No Difference in How I Work with a Hand Therapist, Got It. But Can I Do the Exercises on My Own?

Commentary Experimental evidence from randomized controlled trials is prized in medicine. Randomized trials are particularly useful in orthopaedic surgery, where the treatment goal is often greater comfort and capability, and nonspecific effects (improvements unrelated to alterations in pathophysiology) are prominent. We can also be mindful that the question asked in a trial has the potential to reinforce or normalize practice patterns that might not contribute to health. Consider a randomized controlled trial comparing 2 types of injections in which neither injection has been proved to outperform placebo injections or the natural history of the untreated disease. Simply asking the question may legitimize both types of injection. Such a hypothesis may suggest that one ought to choose one of the tested options. If it turns out that neither injection has specific effects, then the study has misled readers. In the randomized trial by Barrett and colleagues, it makes sense to me that there was no difference between the video-only therapy group and the in-person therapy group with respect to the level of capability after trapeziometacarpal arthroplasty. What I wonder is, are supervised exercises helpful in any form? When my colleagues and I noticed that recovery from volar plate fixation of a distal radial fracture was straightforward, we set up a study. We found that people could do exercises independently, after being taught by the surgeon, with comparable results to people who worked with a hand therapist1. A trial in the U.K. demonstrated that teaching patients how to perform a simple set of exercises for rotator cuff tendinopathy was comparable with a graduated set of exercises implemented over several visits2. I now offer to teach patients the exercises myself, and most patients are happy to avoid the added time, inconvenience, and expense of seeing a physical therapist. I have physical therapists on my team in my office, but the exercises for recovery from distal radius fracture and alleviation of symptoms from rotator cuff tendinopathy are so simple that there is no advantage to involving them for these indications. What about recovery from trapeziometacarpal arthroplasty? Trapeziometacarpal arthritis is a universal aspect of human senescence that most people seem to accommodate and for which a small subset of people accept an offer of surgery3–5. In the long-term randomized trial by Tim Davis and colleagues, ligament reconstruction with or without tendon interposition was not associated with greater comfort, capability, or strength compared with trapeziectomy alone6. In that study, the patients "were shown a simple set of exercises…" and were not referred to a therapist6. There are many benefits to keeping things simple. In addition to more limited use of resources and lower exposure of patients to greater out-of-pocket costs, keeping the exercises simple encourages agency, which is an important aspect of good health. I would like to see a study that compares these simple, independent exercises with virtual, therapist-guided exercises. Another point of discussion in this study is the notable levels of incapability both before and after surgery. The mean preoperative capability (mean PROMIS UE [Patient-Reported Outcome Measurement Information System Upper Extremity CAT [Computer Adaptive Test] score, 32) was nearly 2 standard deviations below the population norm of 50. At 12 weeks and 1 year after surgery, the mean scores (40 and 42, respectively) were still nearly a standard deviation below the population norm. If most 60-year-old individuals have at least some thumb arthritis, levels of capability that are 2 standard deviations below the mean are likely a signal of modifiable personal factors. The evidence regarding relatively high levels of discomfort and incapability points to our internal narrative (thoughts and feelings) about the sensations in our body7,8. In other words, our health is determined, in part, by how we evolve our self-conception to match our body as it ages. I am interested in the movement toward psychologically informed physical therapy9,10. Mental health stigma can keep people from engaging with mindset exercises and mindset professionals. We could leverage the cachet that physical, occupational, and hand therapy enjoy ("I think I need physical therapy" is a common patient expression) and provide the mindset exercises along with the physical exercises.