Active wrist exercises

Flexion

Bend your wrist forwards.

Extension

Bend your wrist backwards.

Ulnar deviation

Put your hand on a flat surface.

Bend your wrist in the direction of your little finger.

Radial deviation

Put your hand on a flat surface.

Bend your wrist in the direction of your thumb.

Supination

Glue your elbow to your waist, then turn your wrist so that the palm faces up.

Pronation

Glue your elbow to your waist, then turn your wrist so that the palm faces down.

Contributors

Liz Alden George Vasilopoulos

Desk health exercises

General exercise advice

It is generally acknowledged that regular exercise can produce natural pain relieving chemicals in the body and increase general wellbeing. Starting a programme of regular exercise can be the start to increasing your activity levels and go a long way to boosting your rehabilitation. Remember to always start any new activity slowly and cautiously.

NHS Direct recommends the following in regards to exercise. A full transcript can be found at NHS Direct.

Exercise can:

reduce the risk of heart attack
reduce the risk of developing long-term diseases
increase life expectancy and improve quality of life in later years
increase confidence
improve posture
provide natural pain relief
have a positive effect on breathing, blood supply, muscles, and bones.

For those beginning a new exercise routine, ‘little and often’ is most beneficial and is particularly useful for those who have difficulty finding spare time.

Those wanting to improve their health by taking up regular moderate exercise may try taking a brisk walk or doing a few laps of the local swimming pool. As little as a brisk thirty minute walk, five times a week will provide some of the most important health benefits.

Because exercise increases energy levels this may also alleviate tiredness and stress after a long hard day.

If you have not been physically active for some time, gentle, steady progress is most important. Be careful not to overdo it at first, and check out the safety advice before you start.

One good way to start exercising is to carry on with your everyday routine, but do things in a way that requires a bit more energy. Build these activities into your daily lifestyle and try to become a little more active every day:

Try getting off the bus or train a stop early and walking the rest of the way.
Use the stairs instead of the lift
Walk or cycle, rather than drive

To increase your level of activity you can gradually progress to more demanding exercise on a more regular basis. If possible, this should make you breathe harder and a little faster, and raise your pulse.

The key is to do activities that you enjoy and that you can do on most days of the week. Just half an hour of moderate activity a day is all it takes to improve overall fitness and health.

For example:

Take a brisk walk (not just a stroll)
Cycle slowly
Have a leisurely swim
Light gardening
Low-impact aerobics
Dancing
Play tennis

Make sure that you drink plenty of water when exercising to prevent dehydration.

Suggested exercise

You may be interested in finding out about local classes in Pilates, Yoga or Alexander technique.

Pilates is a series of exercises designed to improve flexibility and strength through a variety of stretching and balancing movements. Pilates especially appeals to dancers because the workout aids in flexibility without causing muscles to bulk. It is also said to prevent injury and improve posture. Because Pilates are gentle exercises without a lot of bouncing around or muscular stress, it’s recommended to those seeking rehabilitation through physical therapy.

Yoga is a series of gentle exercises, designed to achieve balance between the body and mind. It is best taught by qualified instructors and is said to encourage physical suppleness and flexibility, improve breathing and blood flow, and help prevent anxiety and stress-related problems.

Alexander Technique is a method that works to change movement habits in your everyday activities. It helps to make you aware of balance, posture and co-ordination and aims to help you to relearn the correct way to hold and to move your body and release unnecessary muscular tension.

Contributors

Liz Alden thomastn George Vasilopoulos

Desk health ergonomics

Work station advice

The symptoms you are experiencing are likely to have arisen as a result of a combination of factors which include your work habits, the type of work you do, your workstation arrangements and your hereditary makeup.

The same basic principles apply when preventing and recovering from work related upper limb conditions.

