Journal of Hand Therapy 27 (2014) 254e257

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Journal of Hand Therapy

journal homepage: www.jhandtherapy.org

JHT READ

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CREDIT ARTICLE #320.

Practice Forum

Using smartphone applications as hand therapy interventions

Lori Algar OTD, OTR/L, CHT a, *, Kristin Valdes OTD, OT, CHT b
a
b

Northeast Orthopaedic and Hand Surgery, 60 Westwood Ave. Suite 300, Waterbury, CT 06708, USA
Rocky Mountain University of Health Professions, Provo, UT, USA

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 10 December 2013
Accepted 25 December 2013
Available online 4 January 2014

In the hand therapy clinic, smartphones can be used as an educational resource, to view a photo or video
of a home exercise program, or as a method of electronically documenting progress related to healing
from an injury. Smartphone applications may also serve as appropriate therapy interventions to address
decits often presenting with common hand injuries. For individuals with trapeziometacarpal arthrosis,
gaming can encourage radial abduction range of motion and neuromuscular control required for joint
stability. People with distal radius fractures may benet from smartphone applications for range of
motion and proprioceptive training. These treatments may assist with addressing client-centered goals
and be motivating in the current technology driven times.
2014 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.

Keywords:
Smartphone applications
Hand therapy intervention
Proprioception
Trapeziometacarpal arthrosis
Distal radius fracture
Range of motion exercise
Neuromuscular training
Gaming

Often, when we think of gaming systems, texting, and smartphones, we think of potential overuse problems that can result with
excessive use of such devices. These authors demonstrate that this
modern technology can also be useful as an adjunct to traditional
therapy. Examples are given on how and why we could incorporate
gaming devices into a treatment plan for individuals with trapeziometacarpal arthrosis and for individuals following a distal
radius fracture e Victoria Priganc, PhD, OTR, CHT, CLT, Practice
Forum Editor.
Introduction
During our personal lives, we may nd ourselves increasingly
utilizing and relying on smartphones. In the hand therapy clinic,
our clients likely have smartphones and can use these as an
educational resource, to view a photo or video of their home
exercise program, or as a method of electronically documenting
progress related to healing from a hand injury. Can we additionally
consider using applications on our smartphones as appropriate
therapeutic interventions for conditions commonly treated by hand
therapists?
* Corresponding author. Tel.: 1 203 597 1609; fax: 1 203 597 1581.
E-mail address: Lori.algar@gmail.com (L. Algar).

Using smartphone applications for treatment of

trapeziometacarpal arthrosis
Some smartphone applications, such as Fruit Samurai and Catch
the Fish (Figs. 1 and 2), require both palmar abduction and the
unconscious activation of thumb muscles to swipe the fruit or
catch the sh. There is research evidence1e5 that suggests the
appropriateness of prescribed range of motion exercises, including
active palmar abduction of the thumb and proprioception, for individuals with trapeziometacarpal (TMC) arthrosis. The pain and
decreased range of motion experienced by these individuals
interfere with function6e8 and are related to the progression of TMC
arthrosis.4,5 There is a relationship between decreased pain and
improvement in physical function, stiffness, and perception of
symptom impact on status in individuals with hand osteoarthritis
(OA),9 thus pain should be a primary concern when treating clients
with OA.10
Exercise is benecial to individuals with hand OA, including
TMC arthrosis, to assist with increasing range of motion and grip
strength and decreasing pain.1,2 The TMC joint requires both stability and mobility and is dependent on a combination of static
stability from ligaments and dynamic stability from muscles moving the joint.3 Recent biomechanical analyses3e5 of the TMC joint
have demonstrated that this joints ligaments are important

0894-1130/$ e see front matter 2014 Hanley & Belfus, an imprint of Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jht.2013.12.009

L. Algar, K. Valdes / Journal of Hand Therapy 27 (2014) 254e257

255

Fig. 1. Fruit Samurai.

contributors to neuromuscular stability via their actions of

signaling joint motion and position. Therefore, poor proprioception
and neuromuscular control may contribute to the development of
TMC arthrosis.4,5 The suggested therapeutic intervention to
improve neuromuscular control and proprioceptive sense of the
thumb is conscious neuromuscular training to promote dynamic
joint stability and rehabilitate muscles that reduce dorsoradial
subluxation and instability.5 Thus, the appropriate use of smartphone applications that facilitate neuromuscular control, such as
Fruit Samurai, Catch the Fish, or other similar smartphone applications, may serve as a valuable component of a hand therapy
program for an individual with TMC arthrosis.

Fig. 3. Labyrinth.

Using smartphone applications for treatment following distal

radius fracture
Smartphone applications including Labyrinth (Fig. 3) and Tilt
Maze (Fig. 4) demand wrist proprioceptive and joint sense exercise
from the user. These applications also require active wrist movement in order to navigate a ball through the game screen. Limitations in wrist movement are common following a distal radius
fracture. Additionally, proprioceptive decits may also be present.11

Fig. 2. Catch the Fish.

Fig. 4. Tilt Maze.

