Mindful Body Scans and Sonographic Biofeedback as Preparatory Activities to Address Patient Psychological States in Hand Therapy: A Pilot Study

Abstract

Introduction:

Translational evidence for mind-body interventions in hand therapy is limited. This pilot study aimed to determine potential benefits of including a mindful body scan or sonographic biofeedback at the outset of a hand therapy session on key psychological states.

Methods:

A randomized, repeated-measures, cross-over design was used to evaluate a mindful body scan and sonographic biofeedback at the outset of a hand therapy session. Measures of pain, anxiety, and stress (i.e., salivary cortisol) were obtained from 21 hand therapy patients at the start, after 20 minutes, and at the end of each of three 60-minute treatments. Trends were examined, and mixed-effects regression compared effects across time within and across the sessions for each of the outcome measures.

Results:

For all intervention types, anxiety and stress decreased across the treatment session (p<0.001); no statistically significant changes were noted in pain. Using either mind-body intervention before standard care resulted in a meaningful decrease and statistical trend toward improvement in stress. The use of a mindful body scan produced an immediate, statistically significant reduction in anxiety (β = −0.14, p = 0.03), a lowered level that was maintained throughout the therapy session.

Discussion:

These data provide preliminary support for integrating mind-body interventions as preparatory activities in hand therapy. Mindful body scans may prepare patients for therapeutic interventions by more quickly reducing anxiety, and the use of either intervention may reduce patient stress more than would occur during a standard care session. These effects should be evaluated in an adequately powered clinical trial.

Introduction

Because the mind and body are inextricably connected, an injury to the body can impact the mental state and, in turn, affect recovery.¹ Unfortunately, the psychological and social aspects of recovery are not typically addressed and rarely assessed as a part of routine hand therapy.² As mind-body interventions gain popularity in physical rehabilitation,³ there is increased discussion of the potential benefits of mind-body interventions for the treatment of acute injuries and the advancement of holistic hand therapy practice.^4,5 Two mind-body interventions that may be appropriate are sonographic biofeedback and mindfulness training.

Biofeedback exemplifies the integration of mind and body components by promoting insight on body structures, functions, and physiological states to improve overall physical performance. For example, electromyography (EMG) biofeedback turns muscle activity into sounds and images to assist a patient with understanding when and how muscles are contracting, a technique commonly used in stroke recovery or pelvic floor rehabilitation for urinary incontinence.⁶ Biofeedback using sonographic imaging is becoming more frequently used in physical and occupational therapy treatments.^7–9 Real-time sonographic biofeedback has been shown to improve functional abilities in individuals with gait disorders¹⁰ and to enhance the quality of core stability exercises in individuals with low back pain.¹¹ When used in hand therapy, patients benefit by gaining insight into how their body functions and the impact of their injury on that function, allowing them to be more in control and engaged in their own recovery.¹²

Mindfulness training aims to enhance the state of “awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment.”¹³ This training can improve immune function and reduce inflammation,¹⁴ decrease anxiety,¹⁵ and assist patients in managing their pain.¹⁶ Importantly, when used to address pain or anxiety, mindfulness supports patients in separating symptoms and feelings from personal identity, thereby increasing confidence in managing thoughts and emotions with openness and acceptance.¹⁷ Even when conducted in short, individual bursts, mindfulness-based interventions can promote relaxation and relief of stress, allowing individuals to become more engaged in immediate tasks at hand.¹² The use of mindfulness-based interventions as part of a holistic approach to hand therapy may address critical psychological components of injury and illness and promote patient self-efficacy, engagement, and successful recovery of physical function.

Applied research on the use of sonographic biofeedback and mindfulness training in hand therapy is limited. Studies examining biofeedback have primarily focused on the effects and outcomes relative to discrete body function outcomes (e.g., muscle activation, range-of-motion, strength) without exploring more holistic effects. Similarly, well-researched mindfulness-based interventions are available (e.g., Mindfulness-Based Stress Reduction¹⁸), but these interventions are often not feasible for patients with acute conditions due to the intensive nature of the intervention that requires up to ten weeks of training and significant self-practice at home; there is limited intervention-based literature specific to the translation or use of limited-scope, mindfulness-based practices within acute physical rehabilitation, and no known interventional evidence specific to hand therapy.