Apply sound ergonomic principles to your work station set up
Be aware of ‘good’ postural habits and typing techniques
Take regular, effective breaks from static postures
Carry out regular exercises and stretches to counteract static postures

Good posture at a keyboard

Head: directly over shoulders, about an arms’ length from the screen
Shoulders: relaxed and down
Back: maintaining a gentle curve of the lower back, rest into the back of the chair
Elbows: relaxed at just more than a right angle
Wrists: relaxed in a neutral position
Fingers: gently curved
Knees: slightly lower than hips
Feet: firmly planted on the floor

How you work is important

As well as improving your posture and work station set up, it is vital that you also look at the way you are working. The amount of time spent in a static posture (even if your posture is excellent) can have an effect on your symptoms.

It is important that you regularly change your posture and/or task. These are some suggestions for varying your work patterns.

Every 10–20 minutes (but before your pain increases) STOP working with the keyboard and mouse. Perform one or more of the following:

Take your hands off the keyboard and mouse
Do some simple stretching/refresh exercises
Have a drink of water
Correct your sitting posture
Stand up/move around
Do another task not requiring a PC
Try the 20–40–60 pattern of breaks

Choosing a chair

Prolonged sitting can result in muscle fatigue around the shoulder, neck and back; bad posture can contribute to this. If you commute to work, sit most of the day, have lunch at your desk and relax in the evenings, you could be sitting for 12 hours a day. Maintaining ‘good’ posture is important in preventing WRULD. Using an adjustable chair, appropriately and regularly adjusted for you, combined with good work habits can help you to work more efficiently and comfortably.

General considerations when sitting:

Your feet should be flat on the floor
Maximise the contact between your back and the back rest
The seat depth should provide support under your thighs
A five star base will give most stability
Arm rests should not obstruct access to the desk
Use the available adjustments
It may take experimentation to get the most comfortable position
Regularly check the adjustments, someone else may have used your chair and the position may ‘sink’ with time
Your posture may need to change with a change in task

A good chair should be adjustable in:

Seat height: To fit the height of the user and the height of the desk
Seat Tilt: A variety of angles to allow different postures for different tasks
Seat Depth: There needs to be a 1–2 inch space between the back of your knees and the edge of your seat
Back Height: Should adjust up and down to fit the individuals natural curves
Back Contour: The back of the chair should make full contact with your back and support the lumbar spine
Back Angle: The back should adjust independently from the seat tilt to provide back support in a variety of positions.

Contributors

Liz Alden thomastn George Vasilopoulos

Desk health typing tips

Typing technique

Keep your wrists straight

For the wrist to be straight your hand must be parallel to the floor and the middle finger must be aligned with the centre of the wrist.

Don’t rest your wrists while you type

When you type, let your hands float above the desk/keyboard. Rest your forearms when you are not typing. Move from your shoulder not your wrist, get used to using your whole arm to move your hands over the keys.

Avoid stretching the fingers to reach keys

Move your arm from the shoulder, position your fingers over the keys and then strike.

Keep your fingers curved

Typing with thumbs and little fingers upraised is a common problem.

Let your hands rest by your sides. Keeping this relaxed position, bring your hands to the keyboard. Your fingers should be curved. Gently hit the keys with your fingertips. By relaxing the thumb you tend to relax the whole hand.

Use fingers from both hands

Use one finger from each hand to strike the keys and keep them in a good position while you do.

Use a light touch

Consciously try to use the lightest touch possible.

Basic typing technique

Do:

Sit up straight with back supported
Keep feet flat on the floor
Move from your shoulder
Keep your wrists straight
Keep your fingers curved
Use a light touch
Take frequent breaks
Keep nails short!!

Do not:

Slouch
Rest your wrists on a wrist rest
Stretch your fingers
Move your wrists
Tense your fingers
Pound the keys
Type for hours without a break

Refresh Exercises

If you are experiencing discomfort, carrying out some circulatory and mobilising exercises every 20-30 minutes should help you to control your symptoms:

Take your ear to your shoulder, repeat to the other side
Turn your neck to look to the right then left
Pull your chin gently backwards to produce a ‘double chin’
‘breast stroke’ with your arms
Stretch your forearms
Circle your shoulders backwards
Turn and look behind you
Stand up, turn around and sit back down again

After performing a selection of the above, which should take no longer than a minute, check your posture and return to work.

