Grip Strengthening for non-specific wrist pain with Dr Ian Gatt

In this Episode with Dr Ian Gatt, we discuss a paper that he recently did a research review on covering wrist pain in adolescents. We cover the protocol that they used in the paper, potential limitations and how the outcomes should affect our Physiotherapy practice.

👉🏻  See Ian’s full Research Review here - https://physio.network/reviews-gatt

Ian is the Head of Performance & Lead Physiotherapist for GB Boxing, with 20+ years of experience in a variety of sports. He is an Upper Limb Injury Specialist with the English Institute of Sport, with a keen interest in Hands & Wrists.

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is @James_Armstrong_Physio

👏 Become a better physiotherapist with online education from world-leading experts:

https://www.physio-network.com/

Transcript

UNKNOWN 0:00

So,

SPEAKER_02 0:05

Typically, your diagnosis, you can't really have a lot of information from these non-specific wrist pains from the onset, unless it is actually a fracture, there's trauma, you know, you know what's going on there, or there's a clarity, it's definitely a TFCC because of mechanisms of injury. Then you need something to help your prognostic value, to tell somebody how you think they are going to fare and how you're going to measure their progression. So for me, I then have to rely on the function. And so I tell people in the absence of diagnoses, if you can improve your functional value, you are improving your prognostic value.

SPEAKER_01 0:50

Wrist pain is a common presentation and outside the more straightforward and obvious diagnoses, many will present with chronic, non-specific wrist pain. And this can be really challenging to assess and treat. We're lucky enough to have on the podcast Dr. Ian Gatt, who reviewed an interesting paper looking at grip strengthening algorithms for initial treatment of chronic non-specific wrist pain in adolescents. Ian is the head of performance and lead physiotherapist for GB Boxing with over 20 years of experience in a variety of sports. He is an upper limb injury specialist with the English Institute of Sport with a keen interest in hands and wrists. In this episode Ian gives us a great insight into not just the paper but his expertise in treating this tricky presentation and he shares with us some of his suggestions on how to approach your management of wrist pain so that you can use this with your patients. To learn more about these research reviews and how they can make keeping up to date with research so much easier, click on the link in the show notes below. I'm James Armstrong, and this is Physio Explained. Welcome to the podcast, Ian. It's great to have you on, and personally, it's great to finally have a chance to chat to you. Thanks for having us, James. Brilliant. So today we are looking at an interesting paper that you, not that long ago, did a research review for PhysioNetwork on. And we're going to go into the usual questions. We're going to go through the research review and give listeners a bit of an insight into this. And at the end of it, some real clinical pearls that hopefully our listeners can take away. So without further ado, introduce the paper to us here. What did you look at and what paper did you review?

SPEAKER_02 2:32

Yeah, so the title of this paper was Evaluation of Grip Strengthening Algorithm for the Initial Treatment of Chronic Non-Specific Wrist Pain in Adolescents. And to be fair, although it does mention adolescents, I think there's a lot of information there that we can think that can extrapolate to the older population where we do get a lot of non-specific wrist pain.

SPEAKER_01 3:00

Absolutely, yeah, definitely. And so the paper itself, obviously, around this algorithm in terms of grip strengthening, talk to us about sort of the kind of the objective of the paper and their methods and what were they aiming to do with this?

SPEAKER_02 3:17

Yeah, well, wrist pain, as we know, is a common ailment, particularly around adolescence. And one of the things you get is this presentation, which is nonspecific. So, you know, you could easily... do some physical examinations or do some investigations earlier on and you find nothing. And I think what happens with a lot of clinicians that are either not accustomed to working with the risks, or even that are, sometimes they feel like they hit a dead end, like they hit a wall. And so I think what they try to do in this paper, which is quite nice, is almost approach it from a assessing the functional abilities of somebody, trying to put in an intervention, have a set plan, a set timescale, and when they do remeasures, and then following this algorithm, when you get to six weeks, which was the timescale they put together after their interventions, where is somebody at? And based on where they are, is making those decisions. Do you send for further scans? Do you discharge them because you're happy? And obviously looking at the overall success of this algorithm and whether it made any sense.

