Musculoskeletal Impairments: amputations, contractures, hip fxs/replacement, OA/RA, fibromyalgia, osteoporosis, oncology

Most common cause of upper limb amputation is trauma

Most common cause lower limb amputation is peripheral vascular disease

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Amputation sx aims to?
Preserve as much limb as possible while providing healthy skin, soft tissue, vascularization, sensation, muscle & bone

Goal is a residual limb that is pain free & functional

Pain
Skin complications (delayed healing, necrosis, skin graft adherence to bone)
Edema of residual limb
Bone spurs
Neuroma on distal end of residual limb
Phantom limb & sensation
Postop & preprosthetic S&S

Sensation that the missing limb is still there

*Usually not painful, but may remain for the rest of the person’s life

Phantom limb

Sensation that appears to occur IN the MISSING limb i.e. cramping, relaxed, numb, cold, burning
Phantom sensation

*skin ulcers* as a result of ill-fitting prosthesis socket or wrinkles in prosthetic sock
*Sebaceous cysts* resulting from torques of prosthetic sock
*Edema* resulting from ill-fitting sock or too-tight prosthetic sock
*Sensory changes,* such as loss of sensory info as a result of missing limb, residual limb hypesthesia (OVERSENSITIVITY), areas of absent/impaired sensation, phantom limb/sensations
Prosthetic phase S

Level of limb amputation is IDed by which joint/long bone has been amputated thru
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above the knee
transfemoral

below the knee
transtibial

below the ankle
transmetatarsal

above the elbow
transhumeral

below the elbow
transradial

below the wrist
transmetacarpal

___1___: amputation cross a joint, such as hip, wrist, elbow or shoulder

*ankle is called ___2___

1. Disarticulation

2. Symes amputation

From post surgery until patient receives permanent prosthesis
Pre prosthetic training (phase 1)

After pt receives permanent prosthesis
Prosthetic training (phase 2)

Goals of Preprosthetic Training? (7)
1. A client in *coping with psychological aspects* of limb loss
2. Optimize *wound healing*
3. *Maximize residual limb shrinkage & shaping to achieve tapered distal end, the optimal shape for a prosthetic socket*
4. *Desensitize* residual limb
5. Maintain/increase *ROM & strength*
6. Facilitate *I in BADLs*
7. Explore *prosthetic options*

Goals of Prosthetic Training? (4)
1. Teach client to I don/doff prosthesis
2. Train client to care for prosthesis
3. Increase client’s wearing time to a full day
4. Educate client in I use of prosthesis

Prosthesis collaborates with client & OT to *ID client’s goals & ensure proper fit of prosthesis*

PT is responsible for lower limb amputation training & prosthetic development to *maximize ambulatory skills*

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What should be evaluated both with & without the prosthesis for amputations?
Self-care activities

*Motor skills of the uninvolved hand should be assessed in prep for training in *one-handed techniques* & use of prosthesis when worn

Client factors limiting performance that should be evaluated during OT amputation eval? (6)

*Functional mobility/balance in LE amputations & *driving eval,* voc/recreational interests should also be evaluated & E analysis of community, home, work/school should be completed during eval

1. Changes in sensation in residual limb (i.e. hypersensitivity & sensation loss)
2. Presence & severity of phantom sensations
3. Pain
4. Experiences of self, including body image, self-concept & self-esteem
5. Strength, flexibility & endurance in residual limb & full body
6. Skin integrity

1. Training in *limb hygiene*

2. Wound healing, including *whirlpools & massage*

3. Limb shrinkage & shaping: wrap residual limb in elastic bandage to *reduce edema & develop tapered shape;* elastic shrinker/removable rigid dressing can be used if client unable to perform proper wrapping techniques

4. Desensitization of residual limb: *wt. bearing on various surfaces, massage, tapping, rubbing*

5. Maintain/increase *flexibility & strength* of residual limb to *prevent flexion contractures of knees & hips* in LE amputation pts

6. Maintain/increase *flexibility & strength* of remaining limbs; LE amputations need to strengthen UE’s to maneuver w/c & use mobility aids & LE’s to wt. bear

7. W/c’s: pt’s with LE amputations R residual limb support; *large wheels should be placed FURTHER BACK to counterbalance missing limbs* & w/c should *have antitippers*

Pre prosthetic Ix’s (from post sx until pt receives permanent prosthesis)

Considerations when prescribing UE prosthesis? (7)
1. Length, strength, flexibility & skin integrity of residual limb
2. Pt preference for cosmetic appearance
3. Hand dominance
4. Typical activities to be performed (home, work, leisure)
5. Motivation & attitude
6. Cognition
7. Financial coverage

Terminal Device (TD) for LE amputation?
Foot

Terminal Device (TD) for UE amputation?
Hand

Passive & Active TD’s

Realistic, *nonfunctional hand* worn for cosmetic purposes
Passive TD

*Body-powered, externally powered* (thru electrical connection or EMG signals), or *hybrid-powered* hook or realistic looking hand that *A w/ functional activities*
Active TD

