Transcript Assessment and intervention for people with hand

Orthopedic limitations
and Hand Injuries
Ch 41 and 42 in Trombly
OT 624
Orthopedic Conditions
• Caused by injuries, diseases and
deformities of joints and related
structures
• Caused by trauma, cumulative
trauma, or congenital anomaly
• Rising incidence related to many
competitive and recreational sports
as well as increase in the elderly
population and a concurrent home
injuries and falls
• Prevention= jt protection, positioning
• Remediation= ROM, strength, nerve
Evaluation in OT
• Assessment of roles
• Controlled ROM w/in precautions
• Non-resistive activities for 1st 4-6
wks.
• Orthopedic protocol for specific
condition/ specific physician
• ID tasks that client is having difficulty
with
• Measure ROM early, strength later
• Note skin color, sensation, pain
level, edema
Intervention for fractures
• Medical Treatment
• Mobilization vs. Resting
• Splint, Cast, Brace,
• ORIF vs. External Fixator
• Early mobility when possible
• PROM, AAROM, AROM
• Splinting
• Scar tissue and wound management
• Connective tissue work
• Passive stretch, dynamic splinting,
myofascial release
Shoulder Fx
• Isometric exercises while immobilized
moving toward isotonic ex
• Pain control
• Wall climbing
• Codmans exercises
• Scapular mobilization
• Jt. Replacements- AAROM daily,
skateboard, Pulley
Elbow Fx
• Complication: Volkmann’s ischemia
• Pale, bluish skin
• Absence of radial pulse
• Decreased hand sensation
• Splinting 90-100 degrees of flexion
• Full ROM not always achieved
Forearm fractures
• Radius or ulna short cast
• AROM as soon as possible per MD
protocol
• Manage edema, pain, nerve damage
Hip fractures
• Common in Older adults
• ORIF (femur fx) vs. THR
• Wt. Bearing status
• NWB, TTWB, PWB, 50% WB, FWB
• Precautions:
• No extremes in flexion, adduction,
IR/ER
• Sleep w/abduction wedge
• Use LH equip for reaching,dressing,
bathing
Low Back Pain
• Acute pain- proportional to physical
findings
• Chronic pain- lasts for months/ years
• Results in personality changes
• Disproportionate to physical problem
• Goal to get people back to function,
manage pain, reduce illness behavior,
reduce disuse
Intervention for LBP
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Positioning
Adaptive equipment
Reconditioning
Strengthening
Environmental modification
Body mechanics
Body mechanics
• Neutral pelvis, prop foot
• Bend at the knees to lift, do half-kneel,
squat or golfer’s lift
• Avoid twisting, excessive bending or
reaching
• Sit to work if possible
• Balance load
Hand Impairments
Ch 42 in Trombly
Hand Therapy
• Originated during WWII
• Is done by OT/PT, nurses, orthopedics,
Workman’s comp and voc specialists, PA
• CHT-Certified Hand Therapist- Must have
5 years working with hands. Sit for national
exam by ASHT
• Though tx could focus on specific
anatomic structures, the function is what’s
important
Psychosocial factors
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Adaptive responses
Emotional factors
Support systems
Motivation
Type of injury (e.g. traumatic vs. repetitive)
Hand Therapy Concepts
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Tissue healing
Antideformity positioning
Attend to Pain
PROM can be injurious
Judicious use of heat
Isolated exercise vs. purposeful activity
vs. therapeutic occupation
Tissue Healing
• Sequence: Inflammation, fibroplasia,
maturation and remodeling
• Vasoconstriction to vasodilation
• WBC’s promote phagocytes removing
dead tissue or foreign body
Interventions during tissue
healing phases
• Inflammation phase: rest is
advised, edema management, pain
control and positioning
• Fibroplasia phase- starts at 4 days
to 6 weeks. Formation of scar tissue.