SPEAKER_01 4:34

In terms of the participants they had in the study, was there any flaws in that in terms of, I know it was heavily weighted towards a female population. Is it an irrelevant aspect to this paper? I

SPEAKER_02 4:45

mean, first of all, what the paper doesn't tell you is what is the power of the size of the population and the effect size. We know that there were 28 patients in there. We know that 36 wrists, meaning that some of them had bilateral symptoms. We know that the dominant hand was the most affected. So 19 of those wrists were on the dominant side. And again, there was probably a mix of athletes and non-athletes. So again, you can't generalize straight away. whether it's more impactful on the athletes or not. But one of the things we can say is that it was, in this case, a young population, so 10 to 18 years old. So if you are looking at that young population, it's useful if you have an adolescent coming in there as an initial algorithm and then thinking, okay, this is something I could potentially consider even for an older population.

SPEAKER_01 5:46

What did the algorithm actually look

SPEAKER_02 5:48

like for this

SPEAKER_01 5:48

paper?

SPEAKER_02 5:49

Yeah, so the first thing for me, like even before mentioning that, like I'm a big advocate of when we tend to have somebody in front of us, I like to use an equation, and I use this everywhere where I teach or I tell people, which is a simple equation, which is prognosis equals diagnosis plus function. And so... I really like the simple equation because it does help people and helps me every day. Because if what we're saying here is that typically your diagnosis, you can't really have a lot of information from these non-specific wrist pains from the onset, you know, unless, you know, you know, it is actually a fracture, there's trauma, you know, you know what's going on there, or there's a clarity, it's definitely a TFCC because of mechanisms of injury, then you you need something to help your prognostic value, to tell somebody how do you think they are going to fare and how you're going to measure their progression. And so for me, I then have to rely on the function. And so I tell people in the absence of diagnoses, if you can improve your functional value, you are improving your prognostic value. So it's a simple equation, as I said, but what that means is I don't take away diagnosis completely. I'm all the time thinking at the back of my head, but I'm considering function. So in answering your question, James, what they basically did is they did some measures in the beginning, and the measures were quite simple. It was a questionnaire, which was a pediatric objective type questionnaire, and then they did grip strength. Then they introduced an intervention, which I'll probably have to critique a bit, but I'll leave that for now. And this is what I like, is they had a plan, which is something sometimes most of us don't have. From the onset, they had a plan. So they had an initial evaluation, and they gave an intervention. The intervention was basically group strengthening two times per day for five minutes, aiming for some also activity modification as needed based on the pain. So they're modifying the activities to reduce pain, and they're giving this two times per day, five minutes, which we'll talk later about. And then at two weeks, they were reassessing to see whether there were changes in the pain and whether on the grip strength it was improving. Now, they were telling it was improvement in strength. Now, again, my first critique there is we need to look at the difference between is it strength, Or is it function? Because a grip strength dynamometer gives you force. So we'll talk a bit about that. And then at four weeks, they were doing the same. They were reassessing everything. And then at six weeks, they were reassessing. And based on that, they were looking at, okay, if your strength improved, did the pain get better or not? If not, should we proceed with further evaluation? If the strength increased, but the pain didn't, You know, the pain decreased. Okay, what do I do? Do I continue with the approach? Do I discharge? If the strength has not increased, do I continue with the approach? So they had a nice simple algorithm where somebody's not comfortable managing risks and followed this. At least it gave them some guidance because I'm not one for algorithms because sometimes they can be very strict if you try and follow algorithms. They are a nice way of having some guidance. So at least You know, you don't start from the last part, which is, oh, I'm going to send somebody for a scan straight away. And to be fair, six weeks sounds quite reasonable, albeit it is important to mention that a lot of the participants had probably symptoms for a long period of time. So it was probably around nine months of chronicity that they had symptoms for. So again, though, you know, there wasn't that big difference. rush because they didn't think there were any red flags. They just wanted to do this for a six-week period and see whether it changes symptoms. So I do like that sort of approach that they had.

