Movement Exam Two

Interdisciplinary foundation

Biomedical sciences (anatomy & physiology) Focus on the underlying impairment Physics Kinesiology, kinematics Biomechanics of human movement Exercise physiology Increase strength, flexibility, endurance

Elbow and forearm articulations

Humeroradial Joint Humeroulnar Joint Both are uniaxial hinge joints Flexion/extension in sagittal plane Axis of rotation?

Clinical considerations, ligamentous injury

LCL injury due to medial force MCL injury due to lateral force

Changes in muscle: aging

Loss of muscle fibers / tissue Decreased # type II fibers, increased # type I Decreased # motor units Increased fibers per motor unit Increased connective tissue (endo & perimys) Decreased ROM Increased muscle stiffness Rehab focus: balanced, resistive exercise Resistance training can increase size of muscle fibers, increase strength, and increase performance

Intervention

Setting measurable, client-centered goals Focus of intervention: occupation-based; purposeful activity; preparatory, consultation, education, advocacy

Stability

another function of trunk musculature

Examples of class 3 lever

tongs, tweezers, staple remover, broom, spoon

Lateral compartment

PERONEUS (fibularis) LONGUS & BREVIS Ankle Eversion Where is body weight distributed to?

Elbow extensors

PRIME MOVERS: Triceps brachii Medial head is primary forearm extensor Long head crosses shoulder & elbow: actively insufficient during combined elbow & shoulder extension All 3 (including lateral head) involved in heavy resistance or quick extension movts. ALSO: Anconeus

Elbow flexion/extension-ROM testing

PROM - Normal end-feel? Flexion Extension ROM Testing procedures Palpate landmarks Goniometer Alignment Fulcrum Proximal/stationary arm Distal/moveable arm Stabilization & position are important! Measurement: 0-145°

ROM procedures and alignment

Palpate/identify bony landmarks Align stationary & movable arms parallel to longitudinal axes of proximal/distal joint segments Place fulcrum over axis of motion Axis changes during movement/realign as needed

Rotator cuff

ROLE: Dynamic stabilization of the humeral head Supraspinatus - ABDuction Infraspinatus - External rotation Teres minor - External rotation Subscapularis - Internal rotation "S.I.T.S."

Gait

weight acceptance, single limb support, limb advancement

Loose-packed position

"Resting position" Joint surfaces are not in complete congruence Joint capsule and ligaments are most relaxed Most appropriate for eval of joint play and joint mobilization Examples: near full MCP extension (~20 degrees flexion); 55 degrees GH flexion with 20-30 degrees horizontal ABD

Determine relevance and importance

"The meaning & importance of each occupation is defined by our client's goals, values, beliefs, and needs and the perceived utility of their occupations." (Thomas p. 46)

Defining the occupation

"What occupations does the client want to do - what defines successful participation & performance? Relevance & salience of therapeutic activities are essential to learning and transfer.

Kinematics

- motion of bodies in space over time Displacement, velocity, acceleration, determination of joint angles Arthrokinematics & Osteokinematics

Phalanges

14 Phalanges Finger Phalanges Proximal Middle Distal Thumb Phalanges Proximal Distal

Hand osteology

19 Bones Total 5 Metacarpals 14 Phalanges + 8 Carpal

Concurrent force system

2 or more forces act at a common point of application on an object but in divergent directions

Carpal bones

8 Carpal Bones in 2 rows Proximal Row Scaphoid (boat) Lunate (crescent) Triquetrum (3-cornered) Pisiform (pea-shaped) 8 Carpal Bones in 2 rows Distal Row Trapezium (saddle shaped/CMC OA) Trapezoid Capitate (head) Hamate (hook)

External force

A push or pull on the body that arises from a source outside the body (gravity, wind, water, friction, other people, objects, etc.)

