Sporting Hand and Wrist - Mobility Strength and Endurance

Introduction

The hand anatomy is efficiently organized to carry out a variety of complex tasks combining intricate movements and finely controlled force production. The soft tissue structure of the hand is complicated and any injury to any of these even very small structures can alter the overall function of the hand and thereby complicate the therapeutic management[1]. Hand function and strength are important elements in day to day life and participation in sports [2]. Activities of daily living can use p to 70% of your hand motion.

Hand function and is made up of four important components:

• Mobility
  • The maintenance development of movement through a specific range of motion
• Stability or Motor Control
  • The maintenance or development of kinetic stability during joint static or dynamic skilled movements
• Endurance or Work Capacity
  • The ability to produce or tolerate variable intensities and duration of work whilst maintaining that motor control
• Strength
  • The ability to produce or tolerate maximal strength

It is also important to know and remember the average range of motion of the wrist when conducting an assessment

• Flexion - 70, 75 degrees
• Extension - 70, 75 degrees
• Radial deviation -20 degrees
• Ulnar deviation - 35 degrees

Principles of Dosage in Exercise Prescription

Dosage

There are aspects to consider when prescribing any exercise regime

1. Intention of program (Endurance, strength, stability, mobility)
2. Intensity
3. Repetitions
4. Sets
5. Rest

Make into a table!!

For example, if you are trying to re-educate endurance

1. Low to moderate intensity
2. High repetitions - 15
3. Two to three sets
4. short rest periods - 30seconds to 1 minute

For example, if you are trying to re-educate strength,

1. High intensities
2. Low repetitions
3. Increased sets
4. longer rests periods to allow the recovery

you've got the ability of a muscle muscle group to exert this maximum force against resistance and sometimes you can even consider what is relative strength. So is that measure of strength based on the body size? So ratio of weight lifted to your body weight

Grip Strength in Day to Day Life

Daily activities require a combination of different movements in the upper limb. Hand function is an important component of these movements. The loss of grip strength is associated with a number of pathologies. Hand Osteoarthritis is a is a common chronic condition involving one or more joints of the thumb and fingers. It is associated with pain, reduced grip strength, loss of range of motion (ROM), and joint stiffness leading to impaired hand function and difficulty with daily activities [6]. Stroke is another condition that impacts the upper limb and hand function. Addressing these conditions requires an understanding of the hand anatomy and biomechanics.

There are numerous factors such as sex, age, and hand preference that contribute to the grip strength and they should be considered when making clinical decisions. The average grip strength of women is approximately 60% that of men, and for both sexes, grip strength reaches a maximum during the fourth decade of life and declined thereafter with increasing age[1].

Cold weather causes reduced muscle contraction and affects grip strength and function of the hand[1].

It is believed that the difference between the dominant and non-dominant hand in strength is 10% (known as the 10% rule). This applies to right-handed people. For left-handed persons, grip strength is considered equivalent in both hands[1].

Measuring Grip Strength

Measuring grip strength is commonly used in research and sports to measure the efficacy of an intervention. It is a useful practice to implement in hand rehabilitation that would help on decision making and reporting outcomes.

Dynamometers[2]: the Jamar and the Takei are the most common studied dynamometers in the literature.

The Jamar dynamometer is considered to be the gold standard for documenting manual grip strength. It is comprised of:

• an adjustable anatomical rigid handle
• hydraulic system
• analogue display

The Takei is a valid and reliable tool to measure power grip. It is comprised of:

• Adjustable rectified
• Complacent handle shape
• Electromechanical system
• A digital or analogue display

Important points to consider when testing grip strength[5]:

• Note the associated symptoms such as pain or instability. The timing of the symptoms also matters whether they accompany the movement or start after the testing.
• The difference between the right and left hands. Consider the element of chronicity could lead to weakness due to reciprocal inhibition.
• Repeat the test for 3 times starting with the non-painful side then move on to the other hand and alternate the testing between hands for three times
• Look for the peak force (the best number that could be achieved on testing). Some people might be able to generate a high number on the strength test but then the number lowers due to fatigue or they take few repetitions to generate the force
• Testing position:

1. Elbow in a 90-degree angle: helps to generate the highest peak. However, having the forearm in mid-position could lead to contraction of the brachioradialis muscle and the movement will not be generated purely from the hand.
2. Testing from straight elbow position and wrist in neutral. This position is recommended by Gatt I.[5] to isolate hand muscles.

Rehabilitation of Grip Strength

As mentioned earlier, it's important to understand the factors contributing to the grip strength.

Handgrip measuring should be a key component during the rehabilitation process to measure effectiveness[5].

The available interventions to rehabilitate grip strength are numerous. The selection of the intervention depends on the individual factors, type of sport and used grip, the type of injury, chronicity, severity and also the associated pathologies.

Examples of power grip interventions:

1-Isokinetic training machine:

Expensive but a useful kinetic machine. Could be implemented as testing and also as training equipment for different wrist and hand muscles at both eccentric and concentric measures with speed variations.

2-Rubber tools also known as flex bars. Different colours could be deployed for varying strength and targeting the wrist and forearm muscles.

3-Crushes: is another tool that could be used to improve the power grip. Intensity could be adjusted by the number of springs.

4-Talon grips: could be added to pull-ups. A tool that is designed ergonomically to adapt to the shape of the hand and give a uniform loading on the tendons,

Examples of pinch grip interventions[5]:

1-Pinch grip dynamometer or handheld dynamometer: there are two positions to perform the exercise from as in the image:

Handheld dynamometer for pinch grip strength

2-key grip dynamometer: places the thumb joint in a closed position. Useful for strengthening the thumb flexors

Key Grip

.

