- By Hope Willis Sheehan -
In this story, a mixture of playful activities and couples counseling recovers the enjoyment of a favorite meal.
Mr. Whitaker’s favorite meal is the sirloin steak his wife cooks for him. She broils it till crusty and tops it with a teriyaki glaze. When she plans this sirloin for dinner, he looks forward to it all day. Finally, he slices into his first juicy bite. Or at least he tries to. Unfortunately, he needs help - again. His Parkinson’s disease has zapped his knife-holding hand. Cutting steak is now a struggle because the helping action of his middle finger is missing, perhaps lost.
Mr. Whitaker is tall, in his mid-70's and elegantly lean in upscale slacks and shirt. Only his very serious face and the forward slant to his walk give observable evidence of the disease. He has a firm handshake and can still make a tight fist, so the finger problem is not yet obvious. The crumbling of his coordination however, can be heard in his speech which is now peppered with staccatoed repetitions. Just telling me his problem is tedious so I lead him to a quiet corner in our clinic, helping him to relax. He takes the chair next to me at a table and begins again.
When his labored list is finished, his “can'ts” include: brushing his teeth, shaving, writing a check, and cutting his steak.
I need to see what is wrong; to study the hand problem. I give him a butter knife and ask him to pretend that he is buttering toast. His thumb and index finger readily press onto the shaft but after a few buttering swipes, the knife clatters onto the table. He grimaces in annoyance. The long finger, the middle one, is not holding on. It has forgotten how to help. This is our problem. You may ask, how can this be? How can one unresponsive finger so profoundly limit his grasp on the knife? Is it really so challenging to hold onto a pen or a toothbrush? Why not simply use a different finger, as you might after suffering a small injury? This is a good question. Mr. Whitaker’s finger dilemma is twofold. First, this disease spawns a rigidity, both in movement and thought, which erases the ease of adaptability. Secondly, our middle finger is a vital stabilizer which cannot easily be substituted. [1]
Mr. Whitaker really needs that finger for holding his steak knife: it is part of his three-digit team. These three digits, the thumb and the two forefingers, form his tripod grasp. I will elaborate on this term. Perhaps you are familiar with the amusement game where kids are lured to a big glass case, piled inside with stuffed animals. For a small fee, the animal they want could be theirs if they can successfully operate the crane-like claw hanging overhead. That metal gripper makes grabbing their animal seem so easy. But as most people know, this tripod claw is insensitive and clumsy. Its typically ineffective mechanism cannot compare to the perfection of our own tripod grasp, formed by our thumb and two forefingers. Our tripod is sensitive enough to pick a ripe strawberry without squishing it, strong enough to tighten a bolt and clever enough to tie shoelaces. Our hands can even do these tasks without looking!
We all take this exquisite human gift for granted, Mr. Whitaker included. He was the blithe owner of this precise dexterity which made possible his groomed elegance. Its finesses enabled him to shave around the slopes of his jaw, pluck with tweezers, button his shirts and put on a tie - all until recently. Before our occupational therapy session today, I had the pleasure of meeting his wife in the lobby. She is a lovely, normally poised person, who is understandably tense at this downturn in his self-sufficiency. His “can’t” list is growing, which makes her anxious, as though she is seeing thunder heads mount on the horizon. She tries to forestall that forecast by insisting that he do things for himself, even when he cannot.
It falls to Mr. Whitaker and me then, to recover the invaluable movement of his middle finger. We start by finding out what the finger will do. I choose a simple challenge, not yet asking for a tripod; just selecting a task which hopefully entices the necessary response from the middle finger. I bring out a flat wooden disc, about ½" thick. The disc is a bit larger than a checker piece. The perimeter of this disc is many sided, like a hexagon.
“Mr. Whitaker, let’s see if you can use just your middle finger and thumb to hold onto this. Think of this disc as a tire’s wheel and press here onto the centers where the axle would be. Keep the ‘wheel’ upright, in rolling position, just as it would be on a car.”
I guide his hand into the best position in order to prepare him for the challenge. I raise his wrist into extension and curl his small fingers down into his palm. These postural adjustments effectively bring his thumb and fingers to a close meeting, naturally. [2]
I insert the wheel between his thumb and the forgetful middle finger.
