Improving Grip Strength
Improving Grip Strength
PTs shouldn't overlook the importance of a strong grip
By Jonathan Bassett
Without a functional grip, an otherwise healthy and self-reliant person can quickly find themselves at the mercy of others to be dressed, fed, cleaned, transported and otherwise helped with the countless simple tasks required for daily life. For this reason, returning functional grip strength to a patient with tendon or nerve injury, arthritis, upper extremity trauma, repetitive strain or postoperative weakness is critical.
ADVANCE spoke with three certified hand therapists to discuss the finer points of returning grip strength to patients with the more common conditions they treat.
The most important consideration when strengthening the grip of patients with rheumatoid arthritis is to tone down the exercise considerably.
"You must be very careful not to cause increased pain, swelling or warmth in the joints," advised Marcia Miller, PT, CHT, director of the Williamsburg (VA) Physical Therapy Hand Center. Instead of exercise tools, Miller will start patients with rheumatoid arthritis on very soft sponges or putty. Particularly effective for rheumatoid arthritis, Miller said, are putty and new gel sponges that can be heated, offering patients the dual benefits of exercise and heat, which reduces swelling and eases pain.
Also critical is to verify that the patient's arthritis is in a stable state. "You would not strengthen a rheumatoid arthritis patient who's having an acute flare-up," Miller stressed. "Make sure the condition has been treated and is not acutely inflamed. Otherwise you'll run the risk of aggravating the joints."
PTs will rarely measure strength with this patient group on a dynamometer because of this risk of exacerbating the disease, added Kathleen Hanlon, PT, CHT, co-owner of New Hampshire Hand Therapy Center, Bedford, NH.
One alternative to monitor patient progress is to measure muscle girth. This can be done using volume measurement: the hand is inserted into a volumeter, and the amount of fluid displaced from the container will determine the size of the muscle. But because no norms are established for age and gender classes, these measurements will only be helpful to monitor a patient's personal progress or to compare one with the opposite body part.
Another alternative to establishing a baseline measurement of grip strength is using a blood pressure cuff, explained Teri Bielefeld, PT, CHT, supervisor of ambulatory care at Zablocki VA Medical Center, Milwaukee, and director of the APTA's Hand Rehabilitation Section. Roll the cuff into a compact ball, pump it to 50 mm Hg, and have the patient grip the cuff. If the pressure goes to 75 mm Hg, the difference of 25 mm Hg gives you a quantifiable baseline to work with.
"In addition to being much more cautious in your approach, you want to gear your strengthening program with this patient group toward functional strength," Miller said.
Instead of high resistance exercises, introduce ADLs so patients can recover the ability to feed and dress themselves, turn an oven on and off, and the like.
Isometric exercises, Hanlon said, are also an option to strengthen the weakened grip of patients with rheumatoid arthritis by applying resistance without moving the joints. Light strengthening with resistive bands can also be initiated, such as spreading the hand apart and moving the fingers in and out with the band wrapped around the fingertips. All exercise with patients with rheumatoid arthritis should always be followed by ice, noted Bielefeld.
Osteoarthritis can be distinguished from rheumatoid arthritis on the basis of history and lab work, Miller said. More well-known to the public as typical "old age, wear and tear" arthritis, osteoarthritis often differs from rheumatoid arthritis in that it may not be symmetrical and may involve lower degrees of swelling and less destruction of bone and cartilage. Marked joint deformity is also less common.
The joints that are most often involved are the distal and proximal interphalangeal. Enlargement of the distal interphalangeal joints is common and termed Heberden nodes. Bouchard's nodes occur at the proximal interphalangeal joints. The carpometacarpal joint is also a common site of osteoarthritis.
Osteoarthritis may also develop as a result of pathology or trauma to a joint. "If you sprain your ankle, I can reasonably predict that you'll develop osteoarthritis in the affected ankle before the unaffected one," Bielefeld said.
"With osteoarthritic individuals, it's important to know which joints are involved," Miller noted. For instance, if the basal joint of the thumb is inflamed, avoid repetitive pinching exercises that will irritate that area. "When you're pinching with your thumb and index finger, the forces that are being transferred to the base of the thumb are being magnified 10 to 12 times," Miller said. "Let's say, for instance, that you're trying to push a button through a button hole. While you may be only using three pounds of pinch force at the tip of your thumb, at the base of the thumb that's being multiplied to 30 pounds of pressure or more."
