Health update Thursday?

This post may not be the most exciting as I sit here stinky after a small home workout— smelling the petroleum heavy heat of asphalt. But it is a hopeful post. My roses sit heavy with blooms, and the first flowers have opened behind the bush.

Such a metaphor for life. The whole “bloom where you are planted” concept.

I have been working hard— like I want to stop, I want to vomit, my muscles burn. Andrew at Apex Training has been amazing, helping me stretch and challenge spastic muscles in my lower body.

I have had two days now with no hip or back pain, and I can drop into bed and lie anyway I want.

My weight has been up and down thank to Taco Bell and Mothers’ Day cake and ice cream and generic Takis.

But I went for my check-up bloodwork yesterday, and the phlebotomist told me my insurance doesn’t cover vitamin D unless my doctor codes it a deficiency. We skipped that, but my ferritin has risen from 28, just barely in the normal range, to 36. Still far from the middle of normal but rising.

That might be my theme for right now— rising.

And my bad cholesterol, which should be under 100, has fallen from 109 to 107. Again, not a huge leap, but progress. Progress made during a difficult, difficult time of my life.

My pill dispenser has made it easier to take all my vitamins and allergy meds. And I started the process of putting myself back on a low dose of Lexapro,

Maybe it will help.

My personal cat, Fog, decided to love me today. And I wrote a poem about buying my new socks from the Dollar Tree.

The teenager has been nursing an ear infection all week so between that and the roses bloominfection, spring has really sprung.

She returned to school today.

Today I made a leftover sandwich— some old smoked Turkey, slightly wilted lettuce and my coleslaw mix stirred into chipotle mayonnaise.

I spent the morning with my blind friend, Nan, and took her for her bloodwork.

Came home and the dog came out just in time to see that the paving crew had Taco Bell for lunch.

My trainer asked to reschedule my session today, so I told him I would do something at home.

This was my half-assed work out. My trainer asked me to select exercises and do them with intent, and instead I fought with the dog, picked some exercises I thought would move the important parts and retain the ground I made versus improve. Here is a video.

I also received a payment from my short-term disability insurance through work, and I’m grateful as this is giving me time to strengthen myself and recovery from my mallet finger. Hopefully, this will prevent further “domino effect” on my health. I see the neuro-physiatrist at the end of the month.

I’m curious what she will have to say, and I’m thinking this may be the end of my quest for answers about my cerebral palsy.

Zigzag: Random thoughts about exercise, food and friends

Yesterday before the teenager and I took our impromptu trip to Hershey to visit with Curly, I had the good fortune to have a coffee date with a neighbor who has proven herself time and time again as a reliable friend.

We met while pregnant, due dates a week apart, homes a few blocks apart, and with jobs in the same town in the next state. Even though we lived less than a block apart for most of the teenager’s life (and the fact that her son and my daughter have first names that are one letter apart and family names that are very similar and fall alphabetically beside each other), she and I have not kept in touch the greatest— but somehow— when I need her, she seems to be there.

She even worked for me for about six months when I needed a staff member that could act without much hand-holding and understood my working style. The partnership renewed our connection— and the employer recently asked her to return to the organization and she politely declined.

We had the chance to discuss these things over “coffee” at the diner where the teen used to waitress. But the day was rainy and we both wanted soup instead of coffee, so we had our mom therapy session over bowls of pepper pot.

We talked about the teenagers’ post-high school plans, the value and frustration of college, our health, medical insurance in America, and how hard it must be to be a teen in today’s world.

I mention this as a reminder of how sometimes, sharing a moment can bring laughter and release.

Our latest Hungryroot box came, and I realized for the first times in all these months of Hungryroot that the reusable nitrogen ice packs are plant food. Now I can’t wait to pour that on our compost heap.

Speaking of food subscription services, my breakfast today was Cabot cottage cheese from Grocery Outlet and a sprouted multigrain everything bagel and garlic herb probiotic cream cheese from Hungryroot.

My lunch was leftover cauliflower linguine and one meatball from Hungryroot, basil tomato sauce from ShopRite and a pile of plain lentils I made.

Turns out lentils are a great way to add plant protein to spaghetti.

And finally, my session at Apex Training today was not easy— but I did it. We did a lot of sweat-inducing balance exercises. I have been having issues with stiffness since I left work and my walk has been unstable. This morning my right leg felt off. So I told Andrew and together we thought it might be super tight. Well, by the time I left, my right leg and back were screaming.