“Mr. Whitaker, hold onto that axle the best you can. See if you can keep the wheel from falling.”
He tries really hard. The other hand even clenches in sympathy. The earnestness of his efforts however, mistakenly recruits action from the forefinger too, which is trying to help. This ‘help’ must be barred however, in order to coax the middle finger to do its own work. I lift his forefinger up and away. Eventually, his two-digit pinching efforts succeed and the wheel is held high. The middle finger is remembering how to do, shrugging off some of its ‘senility.’
I am relieved that a starting point for recovery has been found. Mr. Whitaker is happy too and his pleasure shows in a rare small smile. It flickers across his serious face like a stray beam of sunlight. I will mention a few clarifying details about the hand: The unique control of the human tripod is exerted from three sides. Each digit must deliver its own third of pressure from a separate side. The three directions of pressure are as follows: top pressure (dorsally) from the forefinger’s pulpy tip, side pressure (radially) from the thumb’s pulpy tip, and lastly, pressure coming from the opposing ulnar direction , delivered by the inside edge of the middle finger’s tip, (radial lateral surface.) [3]
Should this opposing pressure from the middle finger fail to come from the side of the tip and instead, press with the pulpy bottom as does the index finger, this doubles the top force, leaving that third side with little support. Rather than a Tripod, I call this weaker approach a ‘Bi-pod’ grasp. All kidding aside though, this seemingly small absence in the “triangular hold,” can lead eventually to dire problems in the hand, wrist and elbow. [4]
Over the following week, Mr. Whitaker practices his challenge at home, working to keep that wheel up. A week later, his practice is showing. Now the middle finger is working longer and doing so on its own without the overly helpful forefinger. Thankfully, the know-how and strength of the middle finger is coming back. Now when Mr. Whitaker holds onto the wheel, even if I tug on it a bit, his pinch prevails. With these two sides of the tripod working, we now endeavor to add back the ‘top’ action coming from the forefinger.
For his next challenge, the thumb and middle finger - just as before - will be pinching the wheel’s “axle.” But now in addition, the forefinger must reach out and spin the wheel. The wheel’s hexagonal perimeter will make this more feasible but the spinning will still be difficult for Mr. Whitaker because this additional challenge requires considerable coordination. His thumb and middle finger must stay pressed onto the wheel (static control), while the forefinger moves to turn it (dynamic control). I prepare his hand as before, guiding his fingers and wrist into place. Will the middle finger hold its newly recovered pinch against the thumb or will it grow confused and try to move along with the forefinger? I watch in suspense.
Mr. Whitaker is tall, in his mid-70's and elegantly lean in upscale slacks and shirt. Only his very serious face and the forward slant to his walk give observable evidence of the disease. He has a firm handshake and can still make a tight fist, so the finger problem is not yet obvious. The crumbling of his coordination however, can be heard in his speech which is now peppered with staccatoed repetitions. Just telling me his problem is tedious so I lead him to a quiet corner in our clinic, helping him to relax. He takes the chair next to me at a table and begins again.
When his labored list is finished, his “can'ts” include: brushing his teeth, shaving, writing a check, and cutting his steak.
I need to see what is wrong; to study the hand problem. I give him a butter knife and ask him to pretend that he is buttering toast. His thumb and index finger readily press onto the shaft but after a few buttering swipes, the knife clatters onto the table. He grimaces in annoyance. The long finger, the middle one, is not holding on. It has forgotten how to help. This is our problem. You may ask, how can this be? How can one unresponsive finger so profoundly limit his grasp on the knife? Is it really so challenging to hold onto a pen or a toothbrush? Why not simply use a different finger, as you might after suffering a small injury? This is a good question. Mr. Whitaker’s finger dilemma is twofold. First, this disease spawns a rigidity, both in movement and thought, which erases the ease of adaptability. Secondly, our middle finger is a vital stabilizer which cannot easily be substituted. [1]
Mr. Whitaker really needs that finger for holding his steak knife: it is part of his three-digit team. These three digits, the thumb and the two forefingers, form his tripod grasp. I will elaborate on this term. Perhaps you are familiar with the amusement game where kids are lured to a big glass case, piled inside with stuffed animals. For a small fee, the animal they want could be theirs if they can successfully operate the crane-like claw hanging overhead. That metal gripper makes grabbing their animal seem so easy. But as most people know, this tripod claw is insensitive and clumsy. Its typically ineffective mechanism cannot compare to the perfection of our own tripod grasp, formed by our thumb and two forefingers. Our tripod is sensitive enough to pick a ripe strawberry without squishing it, strong enough to tighten a bolt and clever enough to tie shoelaces. Our hands can even do these tasks without looking!