The decision on the use of which grip (key or pinch) depends on the onset and severity of the injury.

3- Holding a plate: there are different variations depending on the targeted muscles. The time to hold can be adjusted on the type of training e.g. conditioning or endurance, and also could be used to check the difference in the maximum hold between right and left hands. Monitoring the symptoms associated with holding the plate such as pain, the timing of the symptoms and the effect on holding can be useful data in the management.

Key grip

Pinch grip

4-Putty: for pinch or power grip using different variations:

[10]

[11]

5-Flipping Plates: good exercise to improve thumb and wrist proprioception.

[12]

flexing on a FlexBar. Again, we know that this exercise is going to help mobility of the wrist, if it's something you're trying to achieve. May provide a degree of stability, but definitely, it's going to help strength or endurance. So again, it depends on what we said before, the intensity, the reps, that's frequency, the time and so those components are sitting in there. And again, you can do the same around the wrist for your pronation supination or mobility, and particularly trying to get more of that stability around the wrist

green crushes, as you can see again, from this video. So again he's using these wide grips to go as a bit, back to what we discussed in the previous episode around that's power grip, trying to get that strength. Again it is important because that ability to make a fist is so important with stability. In fact, we that stability of the wrist is, you know, is that usage of all the muscles, so it does co-contraction of all the muscles around the wrist and the best position tends to be in a degree of probably around 30 degrees of extension. So really is maximizing that wrist to try and have that ability to maintain stability well at least in the neutral component. So what we need to then look at is from neutral movement is how to maintain stability, throughout the movements we want to achieve, which is your flexion, extension, ulnar, radial deviation

wrist curls in this particular example is extension and again, extension is very important because if you are weak in your extensors, your wrist more likely starts going more into flexion because you can't maintain especially that position we just talked about, that isometric position particularly, to have that really strong power grip

horizontal pully where literally you can work nicely into extension, both concentric, and then on the get down is eccentric. And then you can do the opposite. So you have that flexion concentric, extension eccentric

nudges - strength or stability or endurance

putty - still influencing the wrist

pinch grips

power grips

-flips -pendulums -creating stability to compression

Rainbow et al, 2015. They found that throughout all the motions, the ligaments are always taught. So there's always stiffness of ligaments, not all of them, you know, as you expect another joint, some would be more relaxed, some are tighter and then as you go throughout the range, some get more relaxed, some get tighter.

Kim et al, looking at the tape, again, it's something you could consider using as an adjunct as part of your intervention

fours type position with a gym ball and weights

push-offs from the wall - maintenance of the wrist, rather in a neutral position, quite stable, elbow is quite I'd say rigid, you know, maintained in extension. There's a lot of work actually to the shoulder blade. So you're looking a lot of that serratus anterior work and core activation -maybe do it with a fist in this position where you can actually pushing off from the trampette that, which you can see is put at an angle around 45 degrees - open hand, you can still do it. What I would suggest is you hold on to a ball, one of these rubber balls, maybe even a weighted ball

References

1. ↑ Jump up to:1.0 1.1 1.2 1.3 1.4 1.5 1.6 Duruoz MT. Hand function. Springer-Verlag New York; 2016.
2. ↑ Jump up to:2.0 2.1 Gatt I, Smith-Moore S, Steggles C, Loosemore M. The takei handheld dynamometer: an effective clinical outcome measure tool for hand and wrist function in boxing. HAND. 2018 May;13(3):319-24.
3. ↑ Jump up to:3.0 3.1 Loosemore M, Lightfoot J, Gatt I, Hayton M, Beardsley C. Hand and wrist injuries in elite boxing: a longitudinal prospective study (2005-2012) of the Great Britain Olympic Boxing Squad. Hand. 2017 Mar;12(2):181-7.
4. Jump up↑ Gatt I. Hand and wrist injuries: a focus on boxing. A Comprehensive Guide to Sports Physiology and Injury Management E-Book: An Interdisciplinary Approach. 2020 Nov 28:315.
5. ↑ Jump up to:5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 Gatt I.  Sporting Hand & Wrist - Why Power & Pinch Grips Matter. Physioplus Course 2020
6. Jump up↑ Magni NE, McNair PJ, Rice DA. The effects of resistance training on muscle strength, joint pain, and hand function in individuals with hand osteoarthritis: a systematic review and meta-analysis. Arthritis research & therapy. 2017 Dec 1;19(1):131.
7. Jump up↑ Duruöz MT, Poiraudeau S, Fermanian J, et  al. Development and validation of a rheumatoid hand functional disability scale that assess functional handicap. J Rheumatol. 1996;23:1167–72.
8. Jump up↑ Oranchuk DJ, Drinkwater EJ, Lindsay RS, Helms ER, Harbour ET, Storey AG. Improvement of kinetic, kinematic, and qualitative performance variables of the power clean with the hook grip. International journal of sports physiology and performance. 2019 Mar 1;14(3):378-84.
9. Jump up↑ Hand Grip Dynamometer. Available from:https://www.youtube.com/watch?v=-jmWNKUek3o[last accessed 28/12/2020]
10. Jump up↑ Pinch grip strength putty R. Available from:https://www.youtube.com/watch?v=QxaP5P9CSWc[last accessed 28/12/2020]
11. Jump up↑ Power grip strength putty R. Available from:https://www.youtube.com/watch?v=DufAYWGidsc[last accessed 28/12/2020]
12. Jump up↑ Plate Flip | Better Grip | Forearm Strength | Move and Perform Better. Available from:https://www.youtube.com/watch?v=Z-qNThP5Sjw[last accessed 28/12/2020]