2 Main Types of UE TD’s: hook & hand

___1___: hook *remains closed* until *tension is placed on cable, then it opens*

___2___: hook *remains opened* until *tension is placed on cable, then it closes*

Cosmetic devices have minimal function

TD can be used interchangeably w/ prosthesis of same shaft size

1. Voluntary *opening* (VO)

2. Voluntary *closing* (VC)

Wrapping residual limb during Preprosthetic tx phase?
Wrap *DISTAL TO PROXIMAL*

*Tension should DECR w/ PROXIMAL wrapping*

Use figure 8 pattern

What kind of focus for amputation Ix’s?
compensatory approaches

OT Ix’s for LE amputations? (7)
1. Wrapping residual limb to decr swelling
2. Desensitization
3. *Strengthening UE w/ focus on triceps*
4. T/f training: *stand pivot*
5. Standing tolerance
6. W/c mobility
7. ADL training; *LBD most difficult*

Why is hook considered MORE functional than the hand for UE amputation? (6)
1. Greater precision*
2. Greater visibility of object being grasped*
3. Less weight
4. Less cost
5. Greater reliability
6. Ability to fit in close quarters*

What do patients using myoelectric devices (active TD) need?
*Two superficial muscles sites* that can fit inside the prothesis socket w/ sufficient EMG signals to power the hand

*Attaches* the prosthesis to the residual limb
Socket

Include wrist, elbow, knee, shoulder & ankle devices

These devices may have a *locking system* activated by the user

Positioning Components of a Prosthesis

*Holds* prosthesis to residual limb
*H*arness & suspension system

*Control system combined* with harness (HOLDS prosthesis to residual limb) to *transmit body F’s to control the cable that operates the TD*
UE prosthesis

Pylon is used to connect the TD to the socket
LE prosthesis

Protects residual limb & improves fit of the socket
Prosthetic Sock OR Gel Liner

1. Client education

2. Training to don/doff prostheses

3. Wearing Schedule

4. Limb hygiene

5. Care of prosthesis

6. UE prosthesis training

7. Provision of AE, as needed

8. Develop repertoire of skills needed to perform ADLs/IADLs

Post prosthetic Interventions (once pt has R permanent prosthesis)

Prosthesis wearing schedule?
-*Initial wearing time: 15-30 min,* then prosthesis removed & stump examined for reddened areas

-If NO reddened areas area apparent after 20 min, *wearing time increased by 15-30 min increments,* until pt wear prosthesis for full day

-Reddened areas that do NOT disappear after 20 min should be *reported to prosthetist so prosthesis can be adjusted*

Limb hygiene? (2)
1. Daily cleansing

2. Inspection of stump for reddened areas, particularly insensate areas (one’s pt can’t feel)

Care for prosthesis? (3)
1. Clean interior w/: mild soap & water

2. Clean hook/hand: soap & water (may need additional cleaning if heavily soiled)

3. *Myoelectrically controlled* prosthesis: must *teach pt to change batteries*

Operation of *each component* of UE prosthesis
Prosthesis CONTROL training

*Integration of UE prosthesis components* for efficient A during *functional use*
Prosthesis USE training

*ID of optimal position of each positioning unit (i.e. wrist, elbow)* to perform an activity/grasp an object
Prepositional training

TD control during grasp activities
Prehension training

*CONTROL & USE* of prosthesis during functional activities

-Incorporation of TD as functional A
-Focus on *problem-solving approach*

FUNCTIONAL training

Fixed posture because of:
-Shortening skin, ligaments, joint capsule, tendons & muscles

D/t:
-Peripheral nerve injury
-SCI
-Increased muscle tone from CVA
-Head injury
-CP

Contracture

A contracture that responds to therapy?
Soft tissue contracture

A contracture that requires surgery to release?
Boney block contracture

OT Eval of contractures? (2)
PROM & AROM

3 steps in OT tx of contractures?
1. Superficial & deep heat to *incr tissue extensibility*
2. Slow stretch
3. Static splinting

Types of splints to reduce soft-tissue contractures? (10)
1. Antideformity (safe position) burn splint
2. Elbow/knee extension splint
3. Wrist extension splint
4. Thumb abduction splint
5. Lumbrical bar splints
6. Resting hand, ball & cone anti spasticity splints
7. Soft neoprene splints to position thumb & forearm
8. Splint to prevent foot drop
9. Serial casting
10. Dynamic splinting

Antideformity (safe position) burn splint
Antideformity (safe position) burn splint
-Wrist in 20 deg extension
-MCP’s in 90 deg flexion
-PIP & DIP’s in 0 deg extension

Elbow/knee extension splint
-Positioning in *as much extension as possible*

Wrist extension splint
-Functional splint with 45 deg wrist extension, worn *during the day*

Thumb abduction splint 

-*Prevents thumb ADDUCTION contracture*
Thumb abduction splint

-*Prevents thumb ADDUCTION contracture*

-Splint forms a “C” bar between thumb & index web space

Lumbrical bar splints 

-*Reduces MCP HYPEREXT & IP FLEXION contractures*

use this for ulnar nerve injury causing claw hand
Lumbrical bar splints

-*Reduces MCP HYPEREXT & IP FLEXION contractures*

use this for ulnar nerve injury causing claw hand

-MCP’s are splinted to BLOCK hyperextension

Resting hand, ball & cone anti spasticity splints
Resting hand, ball & cone anti spasticity splints
-Purpose is to decrease tone in the hand & UE

*Image is ball splint

Soft neoprene splints to position thumb & forearm
-Used w/ pt’s w/ *RA or CP* to increase functional use of the hand

Splint to prevent foot drop
Splint to prevent foot drop
-Below the knee splint to keep ankles at 0 deg for possible future ambulation

Serial Casting for contractures
-Use of fiberglass or plaster of paris materials to *position pt’s w/ increased tone & over time, stretch out soft tissue contractures*