Contributors

Liz Alden thomastn George Vasilopoulos

Managing with a hand or wrist injury

Helpful advice around sleeping, bathing and pain management after hand or wrist injury or hand or wrist surgery.

Sleep

After injury or surgery pain and the discomfort of your cast or splint can make it difficult to sleep. It is also recommended to try to keep your arm elevated but this positioning can also make it more difficult to get a good night’s sleep. Lack of sleep can affect pain and make it harder to concentrate. It is common to find your quality of sleep is poor after an injury or surgery.
Using cushions or pillows to support your arm can help to keep it elevated and make you more comfortable. It must be raised above your heart. Taking some painkillers before bed can help manage the pain; it is common for pain to be worse at night and this should settle in the first two weeks. Do not take your splint or cast off unless instructed to do so by your therapist.

There are some basic principles of sleep hygiene that can be useful to try to improve your quality of sleep:

Try to avoid screens one hour before bedtime
Try some relaxation before bed such as calm app or headspace app
Try to go to bed at the same time every night
Exercising during the day can improve your sleep at night, however do not exercise just before bedtime and discuss with your therapist what exercise is safe to do
Pay attention to food and drink intake before bed: Feeling hungry or overly full at bedtime means that you're less likely to get comfortable sleep.
Avoid caffeine after midday.

Bathing

Keeping your arm clean and dry is important when wearing a splint or if you have a wound that is healing. This is to limit the risk of infection and allow wounds to heal without delay. If you don’t have a wound the splint is worn in the shower to ensure your injury is protected and you do not use your hand by accident or by mistake.

It is possible to purchase a waterproof cover, there are several companies who offer products that ensure no water can get in and they will deliver in 24 hours (see picture opposite). However it is also possible to use a plastic bag taped around your arm; if you choose to do this please keep your hand upright as water often can get inside if the arm is not elevated.

Pain

Some pain is normal post injury and post-surgery. Painkillers may be prescribed by your surgeon or over the counter medicine recommended. Ask the pharmacist in your local chemist if you need advice. Often the worst of the pain will settle in two weeks. However, ensuring you are getting enough sleep can also ease pain. Keeping your arm elevated above your heart can limit the throbbing pain that will be worse if you hang your arm down.

Try to get involved with small everyday tasks you can complete with your unaffected hand or spend time with friends or family – our pain is often worse when we have no distraction. Pain is also expected as you start exercises, this is completely normal and will improve. It can be useful to complete your exercises 20-30 minutes after taking pain relief when the effect is strongest. Discuss with your therapist what pain you are experiencing and they can advise you how to manage this. Using heat, such as a wheat bag or hot water bottle can ease pain but if you are very swollen ice can help. Ask your therapist for advice.

Information and resources

NHS sleep hygiene

How to get to sleep

Relaxation (all free from the app store)

Headspace app
Hand therapy app—video n°81 Relaxation and Mindfulness
Calm app

Waterproof protectors

Contributors

thomastn George Vasilopoulos

Joint protection and energy conservation

Joint protection principles require the use of a series of positive techniques that can help to preserve your joints and reduce pain. It is a “style of life” that once learned becomes second nature. It is not designed to make life complicated. It is designed to encourage independence.

The main methods of joint protection

Use joints in a good position.
Avoid activities that do not allow for a change in position.
Respect pain.
Avoid tight grips or gripping for long periods.
Avoid actions that may lead to joint deformity.
Use one large joint or many joints.

Use joints in a good position

Joints work best in certain positions. When they are used in the wrong position, such as twisting, extra force is placed through the joint and the muscles are unable to work as well, eventually causing pain and deformity.

Avoid activities that do not let you change the position of your hand

When you are in a position for a long time your muscles get stiff and pull the joint into a bad position. The muscles also get tired quickly and so the force is taken up by the joint and not the muscles leading to pain and damage.

