Wednesday, 12 December 2018

A Scientific Advisor for the Hand Project

I am delighted to say that Professor Christina Jerosch-Herold, Professor of Rehabilitation Research at the University of East Anglia, has kindly agreed to join the Advisory Board for my British Academy research project, The Hand Book: A Design History of and through the Hand. Christina joins the three other members I am fortunate enough to have assembled for the project: Professor Regina L. Blaszczyk, University of Leeds, UK; Professor Finn Arne Jørgensen, University of Stavanger, Norway; and Professor John Styles, University of Hertfordshire, UK. For The Hand Project, Christina has very kindly agreed to read my writing, to check that it is scientifically correct, and to bring the benefits of her extensive expertise of a career working with persons with hand conditions or injuries.

I attended Christina’s inaugural professorial lecture at UEA on 30th October 2018, a really well-pitched event which began by acknowledging the seminal work of Sir Charles Bell, The Hand: Its Mechanism and Vital Endowments as Evincing Design (London: William Picketing, 1837) and the groundbreaking contributions of C B Wynn-Parry and Guy Pulvertaft and the context provided by the British Society for Surgery of the Hand (BSSH) and British Association of Hand Therapists (BAHT).

The sense of touch is essential for emotional development. The hand is seen as an extension of the brain: Descartes called the hand the ‘outer mind’ while Maria Montessori declared that ‘The hands are the instruments of man’s intelligence’. Her promotion of hands-on learning has influenced education globally.

The connection between the hand and the brain is perhaps most vividly shown in the image of the sensory homunculus which shows the relative size of the parts of the body according to a neurological gauge of the proportions of the brain used for their respective motor or sensory functions. Where a hand is missing, the relevant part of the brain shrinks. Blind people who rely on touch in place of sight have more developed parts of their brains related to touch than neurotypical people. Percussionist Evelyn Glennie is deaf so she relies on vibratory touch to ‘feel’ sound. US author and activist Helen Keller was deaf-blind and used touch to read braille. They exemplify how touch can compensate for the loss of other senses, however Professor Erik Moberg (1905-93), a leading hand surgeon, described a hand without sensation as blind.
From ‘Touch and Pain’ edited by R. Biswas-Diener, E. Diener. In Noba textbook series: Psychology. Champaign IL: DEF Publishers, 2013.
Professor Jerosch-Herold explained the development of her research career. She began as an occupational therapist specialising in the treatment of hand injuries. Clinical work on peripheral nerve injuries resulted in a particular interest in hand sensibility and hand function. Prof Jerosch-Herold undertook a MSc Rehabilitation Studies at Southampton University and then moved to UEA in 1992 to deliver the new BSc in Occupational Therapy and Physiotherapy. Her doctorate (2002) examined the clinical assessment of peripheral nerve injuries in the hand. She is a member of the British Association of Hand Therapists, which gave her the Natalie Barr Award in 2010, the British Association of Occupational Therapists and the Society for Rehabilitation Research. Jerosch-Herold is Editor-in-Chief of Hand Therapy (1998-) and Editorial Board member for the Journal of Hand Surgery (European) (2017-20). She has led a 5-year National Institute for Health Research Senior Research Fellowship (2013-17) investigating the clinical management of hand sensory disorders including carpal tunnel syndrome.
Nerve Injuries in the Hand
Hand sensibility and hand function are governed by receptors (ref. Johansson and Vallbo, ‘Tactile Sensibility in the human hand’, J Physiol January 1979 286: 283-300). Tactile acuity declines with age; we need no assistance with this, we simply adjust to it. The question of sex differences in tactile acuity has been answered by Peters who has demonstrated that diminutive digits enjoy increased tactile acuity as sensors are more closely spaced on smaller fingertips (Ref: RM Peters, E Hackeman and D Goldreich (2009) ‘Diminutive Digits Discern Delicate Details: Fingertip Size and the Sex Difference in Tactile Spatial AcuityJournal of Neuroscience 29 (50) 15756-15761).
On the day of the inaugural lecture, the BBC reported that surgeons could no longer be assumed to have the dexterity needed to undertake the sewing required in surgery, Prof Jerosch-Herold explained how when a nerve injury occurs in the hand, surgeons suture the outer connective tube so that the regrowing nerve fibres can reconnect with their end-organs. This healing process is not perfect, however. Nerve regeneration is slow and can result in sensory loss and muscle paralysis. Discriminative sensibility often never returns to normal. Christina has worked with her collaborators on the challenge of how to assess the recovery of tactile acuity and the evaluation of objective tests vs patient-reported outcomes (PROMs) as integral to value-based health care. See also Prof Jerosch-Herold’s collaboration with Mark Ashwood and Lee Shepstone, ‘Learning to Live with a Hand Nerve Disorder: A Constructed Grounded Theory’, Journal of Hand Surgery (2017).
Carpal Tunnel Syndrome
Traumatic nerve injuries are declining due to better health and safety, making it harder to study at a scientifically significant scale, so Jerosch-Herold has more recently focussed on Carpal Tunnel Syndrome (CTS). As many as 1 in 10 people experience CTS at some point in their lifetime and the c. 55,000 surgically-treated cases cost the National Health Service around £42 million each year. Professor Jerosch-Herold has studied the effect of sensory relearning to restore lost sensibility after carpal tunnel surgery. Sensory relearning is a treatment taught to patients designed to reprogram the brain through cognitive relearning techniques. This process removes the crutch of vision, to emphasise touch without sight. It requires patients to switch between looking and not looking. Although it is very repetitive and can get boring, the result is a mindfulness towards touch and improved ‘tactile gnosis’, that is the ability to recognise shape and form with your hands. Prof Jerosch-Herold’s more recent work on the PALMS project has examined predictive factors for responses to treatment in CTS. 
Wrapping Up
Professor Jerosch-Herold ended her inaugural lecture on October 30th with a timely warning about the dangers to the hand of activities such as bonfires and fireworks. Hand accidents peak at bank holidays and others events as people get to grips with chain saws, fireworks and pumpkin carving. Grievous injuries may benefit from treatment such as that offered to Zion Harvey, a boy who underwent a successful double hand transplant in the US in 2015. Prof Jerosch-Herold gave the final word to occupational therapist Mary Reilly, who stated in her 1961 Eleanor Clarke Slagle Lecture that:
Man, through the use of his hands, as they are energised by his mind and will, can influence the state of his own health.
This week, Christina and I met at UEA to discuss the potential linkage of her work with my project. I am interested in the way that mass production does not always successfully cater for physical differences in consumers and whether this might have some connection to Christina’s work with PROMS where sufferers of hand nerve disorders report their particular experience of the condition, albeit within a questionnaire framework. I look forward to working with Christina and the rest of the Advisory Board as The Hand Book project develops.

Prof Grace Lees-Maffei
Professor of Design History