But after a shower and an NSAID to make sure nothing is inflamed, at least I don’t feel like a pile of grinding gears needing oil.

The ordinary adventures

So, if you’re a friend of mine or a regular here, you know that I have asked my employer, Stitch Fix, for a short-term disability/ FMLA leave to deal with my ruptured tendon (mallet or baseball finger) and its impact on my right hip.

This means I’ve made a commitment to work with my family doctor, my chiropractor (Nicole Jensen at Back in Line Chiropractic and Wellness Center) and Andrew, my personal trainer at Apex Training.

And to keep my hands warm and not use my finger.

Yesterday, I saw Nicole and we discussed the state of my body and the trade-off I seem to be making— working in the Bizzy Hizzy warehouse keeps me active but causes pain, but not being in a physical job makes me stiff and makes it difficult to move, even when I take the same amount of steps I do at work.

Andrew and I are working on strength, mobility, stability and range of motion.

I had lunch with my mother yesterday, who upon her return home had her dog pass away.

In the afternoon, I spoke with my disability claims examiner and gathered paperwork for her. My eligibility confirmation came through this morning, and I think the actual leave is just a matter of paperwork now.

But paperwork sure is sucking the life out of me right now.

So this morning when the weather looked sunny and conducive to a perfect spring day, Nan and I decided to surprise the teenager and retrieve her hearing aids from the ear doctor. Then, we could grab some cold beverages and visit Bethlehem’s Monocacy Park.

The park is quiet, easy to navigate and has a creek. The birds, geese and fishermen would offer entertainment for Nan, as between the water and the animals there would be nature to hear as well as see.

It was a fantastic way to bring some stress-free moments into running errands.

After a modified upper body workout with Andrew, Joan stopped by and brought me an early birthday gift from the residents of Plastiqueville.

A hat!!!!

The hat was not for me but for my mallet finger.

And for dinner, the teenager made Hungryroot meatballs and cauliflower linguine. We used ShopRite tomato and basil pasta sauce. It turned out so lovely I had to make a slice of butter bread to sop up the sauce.

Small pleasures.

Do as I say not as I do, or fun with medical billing practices

I don’t think anyone will disagree with me when I say that medical insurance and medical billing in the United States makes no sense. It’s unfair to patients, unfair to doctors and makes the lives of medical office staff ridiculously complicated.

Let me just give a disclaimer that anything I say in this post is not a reflection of the skill of my physicians or the caliber of my care as both have been excellent.

But basing medical care on the decisions of private insurance companies attached to employment is reminiscent of the “company town” days when employees lived & worked in the same place and businesses profited on and controlled the life experience of their employees. Check out the old coal mines. I am from Pennsylvania after all.

I have spent much of the last year bouncing from specialist to specialist trying to learn how my body works as a 40-something with cerebral palsy and now, almost three weeks ago, I ruptured a tendon taking off my socks.

Last night, when I was already slipping into a fragile emotional state feeling lonely and physically broken (hey, it happens. We’re all human and have moments. Mine happen after dark while binge-watching medical dramas.), the teenager brought me the mail.

It was 9 p.m., I was curled in bed with an episode of The Good Doctor cuddling Louise, the tripod foster cat who deserves a permanent home because she’s such a doll.

I open my EOBs from my insurance company. Now, I know my recent misadventures will be expensive. I also know my therapist has recently sent me a $600 bill and apologized but said he can’t deal with my insurer anymore. But that’s another story and after almost 15 years with the same mental health professional… I will take care of it.

But this particular EOB charged me $200+ to see a specialist (fair) and a $2,000+ fee for surgery. Surgery? I walked into the office, an assistant removed my splint, he looked at me, he looked at the imaging done by Patient First, told me to get a cast and go back to work, and told me to make a follow-up for May 18 and left.

The assistant helped me put my splint back on, I left his office, went to another medical office (unaffiliated with him), filled out new patient paperwork, paid a $50 deposit, and received a cast.

Does any of that sound like surgery to you?

Being an anxious woman of a certain age with a hand injury, I did what seemed best at the time: I poured a whiskey and diet cola and grabbed the bag of sriracha pita chips and binged.

I ate all these chips, but no hummus or tea.