Begin AROM, Splint
• Maturation phase-may last for
years. Gentle resistive activity, avoid
inflammation, dynamic or static
splinting, scar tissue management
Antideformity Positioning
• Position to avoid: Wrist flexed, MP
jts stiffen in hyperextension and
DIP’s flexed, adducted thumb
• Called the Intrinsic Plus position
• Wrist in neutral or extension
• MP’s in Flexion
• IP’s in Extension
• Allows collateral ligaments at the MP
joints and the volar plate at the IP
joints to maintain their lengths
• Flexor and extensor tendon repair
not conducive to these positions
Attend to Pain
• Myth of No-Pain, No Gain
• Pain induced by therapy can cause CRPS
or Complex regional pain syndrome
• Watch for pt’s body language, face,
• Use visual and verbal analog scales
• Change treatment to a “hand’s off
approach”
PROM
• Can be injurious to delicate tissues in the
hand
• Can incite inflammation and trigger CRPS
• Gentle and Pain-Free
• Low load-long duration splinting may be
more effective than PROM
• Can cause inflammation if PROM is done
after heat application
Judicious use of heat
• Do not use on inflamed or edematous
extremities
• May degrade collagen and contribute
to microscopic tears
• Heat can have a rebound effect, with
stiffening following its use
• Use aerobic exercise to warm up
tissue
• Elevate the extremity in conjunction
with heat
• Monitor frequently for signs of
inflammation
Exercise vs. Occupation
• Isolate for discrete components that are
involved
• Integrate pt directed goals into hand therapy
• Encourage use of UE in ADL’s
• Purposeful activity- not only exercise,
produces coordinated movement patterns in
multiple planes, leads to better movement
quality
• Occupational as means instills OT’s
heritage is a less function-oriented
context…incorporate their occupations into
therapy….mechanics, crafts, homemaking,
etc….
Evaluation in Hand Therapy
• History
• Injury, work and leisure interests, roles,
Physician recommendations and
precautions
• Pain•
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Acute vs. chronic
Intensity
Type of pain
Myofascial/ Trigger points vs. joint
Analogs, draw on a body
Evaluation (continued)
• Physical Exam
• Observe, Cervical screening, posture,
guarding, atrophy, edema
• Wounds
• Universal precautions
• Stage, type, (red, yellow, black)
• Red-revascularizing
• Yellow-exuidate- needs cleansing
and debreidment
• Black-necrotic- needs debriedment
Evaluation (continued)
• Types of Debriedment
• Chemical (e.g. peroxide)
• Manual (suture scissors, scrubbing)
• Surgical (scrubbing under anesthesia
(burns)
• Scar Assessment
• Hypertrophic
• Tenodermodesis
• Contracture- wound or scar crossing a
joint
• Mature- flat and softer and has neutral
color, does not blanch to touch
Evaluation
• Vascular Assessment
• Cyanosis, erythemia, pallor,
gangrene, grayish, blanching
within 2 seconds of release of
pressure
• Edema
• Circumferential measurement
• Volumeter
• Range of Motion
• PROM, ROM
• TAM or TROM
Evaluation (continued)
• Grip and Pinch
• 10-15% difference in strength
between dominant and nondominant hands
• No relationship w/increase and
increase function
• Bell shaped curve
• MMT
• Sensibility
• Dexterity and Hand function
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Jebsen
MMRT
Box and Block
Purdue Pegboard
Nine Hole
Clinical Decision Making
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ADL and functional Implications
Goals
Quality of movement
Structures
• Joint vs. musculotendinous
• Lag vs. contracture (extensor lag in
spite of PROM available)
• Intrinsic vs. extrinsic tightness (PROM
of DIP vs. PIP)
• Tightness of extrinsic extensors or
extrinsic flexors
Interventions
• Edema
• Elevation
• Compression
• Manual edema mobilization (different
than retrograde massage)
• Lymphedema pumps
Intervention (continued)
• Scar management
• Compression
• Silicone gel
• Manual edema mobilization vs.