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L. Algar, K. Valdes / Journal of Hand Therapy 27 (2014) 254e257

A descriptive cross-sectional study11 involving females treated

operatively and non-operatively for a distal radius fracture found
that participants had signicantly less joint position sense in comparison to study controls, and these proprioceptive limitations
correlated highly with functional impairment on the Patient Rated
Wrist Evaluation. Additionally, a narrative review12 on proprioception of the wrist joint suggests the possible therapeutic role of proprioceptive re-education with wrist injuries. These ndings support
the use of proprioceptive activities for individuals rehabilitating after
a distal radius fracture. Therefore, use of smartphone applications,
such as Tilt Maze and Labyrinth, may compliment a more traditional
hand therapy program for individuals requiring skilled therapy
following a distal radius fracture by addressing proprioceptive deficits while encouraging functional wrist range of motion.
Conclusion
The twenty rst century clinician can consider using smartphone technology as an intervention for common hand injuries
including TMC arthrosis and distal radius fractures. Skilled hand
therapy can assist with recommendation of appropriate postural
mechanics and encouragement of a therapeutic quantity of gaming
when using smartphone applications as a component of a treatment program. Certain smartphone applications can be used to
address client-specic decits, decrease functional concerns, and
achieve client-centered goals. Incorporating gaming on the
smartphone in a hand therapy rehabilitation program may be
motivating to clients and convenient in the current technologydriven times.

References
1. Kjeken I, Smedslund G, Moe RH, Slatkowsky-Christensen B, Unlig T, Hagen KB.
Systematic review of design and effects of splints and exercise programs in
hand osteoarthritis. Arthritis Care Res. 2011;63(6):834e848.
2. Valdes K, Marik T. A systematic review of conservative interventions for
osteoarthritis of the hand. J Hand Ther. 2010;23(4):334e351.
3. Lee J, Ladd AL, Hagert E. Immunouorescent triple-staining technique to
identify sensory nerve endings in human thumb ligaments. Cells Tissues Organs.
2012;195(5):456e464.
4. Morbargha N, Ludwig C, Ladd AL, Hagert E. Ultrastructure and innervation of
thumb carpometacarpal ligaments in surgical patients with osteoarthritis. Clin
Orthop Relat Res. doi: dx.doi.org/10.1007/s11999-013-3083-7; Published online ahead of print June 13, 2013.
5. Hagert E, Lee J, Ladd AL. Innervation patterns of thumb trapeziometacarpal
joint ligaments. J Hand Surg. 2012;37(4):706e714.
6. Gehrmann SV, Tang J, Li ZM, Goitz RJ, Windolf J, Kaufmann RA. Motion decit of
the thumb in CMC joint arthritis. J Hand Surg. 2010;35A(9):1449e1453.
7. Marshall M, van der Windt D, Nicholls E, Myers H, Dziedzic K. Radiographic
thumb osteoarthritis: frequency, patterns, and associations with pain and
clinical assessment ndings in a community-dwelling population. Rheumatology. 2011;50(4):735e739.
8. Zhang Y, Niu J, Kelley-Hayes M, Chaisson CE, Aliabadi P, Felson D. Prevalence of
symptomatic hand osteoarthritis and its impact on functional status among the
elderly: the Framingham study. Am J Epidemiol. 2002;156(11):1021e1027.
9. Barthel HR, Peniston JH, Clark MB, Gold MS, Altman RD. Correlation of pain
relief with physical function in hand osteoarthritis: randomized controlled trial
post hoc analysis. Arthritis Res Ther. 2010;12(R7):1e8 http://arthritisresearch.com/content/12/1/R7. Accessed 12.09.13.
10. MacDermid JC, Wessel J, MacIntyre N, Galea V. The relationship between
impairment, dexterity, and self-reported disability of persons with osteoarthritis of the hand. J Hand Ther. 2008;21(4):423e424.
11. Karagiannopoulos C, Sitler M, Michlovitz S, Tierney R. A descriptive study on
wrist and hand sensori-motor impairment and function following distal radius
fracture intervention. J Hand Ther. 2013;26(3):204e215.
12. Hagert E. Proprioception of the wrist joint: a review of current concepts and
possible implications on the rehabilitation of the wrist. J Hand Ther.
2010;23(1):2e17.

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JHT Read for Credit

Quiz: #320

Record your answers on the Return Answer Form found on the

tear-out coupon at the back of this issue or to complete online
and use a credit card, go to JHTReadforCredit.com. There is
only one best answer for each question.
#1. An essential assumption implied by the authors is that
a. smart phone users have greater thumb ROM than ip top
cell phone users
b. smart phone use enhances cerebral function
c. swiping on a smart phone enhances thumb ROM and position sense
d. swiping on a smart phone takes advantage of neural
plasticity
#2. The authors suggest that Labyrinth and Tilt Maze
a. may be therapeutic following distal radius fracture
b. were designed for distal radius fracture patients
c. are difcult apps to learn to use
d. may be therapeutic for balance therapy in the elderly
#3. To date the effectiveness of utilizing smart phone apps in hand
therapy is
a. frequently referred to in the literature
b. supported with signicant data

c. conclusive
d. speculative
#4. The cost to benet ratio of investing in a smart phone vs.
attending a clinic is
a. prohibitive
b. within most patients budgets
c. is not addressed in this article
d. excessive
#5. The authors recommend replacing traditional exercises with
smart phone games
a. true
b. false
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