Respect pain

The nature of arthritis means that you may always have pain. If pain continues for hours after an activity has stopped, this means that the activity was too much and should have been changed or stopped sooner. Your therapist will talk to you about the many ways of dealing with pain, such as the use of splints, saving energy, learning relaxation methods, planning the day ahead or using equipment or gadgets to help you with certain activities.

Avoid tight grips or gripping for long periods

Gripping tightly will increase your pain and may damage your joints further. It is better to avoid it. Your therapist will discuss ways with you such as:
Using thicker or padded pens for writing.
Resting books on a table or book rest.
Using a chopping board with spikes to hold vegetables.
Using non-slip mats under bowls to hold them.
Allowing hand washing to drip-dry rather than wringing it out.
Relaxing your hands regularly during activities such as knitting or writing.

Avoid activities that could lead to deformity

Damage to your joints could lead to deformities in your hand, such as your fingers appearing to drift in the direction of your little finger (ulnar deviation) or your individual fingers bending or straightening in unusual positions (swan neck deformity). Activities can be changed to avoid these.
When turning taps or opening and closing jars, use the palm of your hand and use one hand to open and the other to close. Remind others not to close them too tightly.
Use a flat hand where possible such as when dusting or wiping.
Try to use lightweight mugs with large handles rather than small teacups so pressure is not put on just one or two fingers.

Use one large joint or many joints

Stronger muscles protect large joints so it is better to use large joints where possible, or try to spread the force over many joints.
Use the palms of your hands and not your fingers when you carry plates or dishes.
When standing up from a chair, try to rock gently forward and use your leg muscles to stand up rather than pushing from your knuckles or wrists.
Carry light bags from a strap on your shoulder rather than your hands.
Use your bottom or hips to close drawers or move light chairs.
Use your forearms to take the weight of objects when carrying, not your hands.

The main methods of energy conservation

Balance rest and activity.
Organise and arrange space.
Stop activities or parts of them.
Reduce the amount of weight you take through your joints.
Use equipment that saves energy.

Balance rest and activity

It is important to balance your rest and activity to allow your joints to rest and repair. Stop before you feel tired or are in pain and avoid activities that you can’t stop when you need to.
Try to plan ahead. Write a weekly or daily diary with activities in red and rest times in blue. Think about what you need to do and space the harder activities out over time.
Activities such as vacuuming, ironing and cleaning windows mean that you are doing the same movements lots of times and keeping the hand in the same position for long periods of time. Try to do them for very short periods, or where possible get someone else to do them for you.

Organise and arrange space

Prepare your work areas so that everything you need for that activity is there. Store items you use often in places that are easy to reach and keep things in small refillable containers, rather than large, heavy jars.

Stop activities or parts of them

Use clothes that are easy to care for
Make the bed on one side and then the other.
Soak dishes before washing them and let them drip dry.
Where possible use tinned, frozen or prepared foods.
Hang items within easy reach.
Where possible get someone else to help with activities.

Reduce the amount of weight you take through your joints

Consider wheeled trolleys rather than carrying things.
Slide pans where possible and use a wire basket or slotted spoon to drain vegetables
When you buy new equipment, make sure it is lightweight.
Use a teapot and/or kettle tipper and fill the kettle with a lightweight jug.

Use equipment that saves energy

Your therapist will discuss with you some of the things that are available to buy.
Automatic washing machines, frost free freezers and food processors are all energy saving devices however and simple things such as sharp knives use less pressure and so less energy.

Should I exercise my hands?

It is important to maintain the amount of movement you have in your joints so that you are able to use your hands as much as possible. You may find that without regular exercise your hands feel weak and activities become more difficult.
Exercise can help to relieve pain, keep bones and muscles strong and keep your joints moving. Strong muscles around your joints can help keep them in a good position, but do not overdo your exercises or use weights or resistance as this may harm your joints.

Do I need to wear a splint?