SPEAKER_01 9:59

Gives that timescale for evaluation of the next steps, doesn't it? Gives that point to say, well, at six weeks, we're going to stop and we're going to think about where we go next, rather than, as you say, aimlessly going forwards.

SPEAKER_02 10:11

Yes. And I mean, my understanding would be that these participants would have had pain, but it wouldn't have been pain of a certain intensity or affecting the activities that you'd feel uncomfortable that you feel you can load because you know from the beginning they're saying they're loading and then they're reviewing after two weeks four weeks six weeks so there's quite a nice approach and it seems also that with the the intervention that they were doing they had enough time to measure what was going on so i think the median therapies were like four visits, so ranging between two to six visits, which is good. You know, if you are putting in an intervention, on a personal note, if I gave somebody a program like that, I would probably say you could even give them three weeks, for example, see how they're doing. And if they're progressing well, then you review them after six weeks, because it probably takes six to eight weeks anyway, if you're giving a good loading program. to expect changes overall, particularly if you have a certain chronicity.

SPEAKER_00 11:23

Transcription by CastingWords

SPEAKER_01 11:56

Definitely. And so in terms of the actual study itself with the participants they had, what were their main findings in terms of the study, the participants, the interventions? How did that relate to the outcomes?

SPEAKER_02 12:09

The positives, they had 75% improvement. So I would take that as a positive. You are doing your exams and you got 75%. I think you'd be happy with that. There were eight patients, 25% there were deemed positive. unsuccessful. I mean, they use the word failure. I don't think that's a heavy word, really, failure. I think unsuccessful, is it? Which is fair enough. We do interventions like these sometimes. It doesn't work for people. And five of those eight patients required interventions, for example. So I believe there were two ganglion cyst excisions. There were two TFCC repairs needed. I think one of them had a steroid injection. So the interventions were beyond your normal therapeutic modalities. And all of them seem to have improved from there. So again, that shows you that the algorithm tried something and they used the classical approach where if you try something and it fails, okay, I'm going to use that word now, then you can consider things like injection or operations. And it sounds like two received also ongoing pain management for like generalized pain. pain syndrome. One of them apparently was lost for further follow-up. So, you know, again, the dropout rate wasn't bad, really. So considering this approach for the numbers they had, these 28 patients, these 36 risks, I think overall it seemed like a good approach at face value.

SPEAKER_01 13:35

So in terms of clinical implications, what would you say are the key things that would be applicable in terms of the practice right away that they could take away?