Dynamic Splinting for contractures
-May involve metal & loop compartments

-*Angle of pull need to be 90 deg* for most effective outcome

A syndrome of widespread pain affecting the entire musculoskeletal system

Sx:
-Soft tissue pain
-Nonrestorative sleep & fatigue
-Inability to think clearly
-Parasethesias & joint swelling
-Depression & anxiety

Dx:
-Excessive tenderness in 11/18 trigger points

Fibromyalgia

OT Eval for Fibromyalgia?
1. *Daily activity log:* record of baseline of ADL’s pt is engaged in

2. COPM

3. Pain assessments: est. baseline pain & *documentation of improvements/regression of pain levels after OT txt*

1. Pt education to avoid pain triggers & manage stress

2. Gentle regular aerobic ex, gentle daily stretching, strengthening, cog-bx therapy, alternative med (i.e. acupuncture, hypnosis)

3. Sleep hygiene techniques

4. Myofascial release & trigger point tx, massage & relaxation ex, bioFB

5. Memory aids (bc unable to think clearly)

6. Modification of activity/E

OT Intervention for Fibro

OA is sig risk factor for hip fx b/c decr bone density occurs in the neck of the femur

-Poor lighting, throw rugs, unmarked steps & slippery surfaces are associated w/ falls & hip fxs

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ORIF wt bearing restrictions for hip fracture?

*Goals of tx: relieve pain, maintain good bone position, allow fracture healing, restore optimal function

NWB: no wt can be placed on affected E

TTWB: affected E can touch ground for BALANCE ONLY; 90% of BW is placed on unaffected E

PWB: 50% body wt on affected E

WBAT: Pt judges how much they can tolerate based on response of pain

FWB: 100% of their wt on affected E without causing damage

Posterolateral hip precautions?
1. No flexion past 90 deg
2. No IR
3. No adduction (crossing legs)

*Do NOT pivot at hip; sit only on raised chair/toilet; *T/F STS by keeping operated hip in slight abduction & extended out in front*

Anterolateral hip precautions?
1. No extension
2. No ER
3. No adduction (crossing legs)

Partial hip replacement that replaces femoral head (NOT acetabulum)
Austin Moore

For hip replacement eval, REVIEW WT BEARING STATUS BEFORE INITIATING EVAL πŸ™‚ (V. IMP.)
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Out of bed activity after THR/TKR typically occurs 1-3 days post sx, however; depends on the surgeon
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Role of OT in hip replacement AKA arthroplasty?
1. Occupational profile
2. Home safety recommendations i.e. AE
3. Education & reeducation on hip precautions
4. Incr joint ROM
5. Incr strength of surrounding musculature
6. Incr I in ADLs/IADLs w/ precautions, safety techniques & compensatory strategies
7. PAMS as appropriate to OT’s level of training in compliance with state regulation

Result of poor physical fitness, obesity, reduced muscle strength/endurance, poor endurance
LBP

Nerve is trapped in herniated disc
Stiatica pain

Narrowing og intervertebral foramen
Spinal stenosis

Inflammation or changes of spinal points
Facet joint pain

Stress fracture of dorsal to transverse process in back
Spondylosis

slippage of vertebrae out of position
Spondyloisthesis

Stress tearing of the fibers of a disc, causing outward bulge pressing on spinal nerves
Herniated nucleus pulposus

Standards of body mechanics for LBP?
Maintain straight back; minimize lumbar lordosis
Bend from hips
AVOID TWISTING
Carry loads close to body
Lift with legs & wide BOS
Lift in sagittal plane & lift slowly

Ix’s for OT in LBP? (8)
1. Education on back anatomy/movements related to occup performance
2. Neutral spine back stabilization techniques to decr pain
3. Educ on body mechanics
4. Training in AE & modified tasks
5. Ergonomis design
6. Energy conservation
7. Incr strength & endurance
8. Educ on pain management, stress reduction & coping

Safest lift for the back

Ideal for heavy loads i.e. patients

Semisquat

Alternative to semi squat when space is limited

*Preferred by people w/ LBP
Alternative to semi squat when space is limited

*Preferred by people w/ LBP

Squat

Lift only used for *light loads* (<20 lbs)
Lift only used for *light loads* (<20 lbs)
Stoop lift

Lifting the leg opposite the arm used in reach

*Use when removing laundry from machine fro LBP

Golfer’s Lift

Don’t sit longer than how long for LBP?
15-20 minutes

ADLs/IADLs for LBP?
ADLs/IADLs for LBP?

ADLs/IADLs for LBP?
ADLs/IADLs for LBP?

Use of toxic chemicals to kill cancer cells

Side effects: fatigue, anemia, diminished hearing/vision, peripheral neuropathy, thrombocytopenia

Precautions for OT: use mask b/c compromised immunity, screen for anxiety/depression/fatigue, monitor excess bleeding, avoid dropping things

Chemotherapy

Use of radioactive material to kill cancer

Side effect: burns

Precautions for OT: A to maintain ROM while avoiding pulling burned skin, use of water based ointments

Radiation

Removal of cell, tissues, organs

Side effects: vary depending on the sx (i.e. lymphedema w/ mastectomy)

Precautions for OT: refrain from bathing area until staples/sutures are removed, edema prevention

Surgery for Cancer

Hormones to decrease estrogen, which can incr the spread of some cancers

Side effects: menopause like sxs, hot flashes, mood swings

Precautions for OT: monitoring room temp & mood

Hormone therapy

Use of medicine to block OR heighten immune system response

Side effect: skin welts

Precaution: Avoid scratching skin

Immunotherapy

OT Eval & Ax for Oncology:

