Healing our hands

Specializing in hand injuries, Granite Bay occupational therapist Lilaine Hartmann’s practice is based on a paradox of modern times. Long ago, simple technology enabled our distant ancestors to adapt and survive. However, today’s technology has created, for some workers, a hostile environment threatening their ability to make a living.

Some of the earliest tools humans used—stones with sharpened edges—supplemented and enhanced their skills. Today, the amazingly powerful technology surrounding us is supposed to do essentially the same thing. Tapping a computer keyboard, for example, would seem a vastly more effortless and productive way to generate words than hammering a manual typewriter’s keys or writing with our hands. However, Hartmann asserts, this particular technological improvement has also created the largest increase in carpal tunnel syndrome (CTS) cases that she’s seen in her 20 years of working with people’s hands.

Hartmann interned in the Burn Unit of Parkland Hospital in Dallas after completing her undergraduate occupational therapy studies in 1981. Most of the patients she helped rehabilitate had suffered second- and third-degree burns to their hands. They were damaged on the outside but still functional within, a contrast to her later work.

It was a rewarding experience for Hartmann because most of these patients were able to work toward complete recovery and resume normal lives. She became a healer of hands. Instead of pursuing a traditional occupational therapy specialty and treating paraplegics or head injury patients, Hartmann set about creating her unique hand therapy niche.

Although she continued graduate coursework, her real education began, she says, during discussions with an orthopedic surgeon. Though she was then a lowly intern, he was intrigued by her original approach to post-operative rehabilitation. Soon she was working with this surgeon in the operating room and administering follow-up therapy to patients with a variety of hand injuries.

The largest group of patients treated at this clinic in the early 1980s were office workers turning up with CTS. Such a huge incidence of these debilitating nerve disorders had been, the hand surgeon told Hartmann, unheard of 10 to 15 years previously. The culprit: supposedly labor-saving computer keyboards. The technological limits of manual typewriters had created complex choreographies for typists’ wrists and hands.

Like miniaturized, highly specialized Nautilus machines, each old Royal and Underwood typewriter came with CTS-preventive fitness workouts built in. Even if limp-wristed when first hired, manual typists soon developed sinewy forearms, wrists and hands.

Like athletes in training, they also avoided damaging muscles and nerves by allowing for recovery. That is, manual typewriters forced typists to pause momentarily, at the end of each line to hit the carriage return lever and to roll in a fresh sheet of paper periodically. Computer keyboards, on the other hand, offered no alternative to constant repeated motion. While manual typists didn’t have to think about or plan their adaptive behavior, Hartmann realized word processors needed something more than surgery to cure their CTS.

The human hand comprises the most complex constellation of muscles, tendons, bones and ligaments in the body. Hartmann says she feels an aesthetic appreciation for these precision instruments, one that goes far beyond her professional focus on the medical and mechanical.

“Ever since childhood, I’ve loved to draw and design things,” she says. While pursuing her degree, she minored in art, taking courses in woodshop, weaving, welding, sculpture and painting. “In the operating room I gained knowledge of hand anatomy watching surgeons cutting open palms and peeling the skin back. As an art student I learned what my hands are capable of.”

Unaware of her unique career plans, several art professors encouraged her to become a commercial artist. As these professors tended to weed non-artists out of the art curriculum, Hartmann kept her educational goals to herself. “Meanwhile,” she says, “everything was falling into place in terms of my thinking on hand therapy. Somehow, through my interest in art I had stumbled across exactly what I needed to know, understanding hands as we use them.”

Today, most patients arriving in Hartmann’s Orthopedic Hand Therapy Services clinic are at the point where they are “pretty much willing to do anything I say,” she says. All of a sudden they can no longer take their hands for granted. Hartmann’s rehabilitation strategy is quite different from therapeutic practices she’s observed while working as a consultant in HMO occupational therapy clinics. It’s a difference in attitude.

“It’s like they expect their patients to drop their hands off for therapy,” Hartmann asserts disdainfully. “I don’t do assembly-line medicine.”

