Hand Therapy Explained: What Happens After the Surgeon Finishes?

Every day we rely on our hands for the simplest tasks — typing, cooking, driving, even holding a coffee. But when injury or surgery affects the hand, wrist, or elbow, even basic activities can suddenly become impossible.

In this episode of Aussie Med Ed, Host and Orthopaedic surgeon, Dr Gavin Nimon sits down with Charlotte Nash, accredited hand therapist and occupational therapist, to explore the fascinating world of hand therapy and upper limb rehabilitation.

Charlotte explains how occupational therapists help patients rebuild meaningful function after injury — and why early rehabilitation can make the difference between full recovery and long-term stiffness or pain. 

Hand Therapy- what is it

We cover:

• What occupational therapy actually is
• How hand therapists work with surgeons and GPs
• Why early movement and rehabilitation matter
• The surprising role of splints, desensitisation, and oedema control
• When injuries should be referred urgently
• The psychological side of recovery
• New technology in rehab including VR and 3D splinting

If you're a medical student, GP, or clinician managing upper limb injuries, this episode will give you a clearer understanding of what happens after the diagnosis and surgery — and how multidisciplinary rehabilitation helps patients get their lives back.

Heidi Health- AI transcription Software

Aussie med ed is sponsored by HEIDI HEALTH, who provide Heidi AI transcription platform. The team at Heidi have told me that Heidi is the AI scribe built in Australia and trusted in nearly two million consults each week and that Students and trainees get free access to Heidi Pro, which they believe will aid quicker, smarter notes, allowing more time for patients.:-

Aussie Med Ed is supported by HealthShare.

HealthShare is a digital health company that provides solutions for patients, GPs and specialists across Australia. Two of HealthShare's  products are Better Consult, a pre consultation questionnaire that allows GPs to know a patient's agenda before the consult begins,  as well as HealthShare's Specialist Referrals Directory, a specialist and allied health directory helping GPs find the right specialist.

Aussie Med Ed is sponsored by Avant  Medical Indemnity: They state that they offer holistic support to help the doctor practice safely and believe they have extensive cover that's continually evolving to meet your needs in the ever changing regulatory environment.

Transcript

Speaker: 0:31

every day, millions of Australians go about tasks so ordinary. We barely notice them. From preparing breakfast to tapping on a keyboard, but for patients recovering from an illness or injury that affects the use of their hand, even the simplest task can suddenly feel impossible. Today on Aussie Med Ed, we are exploring the world of hand therapy. In the profession of occupational therapy, the profession dedicated to restoring meaningful daily function. Now this work becomes even more specialized when we zoom in on the hand, one of the most intricate tools of the human body.

Dr Gavin Nimon: 1:01

Good day and welcome to Aussie Med Ed. The Aussie style Medical podcast a pragmatic and relaxed medical podcast designed for medical students and general practitioners where we explore relevant and practical medical topics with expert specialists. Hosted by myself, Gavin Nimon, an orthopaedic surgeon, this podcast provides insightful discussions to enhance your clinical knowledge without unnecessary jargon. I'd like to start the podcast by acknowledging the Kaurna people as the traditional custodians of the land on which this podcast is produced. I'd like to pay my respects to the elders, both past, present, and emerging, and recognizing their ongoing connection to land, waters, and culture. I'd like to remind you that all the information presented today is just one opinion, and there are numerous ways of treating all medical conditions. It's just general advice and may vary depending upon the region in which you're practicing or being treated. The information may not be appropriate for your situation or health condition. And you should always seek the advice from your health professionals in the area in which you live.

Speaker: 1:52

Joining us today is Charlotte Nash, an experienced occupational therapist and accredited hand therapist, and the proprietor of full circle hand therapy. She's dedicated her career to upper limb rehabilitation, guiding patients through recovery from injury, surgery, and chronic conditions affecting the hand, wrist, and elbow. Through full circle hand therapy Charlotte leads a multidisciplinary team, that works closely with GP's, surgeons and other allied health professionals to deliver evidence-based patient-centered rehabilitation. it's great to have Charlotte Aussie Med Ed today. Part of full disclosure, one of the locations of Full Circle hand therapy is in my rooms here in Glenelg, and as such, we often work in collaboration caring for patients.

Dr Gavin Nimon: 2:32

Welcome, Charlotte. Thanks very much for coming on. Aussie Med Ed.

Charlotte Nash: 2:34

Lovely to be here. Thank you for inviting me.

Dr Gavin Nimon: 2:36

I thought I'd start off, Charlotte, I really asking you to describe what actually is occupational therapy. perhaps from a patient's perspective, medical student's perspective, what does it involve and how will they encounter you in day-to-day life

Charlotte Nash: 2:49

in day-to-day life? In a general OT sense, you would be, you'd usually see an OT in a hospital setting or be referred once you are starting to move through that rehabilitation process. I describe as OTs, as the person in your life when you've had anything that impacts how you were previously functioning in your life. And we help you create essentially a ladder to get over the wall. That is the thing that disrupted your life. So that could be anything from a mental health issue. It could be a spinal injury, it could be a brain injury, it could be just dealing with that transition As we age through life in children, it can be what some sort of diagnosis that may be preventing that child getting the best out of their life in their future. And OTs will look at how that person may be previously functioned, or that family or community functioned around that person, and try to find tools to create a scaffold to help you over the mountain that might be the incident you've had in your life, whether that's a physical, emotional, or a neurological type injury. And obviously for me, in our space that we work in, we are often dealing with the physical side of an injury. However, it's incredible how much we have to engage that person psychologically to get the best, get them back into their best function in life.

Dr Gavin Nimon: 4:11

So there's a real holistic approach to assessing and real function based approach. Is that correct?

Charlotte Nash: 4:16

We really do and that's why a lot of our sessions, I always tell patients I'm very nosy. I ask lots of questions and it all sounds just like I'm just being distracting and everything. But what I'm really trying to ascertain is what makes this person tick and how am I going to get that person engaged in rehab to then get them the best outcomes and get them back into their life with as few complications as possible.