Functional AROM

AROM needed to perform 24 ADLS 40 degrees wrist extension/flexion 10 degrees radial deviation 30 degrees ulnar deviation What about wrist fusion?? 10-15 degrees wrist extension 10 degrees ulnar deviation

Frontal vs scapular plane

Abduction in scapular plane is 35° anterior of frontal plane More natural movement Allows greater elevation of humerus Greater tubercle clearance Position of humeral head in glenoid fossa

Endurance

Ability to sustain cardiac, pulmonary, & musculoskeletal exertion over time Common diagnoses? Endurance involves muscle function, oxygen supply & their combined effects

Osteology of pelvic girdle

Acetabulum is formed by the: Pubis Ischium Ilium Articulation of femoral head Proximal Femur: Trochanters Neck Head Shaft Angle of inclination

Adductor pollicis

Action: Flexion and ADduction of the CMC joint and flexion of MCP joint of thumb Pinching tasks, Using Scissors, etc. Activity Analysis: Go through the motions of using a scissors and describe the muscles involved

Lumbricals

Action: Flexion of the MCP joints & extension of the IP joints This is called intrinsic plus position Origin: Flexor Digitorum Profundus (moving attachment) Attach: Extensor Digitorum runs on the radial side of it's corresponding digit and attaches at the dorsal digital expansion/lateral bands True or False: Are they active when you make a fist? Innervation: IF & MF = Median Nerve RF & SF = Ulnar What would you see if the ulnar nerve was impaired?

Rehab approach, changing the task

Adapting Task Method or Procedures May involve learning new skills & changing habits by modifying techniques or transferring skills to new situations Examples: upper body dressing after stroke, sitting while preparing vegetables Client must be motivated & committed to change Energy Conservation Principles: Respect pain Take frequent rests Prioritize activities Avoid sustained, static positions or isometrics Avoid stressful positions Consider environment Research evidence supports use of energy conservation to reduce fatigue, improve self efficacy & QoL Adapting Task Method or Procedures Work Simplification Principles: used with energy conservation strategies to reduce fatigue, improve efficiency, and prevent disability Organize storage Plan ahead Ease work flow Eliminate steps or tasks Use efficient methods Team-based learning: You are providing outpatient OT to a 33 y/o mother of twin toddlers after a recent exacerbation of MS. A major concern is her level of fatigue, impacting her ability to prepare healthy meals for her family. Prior to this exacerbation she was responsible for grocery shopping and all meal prep due to her spouse's busy work schedule and long hours. Identify three specific work simplification strategies you would suggest to address her concerns. How might these strategies be used during ADL/IADLs she may encounter on a daily basis? Consider this: What is the difference between 1) Adapting Task Method or Procedures and 2) Adapting Task Objects, Adaptive Devices & Orthotics? When a client presents with impairments in ROM, grasp, strength, coordination, endurance, which approach might you try first? Why? Adapting task object involves changing or substituting objects or tools used in activities. Considerations include: Cost, availability of device, device maintenance & repairs, ease of use, psychological impact of adaptive equipment & client attitude toward adaptive equipment; needs for education for safe and effective use of device Advantages: adaptive devices have good face validity (easily perceived as helpful); offer immediate solution to functional problem; many adaptive devices are low cost (e.g. foam tubing for utensils).

Functional ROM

Amount of motion necessary for ADL without adaptations/equipment

Anatomic factors of posture

Anatomic Factors Body contours Laxity of ligaments Fascial & musculotendinous tightness (e.g. hamstrings, hip flexors) Muscle tone Pelvic Angle (normal is 30 degrees) Joint position/mobility Changes in position of one region require realignment of others Consider pelvis/lumbar alignment, head/neck/trunk

Location of motion

Anatomical Position: Erect posture Face forward Arms at sides Palms forward Fingers straight Reference for planes, axes, & definitions Zero position for measuring joint motions (most joints)

Scapula

Angles - inferior, superior, lateral Borders - medial, lateral, superior Spine Acromion Coracoid Process Glenoid Fossa Angles - inferior, superior, lateral Borders - medial, lateral, superior Spine Acromion Coracoid Process Glenoid Fossa Clavicular Facet

Osteokinematics

Angular changes between the bones forming joints Differs from joint to joint due to bony alignments & soft tissues around the joint Visible motion or displacement of the bones (flex/ext, abd/add, etc) Range of motion (ROM) is measured by goniometry ROM can be normal, hypermobile, or hypomobile

Angular movement and levers

Angular movement occurs around an axis or pivot point Angular motion requires a lever which is a rigid object with a fulcrum or pivot point

MCL

Anterior Posterior Transverse

Process skills

Applying knowledge Temporal organization of steps/actions Organizing space & objects Adapting performance

Maintain

Appropriate for persons with degenerative diseases Goal is to preserve current level of functioning