In the morning, I discovered I put my underwear on backward. I had two cups of coffee and a glass of water (I won’t eat until I get hungry) and called my insurance company.

“I’m not aware of having surgery so I’m confused.”

They arranged a three-way call to the doctor’s office.

The woman, who was polite and professional said, “so you’re not being treated?”

I said, “well yes I am.”

And she explained that’s a blanket term for tendon repair.

I replied, “Okay, so this was not explained to me. Let me just get some clarification. I paid the office fee, so the doctor could evaluate me, and he also gets an additional fee? Even though he sent me to a different doctor for the cast?

“Oh, she explained. “It covers any additional treatment in the next 90 days.”

Well then I hope that covers the office visits for all my check-ups and follow-up care.

I thanked them both— the representative of the insurance company and the billing clerk at my specialist’s office. But this is just another example of how the American medical industrial complex complicates and threatens patient care and a patient’s concern for if that care will financially destroy their stability.

** the title of this piece is a reference to me using binge eating as a coping mechanism

Soothing my wounds with healthy food

After my doctor appointment yesterday, Nan and I went to Grocery Outlet. Advocating for yourself, even in a safe, familiar environment drains a person emotionally.

My work in the kitchen not only provides the nutrients for my recovery from my mallet finger, but also helps me continue my fitness journey with Apex Fitness.

Maybe I’ll finally commit to losing weight.

Last night for dinner I had leftover pancakes, almond butter and apple slices with a can of blueberry elderflower sparkling water.

And this morning, Louise insisted I get up at 4:15 a.m. And it’s only Saturday not even a work day.

I cuddled her for a while, tried to go back to sleep, and finally just got up at 5:45ish.

Someone adopt this love so I can sleep instead of cuddle the cat all night

I came downstairs, had my coffee and started cooking my treasures. I sautéed kale (reduced for quick sale) in extra virgin olive oil, garlic, salt pepper and lemon juice. I made shredded potatoes in the frying pan with peppers. I prepared quinoa and midnight grains.

I fried an egg and mixed some of everything together with some apple, some of my homemade roasted red pepper hummus and pumpkin seeds.

Truly delectable.

And then right before the gym I had two medjool dates.

And I also prepped some plain lentils just to have on hand. I’m taking Nan some of the different ingredients.

Now for lunch I toasted some Ozery multigrain thin and made no-nitrate smoked turkey sandwiches (the free protein of the week from Hungryroot) topped with Brie, roasted red pepper, spinach, butter lettuce (reduced as well) and chipotle mayonnaise also from Hungryroot.

And I fell again today. At the gym today. Andrew my trainer seems to be concerned that I won’t make as much progress with upper body during my injury (but I did bench press today, but I inadvertently favored the right pretty heavily). But I’m okay with that — a body has to stay active and exercise, alcohol and excessive caffeine are the only way I can get my left hand warm. Well, unless I curl into bed under a heat blanket.

That’s two falls this week that lead to not serious but definitely painful bruises and scrapes.

Mallet finger update: my doctor is a good one

If you haven’t heard my saga of rupturing a tendon taking off my socks, you can catch up here:

Today I went to see my family doctor as I am concerned about the interaction of my mallet finger and my list of comorbidities from cerebral palsy. My crooked gait makes me a fall risk and the last five years or so— more or less since I entered my forties— have included broken bones, SI joint pain, back pain and hip pain.

All of this have led to a more-than-one-year journey to understand my body and how cerebral palsy impacts it.

I have visited doctors and specialists and neurologists trying to understand what I can do to minimize further issues as I age.

And it has worked!!!! My pain levels and chronic issues have dropped from daily pain of 5-8 to pain levels.

So I had a long visit with my primary care physician and told him not only about my injury, but also updated him on my fitness and improvements. I explained how I have been learning how muscles are supposed to work with my friends at Apex Training. I also told him I fell onto the brick wall of my house yesterday. I showed him the abrasions on my left arm.

Then I pointed out that traditionally my left side has been my anchor and by removing that from the anchor position, my walk has become more asymmetrical (according to my iPhone) and my hip is out of whack and uncomfortable all of the time and it’s only getting worse in these conditions.

Unlike the specialist— he filled out the paperwork himself and in front of me requesting that I have an FMLA leave until he sees me again after my specialist.