Dr Gavin Nimon: 4:38

So really that's the core philosophy behind occupational therapy. And how does it really work in real practice, perhaps when they patient comes along to see you, what does an assessment involve?

Charlotte Nash: 4:47

Really we're looking at how that, we're trying to understand the trauma they've had from a medical perspective. Again, in my role, we're dealing with physical injuries and we're trying to assess how to best engage that person in the rehabilitation process, whether they're a young, 20-year-old football player or they're more elderly and looking at trying to get back into their sort of hobbies in retirement. We're trying to pick do they have children at home? Do they have a dog they like to take out running? We're trying to get an assessment of who the person is and how they function in their world, where the big sort of things that maybe we are gonna have to slow them down a bit. So if they're just had a distal radius ORIF (open reduction internal fixation) we are not gonna be really letting them back on to play football for the next few weeks and how to give that information carefully. But also looking at in that timeframe, what can they be doing to get back to that goal as quickly as possible. So we're trying to find the really small parts of any task that we can let them do to make sure they feel like they're getting back into things as quickly as possible. As opposed to the old adage of pop it in a sling and don't use it for six weeks or something like that. We are looking at, even if it's something tiny like they can. Play a little bit. And sometimes parents don't always like me. With the younger ones, I say, actually a bit of rehab with using your hand and playing some computer games is actually not the worst thing in the world because at least we're doing something engaging.

Dr Gavin Nimon: 6:11

Yeah. Of obviously any injury can take a long time to recover from.

Charlotte Nash: 6:14

Yes.

Dr Gavin Nimon: 6:14

And you can't just wait for that to recover before you start the process.

Charlotte Nash: 6:17

we'll start as early as medically viable for that person and for some injuries that could be the four days post-op. For some people we give more like 10, 10 days post-op, but we are trying to find even the smallest little hook of engagement and rehab that we can at the earliest possible opportunity.

Dr Gavin Nimon: 6:35

And certainly you guys fit under the allied health profession? Yes. of which probably the average listener will know the physiotherapist is probably the well, known allied health professional. How do you differ from physiotherapy

Charlotte Nash: 6:47

in a basic OT and physio stance? Sort of when you're looking at the, those general cohorts of Allied health, I find that physio is very much about getting the muscle and the joint moving in a controlled setting. So you might be post hip surgery and we are looking at specifically getting certain goals of range of motion in a controlled environment. So that might be in the hospital on the ward, in the physio gym Once we're starting to look at occupational therapy getting involved, we are looking at what's the home environment we're trying to get that person home to? Do we need a different height chair, Do we need some help getting in and out of bed? And we are looking at how we are combining, what the physio's achieving with getting increased range of motion and increased strength. And we're looking at how we're going to put that into the home situation or into the community driving, all those sorts of different things. And we're also looking at how are they gonna engage in exercise. As well. Like how are we gonna get this medical environment where we've got someone pushing you three, four times a day, someone to be there. the patient has to take that on themselves and they have to go from patient to client and take control of their own rehabilitation process and put them back in the driving seat.

Dr Gavin Nimon: 7:59

Brilliant.

Charlotte Nash: 8:00

In hand therapy. Little bit different as a subspecialty of occupational therapy 'cause you can be a physio or an OT to subspecialize into hand therapy. And at that point, once we have our accreditation as a hand therapist, we are performing a very similar role. Like I would interchange in and out with a physiotherapy quite easily. We are doing the same exercises, same splinting. The physios I find tend get a lot of their, their training when they're going through their accreditation process is sometimes looking more at what those OT skills are and how we get that engagement. And the OTs doing the accreditation process have to really drill down on their anatomy and their exercises and becoming, so we fill the gaps of each other in the hand therapy space to come together as an accredited hand therapist. And I'd say we are very interchangeable in that subspecialty, but yet in the community you'll see that we've got slightly different roles.

Dr Gavin Nimon: 8:52

Sure. So that obviously brings me into the idea that o Occupational therapy is a university degree you obtained.

Charlotte Nash: 8:58

Yes.

Dr Gavin Nimon: 8:58

And does it vary between different countries and how many years would've been involved?

Charlotte Nash: 9:02

Yeah, so it's generally a four year degree similar to physio in that regards because I think both physio and OT have got that prac component. So essentially in both of those degrees, there's essentially a year of that degree is prac. So we're out in the community learning those different roles. We have a international World Occupational Therapy Foundation, which is the accrediting board for all OT degrees. So anywhere that is accredited has to meet certain standards for the OT degree to be recognized as an OT degree or it doesn't get accreditation. So we have all our, have our different registration boards in different countries, however. They have to be an accredited degree. You can't just create an OT degree without that. International accreditation.

Dr Gavin Nimon: 9:48

Brilliant. And then the obviously different subspecialties you've mentioned hand therapy, which is your area. Yeah. What, how many other main subspecialties are there for occupational therapy?

Charlotte Nash: 9:56

The ones I would think of at the top of my head, obviously pediatrics is a huge area. Then we've got geriatrics. So at each end of the age spectrum then you would have things like prescription, wheelchair fitting, vision, OTs, people who deal specifically with people with vision issues, low vision. Driving is a big one. So there is a whole group that is just on, competent to drive. And those driving assessors, we would then have neuro burns. Burns is a little bit hand therapy as well. Acquired brain injuries. Then we would have, Community OTs and home modifications is another and I'm talking more complex home modifications. We're all able to put a grab bar in, but I'm talking a full bathroom renovation hoist that complex. Home modifications

Dr Gavin Nimon: 11:22

Occupational therapists fit into occupational assessments as well following your work cover injury, for

Charlotte Nash: 11:27

instance? Yes. Yeah. Occupational rehabilitation, that's actually where I started,

Dr Gavin Nimon: 11:31

right.

Charlotte Nash: 11:31

Was in that occupational rehabilitation space where you're trying to understand a whole range of different types of employment and what effect that has on the body, and how different injuries will require a different pathway to get that person back to that working space.