Internal force

Arises from body: muscle contraction, passive resistance of ligaments, bones; elastic properties of tissues (muscles, tendons, ligaments, fascia, skin) Serves to counteract external forces: provide movement & stability

Ligamentous support

Articular Capsule is reinforced anteriorally by fibrous bands

AROM

Assesses ability to voluntarily produce motion at a joint Willingness to move, coordination, muscle strength, pain Screening of AROM provides focus for quantitative ROM testing

PROM

Assesses amount of motion possible at a joint Normally slightly greater than AROM due to stretch of soft tissues, reduced muscle bulk during passive range Assess integrity of joint structures, extensibility of capsule, soft tissues (e.g. ligaments, muscles, etc)

AAROM

Assisted active ROM: Person initiates motion, movement through end of range is completed by an outside source

Axis of rotation and normal valgus angle

Axis of rotation during flexion/extension - trochlea asymmetry Ulna deviates laterally relative to humerus Normal cubitus valgus = "carrying angle" Keeps carried objects away from thigh during walking Normal Valgus ~15° Women > Men - average 2° Normally > in dominant UE

Surface anatomy and landmarks

Bony Landmarks Arches Creases Cascade Dorsal vs. Volar Surface

Kinematics

Cervical Upper Cervical (C1, C2) - flexion/extension, rotation Lower Cervical (C3-C7) - flex/extend; lateral flexion, rotation Thoracic Less mobile/more stable; downward spinous processes limit hyperextension Articulation with ribs; rotation Lumbar/Sacral Strong ligaments prevent anterior sheer of L4, L5 on sacrum Clinical Considerations: Anterior spondylolisthesis at L5-S1 Herniated Disc (nucleus pulposus) Causes? OT Role?

Changes in muscle: inactivity/immobilization

Change in number & length of sarcomeres: new resting length Decrease if shortened; increase if lengthened Increased perimysium & thickening of endomysium Increased collagen concentration Decreased muscle weight / atrophy Decreased ability to generate maximal tension Changes in joint ROM Degradation of proteins Decreased # of slow-twitch fibers

Gait-clinical considerations

Changes due to orthopedic or neuro impairments? Consider physical abilities AND visual, proprioceptive, vestibular and sensory inputs CoM and balance? Gait symmetry? Gait speed? Energy expenditure?

Carpal tunnel syndrome

Compression of the median nerve as it passes through the carpal tunnel Numbness, tingling, and burning in the thumb, index, long, and radial half of ring finger Symptoms are typically worse at night An individual may notice they are dropping items more often due to decreased sensation Atrophy of the thenar eminence due to compression of motor branch of the median nerve

Hip and pelvic girdle

Comprised of sacrum, coccyx, & 2 coxal (innominate) bones Hip joint (coxofemoral) often compared to GH joint Ball & socket Hip acts more often as closed chain Provides stability, balance & weight bearing for posture & locomotion

Tissue integrity

Conditions include burns, wounds, decubiti, scar formation after injury Evaluation involves observation of skin color, texture, temperature, unusual moistness/dryness, assessment of pain & tenderness

Scapulohumeral rhythm

Consider force couples occurring at the GH joint: Contribute to stability and mobility Location of muscle origins/insertions dictates how applied forces contribute to joint rotation, dynamic stabilization & equilibrium During overhead reach, involves combined motions at SC, AC, ST, GH After ~ 30 degrees of abd/flexion 2:1 ratio GH:ST

Rehab approach, changing the context or environment

Context includes physical environment, cultural & social aspects of the individual, spiritual aspects of tasks & activities, realistic or virtual simulation of an environment (e.g. rehab clinic or technology-based activities vs. home) Clinician must learn & respect client's values and expected outcomes - example? Changing context includes changes to physical environment & education/training of family and/or caregivers Principle: modifications to environment will provide access to transportation, housing, public & private facilities, work, & recreation Disadvantage: Environmental adaptations are expensive Ramps, stair glides, modified vans/cars, lack of portability Consider socioeconomic status of client, community service organizations, diagnosis-specific groups for loaner equipment (e.g. MS Society, ALS groups) Research evidence supports positive impact on home safety, increased performance, satisfaction & occupational performance

