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Hand Postures During Exam Suggests Need for Extra Support During Recovery

Key findings

  • Protective hand postures were associated with greater catastrophic thinking and greater fear of movement
  • Hand postures were not correlated with patient’s ratings of pain interference with daily activities, symptoms of depression or functional limitations specific to the upper extremity
  • Patients with greater catastrophic thinking had a higher total number of hand postures, on average
  • Nonverbal signs of catastrophic thinking should alert clinicians to help patients foster optimal thoughts, emotions and behaviors to facilitate recovery

Certain phrases that patients use during clinic visits such as “I can’t” and “I’m weak,” have been linked to greater levels of catastrophic thinking. Nonverbal cues, too, can signal that patients need extra support with their recovery, according to a report in Clinical Orthopaedics and Related Research.

In the Hand & Arm Center at Massachusetts General Hospital, PhD candidate Jonathan Lans, MD, Interim Chief Neal C. Chen, MD, and colleagues noticed certain hand postures in patients that seemed “protective.” For example, when asked to make a fist, some patients inhibited the stretch by flexing their wrist.

To investigate, the researchers trained physicians to recognize seven specific protective hand postures:

  • Presenting the hand as if it is detached
  • Extending uninjured fingers as the stiff/painful finger is flexed
  • Using the opposite hand to move the injured finger when asked to demonstrate motor strength
  • Flexing the wrist during attempted finger flexion
  • Letting the thumb obstruct the path of finger flexion
  • Avoiding use of uninjured fingers
  • Avoiding all flexion of the stiff/painful finger

Between October 2014 and September 2016, they studied 149 adults who had stiff or painful fingers after a finger, hand or wrist injury. During an examination, the patient was asked to make a fist with the injured side, and the hand movements were observed without any discussion of them with the patient.

In addition, patients were asked to complete computer-adaptive tests or questionnaires about physical functioning, depression, pain interference (how pain affects aspects of the patient’s daily life), pain catastrophizing (exaggerated negative mental state during actual or anticipated painful experiences) and kinesophobia (fear of movement because of injury).

55 patients (37%) displayed one of the hand postures. By far, the most common was wrist flexion during attempted finger flexion at 30%.

The patients who displayed at least one relevant hand posture scored significantly higher on the assessments of catastrophic thinking and kinesophobia compared with the others. On average, patients with greater catastrophic thinking exhibited a higher total number of hand postures. Hand postures were not linked to scores on the other assessments.

The research team suggests that clinicians should stay alert to protective hand postures to help patients foster the thoughts, emotions and behaviors that ease the recovery process. Patients with more than one hand posture, and those who don’t respond well to ordinary support and education, might benefit from cognitive-behavioral therapy.

The authors also point out that watching hand posture has advantages over asking patients to complete psychological questionnaires. Some patients are offended by that request or do not answer honestly. Even if psychological questionnaires are used, nonverbal signs are another way to identify opportunities to improve patients’ resiliency.

37%
Patients who displayed one of the hand postures

30%
Of the hand postures displayed, almost one-third were wrist flexion during attempted finger flexion

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