___1___: client occup profile

___2___: life history & impact of cancer as disability

___3___: description of activities that cause fatigue after cancer diagnosis

___4___: multisymptom, client reported outcomes (subjective)

___5___: general QOL assessment

1. COPM

2. Occup Performance History Interview-II

3. Brief fatigue inventory

4. M.D. Anderson Symptom Inventory

5. Functional Ax of Cancer Therapy- General (FACIT Measurement System)

OT Ix’s for cancer? (12)
1. Energy conservation, fatigue management, activity & exercise tolerance
2. I/safety in ADLs/IADLs
3. AE & AT
4. Psychosocial support, including education in realistic expectations for recovery
5. Caregiver training & support
6. Sensor education & desensitization
7. Scar management
8. W/c seating & positioning
9. Fall prevention & home safety
10. Lymphedema tx after radical mastectomy
11. PAMs (ONLY CRYOTHERAPY!; others are contraindicated)
12. End-of-life care

Primary w/ localized/generalized joint involvement, no known cause, breakdown of cartilage leading to reduced joint space & bone-on-bone contact

Most commonly affected: DIP, PIP, CMC, MTP of foot, cervical/lumbar apophyseal joints, knee & hips joints

Sxs: pain, stiffness, limited ROM, local inflammation, crepitus
*Pain & stiffens relived by rest

OA

Osteophytes/bones spurs on PIP joints

*OA
Osteophytes/bones spurs on PIP joints

*OA

Bouchard’s nodes

(BP)

Osteophytes/bones spurs on DIP joints

*OA
Osteophytes/bones spurs on DIP joints

*OA

Heberden’s Nodes

Medications for OA?
Systemic: analgesic agents, NSAIDs

Local: cortisone injections, topical agents i.e. capsaicin

Replacement of acetabulum & ball of femur
THR (arthroplasty)

Resurfacing of knee joint w/ metal/plastic prosthetic components

Typically femoral component, tibial plate, patellar button

TKR

Main client factors affecting participation w/ OA?
Pain
Joint instability
Decr ROM
Weakness
Fatigue

Pt’s w/ OA THR/TKR should be axed w/ their understanding of precautions during:

-t/f’s
-bed mob
-LBD
-changing body position

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TKR Precautions? (4)
1. *Do NOT put pillow under knee* while in bed
2. *Rest feet on floor* when sitting to incr ROM
3. *Wear immobilizer* as instructed
4. Avoid *kneeling, squatting & twisting the knee*

PAMs for OA to *reduce pain & incr ROM?*
Superficial heating agents:
-Paraffin
-Fluidotherapy
-Hot packs
-Microwave packs
-Hydrotherapy
-EStim

What ROM is encouraged for OA?
AROM

*PROM only used if AROM precluded (not possible)

Isometric & isotonic exercises can be performed to tolerance w/ OA

Low impact conditioning exercise can help OA w/ flexibility, strength, endurance & CV fitness

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Pinching exercises may be contraindicated with ___1___ bc of stresses on the joint
CMC joint OA

Splint to provide stability to CMC joint during pinching activities?
HAND-BASED Spica Splint

Principle for joint protection & fatigue management? (10)

**If answer choice includes *”joint protection”* for arthritis, lupus, or fiber dx, then that is probably the correct answer!

1. Respect pain
2. Maintain strength/ROM
3. Use each joint in its MOST STABLE anatomical/functional place
4. Avoid positions of deformity
5. Use strongest joint available
6. Ensure correct patterns of movement
7. Avoid staying in one position for long periods
8. Avoid starting an activity that cannot be stopped immediately if it becomes too stressful
9. Balance rest & activity
10. Reduce F & effort

Progressive condition of low bone mass/density & deterioration leading to bone fragility & *pathological fractures,* particular of wt bearing bones

Risk factors: inadequate CA2+ intake, estrogen deficiency, sedentary lifestyle
-Can occur secondary to: steroid use, DM, RA, alcoholism, malnutrition, hyperthyroidism

Common sites for fas: vertebrae, wrist, hip, pelvis

“Silent disease” bc at first no sxs; then recurring pathological fas, spinal deformities i.e. kyphosis, loss of height

Gold-standard for dx: dual-energy X-ray absorptiometry

Osteoporosis

Reversible weakening of bone

A precursor to osteoporosis

Osteopenia

Pt’s are rarely referred to OT for primary dx of osteoporosis; it’s often a secondary dx to a hip/wrist fx

These pt’s may need swallowing eval bc kyphosis can influence food intake

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Main client factors w/ osteoporosis?
Pain
Decr ROM
Difficulty breathing secondary to kyphosis/vertebral fxs
Decr work bc decr ability to carry heavy loads

OT Ix’s for Osteoporosis? (5)
1. Adaptations/accommodations/compensations for client factors i.e. devices w/ built up/extended handles
2. Encourage *low-impact wt. being activities* i.e. walking, to increase physical activity
3. Encourage goof positioning/posture
4. E modifications to improve home access & reduce fall risk
5. Educ on body mechanics, energy conservation & joint protection

Chronic, systemic, inflammatory, progressive, joint swelling from excess synovial fluid

Secondary complications may include: CV, ocular, respiratory, GI, renal, neurological sxs

Most commonly affected joints are PIP, MCP, wrist, elbow, ankle, MTP joint, temporomandibular joint, hips, knees, shoulder & cervical spine