Dr Gavin Nimon: 11:48

You've headed down the pathway of hand therapy. How much further training is that involved?

Charlotte Nash: 11:52

It's probably one of the more involved ones we, in Australia, uk, US Europe, you have a sub specialty board. So in Australia it's called the Australian Hand Therapy Association. And essentially it takes two years worth of training, which you can spread out over five. But once you hit five years, you have to start redoing courses to become an accredited hand therapist. So you can join as an associate member so long as you've got sort of 12 months experience. And you've usually need a letter from an accredited hand therapist to say, yes, this person is good to join our association. And then once you're on that associate pathway, you're generally participating in that accreditation journey, which requires you must do certain. Accredited courses. So again, the A HTA has run through and accredited ISOs accredited courses to meet certain standards. There's four foundation courses. Then we have to do electives and you have to do so many hours of mentoring and practical experience within just hand therapy. So only the hours that you do, which are hand therapy related count to that. And once you've ticked those things off, then you go, you complete that accreditation process. In America, they have what's called the certified hand therapist exam.

Dr Gavin Nimon: 13:17

Right,

Charlotte Nash: 13:17

which is a four hour exam. and you have to have done so many hours practical to be able to sit that exam. and that's made up part of my accreditation pathway with the Australian Hand Therapy Association.

Dr Gavin Nimon: 13:28

Excellent. And what took you down that path? Why did you decide to head down the path of hand therapy?

Charlotte Nash: 13:33

I can remember and when I applied to do occupational therapy, like probably a lot of people didn't really understand a hundred percent of what was involved in the degree. And I can remember studying this degree going, this is good. But I hadn't quite found what made me tick. And then we started our semester in hand therapy and splinting. And I can remember coming out of my first anatomy lecture and it was like the moment I went, this is amazing. This is what I wanna do. I loved my anatomy labs, I love human biology and biochemistry, And that all coalesced into that first lecture on a hand therapy. And I was like, that's my pathway.

Dr Gavin Nimon: 14:12

So what are the main conditions you might see as a hand therapist? I know there's a large number. What are the main ones you come across?

Charlotte Nash: 14:18

We would see, I tend to break them into what we would look at as a conservative group of injuries where we're trying to manage people and avoid having to go down that surgical pathway. And that would be a lot of tendinopathies overuse injuries. Yeah, anything that has a high inflammation background, like it's an, we are managing an inflammatory response to arthritises. Again, just trying to help people manage pain and discomfort. And then we've got our postoperative type conditions. Some of those are like if you've got carpal tunnel, we might do a bit conservatively to see if we can help that person. And then that might be a postoperative carpal tunnel as well. Lots of Orthopaedic things like the wrist fractures, distal radius, wrist fractures, Phalangeal fractures, metacarpal fractures, issues with the carpal bones, ligamentous repairs, and stabilizations, again, postoperatively. Then we would have looking into different soft tissues. Things like flexer tendon repairs, extensor tendon repairs, grafts, skin issues, flaps, things like that.

Dr Gavin Nimon: 15:22

Brilliant.

Charlotte Nash: 15:23

So yeah, so We do tend to look at things, conservative or postoperative, and we have different ways of managing those different pathways. So deQuervain's (tenosynovitis) is quite common. pre and post, we've got tennis elbow, golfers elbow less common, the neuropathies, median nerve, radial nerve, ulnar nerve. Trying to help people manage those sorts of things. And these could be caused by cumulative type buildup or trauma, or they could be caused acutely by an incident depending on

Dr Gavin Nimon: 15:56

What about things like post-stroke recovery? Are you involved in that as well?

Charlotte Nash: 15:59

Yes, definitely, because you'll get that hemiplegic effect. We would obviously be focused on the upper quadrant, same with like cerebral palsy anything like that where you've got loss of function in that upper quadrant. In our background. Obviously in hand therapy, we're obviously focused here, but then in the broader space of someone who has had a stroke, it would be looking at that whole person and how that whole person as an OT assists that person getting their function back and goes back into that home environment post rehab.

Dr Gavin Nimon: 16:28

One of the more common things I see that usually I think would be better be seen straight off with the hand therapist, be something like proximal interphalangeal injury, joint injury Are there other conditions too that you might see that a GP could really refer straight off to you first?

Charlotte Nash: 16:40

certainly tennis elbow is one because we would like to try it. Try a lot of conservative measures with that prior to any sort of surgical intervention. deQuervain's again, that's another good one. If we catch things early and we've got a window where we are not getting into quite an entrenched pattern of injury, then the deQuervain's, carpal tunnels any sort of flexor or extensor tenosynovitis where we can try to rest and mobilize at the same time is quite useful. That works quite well in combination. If that person doesn't respond reasonably quickly then combining that with a cortisone injection and that rehabilitative process or the, while monitoring at what point we're like, we need to get that surgeon involved and take that next step. I sort of describe it to people as like the management ladder and if we check these things off, then We providing best care.

Dr Gavin Nimon: 17:31

Yeah, certainly trying non-operative measures and being supported by Allied Health like yourselves is a first line of treatment for most things that. Don't need urgent surgery, that's for sure. Are there things that worry you when you see them? that have really worried you and send 'em straight back to a surgeon or a general practitioner

Charlotte Nash: 17:48

I think when looking at pain management, how that person is coping with the injury and how that initial response is being managed, and how that person psychologically is managing that injury. And that's where we might look at getting even psychology or adjustment to injury and counseling put in place really quickly so that person can just have a bit of that catastrophizing to settle down a little bit more. from a clinical perspective, if we're looking at something where we see. There's abnormal amounts of swelling or the pain is very acute. or trigger finger, if we've got locking happening, if we've got more significant factors than what we can think, we will manage, we'll get someone involved straight away. Because I do believe that getting people through that early intervention and getting things before they become chronic is really important. So I would be saying that, yeah there's that psychological profile, but there's also that immune response profile. Maybe if someone has got underlying conditions, do we have diabetes, do we have history of immune issues, cancers, anything like that, then we start to need to make sure that we're not missing anything. And obviously if we've got any concerns, things like making sure we're getting the radiology involved. So someone might come to me and they may have come from the trainer on the football field and they go, oh, just dislocated. Did it just dislocate? So I want to be making sure that I have not yet got my x-ray vision installed, so I need to make sure I've got radiology behind me. Have we got actual evidence that this is just a dislocation or do we have a fracture that we're actually dealing with as well? Anything where I see something with, if it's an acute injury, if I see really deep bruising, so it might not be extensive, but you'd have that really deep purple bruising coming out within 24 hours. I'm like, that's quite fracture risk. So I'm really looking at those acute and like very point tender, swollen immediately, deep bruising. I make sure I get that rechecked and scanned and that quick pathway might be a GP just to say, can we get a referral? If we know someone is down there and I'm only quite worried, I'll just reach out straight away and say, it may not always be the most right pathway, but my main thing is getting people the care they need really quickly.