SPEAKER_02 13:45

So if somebody comes and sees you with a chronic wrist where maybe there was a history of trauma, maybe there wasn't, sometimes these come insidious, whether they're young adolescents, and I'm going to extrapolate because of my experience, even older people, unless there's something shouting out to you, red flag, then consider function. So that equation which I told you is really nice because you're always thinking prognosis and And you're never missing diagnosis on one side. So you're always hypothesizing what it could be. Obviously, you don't want to miss the noughties around the hand and wrist. There's something obvious that you're seeing, you know, gross swelling, redness, unexplained, tingling in the fingers. But then the function helps because if there is gross difference between one side and another, example, 50%, there's a lot of gross dysfunction. So you start thinking, wait a bit. is that a lot, you know, rather than down to 30%, 20%, which sometimes, you know, you're closing those numbers. So what are we saying here? When somebody comes to see you, consider how to measure function by having simple tools like a handheld dynamometer, which these days you can buy for very, very, very cheap. Trust me, you can buy them for like 20 quid. Back in the days, they were like 200 quid, and I can understand people feeling a bit like, ooh, should I buy that piece of equipment? And you can use it as a very quick measure of function, and you can add it, and then you can decide, you know, is the information there good enough? So it's a nice baseline and I can use it in case somebody regresses. I can measure later on and if things are regressing, that's a red flag. Are things the same? Okay, there's no change in those measures I've taken. So how does it help me? Where do I go next? Or it's improving. Oh, great. Even the person in front of you straight away, it really helps. I think it also helps because from my experience, a lot of people that come after such a long time, And possibly they've already had the scans by now. So although this algorithm is nice, a lot of times they've already reached you with the opposite algorithm. People have already had the scans and have hit a dead end. And what there is, is the fear of the unknown. Is there something wrong with my wrist? And so for me, when you take these objective measures, they can be useful because they can form part of your communication skills. and building rapport. Because you'll do something that maybe nobody else has done so far. Because I sometimes ask them, have they measured your strength, for example, your function? No, but they've told me it's weak. Okay, well, they've told you it's weak, but then third, but not tested it. So this is a quick test. And you can see the change on people's faces when, you know, you ask them the question, how much difference do you think there is? An example, they tell you, oh, I think it's 60% or whatever. And It's much, much less, for example. And you've got something to build. Even if it matches what they think it is, or even if it's more, don't worry. You've got a baseline. And I always tell people, look, you've got a difference, but let's look at the positive. It's not 100% different. We've got somewhere where to start. So from here, we can proceed there. And obviously, when we're providing certain interventions, we're trying to match that percentage of So, you know, if somebody has a 50% difference, I'm not going to start by giving them an 80% difference load. It's like, why? Why am I adding that 30%? Why am I underloading? Equally, you know, it might explain to me why certain things are painful when they're going beyond certain capabilities. You know, somebody can tell you, look, I can do these activities, but once I do this little bit extra, it becomes painful. Just also to mention that there's one tool. So the reminder to people is that obviously there are other ways of measuring. First of all, considerations around beyond force production, there's range of motion. Beyond the handgrip dynamometer, you could be using other things like weights. You could be using things like force plates or weight-bearing scales, things you've got at home, which can actually, you can measure the ability of somebody to load. But they give you numbers that, And the person can give you their subjective feeling, that numerical rating scale. So it's 4 out of 10, 5 out of 10, or mild, moderate, severe. Use whatever you want. There are so many ways. And add it to that numerical value. And that becomes powerful. But remember, that's not the whole assessment. I don't want you to go away thinking, oh, Ian Gutt just does this measure and pays everything around 1, 2. No, it's a measure. part of your overall assessment, but it's a very useful component.

SPEAKER_01 18:46

Definitely, definitely. I think you've hit the nail on the head there, Ian, and absolutely, I think many of our listeners would be able to agree with that and pitch that in their own practice whereby these tools are great and it's useful with a paper like this to kind of put it into practice and give us another arm of how to deal with maybe some more tricky patients and where to go and give an algorithm. But it's not always going to work for every patient and nor should it be expected to, I suppose. So that's really, really useful, Ian. So thank you so much for your time. I think the time has absolutely flown by today. So really appreciate it. So for everyone listening, if you're interested in reading any more research reviews on this topic and over 10 other research reviews that Ian alone has done for the physio network, I've just looked at that and hundreds of others from world leading experts and do click in the show notes below to try out the physio network research reviews for free. So once again, thank you so much for your time and I'm sure we'll have you on again.

SPEAKER_02 19:40

Thanks a lot, James. And time really flies. But also give us a follow if you want on social media, guys, whether it's LinkedIn, Instagram or Twitter. You'll always find me there posting on everything that is linked to or about the upper limb.

SPEAKER_01 19:56

Brilliant. Absolutely. I'll second that. I've been following Ian for a while. It's all good stuff. Ian, thanks very much. Enjoy the rest of your evening. Likewise, James. Thank you.

UNKNOWN 20:11

you