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Introduction

         Facilitating quality of life is an essential component of pilates programming and our clients’ motivation for attending classes. Quality of life could be considered the ability to function and perform our daily activities with ease. I have noticed a recent trend to say we do activities now, for example weights and strength bearing exercises, so that we can continue to do these activities when we are in our 80s. Weights and strength loading are promoted as part of that focus arguing that doing this reduces the frequency of sarcopenia and osteoporosis as we age. All of which is important for our future, but also for our present. However, if we don’t have a good function and range in the upper limb now we don’t have quality of life now or in the future.

             In this article I will explore some of the concepts of reach and grasps as part of our work with clients who have impacted hands but also in our preparation for work in a Pilates studio setting. Remember that hands and wrists are essential in a pilates class. Think about the role of your hands when performing a plank or an elephant. Hands and wrists need attention and in this article I will discuss the why and how.

A quick anatomy overview?

Our hands have small muscles within them ( intrinsic muscles) and these are needed for fine dexterity work.  We also have extrinsic muscles of the hands that start in our forearm, and some on our humerus,  and cross over the wrist into our fingers (extrinsic muscles). Adding complexity is that some of the fine intrinsic muscles originate or attach into the tendons of the extrinsic muscles.  Extrinsic muscles are associated with power of the hand and the intrinsic muscles are associated with dexterity. It is not uncommon for extrinsic muscles overworking leading to a tightness and restrictions in the ulnar bone and radial bone  This forearm tightness can be a compensation strategy for an unstable shoulder girdle. Important muscles of the shoulder girdle, such as the  tricep and bicep muscles, cross the elbow and attach to the ulnar and radius bones as well. In summary, there is a kinetic chain from fingers to shoulders, which when working well, supports reach, grasp and dexterity whilst balancing power and control.

           You can observe this important kinetic chain when clients have restrictions in their supination or pronation of their forearms when their elbows are bent. Try it yourself – put your arms flat on a table with your elbow bent, and palm facing the table. Now try and turn your forearm (supinate) so that your palm is facing the ceiling. Can you fully pronate your forearm and hand? Observe the tensions in your arm and shoulder.

Who does this affect?

             This affects everyone! We all need good upper limb function for everyday tasks. There are, of course, some people who will have injuries or conditions that compound problems in their hands eg various arthritic conditions, neurological conditions eg post stroke. In these conditions the hands are generally stuck in flexion and there are problems for the person extending or straightening out their fingers or wrists.

          Think also about popular activities of daily living, from texting and gaming to rock climbing, which impact on hand function.  Rock climbing is increasingly popular as a sport, and there is substantial evidence that climbing results in soft tissue and bone adaptations in the fingers. The literature provides evidence that these adaptations increase over the career of elite climbers (Paster et al, 2022). There are also increased incidences or reported stress fractures in the hands of adolescent climbers (Lutter et el, 2017). When we have fractures in our bones there are consequences later in life eg arthritis.

A taxonomy of grasp?

There are many different types of grasp, but the most common we see in our daily lives are the:

// Cylindrical – eg  grabbing a reformer spring and changing this on the reformer

// Spherical  – eg  holding your hands to pick up a ball or open a jar

// Hook – eg carrying your shopping bags, holding onto kettle bells

// Pinch (pincer)  eg doing up buttons or using a clip on your reformer straps

// Tripod eg holding a pen to write

// Lumbrical eg holding your phone.

All of these different grips are essential for us to manipulate objects needed for functional activities; whether that be dressing, feeding and typing. When our fingers, wrists and hands do not function properly, basic activities can become difficult. Think of how hard it would be to do up buttons and dress yourself if you could not use a pincer grip with your fingers. Consider the implications of carrying your shopping if your fingers are not able to manage a hook grasp. Many of the power grasps are the type needed for weight lifting (cylindrical and spherical) or kettlebells (hook grasp). To improve our strength and load we must first start with our hands and shoulders. That means support proximal organisation and distal mobility.

Types of Grasp (Yang et al., 2015)

What do we have to consider when working with grasp?