friction massage
• Tendon Gliding exercises (figure
42.3)
• Blocking exercises
• Place and Hold
• End feel and Splinting
Interventions
• Splinting
• Blocking
• Buddy strapping
• Dynamic vs. static
Common conditions
• Stiff hand
• Result of fracture
• Decrease PROM/AROM if painful or
swollen
• Static splinting during acute
inflammatory phase, dynamic when
joint has a soft end feel
• Tendonitis
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More than half of occupational illnesses
Tx= RICE
Splinting @ night
Gradual mobilization balanced w/rest
Prevent reinjury though education
Types of Tendonitis
• Lateral Epicondylitis
• Proximal conditioning and scapular
stabilizing
• Built up handles
• Splinting
• Counterforce strap-reduces load on the
tendon
• Medial epicondylitis- Golfers elbow
• Involves the FCR
• Proximal conditioning, avoid end
ranges, built up handles, and splinting
as well as counterforce strap
Types of Tendonitis
• DeQuervains Disease
• APL and EPB at first dorsal
compartment
• Avoid wrist deviation (esp w/pinching)
• Forearm thumb spica
• Others (less common)
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Intersection syndrome
EPL tendonitis
ECU, FCR, FCU tendonitis
Flexor Tendonsynovitis or trigger finger
Nerve Injuries
• Median nerve compression- CTS
• Steroid injection
• Night splinting in neutral
• Exercises for tendon gliding
• Aerobic exercises
• Proximal conditioning
• Ergonomic modification
• Postural training
Nerve Injuries (continued)
• Cubital Tunnel Syndrome
• Between the medial epicondyle and the
olecranon
• Ulnar nerve entrapment
• Proximal and medial forearm pain
• Radial Nerve Compression
• Purely motor, inability to ext MP jts.
• Can be entrapped at the supinator muscle
• Nerve laceration
• Surgical intervention w/protective splinting
• Sensory re-ed
• Reduction/prevention of a neuroma
Types of nerve injuries
• Low median- OP and APB of thumb
• Hi Median- FDP to IF and MF and DGS to
all digits and pronation
• Low ulnar- intrinsic loss= claw hand
• Hi Ulnar- FDP of RF and SF and FDU
• Low radial-MP ext is affected
• Hi Radial-supinator, wrist and finger ext
out
Fractures
• Distal Radius fx- most common
• Scaphoid- FOOSH, may accompany EPL
and EPB stretching and ligamentous
injury. Avascular necrosis is a risk.
• Non Articular Hand Fx
• Distal phalanx, Middle, Proximal,
Metacarpal Fx (Fixation with wires,
screws)
Ligament
and
Tendon
Injuries
• PIP joint sprain
• Skier Thumb-collateral ligament of
the thumb w/acute radial deviation
• Flexor Tendon Injury
• Zones of the hand
• Passive Flexion-active extension
protocol
• Chow advocates early motion
• Extensor Tendon Injury
• Less common
• 7 zones in the dorsum of the hand
• In zones 3 and 4 can lead to
boutonniere deformity
• Tenolysis- surgical procedure to
release tendon adhesion. Therapy
begins a few hours after surgery
Complex Regional Pain Syndrome
• CRPS- used to be called RSD
• Type 1- follows noxious event, pain,
edema, abnormal skin color, pseudomotor
activity
• Type 2-develops after a nerve injury
• Pain is disproportionate to the injury
• Four cardinal symptoms
• Pain, swelling, stiffness, discoloration
• Secondary symptoms
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Osseous demineralization
Sudomotor and temperature changes
Trophic changes
Vasomotor instability
Palmar fascitis
Pilomotor activity
Management of CRPS
• Management of pain through medications,
sympathetic blocks, modalities
• Vaso motor challenge through stress
loading (scrubbing)
• change positions, temperature
biofeedback, contrast, vibration,
desensitization, water aerobics
• Patient Directed therapy
Arthritis
• Osteoarthritis or DJD
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Heberden’s nodes (@ DIP)
Bouchard’s nodes at the PIP
Thumb CMC arthroplasty is common
TX includes splinting, pain mgmt, jt.
Prot.
• Rheumatoid (a systemic disease)
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Tx reduce inflammation
Jt. Protection
Splinting,
Energy Conservation