Dr Gavin Nimon: 20:00

So what you're saying is of anything significant that. Is more than a minor trauma. You're always worried about a fracture being missed

Charlotte Nash: 20:06

Even same with infection. Like you can have someone come in and then, but by the time they get to you 24, 48, 72 hours later, if there's an, there's a different type of redness that I always say is angry. If we've got any signs and that could, it could be anything from a cellulitis to someone having a hematoma that created an abscess or they've had surgery and it's six weeks later and something has gone amiss. And if I'm seeing angry signs of infection, I'm not missing a beat on that. I'm making sure that someone is checking that out really quickly because again, getting control of an infection is really important quickly.

Dr Gavin Nimon: 20:46

Yeah.

Charlotte Nash: 20:46

And not letting it linger.

Dr Gavin Nimon: 20:47

So make sure we don't miss a fracture or infection.

Charlotte Nash: 20:50

Yeah. And I think part of that is I was, I remember having a, this was more, probably more of a pain thing where you've got two cases. One is the football player on field does a fractured middle phalanx barely skips a beat, straps it up, trainer, put some of the magic cold spray on, put some tape on back on the field, plays the rest of the game. Then you've got the solo violinist about to go into her major concerto season for the year and she slams her finger in the car door as she gets out. Same fracture, completely different psychological management.

Dr Gavin Nimon: 21:25

Yeah.

Charlotte Nash: 21:26

The anxiety, the stress and everything about a finger being injured for the violinist is completely acutely a different management pathway to the football player who's gone and played another 90 minutes of football with their broken finger.

Dr Gavin Nimon: 21:38

Yeah.

Charlotte Nash: 21:39

And just how you manage those expectations can create Yep. The injury is the same, but the pathways of how we get to that end point can be quite different.

Dr Gavin Nimon: 21:46

Yeah. So you gotta assess the whole patient as we do. Yeah. obviously you can't really manage a patient with one consult.

Charlotte Nash: 21:53

No.

Dr Gavin Nimon: 21:54

And obviously you have to assess a patient first, ascertain what their problem is, and coordinate a program for that individual.

Charlotte Nash: 22:02

generally speaking where that first consultation, and often, this is what I say to my team of therapists. Things are getting tricky. So if that person has come in, that person needs to leave safe. So that's our first goal. So that first consultation, if there's a fracture, if there's a surgical intervention that's being done, we need to make that person safe to go home. So that will be, if you've taken a backslab off, usually there's an expectation we might be putting a splint back on. Have they got the right bandages to keep their dressing safe? is the person safe? And that's the first goal. So we'll be getting information on the op note from the operation note from the surgeon, or we'll be reviewing the referral that's been coming through. We will then review x-rays. And even though the person might say yeah, it's fractured, you'll often find us seeking the actual x-ray so that we can see exactly where it's fractured. Because a mid shaft metacarpal fracture is very different to a proximal metacarpal fracture and how we manage a distal metacarpal fracture. So we want to ideally be visualizing where a fracture is what zone a tendon has been lacerated in to be creating then the pathway for the type of splint we're choosing and the exercises that we're choosing. So typically you would see us, we would be reviewing those documentations, looking at the actual hand and seeing what that hand requires, seeing what the expectations are of the patient and how we match a splint and a rehab program to that person. You would usually go away from that initial consult with some sort of device if appropriate, and the first three to five exercises that we want you getting on with. Then we would have either weekly or fortnightly appointments depending on the injury.

Dr Gavin Nimon: 23:43

And obviously every injury depends on how quickly they recover.

Charlotte Nash: 23:46

Yep.

Dr Gavin Nimon: 23:46

Tendonitis would normally take about three to four months to really settle down.

Charlotte Nash: 23:49

Yep.

Dr Gavin Nimon: 23:50

While a fracture can often, we're talking about four to six weeks, depending on. location.

Charlotte Nash: 23:54

Yep.

Dr Gavin Nimon: 23:54

Yeah.

Charlotte Nash: 23:54

And different ways people, some people will regain their range of motion back at different rates to other people. Some people will have different swelling responses. Like some people you can't push as hard as other people.'cause if we get the swelling is problematic, then we're just creating more dramas and more problem how stable the fracture is. And that can be a tricky one on the operation report.'cause we want to be getting a feel for how stable we think the surgeon has been able to secure that fracture. do we need to slow that person down, keep things a bit more steady or have we got great screw fixation and we can move that pretty much normally from the get go.

Dr Gavin Nimon: 24:35

Yeah. Excellent.

Charlotte Nash: 24:37

And the idea would be as we are only immobilizing what needs to be immobilized. So if we don't have to have a wrist involved, we won't include a wrist. If we don't have to have fingers splintered. We won't be splinting unnecessary joints. we want to be providing the most effective immobilization as possible so that everything else can be mobilized.

Dr Gavin Nimon: 24:58

Yeah. And obviously in the days gone by, but there used to be plaster of Paris. Yes. it never goes off. I've still got Plaster Paris, which I bought 20 years ago, which I still haven't got through because we hardly ever use it.

Charlotte Nash: 25:07

Still a useful tool. I still for some conditions, still pull out the plaster of Paris.