This randomized pilot study was developed to explore how these mind-body interventions affect common psychological states when incorporated as a preparatory activity in hand therapy. Specifically, we aimed to examine how including sonographic biofeedback or a mindful body scan as a preparatory activity at the outset of a hand therapy session impacted patient pain, anxiety, and stress. Understanding the impact of these interventions and establishing proof of concept within the hand therapy context is a foundational step for developing best practices for the integration of mind-body interventions into the rehabilitation process for acute musculoskeletal injuries.

Methods

This pilot study used a randomized, cross-over design consisting of four, 60-minute research visits across two weeks. Every participant received all interventions (i.e., full allocation), and no alterations were made to the study methods once enrollment commenced. The university’s institutional review board approved this study, and all patients provided written informed consent before participating.

Participants

We sequentially recruited patients from an outpatient hand therapy clinic at an academic medical center on the west coast of the United States. Patients eligible for the study were at least 18 years old, spoke English, and could independently respond to questionnaires. We only included patients who verbally reported hand pain greater than 2 out of 10 on a numeric rating scale while at rest and those who were scheduled to attend at least two therapy visits per week. We excluded patients with bilateral hand involvement and patients who had a cast or an open wound due to the inability to complete the sonographic biofeedback protocol without an unaffected comparator. Patients were recruited at the end of their initial evaluation in the therapy clinic and initiated study participation at their second therapy visit.

Interventions

We obtained data during four 60-minute therapy sessions. During the first and third sessions, the participant received 60-minutes of standard care. The purpose of the third session was to wash out any potential effects of the first mind-body session as participants crossed-over; thus, we did not analyze data from this washout session. During the second and fourth sessions, the participant received a 20-minute mind-body intervention followed by 40-minutes of standard care. A 10-min calming period in a quiet space was used before each treatment session to minimize the effects of pre-session stressors. All interventions were provided by one of two individuals, both of whom were occupational therapists and certified hand therapists with more than 10-years of experience.

Standard care.

The treating hand therapists used their discretion in selecting treatments during standard care. That is, the interventions varied by the type and severity of each participant’s diagnosis. Standard care interventions crossed the spectrum of hand therapy practice. These interventions included physical agent modalities, manual therapy techniques, passive and active therapeutic exercises, occupation-focused therapeutic activities, educational instruction, and home exercise program training.

Mindful body scan.

This mindfulness-based intervention incorporated a 19-minute, audio-guided meditation written and pre-recorded by an experienced mindfulness trainer. The session led participants through an attentional practice of focused awareness on the body, starting at the ankles, progressing upward through the trunk, arms, and hands, then ending on the neck and face. During this focused attention, the trainer fostered an attitude of acceptance of feelings and curiosity about sensations. Guiding questions were used throughout the session to highlight the many types of sensations, including light touch, pressure, temperature, taste, smell, and sight. Participants used noise-canceling headphones and completed this training in a private area of the hand therapy clinic.

Sonographic biofeedback.

The treating therapists conducted the sonographic biofeedback with a Venue 40 sonography machine (GE Healthcare Ultrasound, Milwaukee, WI) and a 12-MHz or 18-MHz linear transducer. The therapists had previous training in sonographic image acquisition and analysis from a registered musculoskeletal sonographer (RMSKS). A general standardized protocol was followed, with specific images tailored to the patient’s diagnosis. To begin, the therapist oriented the participant to the sonographic images and identified structures on the unaffected side. The therapist then imaged the affected side, pointing out differences in each anatomical structure that was affected. Finally, dynamic movements of tendons and muscles were demonstrated on both sides during finger and wrist motions, as well as during functional tasks (e.g., pinching tweezers). Patients were instructed to imagine these movements while completing subsequent therapeutic activities.

Outcomes

Baseline demographic measures at the first visit included height, weight, age, gender, work status, and diagnosis. Functional limitations and symptoms were captured using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.¹⁹ Baseline trait anxiety was evaluated using the State-Trait Anxiety Inventory (STAI).²⁰ Finally, the Five Facet Mindfulness Questionnaire Short Form (FFMQ-SF) was used to describe participants’ innate level of trait mindfulness.²¹

We explored the impact of the mind-body interventions on three primary candidate outcome measures: state anxiety, pain, and stress. State anxiety was measured using the state scale of the STAI. Patients indicated their pain level on a visual analog scale (VAS), placing a mark on a 10-cm line between two verbal anchors of “no pain” and “worst pain imaginable.”²² An analysis of cortisol concentration (nmol/L) within saliva obtained using mouth swabs at each time point provided a measure of participant stress.²³ Each outcome measure was obtained during the baseline standard care and each of the two mind-body augmented sessions using repeated measurement at minutes 0, 20, and 60.