Better options for avoiding irritation of basal and distal-interphalangeal joints are gentle exercise with foam balls, gel cushions or soft putty, Hanlon said.
"The reason I like putty," agreed Bielefeld, "is that it allows the hand to completely close, thereby working through a full range of function. You won't get that using a tennis ball or racquetball."
"With all patients with arthritis, you want to pay particular attention to monitoring them for increased pain, increased joint swelling and tenderness," Hanlon added.
Miller will measure the patient's grip strength at two-week intervals because little progress is seen from week to week, which can become frustrating for the patient.
Also very important to this population is education. Because osteoarthritis can often be a lifelong ailment, Miller will inform patients of adaptive equipment that may make their lives easier: electric can openers, under-the-counter jar openers, large-handled cooking utensils and the like.
CHTs will treat a large number of patients with wrist and hand fractures as well as a variety of surgical and other post-trauma cases. "If a patient has been in a cast for six to eight weeks, they can generally benefit from a somewhat more aggressive grip strengthening program," Hanlon said. As such, she will often introduce mild exercise for surrounding muscles while the patient is still in a cast. Forearm and shoulder exercises can go a long way to restore lost grip strength, as can gentle grip movements (if allowed by the cast) to keep swelling in check and to keep fingers limber.
A variety of hand exercisers are available, including spring-loaded resistive devices, resistive bands and exercise sticks, to complement the more traditional foam sponges, paraffin and putty. Bielefeld will have patients work on twisting a hammer, at first choking up on the handle, then gradually working their way down as their grip becomes stronger.
"You're going to strengthen them as tolerated," Miller said, "without having to worry as much about causing increased joint pain or discomfort."
Another advantage for treating patients after surgery or fracture is the use of a dynamometer and pinch meter, which offer PTs accurate ways to establish current grip strength and progress. Data can be compared with established norms for a patient's age and sex as well as a patient's original readings.
Both PTs will always complement in-clinic work with a home exercise regimen. Hard data from the dynamometer and pinch meter can boost patient motivation, prompting them to continue to work toward a set goal, Hanlon explained.
Beginning with the first week out of the cast, a patient can typically expect their strength to steadily progress for the first two to three months. While it may take up to a year for grip to be fully restored, "What we're looking to do is get them to the point of being functional," Miller noted. That usually falls in the 40 to 45 pound range in dynamometer readings, but can vary between patients.
Tendonitis and Repetitive Strain
Because young, otherwise healthy individuals with tendonitis or one of a wide variety of repetitive strain conditions, such as carpal tunnel syndrome, often retain a high degree of grip strength, Hanlon and Miller do not generally focus on strengthening as a goal of therapy.
"Your first goal here will be to reduce swelling and inflammation, while increasing flexibility and range of motion," Hanlon said. "You generally won't perform grip strengthening because it will aggravate the condition."
"If a patient has a diagnosis of tendonitis, or trigger finger, it's not appropriate to strengthen, at least until the inflammation is under control," agreed Miller. "The emphasis will instead be on stretching, and patient education about the importance of ergonomics and periodic breaks at work."
Exercises that specifically target tendon glide, such as varying fist positions, can do much to ensure the independent movement of hand tendons, inhibit atrophy of grip muscles, and reduce pain, swelling and stiffness, Hanlon explained. Range of motion movements should be introduced, since a decrease in ROM can result in weakness of the hand and related structures.
Vital to any rehab program for tendonitis or repetitive strain is striking a balance between too little grip strengthening, which does little to reduce swelling and tightness, and too much, which will induce swelling, Hanlon pointed out. In more severe cases, treatment of edema with compression sleeves or selected modalities may be indicated before light strengthening can begin.
Whatever the condition or cause, strengthening grip is as crucial a link as any in a successful rehabilitation program. "Sometimes PTs will tend to move patients more quickly through a hand strengthening regimen," Bielefeld observed. "CHTs will tell you that it's crucial to slow it down, taking the time to properly move the program along. Going too fast can create real problems." Don't overlook the importance of a strict, well-planned and steady strengthening regimen because without a strong grip, even healthy, pain-free and limber hands can make a patient's life unbearable. *
Jonathan Bassett is on staff at ADVANCE, and can be reached at firstname.lastname@example.org.