Dr Gavin Nimon: 25:12

Right.

Charlotte Nash: 25:13

Which is quite interesting. But yes, typically these days we are using the low temperature thermoplastics, which are strong light, durable remoldable, which I think is important. We don't, every time a person needs a change made to a splint, we are remolding the old splint. And we are trimming it down. So we might start with a. A wrist splint to the pip PJs down to the two thirds forearm. But every sort of week we're making it smaller and smaller so that as the injury heals, we're freeing the joints that don't need to be stabilized anymore.

Dr Gavin Nimon: 25:47

So these are those large sheets of plastic which heat up in a hot water. And then molded to the patient, perhaps you can show us a few on our little demonstration mat here.

Charlotte Nash: 25:55

So I've got a few classics. So this one, this would be a classic splint that most graduates or university students are learning how to make at university level called a posi splint or position of safe. immobilization. This would be seen in neuro situations or in ICU where someone has a stroke and we're trying to prevent contracted. Down hands and fists like this. So

Dr Gavin Nimon: 26:19

this is a, this is for the listener is a one that's going over the forearm and on the Palmer side, what we call the volar side of the hand And then also incorporating the thumb in it in this particular one.

Charlotte Nash: 26:30

Yep. So thumb is included. Fingers are slightly and comfortably extended. It's a bit of a workhorse in the OT world for splinting because it's got multiple different applications. Essentially it is immobilizing the DIPs PIPs, MCPs, wrist, and then similar joints like all the way to the tip of the thumb. And we would. Yeah, that might be used preventatively to prevent contractures, to prevent deformity, to maintain web spaces. Or it may be used if someone has had lots of extensor tendon injuries and we just need to get a bit of stillness and rest. It's a bit of a workhorse.

Dr Gavin Nimon: 27:08

And the ideal positioning for the MCPs and the PIPs in that scenario?

Charlotte Nash: 27:11

In that scenario, we would say about 70 degree flexion at the MCPs. And we like to have our ips out reasonably straight. And then the thumb is slightly or comfortably positioned in opposition. Slight flexion at the mp, probably IP straight. But you're also wanting to balance, especially if someone has tone. So if they've had a. Injury that affects like stroke, a spinal injury or they've got a, some sort of neurological situation. If someone's really flexing down, if we put them into the position that we want and don't give any care for what the body's actually doing, you can get pressure injuries under the fingers. So it's sometimes it's not always the perfect position. You might have some flexion or not quite full wrist extension, but you want that balance between not having a thumb clenched inside a fist and not being able to get hygiene. But we want something sort of comfortable and open so that when that person gradually recovers, we are not having to deal with fixed flexion deformities and things like that.

Dr Gavin Nimon: 28:12

Excellent.

Charlotte Nash: 28:13

So then we've got another workhorse in the OT world, which is called a thumb Spica. This is forearm based in this example and this immobilizes, the thumb and the wrist, again, different applications will require different. Positioning. So if we've got someone who's got a scaphoid fracture we will be making sure that the fractures aligned in the right position. If we are looking at more of a wrist issue, then we're changing the positioning of things ever so slightly. But key thing we're looking at is making sure we've got full range of motion in this instance of the fingers and in this splint we can mobilize the IP joints so someone's got reasonable function. We can actually oppose, we can use that hand quite freely. We're clearing the distal palm crease and it's easy to take on and off if that's what we want for the patient to be able to do for hygiene purposes so that we can take that splint off the shower, and that as well, the level of independence we give a patient will change at different points through someone's rehabilitation progress. So if someone has a flexer tendon laceration that's been repaired in zone two, we are managing that hygiene primarily until that tendon is safe enough to be moved.

Dr Gavin Nimon: 29:28

And so obviously with all these splints I always tell the patients that they shouldn't really be driving a car because they can't control it safely.

Charlotte Nash: 29:35

Certainly with the, we have had a few conversations with different people of in law enforcement, both lawyers, police officers, detectives. but I definitely say that if you have your thumb in a splint and your wrist and a splint, then that's definitely not driving. It's usually as well, if they're wearing a splint it's not best for them.

Dr Gavin Nimon: 29:56

Yeah.

Charlotte Nash: 29:56

Because I don't want them putting that tension or that load through that joint. So And we say it's, there was no point going through all this surgery only then to overload the joint and not let it heal correctly as we need to. And if we've seen them, if that's someone we might have seen conservatively, we'll prep them for that. We'll say you need a window of time leading up to surgery. Make sure you've got some people around you that can drive you different places. And that's where I always say as well, we try to have different locations in different aspects of OT so that your rehab is close to home.

Dr Gavin Nimon: 30:28

Yeah.

Charlotte Nash: 30:28

It's great. Like with your surgeon, you go and see the surgeon that might not be super close to home 'cause you want that person doing that thing. But the touch points postoperatively may not be so high. So you might two weeks, six weeks.

Dr Gavin Nimon: 30:41

Yeah.

Charlotte Nash: 30:41

So you make. A big drive to go and see a surgeon'cause that's the person that is doing all the work on the inside. But for rehabilitation, we try and make it close to home. So we try and make it convenient. So yes, smaller little splints that are less occlusive to the hand we say and we've checked that. That's not so problematic for driving. Yeah. And then at the right time, if they're safe to do I always say I like people to have a reasonable grip strength of 10 kilos, even though there's no rule for this. This isn't law. This is just my preferences. I like people to have at least 10 kilos of grip strengths so that they've got enough strength on a power steering vehicle to drive. I like them having an auto as well, and I like them. To be able to, at home, be able to do a three point turn and a reverse parallel park. Yeah. And once they can achieve that, I say, then you can get yourself in and out of the car park, being able to stop suddenly and stop and avoid an accident. That's where the stress comes in the hand with driving. So that's on top of the general rules. I get a little bit more specific about what I want people to be able to do before they're out driving.