We all take this exquisite human gift for granted, Mr. Whitaker included. He was the blithe owner of this precise dexterity which made possible his groomed elegance. Its finesses enabled him to shave around the slopes of his jaw, pluck with tweezers, button his shirts and put on a tie - all until recently. Before our occupational therapy session today, I had the pleasure of meeting his wife in the lobby. She is a lovely, normally poised person, who is understandably tense at this downturn in his self-sufficiency. His “can’t” list is growing, which makes her anxious, as though she is seeing thunder heads mount on the horizon. She tries to forestall that forecast by insisting that he do things for himself, even when he cannot.
It falls to Mr. Whitaker and me then, to recover the invaluable movement of his middle finger. We start by finding out what the finger will do. I choose a simple challenge, not yet asking for a tripod; just selecting a task which hopefully entices the necessary response from the middle finger. I bring out a flat wooden disc, about ½" thick. The disc is a bit larger than a checker piece. The perimeter of this disc is many sided, like a hexagon.
“Mr. Whitaker, let’s see if you can use just your middle finger and thumb to hold onto this. Think of this disc as a tire’s wheel and press here onto the centers where the axle would be. Keep the ‘wheel’ upright, in rolling position, just as it would be on a car.”
I guide his hand into the best position in order to prepare him for the challenge. I raise his wrist into extension and curl his small fingers down into his palm. These postural adjustments effectively bring his thumb and fingers to a close meeting, naturally. [2]
I insert the wheel between his thumb and the forgetful middle finger.
“Mr. Whitaker, hold onto that axle the best you can. See if you can keep the wheel from falling.”
He tries really hard. The other hand even clenches in sympathy. The earnestness of his efforts however, mistakenly recruits action from the forefinger too, which is trying to help. This ‘help’ must be barred however, in order to coax the middle finger to do its own work. I lift his forefinger up and away. Eventually, his two-digit pinching efforts succeed and the wheel is held high. The middle finger is remembering how to do, shrugging off some of its ‘senility.’
I am relieved that a starting point for recovery has been found. Mr. Whitaker is happy too and his pleasure shows in a rare small smile. It flickers across his serious face like a stray beam of sunlight. I will mention a few clarifying details about the hand: The unique control of the human tripod is exerted from three sides. Each digit must deliver its own third of pressure from a separate side. The three directions of pressure are as follows: top pressure (dorsally) from the forefinger’s pulpy tip, side pressure (radially) from the thumb’s pulpy tip, and lastly, pressure coming from the opposing ulnar direction , delivered by the inside edge of the middle finger’s tip, (radial lateral surface.) [3]
Should this opposing pressure from the middle finger fail to come from the side of the tip and instead, press with the pulpy bottom as does the index finger, this doubles the top force, leaving that third side with little support. Rather than a Tripod, I call this weaker approach a ‘Bi-pod’ grasp. All kidding aside though, this seemingly small absence in the “triangular hold,” can lead eventually to dire problems in the hand, wrist and elbow. [4]
Over the following week, Mr. Whitaker practices his challenge at home, working to keep that wheel up. A week later, his practice is showing. Now the middle finger is working longer and doing so on its own without the overly helpful forefinger. Thankfully, the know-how and strength of the middle finger is coming back. Now when Mr. Whitaker holds onto the wheel, even if I tug on it a bit, his pinch prevails. With these two sides of the tripod working, we now endeavor to add back the ‘top’ action coming from the forefinger.