Criteria for classification of RA require that the client have four of seven diagnostic criteria:
1. Morning stiffness
2. Three or more swollen joints in 14 possible areas
3. Swollen joints of the hands
4. Symmetric swollen joints
5. Rheumatoid nodules
6. Serum rheumatoid factor on laboratory tests
7. Radiographic changes on posterioanterior hand and wrist radiographs

The recent advent of the new *disease-modifying antirheumatic drugs (DMARDs),* such as methotrexate, and biological response modi ers is likely to *significantly reduce the number of clients with RA who move to Stages III and IV*

RA

Flexion of PIP & hyperextension of DIP

Splint: PIP extension, DIP free

Boutonniere deformity

Hyperextension of PIP & flexion of DIP

Splint: PIP slight flexion

Swan neck deformity

Extensor tendon avulsion injury causing *flexion of DIP joint*

Splint: DIP extension splint

Mallet finger

*Trigger finger is flexion of MCP joint so want MCP extension splint! :)*

Tenosynovitis of finger flexor of A1 pulley of MCP

Splint: MCP extension splint, IP’s free

Trigger Finger

*Radial deviation of wrist* & *ulnar deviation of MCP joints*
Ulnar drift

AKA zig zag deformity

Very floppy joints w/ shortened bones & redundant skin

Cause by reabsorption of bone ends

Most common in: MCP, PIP, radoiocarpal/ulnar ligaments

Mutilans Deformity

Patterns of thumb deformity w/ RA & LE deformities?
Patterns of thumb deformity w/ RA & LE deformities?

Four Stages of RA?
1. Acute
2. Subacute
3. Chronic-active
4. Chronic-inactive

*pain and tenderness at rest that increases with movement;* limited ROM; overall stiffness; *gel phenomenon (inability to move joints after rest);* weakness; tingling or numbness; *hot, red joints;* cold, sweaty hands; low endurance; weight loss or decreased appetite; fever
Acute Phase of RA

Reduced pain and tenderness; morning stiffness; limited movement; tingling or numbness; *pink, warm joints;* low endurance; weakness; gel phenomenon; weight loss or decreased ap- petite; mild fever
Subacute Phase of RA

low-grade inflammation, decreased ROM, less tingling, pain and tenderness primarily with movement, low endurance
Chronic-active Phase of RA

No signs of inflammation, low endurance, pain from stiffness and weakened joints, morning stiffness primarily related to disuse, limited ROM, weakness and muscle atrophy, contractures
Chronic-inactive Phase of RA

Classification of progression of RA?
Classification of progression of RA?

OT Eval for RA? (7)
1. Assess work disability, functional mobility, driving
2. Biomechanical factors are pain, joint stiffness, joint deformity, decreased joint mobility and stabil- ity, atrophy and decreased muscle power, and fatigue. Clients may have peripheral neuropathies, so sensation should be evaluated.
3. Cognitive function factorsβ€”attention span, short-term memory, and problem solvingβ€”can be af- fected by pain, sleep disturbances, depression, and medication.
4. Depression, dependence, stress
5. Performance can be affected by time of day and medication use.
6. Fatigue can significantly affect the ability to perform throughout the day.
7. Loss of social relationships

What ROM appropriate thru full range during remission for RA?
AROM

Strengthening exercises during acute flareups of RA?
Isometric exercises w/i pain-free exertions

Strengthening exercises during remission for RA?
Isotonic exercises as tolerated

Aerobic exercise for RA?
Low-impact aerobic activities, such as walking, stationary bicycling, or low-im- pact dancing can increase flexibility, strength, endurance, and cardiovascular fitness.

Splinting & RA:

Splinting can be used to reduce in ammation and pain (i.e., resting hand splint), properly position and support unstable joints (e.g., MCP ulnar deviation, swan neck deformity), limit undesirable motions, increase ROM, prevent deformity, and increase function.

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Tool: Goniometer

Types:
-Functional ROM: ROM needed to perform functional movements i.e. reach top of head (ER), small of back (IR)
-AROM (contractile structures)
-PROM (non contractile structures)
-AAROM (movement produced by one’s own muscles, assisted by an external F)

Recording Mx’s:
-Starting position/ending position i.e. 0 deg – 115 deg
-Do NOT use negatives

ROM

ROM is functional
WFL

ROM is within normal ranges
WNL

Finger ROM: mx's tendon excursion
Finger ROM: mx’s tendon excursion

Tool: Dynamometer

-Handle placed on position #2; mean of 3 trials on each hand is compared to norms
-One trial in all 5 positions; *A bell curve is observed if pt is applying MAX effort;* if not, no bell curve (V. IMP)

Grip Strength

What’s used to evaluate grip strength in person w/ arthritis?
Sphygmomanometer cuff
Vigorometer/bulb dynometer

Tool: Pinchmeter

Position: Shoulder adducted, elbow flexed to 90 degrees, forearm in neutral

3 trials on each hand are obtained & mean of 3 trials compared to norms

Pinch strength

Thumb pulp to aspect of index MIDDLE PHALANX
Key/lateral pinch

Pulp of thumb to pull of index & middle fingers
3 jaw chuck (palmar pinch)

Thumb pulp to pulp of index finger
Tip to tip

How to mx endurance/activity tolerance? (4)
1. Reps/unit time
2. Max HR
3. Mx time until fatigue
4. MET levels

Body’s initial response to injury

-Pitting: acute
-Brawny: chronic

Eval based on *circumference & hand/arm mass*

Edema

Tool: tape measured in cm

Compare extremities, doc landmarks

*To mx entire hand, use figure-of-eight method; *This is the most reliable method*

Evaluation of Circumference to Mx Edema

Tool: Volumeter measured in mm

Significant change would be >10 mL

Only TRUE OBJECTIVE tool

Eval of Hand/Arm Mass to Mx Edema

Sensation Test Administration? (2)

*NOTE DIFFERENCES OF SCI vs. Peripheral nerve injuries!