Dr Gavin Nimon: 31:49

Yeah. I'm very cautious. I feel if a little lad runs out in front of the car with a chasing a ball and you haven't got perfect control of that

Charlotte Nash: 31:56

vehicle, and that's what I say if I feel like someone is gonna be a bit. Not maybe listen to that so much. I say, this is not the time to have a little kid's life on your conscience. Yeah. Because you just wanted that shortcut. And I do come down pretty hard on that sometimes. I said, one of two things is gonna happen. You're gonna hurt yourself or you're gonna hurt someone else. Just don't do it.

Dr Gavin Nimon: 32:16

Brilliant. Okay, Charlotte obviously you provide this treatment and splints, but obviously it's a two-way process. What are your tips for collaborating with, say, surgeons or general practitioners who refer to you?

Charlotte Nash: 32:28

So ultimately it starts with that referral to an occupational therapy provider. Similar to physio the client might reach out independently. if you're privately paying or using private health insurance, you don't technically need someone beyond that process to refer you to our service. So you can self-refer. Otherwise, typically someone goes to see their GP 'cause they have pain and a problem that GP may organize that referral for you. So typically they write a bit of a letter as to what might have happened. fallen outstretched hand or they might have had a baby and they've got to deQuervain's. Little bit of information. Please assess, give us your thoughts. So we'll meet that person, give them our thoughts. Sometimes we might say maybe it's intersection syndrome not deQuervain's, and We will try and feed that information back via another letter back and email or a phone call again from that surgical pathway is quite similar, but we might be utilizing that operative report. And on that operative report, there might just be a sentence like immobilize for six weeks in a splint. Take down bandages. Sutures out at 10 days, or a little bit of information. Just usually at the bottom of the op note. Referral can just be named detail phone number, and particularly if we are then reaching out to that patient And in terms of communication back, we try to find out what suits the person that's referring. Generally with gps, we're bouncing back with another letter that we're trying to get through quickly and efficiently. Most injuries have a very basic recipe book that we as beginner therapists learn. So we know like distal radius fracture is a splint for so many weeks, and at this week we do X, and at week four we do a bit more and we try to progress, but we learn what particular surgeons also like. Have, you've done your suspension arthroplasty and you've got the mini tightrope in as well, and how do you like to manage that versus if there's K wires and we grow our particular protocols and we use our track active program and we'll have Dr. Nimon's distal radius program that we like doing. Or even if it's things like, we try to have that information recorded so that the therapists can pick that information up, see what protocol someone likes to do and see how we move things along from there. So it's quite collaborative at that post-surgical level because everyone has developed their own slightly unique approach to managing these conditions. And we like to match our rehab protocols to suit what's happened surgically. When we are looking at conservatively managed, again, there's protocols, there's recommendations, but we're also trying to match that with a person themselves and we try to communicate what we're doing back as regularly as we can.

Dr Gavin Nimon: 35:06

Brilliant. On that process of the work cover, There's all these different scores and patient related outcome measures and things that they often are done as part of the assessment for work cover type injury or

Charlotte Nash: 35:16

Yeah.

Dr Gavin Nimon: 35:16

Motor vehicle accident. What's the process that they demanded by legislation in Australia or they things that just help your recovery or

Charlotte Nash: 35:23

They're not so demanded they're useful tools to try and quantify. A qualitative process is the way I describe them. Sometimes the quick dash is, or Quick Dash or the dash is a classic. and they're used as indicators. from a work cover perspective, I think they're trying to see those red flags as to how some, how is someone's pain tracking and how is this going? Are we gonna have issues returning to work? So sometimes they're used in that predictive sense, otherwise they're just used to track how well that person feels they're going with their injury. And we do them at rate. We don't do them all the time for, in our space, in the hand therapy space, we are really seeing what gives that person information. We're usually range of motion and grip strength are our big ones that we would use regularly as our reliable factors. And patients love it. They can, they can see their movements happening or they come in a week later, they go, I haven't really improved, but I've been doing everything. And I can say, no, you actually improved six degrees. That's fantastic. So it's quite motivating. They love seeing their strength go up. That's fantastic. Using the questionaires we might send that home as an email and then it, it builds information in a report. We can say, Hey, this person's tracking really well. Or if we're seeing those pain factors hanging around, we can say, this person's a bit stagnant. We need to put some more intervention in place. Maybe some adjustment to injury counseling, maybe some physio, even at that transition point, looking at getting an ep, an exercise physiologist involved is really useful. So they're not be all and end all measures, like they're useful. So

Dr Gavin Nimon: 36:58

it's a

Charlotte Nash: 36:58

guide. Yeah. Guides to information as to what's going on and how we're tracking with progress

Dr Gavin Nimon: 37:04

Excellent. And what about Oedema I believe getting movement helps get the swelling out. I know traditionally that we talked about using Coban wrapping to try and get swelling out to help the movement. I presume it's a bit of both. Yeah.

Charlotte Nash: 37:16

It's, again, it's picking the right modality for the right base. generally, if we're making a splint, we use the tubi grip for a few different things. The plastic itself is quite hot when it comes out of a pan. So if we're molding someone, we generally have a light tubi grip on place just to protect the skin it's not that hot, but you just need to protect someone. I don't like tuby grip too tight. The, my, one of my biggest things is when you see it leaving. Marks on the skin. It's too tight.

Dr Gavin Nimon: 37:44

Yeah.