On top of all of that attention, he then gave me a full physical.

It was very hard for me to be vulnerable and ask for help, and my doctor and his staff made me feel heard, valued, and as if they truly cared about me.

I brought the paperwork home and started the claim process to initiate a short-term disability leave. It took about an hour and I realized my doctor missed one of the pages and on another he misread the questions. (So I added post-it notes.)

And if I’m 100% honest, despite everything I deal with, I still harbor feelings of guilt for asking for this time— much of which I intend to use doing work with my personal trainer and chiropractor to strengthen this hip and improve my walk so I can return to my warehouse job with a strong core and a better understanding of how normal legs work. I’m going to try to teach them. But, with my femoral anteversion, I know there is only so much I can do.

I deserve a chance to make myself strong and healthy.

Cute animal photos and mallet finger impact

It’s the end of April and it was 35 degrees last night. The price of oil continues to skyrocket and I’m still heating my house halfway through spring.

The cold does not help the poor circulation in my hands which has intensified in my left hand because my mallet finger restricts my movement.

My hands are painfully cold, except when Andrew is making me curse him in my head at Apex Training. Today was leg day, and I was so tired that when I came home and let the dog out I turned around and lost my balance and slammed right into the brick wall between my mud room and my kitchen.

Nala, my six-year-old Goffin’s cockatoo, started shaking and plucking her feathers today. Nothing in her environment has changed except the neighbor’s dog has been barking nonstop all day. The teenager believes his distress causes her anxiety.

Speaking of the teenager, she made this thick chocolate chip cookie/blondie dessert that I topped with ice cream that Sobaka’s mom brought home from Penn State when we dog sat last weekend.

Before the teenager brought home our dog, I would never criticize a dog owner, but now that I see the difference between different dog care styles, I feel back for dogs that aren’t spoiled like Sobaka and Bean.

And I don’t know how Sobaka’s mom does it— that dog is a bed hog.

But now an update on my mallet finger:

  • Stitch Fix has been amazing. Because my specialist at OAA took a week to return my paperwork and then didn’t properly fill it out, the onus was on me to find jobs I could do to not hurt myself. It turned out I can QC just fine— I hit 92% just fine.
  • But here’s the thing… my specialist knows hands, he doesn’t know me. I don’t think he heard me when I said I have cerebral palsy and that I work 10 hours a day in a warehouse. I’m just not sure that environment is safe for me right now,
  • Why do I say this? Because this week drove home to me how much I rely on my left side for stability. By forcing me to work 90% on the right, I am struggling to keep my right hip in place.
  • I am so stiff by the end of the work day. I also end up pinching and slamming my right fingertips and by the end of the day my left fingers I can use are swollen and sore.
  • And I fold 750 clothing items a day, handle 150 boxes and rip open probably 500 plastic bags. That’s a lot of fingers moving.
  • Once I consider the risk of accidentally losing my cast and bending my finger (which would extend my healing time) and adding the increased fall risk of mine because I am aggravating known issues with my balance and mobility, I just don’t feel safe.
  • This is a horribly stressful feeling.
  • I’m going to talk with my family doctor about it. I already mentioned it to my therapist, because I wanted to confirm my thoughts were rational and not whiny or emotional.

Today’s vegan lunch: curry carrots, lentils, quinoa, my own roasted chick peas, toasted sesame seeds, green olives and a touch of Thai peanut sauce topped with pumpkin seeds

And last but not least, cats. Misty caught a mouse! Video here.

First day back at the warehouse with mallet finger in a cast

According to the Stitch Fix timekeeping software, their human resource interface and their payroll, I am still on leave.

But when I got to the time clock, I was able to clock in without an issue and a supervisor and I discussed how best to put me to work at the Bizzy Hizzy.

The paperwork from my doctor still has not arrived, and my actual supervisor was out sick today.

But I was very grateful for the opportunity to have my first day back fall on a Sunday as Sundays are way quieter and less hectic.

We decided that I would pick a cart of Freestyle purchases and then fold and ship them— which would allow me to test my functionality in the two main areas of outbound, folding and picking.

A freestyle cart should take 40 minutes to pick, and it covers a good 3,000 plus steps, because it contains 80 individual items. My cart took 65 minutes, but it took me three to get started and another seven to deal with internet problems.