1. Demo sensory test w/ vision; then *occlude vision for actual test*
2. Test *uninvolved side FIRST;* apply stem to volar & dorsal surfaces

SCI Sensation Testing?
Proximal to distal
Dermatome pattern

Peripheral Nerve Injury Sensation Testing?

*Order of return for periphery n: pain, moving touch, static light touch, touch localization

Distal to proximal
Follow peripheral nerves (NOT dermatomes…)

Cotton swab; person response Y/touched when touched

+: intact
-: impaired
0: absent

Light touch

Cotton swab; person response Y/touched when touched *& then points to the area touched*

+: intact
-: impaired
0: absent

Localization

Paper clip; pt respond sharp/dull
Pain Sensation Test

Test tubes or thermal kit; pt responds hot/cold

+: intact
-: impaired
0: absent

Temperature sensation

Recognition of touch by common objects

Scoring: # of objects correct

*Second set of identical common objects used for expressive aphasia

Stereognosis

Disk-criminator or caliper; start w/ points 5-8 mm apart; apply *prox to distal* in a *horizontal orientation*; pt response if they feel 1 or 2; 7/10 responses must be correct before decr the distance btw points

Scoring: normal 2mm

ML

Moving two point discrimination

Disk-criminator or caliper; start w/ points 5 mm apart; apply in a *longitudinal orientation*; pt response if they feel 1 or 2; 7/10 responses must be correct before decr the distance btw points; stopped at 15 mm

Normal: 5 mm
Fair: 6-10 mm
Poor: 11-15 mm
Protective: 1 point perceived*
Anesthetic: no points received*

Static two point discrimination

*Position sense*

1. OT positions its involved extremity
2. Pt duplicates position w/ contralateral extremity

Proprioception

*Movement sense*

1. OT moves segment
2. Pt responds movement is either up or down

Kinesthesia

Test of fingertip dexterity & assembly simulation (test bilateral & individual!) *preferred over 9 hole peg*
Purdue Pegboard

Test of gross hand & arm movements

Placing test: rate of hand movement (1 hand only)
Turning test: rate of finger manipulation (bilateral)

Minnesota Manual Dexterity Test

Test of eye-hand coordination using tweezers to place pins on a board
O’Connor Tweezer Test

Test of FM dexterity using small tools (tweezers & screwdriver)
Crawford Small Parts Dexterity Test

Measures finger dexterity
9-hole peg

*Purdue pegboard is preferred, however because tests bilateral hands & more reliable!

Purdue Pegboard is preferred > 9-hole peg because unilateral & bilateral & more reliable!
πŸ™‚

Test of hand function (writing, page turning, picking up common objects, simulated feeding, stacking)
Jepson Hand Function Scale

Informal assessment of FM/GM coordination?
Informal assessment of FM/GM coordination?

___1___: moving jt to desired range using an external F

___2___: PROM w/ overpressure

1. PROM

2. Passive stretching

What increases extensibility prior to stretch?
heat

Joint mobs R sp training; more effective if performed b4 PROM

Also, contract/relax, hold/relax can incr ROM

PROM Ix’s

Common form of PROM for post sx shoulder patients
*Codman’s exercise* (AKA pendulums)

Splints to incr PROM?
Dynamic splint & serial casting

Should be performed when PROM is > than AROM
AROM

1. Tendon Gliding Exercises: differentiates tendon movement & incr tendon excursion 
2. Blocking exercises: *isolate individual jt motions*
3. Emphasize functional use 
4. Prep Ix's: wall walking, AROM can exercises
1. Tendon Gliding Exercises: differentiates tendon movement & incr tendon excursion
2. Blocking exercises: *isolate individual jt motions*
3. Emphasize functional use
4. Prep Ix’s: wall walking, AROM can exercises
AROM Ix’s

Precaution: ___1___ can form from overstitching (esp in elbow flexors)
1. myositis ossifcans

*High resistance, low reps*

Isometric & isotonic ex

Increase strength

Contraction w/o movement

-Can produce more F contraction

*Contraindicated for ppl w/ HTN & CV problems bc can incr BP and HR*

Isometric Ex to incr strength

Contraction WITH movement

eccentric lengthening and concentric shortening

Isotonic Ex to incr strength

Work at 50% max resistance or less
*Incr reps & duration, NOT resistance*
Use energy conservation techniques
Incr Endurance

1. Elevation of extremity above heart (*contraindicated off pt has circulatory probs*)
2. Manual edema mobilization: activates lymph system to remove edema (R sp training)
3. Retrograde Massage: returns blood/lymph to venous system by stroking in a centripetal direction w/ extremity elevated (replacing manual edema mob)
4. Compression garments to prevent re-accumulation of fluids following retrograde massage
5. Cold packs: *most effective when combined with elevation* (monitor vascular status)
6. Contrast bath: immersing hand in warm & cold water (conflicting evidence)
Edema Reduction Ix’s