Charlotte Nash: 37:44

A light bit of compression with tubi grip, getting it moving, getting it elevated. I'm a big one with elevation for making sure that your elbow is straight. A lot of people just have their hand elevated with the kink in the elbow still, and I feel it slows the lymphatic system being able to drain. I like getting people draining the fluid back to the shoulder and moving the hand to pump the swelling out of the hand. That's my, probably my go-to initially, so long as nothing is too crazy. And ICE is another great one. So acutely postoperatively, people always say, do you use heat or do you use ice? But they're different tools, they're different things. I like acute swelling, so 24 to even a week after an injury or surgery, ICE is your best friend. We want that vasoconstriction. We want that pumping away from the peripheral back to, back to into that lymphatic system. So movement, a light cover of Tubi Grip, maybe to just help support the lymphatic system a little bit. I was taught, when I did a fair bit of work with lymphedema that if you are leaving white marks on the skin, you're compressing your lymphatic system so you can't be too tight. When we start to bring Coban and Handi Gores into the situation, we're looking at more entrenched and worrying edema. Someone has had a distal radius fracture, so they've had a fall with some force or some velocity, and the whole hand has puffed up and we've got that swollen look to the hand and the movement is restricted because the hand is so swollen they can't move. Then we have to activate things a little bit more intensely and my go-to with that style of swelling is actually handy Gores, which is a softer white wrap that. It goes on the fingers and then I might use Coban on the hand. Again, it's about the tension. So I say I'm opening the wave of the bandage, It can stretch up to 70% of its length, so you don't want it on that tight. Then what happens is, as their movement is so restricted from the swelling, this little bit of movement that they do have, the uneven surface of the bandaging and the spiral nature you've applied it on actually helps that lymphatic system to pump and get that fluid away. So if we're wrapping fingers, there's a very specific reason as to why we're doing that. And again, in most instances, Tubi Grip is not too tight, is supportive for the situation, comfort for the patient, wearing a splint, and is supposed to be working with you and not getting. tourniqueted off and creating those big divots. So yeah. But then the wrapping things that we do, were very specific. So I had a lady the other day, she crushed her back of her hand massive hematoma like it is, like you could hold the hematoma, but then the entire hand puffed up. So that was an instance where we're using this wrapping technique and mobilizing the hand a lot, and even using little devices to create an uneven surface to stimulate the lymphatic system. So that's just, that's. Different types of interventions for different types of situations.

Dr Gavin Nimon: 41:00

Brilliant, brilliant. Yeah, I've certainly there's always a importance to get the swelling out and get the movement back. The other thing too, that patients may not understand is the importance of desensitization as well. And particularly after surgery, but after any injury.

Charlotte Nash: 41:13

Yeah.

Dr Gavin Nimon: 41:13

Perhaps you can explain that and what your role is in that scenario.

Charlotte Nash: 41:16

So that's where you may have had someone who's again, had a trauma and their nerve has had some sort of injury to itself, whether it's been bruised lacerated, or even just the little postoperative bit of numbness that they get. And we start to get people giving some gentle feedback to those nerves that are, I always say they're just. They've gone out on strike And you have to grade how you get that nerve to respond. Again, if you go and give it too much feedback. So you too much scratchy material tapping too soon you can actually create more pain because it seems to disrupt the nervous system too much.

Dr Gavin Nimon: 41:52

Right?

Charlotte Nash: 41:52

So we start with graded desensitization. Maybe we'll use the soft side of the Velcro. Just gentle touching, giving the nerve feedback constantly gives it a reason to come back, is the way I explain it. If you don't give the nerve any input, it's what we don't use, we don't need. So The body tends to not focus on trying to recover that sensation. But if we give it graded input as it can tolerate it, if some people just, they become very hypersensitive and they can't tolerate anything on there, and if you push them too hard, you'll just make the patient feel sick. They, and they'll start sweating. It's a really visceral response. You can see that they get to it, but so we grade it, we use soft textures. Light textures will start distal to the lesion and slowly work up so that we can really find where the problem is and just psychologically help that person through getting that sensation back and getting used to building up to things like tapping rougher textures, different inputs and stimulations

Dr Gavin Nimon: 42:57

on the other side of the coin where the nerve is hypersensitive. General touching can help desensitize

Charlotte Nash: 43:01

Yeah. Yeah. So it's about just finding the right point. So sometimes we, you'll see the little mini massages that provide vibration stimulation, that can be, if you put that into soon, that can really upset someone. So it's just about finding the different point at which you introduce all these different things. You need the stimulation, you need to settle it down, and you just need to find the right type of input for that nerve to help. And it can be working, finding that point at which they're really like, there's usually almost a clear line you can draw around the boundary between what feels good and what doesn't. And up to a certain point you'll use one type of stimulus, but then over that area you'll use another type of stimulus. Sometimes this can be good and bad and you've got to really understand how your patient. Mind is ticking. We can put like a towel over where the injury is to dull the sensation slightly so that they're still touching it, but they're getting some stimulation back. So it's just about trying to find different ways of helping that person. Sometimes we say a person put a light bracelet on and that bracelet just helps constantly give a bit more feedback, or some people can't tolerate that. So it's just about finding those different little ways to constantly get little bits of stimulation back into it so that we don't create an entrenched hypersensitivity pattern where they don't use the hand. That's the big thing we want to avoid.

Dr Gavin Nimon: 44:32

Brilliant. So Charlotte, obviously you're quite passionate about providing good care and for these patients. Are there any barriers you come across that might affect recovery in. Is it important to really have a patient who's engaged in their own process as well?

Charlotte Nash: 44:45

Yes. So I probably find, I'd say one of my biggest barriers is if we have late referral or an injury's been put to the back burner for a few months, I always say it's almost like the longer an injury's been present for that amount of time is what it's gonna take to recover from. So if we've been ignoring tennis elbow for 12 months and now it's raging and it's really unhappy and can't talk about, can't even think about it, we've got a longer journey ahead of us for that recovery timeframe. Similarly, if we've had a Boutonniere deformity and we've played the whole season and thought it would just get better and then nine months later we've got a nice little 45 degree plus a fixed flexion deformity, we are gonna be battleing for a while to get those to recover from those sorts of things. So that's where we do, and that engagement in rehab and finding what that person does, do they use a computer for a living? And if I make a few adjustments to their computer set up and get their finger moving on the top keyboard, are they an keen knitter? And I need to know how do I include those things into their rehab program as opposed to being told to do these little weird hand therapy exercises 16 times a day or whatever. I try to utilize the aspects of their life that are naturally the therapeutic or rehabilitative into their program. Or I tie things in with the day. I say pop this thera putty next to the kettle whilst you're waiting for the kettle. We're gonna do some putty squeezes so that we're trying to tag our intervention to fixtures that are already in their day. And we just asking like one little thing on top of that so that we are not creating. A huge, extensive programs, complicated programs that can be quite difficult for a patient to engage in. So I like to use what their natural things of hobbies and enjoyment are. Or I make things very specific. So how can someone wants to get back to lawn bowls? Maybe we need a bit of an adaptive equipment. You can get different little things to help bowl. So the person is still doing the thing they love, but they're able to now wear the splint that I want them to wear because they've had a fracture or something and we are combining the two things. I'm getting my rehabilitation. They're still participating in their thing that they love doing. Same. We take the same approach with work. What small aspect of work can be done? Can it be done in a different environment? Can we take that? Can someone do something from home? Can we adapt to the ergonomics to make sure someone is. Engaged and happy and feeling useful. And I think that really helps people's rehab. I try to not over medicalize things too much and Yep. You are there with them on the journey, but they're in control of how well their outcome is at the end of the day, and we make sure they don't feel lost along that pathway. Okay.