And I quickly realized that as the cart got heavier it got harder to steer to the left because my hand didn’t have a good grip on the left side.

At first break, I was at 98% of the required metrics in folding and shipping, but then I got a cart of shoes and ended up falling to 85% because it’s hard not to stick both hands in the envelope when you have trouble stuffing those shoes in there.

My direct supervisor emailed to check on me, so I gave him my full report.

He said not to worry, I’d be back at 100% before I knew it and he didn’t want me hurting myself. If anything changed or I felt pain, I was to let him know immediately.

The supervisor filling in for him also checked in with me periodically.

By the end of the day, I was over 90%.

I can’t help but wonder if the constant movement of all my other fingers makes my injured figure wiggle in my cast. If so, will that loosen the cast prematurely? Something to keep an eye on….

The latest in the saga

So I spent a good deal of today dealing with paperwork for my mallet finger— trying to get the info I need to return to work since my specialist doesn’t think I need short-term disability for my finger to heal. That I just need to not use the finger.

For info on my injury:

The original blog post on the incident is here.

And the follow-up medical stuff is here.

I had filed a FMLA leave request, which I thought would lead to at least a week or so of short-term disability since Patient First told me to anticipate potential surgery and eight weeks of healing time.

But the doctor avoided both of those with a cast.

I’m stuck in limbo between waiting for the specialist’s office to fill out the forms to release me from my FMLA leave and the accommodation form for Stitch Fix, and I never quite reached the point of short-term disability but had started a claim.

I called the medical forms office at my specialist, and it took a chunk of the day to verify that they won’t have my forms ready until potentially next week— which of course intensifies my need for short-term disability which is a different set of paperwork a doctor needs to sign.

With my work week starting on Sunday, even if my release form arrived Monday morning and Stitch Fix could work everything out for me to return Tuesday, at that point I’ve already missed 1.5 weeks of work.

And I’ve used a lot of my paid time off recently while I was accepting voluntary time off— so when this occurred I only had 20 hours of sick time.

I’m not complaining, but I am trying to plan my household finances.

And then my supervisor said to come to work Sunday and we’ll see what we can figure out.

The ups-and-downs of navigating this system where medicine has become such a business that everything is so complex even for someone as organized as I am is exhausting.

But luckily the teenager puts reminders like this on my iPad. “Have a good day and don’t kill anyone.”

As compensation for my draining day, the teenager and I went to Aldi in our pajamas planning to buy chips, get gas, and stop at Arby’s to try their new boneless wings. The commercial got me. Because I hate celery. Watch it here to understand.

But when we got to Aldi, and bought our chips, the car wouldn’t start.

So I got to call AAA. Or in my case, text AAA. The teenager was very excited because she never witnessed a AAA call before. Because she doesn’t remember when I locked the keys in the trunk when she was 2.

It was the battery, which George from AAA replaced. We left Aldi 30 minutes after we called. It was all super fast.

And then we met George again at Wawa for gas.

The teenager loved the whole process and wants to learn more about cars and car repair even more than she did a few months ago.

As for the winds, for six dollars I was pleased but the teenager noted they were all spice and no flavor. I enjoyed them but they were over-sauced and the two flavors did taste extremely similar.

Treating my mallet finger

It’s Tuesday and my life has been turned upside down by my “mallet finger” injury acquired Friday night, taking off my socks as I chronicled here.

I filed for short term disability leave based on what Patient First told me about the injury. Since my work week starts on Sunday, and the accident happened Friday night I thought it best to get the incident in the system as soon as possible.

With it happening on Easter Weekend, I was told by the doctor at Patient First to make an appointment with an orthopedic hand specialist Monday.

The doctor at Patient First explained that I had pulled the tendon out of my knuckle and that I needed a specialist to determine whether it would heal or if I needed surgery.

And I did my best to work around my enormous splint and changed the tape once Sunday night.

Even on Sunday night, I had no pain, minimal swelling and no bruising or discoloration. The nail was fine, too. And I was amazed at how the angle of the finger had improved.

Some recommendations came my way from friends and everyone recommended the same doctor at OAA Orthopedic Specialists. Unfortunately, he was booked into July. So I accepted an appointment with one of his colleagues, at an office 18 miles from my house. I called at Monday morning 8 a.m. and the only appointments they had this week were Tuesday at this office in the Allentown area.