Manual edema mob & retrograde massage CONTRAINDICATED when?
CARDIAC EDEMA IS PRESENT

Heat is commonly CONTRAINDICATED FOR EDEMA; however, if effect of heat is needed in mild case of edema, can be used & combined w/ elevation cautiously
πŸ™‚

Precautions/contraindications for Edema Ix’s? (5)
1. Infection
2. Grafts/wounds
3. Vascular damage
4. Unstable Fx’s
5. CHF

1. ROM (early mob programs most effective)
2. Massage (circles & friction)
3. Compression: coban for digits, isotonic glove for hand, tubigrip for UE
4. Scar pad w/ compression
5. Splinting to prevent contractures from scar
6. Edema control, ESP in acute phase
Scar Management

Sensory Tr.ing Ix’s? (3)
1. Desensitization for hypersensitivity
2. Sensory re-education
3. Compensation: avoid use of hands where vision is occluded & observe safety precautions

-If post-sx, *begin in periphery of scar & as tolerated, work over the scar*
-Massage
-Textures
-Vibration
-3-phase desensitization kit
-*Fluidotherapy*
Desensitization for hypersensitivity (Sensation Tr.ing)

-Massage
-Textures
-Vibration
-3-phase desensitization kit
-Fluidotherapy
-Rv. safety precautions
Sensory re-education (Sensation Tr.ing)

Improving Coordination Ix’s? (3)
1. Begin with GM activities and work up to FM
2. Select activities where ROM is w/i pt’s reach but yet challenging
3. Focus on accuracy & speed; begin slow & progress to fast

Energy Conservation & Work Simplification Principles & Methods? (14)
1. Short rest periods of 5-10 min
2. Alternate and balance heavy & light work tasks
3. Gather all items needed/equip prior to beg task
4. Avoid multiple trips by using a cart, bag, etc.
5. Eliminate tasks that are nonessential
6. Delegate tasks that are beyond one’s capacity
7. Comine tasks
8. Sit to work at a table/high stool for counter work
9. Organize cabinet so items are easy to reach
10. Use AE i.e. reacher to avoid bending/stooping
11. Use electrical appliances i.e. mixer to decr personal effort
12. Slide heavy items rather than lift
13. Use lightweight equipment/tools
14. *Resting BEFORE fatigue sets in during activity is more effective than resting after exhaustion has occurred*

Body Mechanics Principles & Methods? (14)
1. Do NOT move heavy items; ask for A
2. Slide/push object along surface rather than lift
3. Directly face object about to be lifted
4. Keep object close to body
5. Hold object centered at waist level
6. Feet kept flat on floor
7. Broad BOS
8. Bend at knees & hips
9. Back straight as possible
10. Breathe while lifting
11. Lift by straightening legs
12. Move smoothly
13. Do NOT rotate the trunk
14. Lower body to the level of work

Has resilient component designed to:

1. Incr PROM
2. Augment AROM

Dynamic Splint

Hand Splint Design Standards:

Maintain arches of hand: proximal & distal transverse arches & longitudinal arch

Do not impinge upon creases of hand: distal/prox palmar crease; distal/prox wrist crease, thenar crease

πŸ™‚

1. Decr pr: *wide, long splint is most desirable*
2. 90 degree angle of pull
3. *Low load to incr duration*
4. Maintain 3 point pr versus circumference*
5. *Avoid positions of deformity: wrist flexion (bc radial compression), MCP hyperextension, IP flexion, thumb adduction*
Mechanical Principles of Splinting

Resting hand splint (functional position)?
Wrist 20-30 deg extension
MCPs 30-45 deg flexion
IP’s 0-20 deg flexion
Thumb abducted (opposition)

Safe position splint (AKA intrinsic-plus, anti deformity splint, for burns)?
Wrist 20-30 deg extension; however several texts suggest 30-40 deg, however, OT must be cautious bc of the incr pr on carpal canal

MCPs 70-90 deg flexion
IP’s full extension
Thumb abducted & extended

OT vs. OTA’s Role in Splinting?
OT: MUST SET THE GOALS

OTA: *can fabricate static* splints & *ASSIST with dynamic*

OT/OTA team must carefully assess for the appropriate splint*

Brachial plexus injury splint
Brachial plexus injury splint
Flail Arm Splint

___1___: dynamic wrist, finger & thumb extension splint

___2___: opponens splint, C-bar or thumb post splint

___3___: dynamic/static splint to position MCP’s in flexion

___4___: figure-of-eight or dynamic MCP flexion splint

1. Radial nerve palsy (wrist drop)

2. Median nerve injury

3. Ulnar nerve injury

4. Combined median & ulnar nerve injury

Carpal tunnel splint?
Wrist in neutral position

Cubital tunnel splint? (ulnar n. injury)
Elbow splint at 30 deg flexion

deQuervain’s splint?
Wrist based thumb splint, IP joint FREE

Skier’s thumb splint (ulnar collateral lig)?
Hand-based thumb splint

CMC arthritis splint?
Hand-based thumb splint

Ulnar drift splint? *MCP UD, wrist RD
Ulnar drift splint? *MCP UD, wrist RD
Ulnar drift splint

Flexor tendon injury?
DORSAL protection splint (bc want to prevent hyper flexion)

Swan neck splint?
Silver ring splint or buttonhole splint

Boutonniere splint?
Silver ring splint or PIP extension splint

Arthritis splint?
Functional splint or safe splint, depending on stage

Flaccidity splint?
Resting hand splint

Spasticity splint?
Spasticity splint or cone splint

Muscle weakness splint (i.e. ALS, SCI, GBS)?
Balanced forearm orthosis (BFO)