Dr Gavin Nimon: 47:36

Brilliant.

Charlotte Nash: 47:36

So that's how we'd approach that side of things. I think.

Dr Gavin Nimon: 47:40

That basis. Are there new technologies or advances in the whole system? It makes people both more engaged but also helps the rehab as well.

Charlotte Nash: 47:48

I think we're on the cusp of a few amazing things. I'm watching all the spaces as best I can. I do love little interactive apps on phones. that can just gamify exercises. So we've got a few script strength things that make a little action person move along a screen, make it a game, but they don't realize that they're actually doing their rehab at the same time. If that is. What we think is gonna engage that person. Then we'll do it. If we have different games that we can play with someone that is more engaging, that's fantastic. In terms of the technology, I think we will see at some point 3 d printing become part of our toolkit. At the moment, it's not quite there. It just takes too long to print. The printing a splint of this size, the timeframe would just be too long. They're not rem moldable. They're still a bit rough, but I think we're gonna get there. There's some really cool stuff happening in the Netherlands where they'll scan an image of your hand. It then goes to the Netherlands. This amazing, cool looking pearlescent, futuristic looking splint is then created and sent back. That's really great for things that are needed long term. So if someone needs, has a bit of arthritis, adamant they're not having surgery and we can create something like that's becoming more available. it's not quite available here as freely yet, and the splint isn't quite as cool or up there yet on top of what we've got available here in Australia. So I haven't gone down that path personally myself yet, but I think it's getting really close, which is great. And then looking at different things, Virtual reality, I think has got huge impact in returning to your work or tasks a lot quicker because suddenly you can be immersed in a world where you're doing the work thing. And I've seen these situations, they're filming like in real life. It's not a gamified cartoon environment. It's real. And you are walking down the street and your hand is there functioning beautifully and normally. In the vision, you might have a very injured hand in real life, but it's doing the things that you want your hand to be doing in real life. So I think in terms of a lot of pain management, a lot of getting people's brain, recognizing that their hand can do things sooner with the use of VR is going to become really, exciting in that space. And I think that will have a huge benefit to adjustment, to injury, to adjustment to, even in our prosthetics group where people have had amputations, it's going to, that I think is gonna be amazing to research as well.

Dr Gavin Nimon: 50:29

Brilliant. Sounds exciting times. So what do you, what advice would you give to the young medical student or young GP coming through the process about occupational therapy and hand therapy in particular

Charlotte Nash: 50:39

I think it would be really interesting for someone who's learning that medical space once you're feeling like you've heading into a path that you like, if you can see a specialty you're heading towards, try to get to the spend a day in the life at the end of that rehab process, as much as you may be at the beginning of that process so that you are really creating that sort of 360 view of how that injury process looks to that person. I think we can get a bit stuck at our either end. Similarly, I tell my students and my young therapist to go and attend as many surgeries as possible. Yeah. So that they're seeing,'cause we see the end.

Dr Gavin Nimon: 51:19

Yeah.

Charlotte Nash: 51:19

We see them all wrapped up neatly stitched up and looking beautiful. I said, go and see what's happened and then you'll understand the trauma. You'll understand why your PIP joint is so swollen afterwards.'cause you're gonna see what it's gone through. It's been through a lot. Similarly, I'd say to that new surgeon, that gp, that person try and spend a day. Half a day, whatever time you've got. No time is precious. Understanding what we are dealing with at our end and how we're engaging that person. The pain that we might be experiencing at six weeks, which they don't write about in the textbooks, and that isn't the common sort of standard and process. If you can see what it's like at the other end and how that person is going six weeks later and what we are putting them through and what we're trying to achieve with. I think sometimes splints are seen as just things that keep things still, and we love people understanding. It's no, this is helping us mobilize. I know it's a rigid piece of plastic, but we are doing this amazing stuff with this rigid piece of plastic. And as much as not splinting, yes, they're gonna move their hand more, but we're trying to overcome a few deficits at the same time. So seeing what we can do and the creativeness with which we are trying to get people moving and functioning. Would be really amazing. Even if someone's in a more medical space as opposed to surgical, seeing what's happening when that OT is trying to get that person home. What are we trying to achieve with medications? Like I had a, a few things where someone's got dementia but they've suddenly been given medication to take six times a day. And how are we making that happen? Because there's some huge, big functional things that we've gotta get through there and how we support that person through that process. So on both ends of that spectrum, I think it's, remember that it's this part of care is linked to this part of care over here. And trying to approach it from both ends to really understand that process.

Dr Gavin Nimon: 53:15

Brilliant. It's been fantastic having you come on. Aussie Med Ed today

Charlotte Nash: 53:19

thank you for inviting us along.

Dr Gavin Nimon: 53:20

It's been great. So sharing your expertise and shed a light on both occupational and hand therapy. Your insights and patient centered rehab and collaborative practice are really useful. To our listeners, thanks for joining us and hopefully this podcast today will shed more light on another area of important part of rehab for a patient under your care. Thanks very much.

Charlotte Nash: 53:40

Thank you.

Dr Gavin Nimon: 53:41

Thanks again for listening to the podcast and please subscribe to the podcast for the next episode. Until then, please stay safe.