative Study on Parents' Perspectives.

Background: Interest in adaptive sports for children with cerebral palsy (CP) is growing, but current evidence on the benefits and indications for one sport, adaptive climbing, is limited. Purpose: We sought to describe perceived changes observed by parents of children with CP who participated in adaptive climbing. Methods: Parents whose children with CP participated in 5 or more adaptive climbing sessions were eligible to participate and were emailed a recruitment letter and flyer. Data were collected through semi-structured interviews, using a moderator guide. Interviews were transcribed and content analyzed, with data grouped into concepts, categories, and themes until data saturation. Results: Ten parents (9 mothers, 1 father) of 10 children with CP (5 girls, 5 boys; ages 7 to 19 years) were interviewed for 15 to 45 minutes each, yielding 4 themes. First, parents perceived that adaptive climbing challenged the children physically (in reach, balance, strength, and head/neck and lower limb motion); second, that it sharpened children's cognitive skills (in focus, problem-solving, and strategic thinking); third, that it raised children's confidence (socially, physically, and emotionally); and fourth, that it expanded children's sense of what they could do (in mastering a challenge, claiming an athletic identity, and participating in a sport like their peers). Conclusions: In this qualitative study, parents described physical, cognitive, and psychosocial benefits of adaptive climbing for their children with CP. These descriptions can be used to inform future studies of children with CP who participate in adaptive climbing.

Elevating patient experience: Transformative strategies in hand therapy.

This paper explores transformative strategies in hand therapy aimed at improving the patient experience - a critical factor linked to improved clinical outcomes and increased satisfaction for patients and therapists. The focus is on three key areas: personalized interactions, empathic communication, and sensory engagement. Personalized interactions ensure therapy is uniquely tailored to each patient' needs, fostering a sense of individual attention and care. Empathic communication involves understanding and responding effectively to patients' verbal and nonverbal cues, creating a supportive environment where patients feel genuinely heard. Sensory engagement utilizes the therapeutic environment's visual, olfactory, and auditory elements to create a calming, welcoming space conducive to healing and relaxation. Integrating these strategies aims to increase treatment effectiveness and improve therapist well-being by promoting a fulfilling and less stressful work environment. Through a comprehensive review of existing evidence, current practices and innovative approaches, this paper advocates for a holistic, patient-centered model of hand therapy that significantly improves treatment outcomes and enhances the overall therapeutic experience, ensuring it is both practical and compassionate.