Your therapist will talk to you about wearing a splint. They can be used to rest a joint and allow the muscles around it to relax. This can help reduce swelling and pain. Splints can also be used to prevent deformities around the joint or stop existing deformities from worsening. It is often advisable to wear one during activity to support a joint and restrict movement.
There are various types of splint and your therapist may provide you with more than one.
A thermoplastic resting splint can be made, which due to its strength can also be used during activity to restrict movement around the joint. Softer splints made from neoprene are also available that will allow more movement.
Other therapy tools that people have found useful are Lycra gloves worn at night and hot or cold gel packs. Your therapist will talk about your symptoms and your daily activities.

Contributors

thomastn

How to access sick pay/employment support following hand Injury

Why can’t I work?

Having a job is an essential part of most people’s lives. When something unexpected happens and you find yourself unable to work it is important to know your options.

With most hand injuries the body takes time to heal and repair; the tendons and bones take a few months to regain strength.

Returning to work, particularly heavy or manual jobs too soon can disturb the healing process or cause further injury, on-going pain and poorer outcomes.

We understand that not being able to work for 8-12 weeks is a significant period of time and may affect you financially.

There are a few ways you can access financial support during this time:

If you are unable to work due to your hand or wrist injury you may be eligible for Statutory Sick Pay (SSP):

To qualify for Statutory Sick Pay (SSP) you must:

be classed as an employee and have done some work for your employer
earn an average of at least £120 per week
have been ill for at least 4 days in a row (including non-working days)

How many days you can get SSP for depends on why you’re off work.

You only have to give your employer a fit note (sometimes called a sick note) if you’re off sick for more than 7 days in a row (including non-working days).

You can get a fit note from your GP or hospital doctor.

If required by your employer your physiotherapist or occupational therapist can provide advice and guidance on your return to work. This is called an Allied Health Professional (AHP) Health and Work Report and can help employers understand what you are able to do at that stage of your recovery. This is not a sick note and cannot be used for SSP.

If you are an Agency worker you are also entitled to Statutory Sick Pay.

How can I start this process?

Tell your employer as soon as possible and ensure you have a fit note/ sick note. You must usually tell your employer within 7 working days.
Go to Gov.uk to access the statutory sick pay form, this should be completed with your employer.

What if I’m self-employed?

If you are self-employed you are not entitled to statutory sick pay (SSP) however you may be able to claim universal credit or employment and support allowance (ESA).

Universal Credit is a payment to help with your living costs if you are unable to work.

Employment and support allowance provides you with money to help with living costs if you’re unable to work. You cannot apply for ESA or universal credit if you are getting SSP.

You cannot get universal credit or income-related ESA if you have savings or investments worth over £16,000.

You can apply for both universal credit and ESA online and may be eligible for both.

How can I access more help?

Each borough will have a Citizen’s Advice Bureau (CAB), a network of independent charities.
They provide confidential advice online, over the phone and in person for free.
Help to Claim is part of CAB and can support you in the early stages of your Universal Credit claim.
They can help you complete the relevant paperwork needed to access financial support.

Please note that following a successful application there might be a wait to receive your first payment.

For more information search:

Gov.UK statutory sick pay: https://www.gov.uk/statutory-sick-pay
Citizen’s advice bureau (CAB): https://www.citizensadvice.org.uk/
Universal Credit helpline Telephone: 0800 328 5644

Talk to your employer if you think:

the decision not to pay you SSP is wrong
you’re not getting the right amount of SSP

You can ask them for a reason. If this does not sort the problem, contact HM Revenue and Customs (HMRC).

HMRC statutory payment dispute team
Telephone: 03000 560 630
Monday to Thursday, 8:30am to 5pm Friday, 8:30am to 4:30pm call charges apply.

Contributors

thomastn

Coping with stress following hand injury

Information to help you understand and have more control over your experience

It’s not just you

Following a hand injury, you will be seen by the medical and therapy team to manage the physical problem. However, the consequences are greater than just the physical. Your injury may mean you are unable to work or carry out your normal activities and it can be difficult to manage even the most basic of day to day tasks. This can be distressing but most people overcome this in the first month or so. It is important to be aware that feelings of frustration or not feeling like yourself can be a normal response to injury.