Sample Size

As a resource-constrained study, we examined similar preliminary trials in rehabilitation, and we determined a sample size of 20 individuals would be feasible and would provide the preliminary data necessary to investigate immediate effects on key outcomes.

Randomization, Allocation, and Blinding

We use a random sequence generator to determine the sequence that study identification numbers were assigned to participants as they enrolled in the study. Each identification number had been previously allocated to one of the two groups by a member of the study team. The upcoming identification number was unknown until a patient had fully enrolled, ensuring blinding of the therapist and patient to group assignment during the recruitment phase. The intervening therapist and patients remained blinded to group allocation until the first mind-body intervention was provided at the second research visit. Rater-blinding was not possible for the outcomes of pain and anxiety as these were self-reported measures; however, an external laboratory blinded to group allocation and intervention type completed the cortisol analysis for the outcome measure of stress.

Statistical Methods

We analyzed our data in three steps. First, we calculated descriptive statistics for all demographic characteristics and other baseline measures to provide summary data regarding our participant sample. Second, we evaluated visual trends by plotting the averages across time for each outcome measure by intervention type and compared changes in these psychological states among the three interventions. All changes were compared to minimally important differences (MID) to determine the clinical impact of the findings. A MID of 10-points and clinical diagnostic threshold of 40 points applies for measures on the STAI.^24,25 For individuals with musculoskeletal conditions of the upper extremity, a VAS-pain change in the range of 1.1 – 1.6 points indicates a MID.^26–28 Salivary cortisol typically follows a regular homeostatic pattern across a 24-hour sleep/wake cycle. Specifically, cortisol levels are higher in the morning, naturally dropping approximately 9.8 nanomoles per liter (nmol/L) in 8 hours from the morning to the evening.²⁹ Given that intervention and data collection occurred during this period, a decrease of 1.2 nmol/L was the expected change in cortisol due to the typical daily cycle across the 60-minute visit. Deviance from this expected change in cortisol concentration was interpreted as clinically relevant.

Finally, mixed-effects regression models were used to explore potential differential effects of adding mind-body interventions to standard care, accounting for the repeated measures over time and the crossed conditions. We used a gamma distribution to satisfy the normality of residuals requirement. Although both time and visit number were time-related variables, these data were treated as nominal variables to allow for the detection of non-linear changes in outcomes. Preliminary models tested each of the primary variables (i.e., pain, anxiety, and cortisol) as a function of time independent of intervention type and the research visit number adjusted for intervention type. This adjustment addressed confounding caused by the cross-over design. We ran models for each of the primary outcome variables as a function of visit number, intervention, time, and intervention-by-time. The baseline standard care session served as the reference group in the regression models, and p < 0.05 was identified as the statistical significance threshold. All data were analyzed using SAS for Windows, Version 9.4 (SAS, Cary, NC).

Results

Of 181 consecutive patients screened, 21 individuals met eligibility requirements and were enrolled in the study (Figure 1). Participants were 53 years old on average and included 8 men and 13 women who were most often working at least part-time (Table 1). Diagnoses varied across the participants (e.g., bone fracture, trigger finger, trapeziectomy, tendon transfer), manifesting in heterogeneity in the severity of disability as indicated by DASH scores ranging from 18 to 75. Participants exhibited moderate levels of trait anxiety, with an overall average approaching a clinical diagnostic threshold. Baseline scores on the five facets of mindfulness varied widely across the entire range of the scale, indicating heterogeneity in mindful traits among the participants.

Figure 1.

CONSORT flow diagram of patient enrollment and progression through the study.

Table 1.

Descriptive statistics of participants at baseline (N = 21).