When building strength in our hands and fingers for improved grasp we have to remember the anatomical relationships between our fingers, wrists, forearms and shoulders. 

The grip of a traditional weight encourages the use of the muscles of the forearm, eg flexor digitorum superficialis and profundus as well as flexor pollicis longus, and can therefore undermine strengthening of intrinsic muscles eg lumbrical muscles. The lumbrical muscles are important for finger extension of the Interphalangeal(IPPs) and Distal Phalangeal joints (DIPS) and supporting precision grasp.

The tendons of the flexor muscles pass through, the flexor retinaculum, cross over our fingers joints (phalangeal joints). All of which means that grasp can aggravate conditions such as carpal tunnel syndrome and arthritis.

Accordingly, it is important to reduce tendon loading and contraction to protect the tendon sheaths of the fingers which can be vulnerable to a lot of damage e.g. in arthritic conditions or repetitive strain injuries.

Wrist strengthening should be supported through isometric contractions when the wrist is in neutral, before taking the movement into loaded flexion and extension. Load should be applied progressively to tolerance.

Shoulder organisation and proximal strengthening through direct force focus is possible when the fingers and wrist are in a neutral position.

Exercises 

When working to build strength and reduce grip strain, I incorporate the following focus.

Step one: Strengthen the wrists in neutral position using isometrics. Hold your hands so that they are facing each other and press them out into a door for ten second holds. Then press them into the side of the door for another ten second hold. I like to do this when teaching reformer classes by having clients press out or into the metal struts of the foot bar

Step two: Build intrinsic muscle strength – with a focus on the palmer muscles

Step three:  Support load through holding the hand in an open position to reduce the loads on the flexor tendons and encourage isometric lumbrical grasp and strengthening of the intrinsic muscles of the hand.

Step

Four: As with all tendon work, gradual addition of load is important, for recovery. This is a topic I cover in detail in the Body Organics Education Love Me Tendon course.

Step five : Build wrist strength in flexion and extension with the fingers in an open position. Then add load. 

When you are working on grasp – take your time start unloaded the tendons and then add weight progressively.  For some people with damage to their finger joints

eg think swollen nuckles, a small hold like a stick is painful. In that case I would wrap something around the pole ( eg put a pool noodle over the stick) to allow the fingers to grasp, but not at such a sharp angle in the finger joints so that the joints aren’t worked into the angle of deformity.

Start with a stick and then gradually add weight eg with the pods attached to the broom stick below ( we call this the barbie bell) 

To build proximal strength in the shoulders – add load with direct force through the arms. I prefer to use the Makarlu pod for this, as the hands can be organised to reduce the use of the forearm flexor muscles and encourage intrinsic hand strength.

Step six: In building proximal strength, it is important to ensure deep rotator cuff stabilisation and control in the biceps and triceps. This helps create the balance of pull on the placement of the glenohumeral socket. Ensure alignment is achieved.

To learn more :

BOE offers courses around the upper limb eg Anatomy Dimensions Elbow Wrists and Hands.   (www.bodyorganicseducation.com).

Check out #handyhints on instagram Body_Organics_Education that will be available from August.

Acknowledgement of Craig Perry Photographer for the images produced.

To buy Makarlu 
References 

Lutter C., El-Sheikh Y., Schöffl I., Schöffl V. Sport climbing: Medical considerations for this new Olympic discipline. Br. J. Sports Med. 2017;51:2–3. doi: 10.1136/bjsports-2016-096871. [PubMed] [CrossRef] [Google Scholar] [Ref list]

Pastor T, Schweizer A, Andronic O, Dietrich LG, Berk T, Gueorguiev B, Pastor T. A Life Dedicated to Climbing and Its Sequelae in the Fingers-A Review of the Literature. Int J Environ Res Public Health. 2022 Dec 19;19(24):17050. doi: 10.3390/ijerph192417050. PMID: 36554928; PMCID: PMC9778768.

Yang, Yezhou & Fermüller, Cornelia & Li, Yi & Aloimonos, Yiannis. (2015). Grasp Type Revisited: A Modern Perspective on A Classical Feature for Vision. 10.1109/CVPR.2015.7298637.