Since 1986 (Mendelson et al, 1986) research has shown that people with hand injuries can also experience symptoms of post traumatic stress such as nightmares, flashbacks and difficulty concentrating. This is normal and can be expected in the first 3 months. One of the big myths we work with all the time is that the size and location of injury relate to the level of psychological distress. This is not only untrue, but also unhelpful to those who have smaller and less visible injuries. Sometimes these things can’t be resolved on their own and you may need some help to work through them.

If you have been experiencing the following symptoms for several weeks and there is no sign of improvement you may need help:

You have disturbed sleep or nightmares and may find it difficult to concentrate in the day.
You performance at work has suffered since the injury.
You feel emotionally numb.
You may feel you want to talk about what happened yet feel you don’t have anyone to tell.
You find you are easily startled or agitated.
You relationships seem to be suffering since the incident.
Someone you are close to tells you they are concerned.
You find it hard to look at your hand or scar and want to always cover it.

How can I help myself?

Do tell people what you need, talk with someone you trust.
Try to get a good night’s sleep.
Reduce outside demands on you so you can focus on recovery.

IAPT

IAPT (improved access to psychological therapies) was set up by the NHS in 2008 to address the gap in our healthcare system for the psychological side of our wellbeing. IAPT provide talking therapies such as counselling and cognitive behavioural therapy (CBT). They will decide with you which approach will be the most helpful.

If by reading this leaflet you feel you may benefit from some help coming to terms with your injury and how it has affected you then please make an appointment with your GP. Some services allow you to refer yourself but for others you will need to speak with your GP. NHS Choices website has a search option for IAPT; it will tell you which service is closest to you based on your postcode and whether or not you can self-refer.

It also provides information on waiting times.

How can I help myself?

Don’t be ashamed of your feelings, they are a normal response to a stressful event.
Don’t keep quiet about how you are feeling.

How to get help

NHS psychological therapies services (IAPT)
Contact your GP or NHS111 about possible symptoms of anxiety, depression or post-traumatic stress
Phone: 111 (NHS non-emergency helpline)
Text: 18001 111

Contributors

thomastn

Guide to therapy putty purchase

The hand therapy department does not recommend any single company over another. This leaflet has been designed to provide a resource of several purchase options.

Please note colours may vary across providers so ensure you purchase based on your therapist’s strength recommendation rather than colour. Prices range from £3.36- £65.75.

NRS Healthcare

www.nrshealthcare.co.uk
Search: therapeutic putty
Strengths available: extra soft; soft; medium/soft; medium; firm
Weights available: 57g; 454g

Patterson Medical

www.pattersonmedical.co.uk
Search: therapy putty
Strengths available: super soft; soft; medium soft; medium; firm; extra firm
Weights available: 57g; 85g; 113g; 454g; 2.3kg

Amazon

www.amazon.co.uk
Search: cando therapy putty
Strengths available: extremely easy; very easy; easy; medium; difficult; very difficult
Weights available: 56g; 85g; 113g; 450g

Sensory Direct

www.sensorydirect.com
Search: putty
Strengths available: soft; medium/soft; medium; firm
Weights available: 56g; 450g

Sissel UK

www.sisseluk.com
Search: theraputty
Strengths available: extra soft; soft; medium; strong; extra strong; set of 5
Weights available: 85g

PhysioParts

www.physioparts.co.uk
Search: cando theraputty
Strengths available: xxlight; xlight; light; medium; firm; xfirm
Weights available: 56g; 500g

Contributors

Liz Alden George Vasilopoulos

Guide to purchase of therapy supplies

Please be advised the hand therapy department favours no single company or provider over another. This leaflet has been designed to provide a resource of several purchase options.

Please liaise with your therapist for details of purchase recommendations specific to your treatment plan.