For his next challenge, the thumb and middle finger - just as before - will be pinching the wheel’s “axle.” But now in addition, the forefinger must reach out and spin the wheel. The wheel’s hexagonal perimeter will make this more feasible but the spinning will still be difficult for Mr. Whitaker because this additional challenge requires considerable coordination. His thumb and middle finger must stay pressed onto the wheel (static control), while the forefinger moves to turn it (dynamic control). I prepare his hand as before, guiding his fingers and wrist into place. Will the middle finger hold its newly recovered pinch against the thumb or will it grow confused and try to move along with the forefinger? I watch in suspense.
In the rest of the story, found in my book, Mr. Whitaker recuperates adequately with a few more weeks of carefully tailored activities.
He and his wife eventually devise a clever compromise for enjoying their meal together.
He and his wife eventually devise a clever compromise for enjoying their meal together.
[1] Using other fingers and different positions as substitutes for a tripod is hard on the hand, long-term. Patients as young as 23 years of age have come to me with hand pain, their symptoms at this young age almost always traceable to the lack of a classic tripod grasp.
[2] This ‘set-up’ positioning is vital, because it supports the working integrity of the hand. Before Mr. Whitaker attempts to achieve a tripod grasp, both little fingers must first curl into the palm, where they provide important advantages: first, when the small fingers are curled down tight, they provide a buttressing wall of support for the middle finger to lean on in its work of opposing the thumb. Secondly, when the little fingers curl into the palm, they curl the middle finger down a bit (into MCP flexion), which makes it most likely that the pressing surface of the middle finger will come from its side, not the top. Please see the case study ‘I Can Feel That Clear Into My Soul’ for more description of these small finger dynamics.
[3] Should the side-pressing/ulnar force, ideally by the middle finger be substituted instead by the ring finger, then the ring finger now abandons its critical role of buttressing support, properly formed by both small fingers. Without this buttressing stability, long-term consequences may develop in the hand, wrist and elbow.
The lack of a true three-sided tripod in many of my patients today, has its roots, I believe, in a childhood emphasis on early coloring and writing numbers and letters. Many children are encouraged to hold crayons, pencils and pens before their hands are mature enough to assume the correct position. The children then adaptively adopt problematic prehensile patterns which are difficult to change and correct. The consequence of these substitute patterns has long-term deleterious effects because the child’s formative grip on the crayon or pencil is carried on into adulthood, and adopted permanently for handling tools.
The long-term wear and tear on the hand caused by using these problematic approaches underlies many serious and chronic conditions. These include: trigger finger, carpal tunnel syndrome, tendinitis, pain in the wrist and thumb and tennis elbow (lateral epicondylitis).
[2] This ‘set-up’ positioning is vital, because it supports the working integrity of the hand. Before Mr. Whitaker attempts to achieve a tripod grasp, both little fingers must first curl into the palm, where they provide important advantages: first, when the small fingers are curled down tight, they provide a buttressing wall of support for the middle finger to lean on in its work of opposing the thumb. Secondly, when the little fingers curl into the palm, they curl the middle finger down a bit (into MCP flexion), which makes it most likely that the pressing surface of the middle finger will come from its side, not the top. Please see the case study ‘I Can Feel That Clear Into My Soul’ for more description of these small finger dynamics.
[3] Should the side-pressing/ulnar force, ideally by the middle finger be substituted instead by the ring finger, then the ring finger now abandons its critical role of buttressing support, properly formed by both small fingers. Without this buttressing stability, long-term consequences may develop in the hand, wrist and elbow.
The lack of a true three-sided tripod in many of my patients today, has its roots, I believe, in a childhood emphasis on early coloring and writing numbers and letters. Many children are encouraged to hold crayons, pencils and pens before their hands are mature enough to assume the correct position. The children then adaptively adopt problematic prehensile patterns which are difficult to change and correct. The consequence of these substitute patterns has long-term deleterious effects because the child’s formative grip on the crayon or pencil is carried on into adulthood, and adopted permanently for handling tools.
The long-term wear and tear on the hand caused by using these problematic approaches underlies many serious and chronic conditions. These include: trigger finger, carpal tunnel syndrome, tendinitis, pain in the wrist and thumb and tennis elbow (lateral epicondylitis).