	Frequency / Mean (SD)	Observed Range
Gender, male:female	8:13	-
Work Status, working:limited-by-injury:retired:other	9:5:5:2	-
Age, years	52.8 (13.5)	[22–75]
DASH [0 – 100]	47.1 (17.9)	[18–75]
STAI: Trait [20 – 80]	37.5 (10.1)	[22–61]
FFMQ-SF
Nonreactivity [5 – 25]	16.0 (3.4)	[7–24]
Observing [4 – 20]	15.5 (3.1)	[9–20]
Acting with Awareness [5 – 25]	18.7 (4.6)	[11–25]
Describing [5 – 25]	19.1 (3.2)	[14–25]
Nonjudginga [5 – 25]	17.6 (3.3)	[12–23]

DASH = Disability of the Arm, Shoulder, and Hand; STAI = State Trait Anxiety Inventory; FFMQ-SF = Five-Factor Mindfulness Questionnaire Short Form

^aOne participant failed to complete the full FFMQ-SF causing N = 20 for this subscale only

Plots of average outcome measures across time are provided in Figure 2. Despite appearing to start at a higher level, downward trends in anxiety were similar between the sonographic biofeedback session and the standard care session. In the mindful body scan session, there was a large initial drop in anxiety immediately following the mind-body intervention that was then maintained at the lowered level throughout the remainder of the session. Changes in pain were minimal and varied by intervention, with an initial decrease in pain immediately following the two mind-body interventions as compared to an initial increase in pain during standard care. None of the changes in anxiety or pain were noted to surpass clinically meaningful levels of change (Table 2).

Figure 2.

Line graphs of mean anxiety, stress, and pain at 0, 20, and 60 minutes by intervention session type.

Table 2.

Marginal means (SD) for anxiety, stress (i.e., nmol/L of salivary cortisol), and pain at 0 minutes, 20 minutes, and 60 minutes by intervention.

	Min 0	Min 20	Min 60
Standard Care
Anxiety	31.10 (6.75)	30.81 (6.10)	28.93 (5.10)
Stress	3.76 (2.96)	3.34 (2.29)	3.06 (3.06)
Pain	3.27 (2.17)	3.42 (2.02)	2.97 (1.95)
Mindful Body Scan
Anxiety	34.30 (10.21)	29.40 (6.86)	29.22 (7.08)
Stressa	3.96 (2.60)	3.20 (1.95)	2.37 (1.30)
Pain	3.09 (2.08)	2.67 (2.09)	2.90 (2.27)
Sonographic Biofeedback
Anxiety	33.75 (8.06)	33.05 (7.62)	30.74 (8.23)
Stressa	4.46 (2.77)	3.17 (1.80)	2.40 (1.31)
Pain	3.03 (2.13)	2.84 (2.10)	2.69 (2.22)

^aChanges across time exceed clinical minimal important differences (MID) as follows: anxiety = 10 points; stress = 1.2 nmol/L; pain = 1.1 points

In contrast, clinically meaningful decreases in stress, as measured by salivary cortisol levels, were noted during sessions that included mind-body interventions. Specifically, salivary cortisol levels were expected to decrease by 1.2 nmol/L across the hour-long session due to natural physiological processes. Changes in cortisol across the mindful body scan (−1.6 nmol/L) and sonographic biofeedback (−2.1 nmol/L) sessions exceeded this expected decrease, indicating that the use of mind-body interventions had a positive effect on stress reduction. In contrast, during the standard care session, cortisol levels decreased by only 0.7 nmol/L. Given that this drop was less than would naturally occur, it is likely that the standard care session increased patient stress resulting in an overall slowed relative decrease in cortisol.

No outcomes varied significantly by the research visit number within the mixed-effects regression analyses (p > 0.13 for all). This finding indicates that there was no influence of the order in which patients received the interventions in our cross-over design, and there was no effect of healing or recovery on the outcome measures obtained over a 2-week period. Although no direct evidence of order or time effect was found, we included statistical controls for session order in our calculations of the marginal effects of time and time by intervention to strengthen the analysis due to the heterogeneous and limited sample size in this pilot study. In the final controlled statistical models, statistically significant main effects for both anxiety and cortisol levels indicate that these traits decreased across sessions irrespective of the intervention being provided (p < 0.001). Despite anxiety appearing higher at baseline for the mind-body session, no main effects for intervention type were observed, and pain levels did not change significantly during any sessions (p = 0.14).