That was today. The splint Patient First gave me is enormous— and I was very anxious to get not only news and a treatment plan, but also something more reasonable.

I filled out all the paperwork I could online, and headed out of the house for the 30-minute drive to the doctor. On Monday, I had already gathered my x-rays and reports from Patient First, a release of medical information form, my return-to-work form for the Stitch Fix Bizzy Hizzy and the FMLA/short-term disability insurance paperwork.

(I also tried to clean the Tupperware cupboard, loaded and unloaded the dishwasher and made an enormous homemade Crunchwrap with homemade tortilla chips.)

I cried all the way down the highway. I miss my dad, who passed away in December, and I’m struggling with a lot of life right now. And I snapped driving to the specialist.

But when I arrived— h*ly sh*t. The orthopedic office shared a plaza with the Lehigh Valley Hospital Cancer Center and the Steel Fitness Premier Facility. The scheduler told me they had free valet parking but damn I did not expect that. It was a big hospital facility.

I went in, read the directory and discovered my office was on the second floor. And when I got to the second floor, I saw about ten check-in/ receptionists. Damn.

One checked me in and I was told to proceed to waiting room seven. The whole arrangement vaguely reminded me of the Beetlejuice scene where the dead people wait to see their counselor.

But they moved me right along and I met my doctor very quickly. And I was told getting dressed and undressed is a common way of getting injured.

The doctor produced a brochure from a nearby drawer. And it was the same information from the same hand specialist professional organization I had found online.

He explains that there are two tendons in each finger, one running along the top from knuckles to fingernail, and another running under the finger. I overextended the top tendon at that tip-top knuckle, tearing it from the joint.

Because I did not damage or break free any bone, this means I don’t necessarily need surgery. That immobilizing the finger at the top knuckle will allow the scar tissue to reconnect the tendon. And then occupational therapy will get that tissue usable.

The mallet finger brochure

The doctor said there are three treatment options:

  1. Splint
  2. A surgically-placed pin
  3. A finger cast

He recommended the finger cast. For eight weeks. And that he will see me in four weeks.

Paperwork and work release proved to be more complicated. He simply gave me a note asking me not to use the finger and that I could return to work today. I don’t think that’s enough for the folks at the Bizzy. So I asked the staff to please fill out the two forms— the one for the Bizzy Hizzy and the one for disability insurance— and told them I had read the sign and would gladly pay the $10 per form.

They wanted fax numbers or for me to pick up the forms, but I’m not driving 30 minutes back tomorrow or whenever they get the forms done. I think I found the fax for the disability folks and finally reneged and let them mail the form to my warehouse.

They also told me the forms should be in my portal so when they are done I hope I can download from the portal and send them where they need to go. If that doesn’t work, I have to call the Bethlehem office and make arrangements to pick them up there.

The OAA office also called The Institute for Hand and Upper Extremity Rehabilitation (a mere mile away) and arranged for them to see me. When I arrived, they were on the phone with my insurance company.

The staff at The Institute were beyond friendly, and every staff member apologized for making me wait. But I was impressed at how smoothly they ran and how they managed to balance the walk-ins and the scheduled patients.

Even more impressive, they had a binder promoting the small businesses they have “interacted” with— I hope I can leave one next time. I forgot by the end of my visit.

The Institute has one main rehab room so I got to see other patients at work, and every therapist acknowledged me, and apologized that I was waiting. One therapist, fitting a patient with some sort of brace or sling, was chatting with me about my injury.

The casting process was fascinating as I had never heard of casting a finger before and the person helping me also explained my injury. In this day and age when medical professionals usually don’t explain things, I was amazed at how many people took time to explain.

Mallet finger cast

My finger was only 15 degrees floppy today, which is a huge improvement from Friday. BUT if anything bends the injured area of the finger that could start the recovery clock back to zero as it could tear the scar tissue (which is why the hand specialist recommended the cast).

I certainly don’t relish the idea of eight weeks in a finger cast, nor do I enjoy the paperwork hurdles I now have to jump, but I’m relieved to have moved on to the next stage of the process.

The staff at the Institute also commended me for seeking treatment right away, as most people wait a week or more to address it and that causes more stress and damage to the healthy parts of the finger and can make the healing process more complicated and less successful.

My professionals:

OAA Othopedic Specialists

The Institute for Hand and Upper Extremity Rehabilitation