At one HMO clinic she observed, patients with hand injuries were treated in groups of five or more and each underwent identical procedures. Hartmann believes treating the hand as a damaged technological artifact detached from the patient can cause more problems than it cures. One HMO’s occupational therapy procedure she observed, applying ice to injured hands, could even be harmful, as this practice tends to slow blood circulation.

Rather than release patients to return to work when they have recovered a pre-determined level of functionality, Hartmann sets goals for her patients based on her guiding principle: “Each patient is their own norm.”

Many recoveries are thwarted by patients trying to do too much too soon when they return to work. They still take their hands for granted. So Hartmann begins her rehabilitation program with informal counseling and education. Privacy is key. Patients identify to varying degrees with their occupations, with what they do with their hands.

To start on the road to recovery they need to feel free to voice their frustrations and fears, Hartmann believes. During these discussions, Hartmann often identifies repetitive movements or injurious grips patients may not have been aware they were using. Hands so often seem to just act on their own—acting from memory or necessity—and Hartmann wants them to understand their hands, to focus on them, to see them as more than mere means to an end.

Then the teaching begins.

Hartmann’s phenomenal success rate—virtually all her patients return to work—stems from her insistence that patients take responsibility for their recovery. With a vast collection of reference and training books, brochures, videos and other educational materials “ … at my fingertips,” she says with a smile at the pun, “I’m able to teach my patients about themselves, how they use their hands and what that means to them in terms of their identity and self-esteem. There’s a certain dignity to physical labor, working with the hands, that tends to be taken for granted until it is lost.”

Hartmann takes myriad factors into account—work environment, job description and individual physical tone—before mapping out a patient’s rehabilitation. It is almost more art than science.

There is usually a fitness component, working with weights and/or manipulating a variety of OT contraptions designed to imitate the fitness regimen enforced by the old manual typewriter. Hartmann provides instruction but the patient has to follow through on their own at home. She is quick to emphasize that, unlike some OT programs, she frowns on therapy that extends rehabilitation needlessly.

“I don’t need to go to the expense of running an ultrasound to determine my patient’s progress each time they come to the clinic,” she says. Instead, like any fitness instructor, she can tell if they are making progress by observing them perform the exercises she’s prescribed. “Naturally, if they’ve been doing the exercises at home, they are going to strengthen their hands and wrists,” she observes.

With the incentive of getting back to work, the vast majority of Hartmann’s patients overcome CTS and related repetitive stress injuries (RSI). An insurance company recently informed her that compared to the average similarly injured patient, her patients were billing one-quarter to one-third less and getting back to work much more quickly.

There’s only one proviso to these success stories. The patients need to get surgery or come directly to Hartmann for rehabilitation before doing permanent damage to their wrists and hands. That means that, for example, unlike manual typists 30 years ago, today’s computer operators need to be more self-aware. “No pain, no gain” does not apply to their job description.

Classic CTS symptoms—numbness, pain, semi-paralysis—are warnings. Hartmann has recently expanded her practice to include onsite visits to patients’ workplaces. That way she can ergonomically evaluate workstations and advocate for her patients if necessary to make sure employers are aware of deficiencies in furniture, computer equipment or work rules that may be causing injuries. Many times the only change necessary is providing for short breaks from keyboard typing and varying tasks performed. She does not charge for these visits.

“If I was in this only for the money,” she says of her independent practice, “I’d work for an HMO or go into consulting. But I take great satisfaction in my ‘hands-on’ methods, getting through to patients on a one-on-one basis, helping them understand the miracles that are their hands.”

As she relates the experience of one of her stellar patients, her hands, perhaps unconsciously, weave and gesture in intricate counterpoint to the story. This patient was a policeman who’d had the thumb on his shooting hand amputated down to the first joint. It seemed as if he was going to spend the rest of his career behind a desk.

He was determined to avoid this fate. Hartmann created a prosthetic thumb so that he could exercise and increase the muscle mass at the base of the thumb. Eventually, after many months he was able, without the prosthetic, to requalify on the shooting range and get back to work on the street.

Asked a technical question about sculpting the prosthetic, Hartmann reflects a moment on the confluence of art and life in her unique line of work, and says, “ You know, in a way, come to think of it, people’s injured hands are like living sculptures for me.”