In all cases, changes in pain, anxiety, and cortisol from baseline to 20-minutes and baseline to 60-minutes favored the sonographic biofeedback and mindful body-scan conditions over the standard care condition (Table 3). The decrease in anxiety from 0 to 20 minutes in the mindful body scan intervention as compared to standard care was the only result that achieved statistical significance (p=0.03). Specifically, the mindfulness-based intervention demonstrated a reduction in the STAI of 4.9 points (Cohen’s D = −0.95) after the 20-minute intervention, a lowered state that was maintained at 60 minutes. Differences in within-session patterns of pain among three interventions showed a trend toward statistical significance for the 0 to 20-minute change (p = 0.06) due to decreases in the mind-body interventions compared to increases in the standard care average.

Table 3.

Marginal effects of each mind-body augmented intervention session compared to standard care at 20-minutes and 60-minutes on pain, anxiety, and cortisol measures adjusted for research visit number.

	Sonographic Biofeedback vs. Standard Care			Mindful Body Scan vs. Standard Care
	Beta estimate (95% confidence interval)	p-valuea	Effect Sizeb	Beta estimate (95% confidence interval)	p-valuea	Effect Sizeb
Pain
20 vs. 0 minutes	−0.14 (−0.49,0.22)	0.45	−0.40	−0.34 (−0.70,0.02)	0.06	−0.69
60 vs. 0 minutes	−0.03 (−0.38,0.33)	0.87	−0.02	−0.06 (−0.42,0.30)	0.73	0.08
Anxiety
20 vs. 0 minutes	−0.02 (−0.14,0.10)	0.76	−0.09	−0.14 (−0.26,−0.02)	0.03	−0.95
60 vs. 0 minutes	−0.04 (−0.16,0.08)	0.55	−0.14	−0.09 (−0.21,0.03)	0.16	−0.49
Cortisol
20 vs. 0 minutes	−0.22 (−0.62,0.18)	0.27	−0.70	−0.08 (−0.47,0.32)	0.71	−0.27
60 vs. 0 minutes	−0.34 (−0.74,0.06)	0.09	−0.45	−0.25 (−0.65,0.15)	0.22	−0.29

^aSignificance level for the beta estimate for the intervention*time variable in the mixed effects regression model.

^bCohen’s d for between-group differences = [(intervention mean change from baseline)-(standard care mean change from baseline)] / (standard deviation of standard care mean change from baseline)

Discussion

This study sought to explore the impact of including a mind-body intervention as a preparatory activity at the outset of hand therapy on patient psychological states. Improvements in anxiety and stress (i.e., reduction in salivary cortisol) were observed across the 60-minute therapy visit regardless of the interventions provided. The stress biomarker of salivary cortisol outpaced the expected homeostatic decrease when a session started with either mind-body intervention. In contrast, changes in cortisol under paced the expected decline during the standard care therapy session that did include a preparatory mind-body intervention. In addition to the clinically meaningful reduction in patient stress, receipt of the mindful body scan resulted in an immediate statically significant drop in patient anxiety that differed from the more gradual decrease in anxiety in the other two sessions.

High levels of patient anxiety interfere with the therapeutic process by distracting patients and lowering educational retention.^30–32 Not only did we find that the use of a mindful body scan led to a more immediate decrease in patient anxiety as compared to other interventions, the effect of was substantially large (Cohen’s D = −0.95). These quantitative findings mirror qualitative evidence that suggests the use of a mindful body scan supports relaxation and a sense of relief in hand therapy patients.¹² While having a different and substantial effect compared to the other sessions, the average decrease in state anxiety following the mindful body scan was only half of the MID. When interpreting the MID, it is important to note that the threshold for meaningful change in state anxiety was established based on expected changes following a 2-month intervention²² as compared to the 20-minute intervention provided in this study. Given the substantial effect noted, these data provide preliminary support for further exploration of using a mindful body scan at the start of a hand therapy session as a preparatory activity. Specifically, immediate decreases in patient anxiety at the outset of a session could promote more engaged, efficient, and effective hand therapy interventions that follow.

As with anxiety, elevated levels of psychological stress can have detrimental effects on recovery and healing following an injury.³³ The role of psychological elements during recovery has been demonstrated in recent research in upper extremity physical rehabilitation where patient self-efficacy and expectations were shown to be predictive of better outcomes for patients receiving physiotherapy for a shoulder injury.³⁴ Additionally, measuring salivary cortisol levels is a useful means for obtaining insight into the potential impact stress on physical recovery.³⁵ In our study, cortisol levels decreased across all sessions regardless of the intervention. However, therapy sessions that included a mind-body intervention resulted in changes in the stress biomarker that outpaced expectations. These decreases in stress biomarkers are coherent with qualitative patient experiences, where overall reports suggest that the use of sonographic biofeedback and mindful body scans allow patients to feel more in control.¹² Feeling more informed, engaged, and in control of their injury, body, and overall recovery likely translates into lowered stress that, in turn, can support physical recovery.