Deltoid sling/suspension sling

*These mount to w/c; pt must have shoulder or trunk movement to use these*

Hotpacks (heats 1 cm)
Paraffin (heats 1 cm)
Fluidotherapy (convection heat t/f)
Whirlpool (heats 1 cm)
Superficial thermal heat modalities

Cool packs
Ice massage
Superficial cooling agents

US (heats deeper, 4-5 cm)
Whirlpool
Mechanotherapy

NMES (use this for CVA)
TENS
High volt gallons stim (HVGS)
Iontophoresis
Electrical stim units

Benefits of superficial heat therapy? (4)
1. Incr tissue extensibility (incr ROM)
2. A w/ wound healing (incr blood flow)
3. Decr muscle spasms
4. Decr pain

Contraindications w/ heat? (4)
1. Postsurgical repairs
2. Acute injuries
3. Impaired sensation
4. Impaired vascular supply

Layers for hot pack? (superficial heat PAM)
Place hot pack in cover and add 4 laters of one folded towel between hot pack cover & pt

Check skin after 5 min; remove after 20 min

Paraffin method? (superficial heat PAM)
Check skin before & after

After washing & drying hand, dip and into paraffin & quickly pull out; repeat this “dip method” 8-12x, forming a glove of paraffin over hand; wrap w/ cellophane

Fluidotherapy method? (superficial heat PAM)
Place pt’s hand in fluidotherapy via sleeve on machine for 20 min; during this time pt can exercise their hand/wrist in machine

Do this for 20 min; slowly remove hand, making sure no particle of ground cornhusk spills out

Whirlpool method? (superficial heat PAM)
To clean & debride wounds, fill tank w/ water, adjust & turn on turbine, slowly lower extremity into whirlpool for 20 min while *maintaining sterile technique*

*No longer as common

Benefits of cryotherapy? (4)
1. Decr pain
2.* Decr abnormal tone & facilitates muscle tone*
3. Controls edema
4. Commonly *used to treat acute injuries & post surgical repairs*

Contraindications for cryotherapy? (3)
1. Sensory deficits, including hypersensitivity
2. Impaired circulation
3. Raynaud’s disease

Ice pack method? (cryotherapy)
Check skin before & after

Dry or wet towel between pt and cold pack; check skin after 3-5 min; remove after 10 min

*Ice massage also used: apply to smaller areas *directly to skin* for 3-5 min

Benefits of electrical stem? (5)
1. Pain control
2. Decr swelling
3. Stimulates & strengthens muscles
4. Stimulates denervated muscles
5. Muscle reeducation (so, good for CVA)

Contraindications for e-stim? (4)
1. Cardiac pacemaker
2. Phrenic/urinary bladder stimulators
3. Thrombosis
4. Over carotid sinus

Benefits of US? (~7)
-Continous (thermal effects) benefits
1. Decr pain
2. Decr muscle spasms
3. Incr blood flow/tissue permeability
4. Incr tissue extensibility (so incr ROM/decr stiffness)
5. Reaches deeper tissues (up to 5 cm)

-Pulsed (non thermal effects) benefits
1. Decr inflammation
2. Heals tissue

Contraindications of US? (~6)
1. Active malignant tumor
2. Pregnancy
3. Near pacemaker
4. Some joint replacements
5. Thrombosis
6. Precautions:* fractures, growth plates, breast implants

General PAMS contraindications? (7)
1. Cancer
2. Pacemaker
3. Pregnancy
4. *Cog impairment*
5. Sensory impairment
6. Vascular impairment
7. DVT

How to assess muscle strength w/ arthritis?
AVOID MUSCLE TESTING UNLESS REQUESTED BY PHYSICIAN

*Document strength in relation to observed function

AVOID STRENGTHENING during inflammatory stage

*Focus on AROM, avoid PROM in acute stage; however, gentle PROM if pt unable to perform AROM

Hot packs can be used before exercise, bit avoid during inflammatory stage for arthritis

Paraffin is recommend for hand arthritis

πŸ™‚

D/o caused by dysfunction of 1+ genes responsible for producing collagen to strengthen bones

S&S:
-Malformed bones (short, small body; brittle bones; barrel-shaped rib cage; multiple fas as child grows; developmental growth problems)
-Loose joints
-Sclera of eye is blue/purple
-Brittle teeth
-Hearing loss
-Respiratory problems
-Insufficient collagen

*Make sure question answers choices for activities with this d/o do NOT PUT STRESS ON BONE! i.e. would put baby in recliner swing before propping it on forearms*

During OT eval, assess activity interest that can be safely pursues & E risk factors & ax pain

Osteogenesis Imperfecta

1. Activity adaptation & AD to facilitate safe play
2. E modifications for safety
3. *Preventative positioning & splinting to prevent contractures & deformities (this is a priority!)*
4. Incr muscle strength
5. *Wt. bearing activities to facilitate bone growth
6. Health educ i.e. healthy diet, walk, swim, etc.
7. Family deuce on proper handling, position & activity adaptions *i.e. choose video games > sports*
OT Ix’s for Osteogenesis Imperfecta

Pain scales that commonly address function?

-*Splint in resting position for pain*

1. McGill Pain Questionnaire
2. Pain Disability Index
3. Functional Interference Estimate

Which tool assesses for return of vibration
Tuning fork

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