Although we found no statistically significant findings for pain, there was a trend toward significant differences among the intervention types at 20-minutes. Average pain decreased following the mind-body component, whereas pain increased in the first 20-minutes of the standard care sessions. This impact is not surprising as many standard interventions can often increase discomfort (e.g., passive range of motion in a stiff joint); whereas, mind-body interventions are commonly used for pain management. Strong effects for pain are more often observed when mindfulness-based interventions are provided across multiple weeks and include on-going practice by the patient.³⁶ The increase in pain from 20 to 60 minutes in the session where the mindful body scan was unexpected, and further exploration of the within-session impacts of the use of mind-body interventions in larger samples are needed to evaluate actual effects. Furthermore, as with anxiety and stress, the effects of these mind-body interventions on pain outcomes may be more likely seen with repeated use over the full episode of care.

Given the potential benefits as preparatory activities, it is important to consider feasibility and long-term outcomes of these mind-body interventions. The mindful body scan was inexpensive (i.e., mp3 player, headphones) and required minimal training due to the use of pre-recorded audio files. In contrast, conducting biofeedback required access to a sonography machine and training of therapists.³⁷ While the quantitative findings relative to anxiety and stress favored the mindful body scan, qualitative patient reports support both interventions, with numerous educational benefits of the sonographic biofeedback.¹² Future research examining cumulative effects of repeated or extended use of these mind-body interventions across the entire episode of care for a hand injury could determine if such interventions promote incremental or lasting decreases in stress responses or state anxiety. Reducing the long-term or chronic psychological sequelae associated with a hand injury could promote faster recovery and translate into improvement in other long-term, down-stream outcomes (e.g., function and wellbeing).

Findings in this study must be interpreted with consideration of multiple limitations. First, because no prior data were available to provide a reasonable estimate of effect sizes within this population, an a priori sample size calculation was not conducted. Instead, we intentionally recruited a small sample to develop these estimates of effects to inform sample size calculations for future fully-powered studies. This small sample size increases the risk of over-estimating the actual effects of our interventions in a larger, more heterogeneous sample. Conversely, without being adequately powered, the small sample may have resulted in an inability to detect actual effects for the outcomes showing trends in our analysis. Additionally, the low average reports of pain and moderate reports of anxiety at the start of all sessions in our small sample may have contributed to a floor effect that limited the ability to detect statistical differences or MID for these outcomes.

In addition to sample size limitations, the narrow scope and preliminary nature of this study limit the ability to infer broad practice-based implications. Specifically, we conducted this study to establish initial proof of concept for the positive effects of augmenting hand therapy with preparatory mind-body interventions. As such, we only evaluated immediate within-session effects on selected psychological state outcomes, and the long-term impact on either psychological or physical recovery (e.g., functional outcomes) were unable to be determined. Similarly, our analysis was unable to account for the relative impact of various standard care interventions that could have had a differential impact on patients’ outcomes. However, we reduced the impact of these limitations by (1) minimizing potential bias through randomization and blinding, (2) using a cross-over design to obtain a larger effective data sample size by providing all interventions to all participants, and (3) employing robust statistical methods to control for intervention order effects.

Conclusion

Although well explored in other clinical contexts, this study is the first known empirical evidence for the use of a mindful body scan or sonographic biofeedback within hand therapy. In our study, the inclusion of a preparatory mindful body scan expedited the reduction in patient anxiety. Additionally, both mind-body interventions led to a larger decrease in the level of the stress marker of salivary cortisol than would be anticipated to occur in the absence of any intervention. These positive and promising preliminary findings give impetus for further exploration of incorporating these techniques as preparatory activities in hand therapy. Future studies are needed to ascertain the appropriate dosage and cumulative effects of these interventions across a full episode of care, to examine how these interventions impact chief rehabilitation outcomes of physical and functional recovery, and to understand factors that support or challenge the integration and implementation of these interventions within contemporary clinical practice. Together this study and future work can support the development of an integrative and holistic approach to the treatment of acute upper extremity musculoskeletal conditions.