Dorsal palmar interossei

DABS and PADS

Mobility of the wrist

Distal Radioulnar Joint Radiocarpal Joint Midcarpal Joint Radiocarpal Joint Radius/Articular disc with the proximal carpal row Convex on Concave Movement Wrist Extension/Flexion Wrist Extension: Palmar glide of proximal row on distal radius Wrist Flexion: Dorsal glide of proximal row on distal radius Wrist Radial/Ulnar Deviation Radial Deviation: Ulnar glide of proximal row on distal radius Ulnar Deviation: Radial glide of proximal row on distal radius Midcarpal Joint Joint between proximal and distal carpal rows Capitate "rolls-slides" Movement Wrist Flexion/Extension Wrist Extension: Palmar glide of distal row on proximal row Wrist Flexion: Dorsal glide of distal row on proximal row Wrist Radial/Ulnar Deviation Radial Deviation: Ulnar glide of distal row on proximal row Ulnar Deviation: Radial glide of distal row on proximal row

Closed chain

Distal end of the joint linkage (limb) is fixed Motion occurs in a predictable fashion Joints are interdependent Examples: legs when standing push-ups

Open chain

Distal end of the joint linkage (limb) is free Motion occurs in various directions Joints may function independently or in unison Examples: waving hand kicking a ball

Anatomical pulleys

Do not change the magnitude of a muscle force... Do change the direction of the muscle force, which deflects the line of pull of the muscle from the joint axis This increases the mechanical advantage of the muscle by increasing the force moment arm Do change the amount of torque the muscle can produce

Biomechanical Approach is divided into 3 treatment domains outlined in OTPF

Establish/restore - remediation of biomechanical capacity for motion Maintain - focus on maintaining current level of function Appropriate for what types of diagnoses? Prevent - prevention of occupational performance problems. Who are at-risk populations for disability prevention?

Extrinsic extensors

Extensor Digitorum Extensor Indicis Extensor Digiti Minimi What structures could limit finger extension?

Forces can be

External Internal Observable Indiscernible

Hip muscles

FLEXOR GROUP EXTENSOR GROUP ADDUCTOR GROUP ABDUCTOR GROUP INT/EXT ROTATORS

Expiration

FORCED - gag reflex or choking may result in throat clear or cough -Driven primarily by abdominals -Critical to health and safety

Biomechanical approach: scope

Facilitates treatment planning when a client's physical impairments limit activity performance and participation Addresses how the body is designed and used to accomplish motion for occupational performance Applies to impairments in body function and structure such as: Decreased strength Limited range of motion (ROM) Poor endurance Structural instability Pain tolerance/management Edema Skin tightness from burns

After breaking down the activity, we can identify:

Factors that contribute to limited function and/or participation At a particular step? Due to an environmental factor vs personal factor? Where we should focus our intervention

Medial and lateral meniscus

Fibrocartilaginous discs Decrease compressive forces by increasing area of joint contact Help with stabilization and lubrication Medial meniscus more often damaged

Extensor hood mechanism

Fibrous expansion of connective tissue located on the dorsal fingers. It serves as an attachment for the EDC, EIP, EDM. It is where the intrinsic and extrinsic tendons merge to control PIP and MCP motion.

Shoulder motions

Flexion, ExtensionABDuction, ADDuction Horizontal ABD, ADD Internal & External (medial/lateral) Rotation

Elbow motion & functions

Flexion/extension Supination/pronation Important for positioning of hands/fingers in space Permit height & length adjustments during reach Rotation of forearm allows hand to face/mouth Elbow joint assists shoulder with force distribution & UE stabilization for power & fine coordination Elbow contractures/restrictions in ROM can significantly impede functional reach

Flexor retinaculum and carpal tunnel

Flexor Retinaculum (transverse carpal ligament) attachments: 1=Scaphoid 2=Trapezium 3=Pisiform 4=Hamate

humerus

Head Anatomic Neck Lesser Tubercle Greater Tubercle Deltoid Tuberosity

Hand joint classification

Hinge Condyloid Saddle

What contributes to the function of the hand?

Hold Grasp Prehension Manipulation Sensation Expression of Emotions/Language

Occuption-based activity analysis

How an activity is done & experienced by a particular individual

Elbow Flexion Contracture & Loss of Forward Reach

How could flexion contracture impact function? Therapy interventions to reduce contracture: Decrease inflammation Position in extension Stretching, joint mobilization Strengthening antagonist (which is?) Most effective intervention is prevention!

Structural Stability

Impairments in ligament structures may be related to genetics (e.g. Ehlers-Danlos syndrome), trauma, development of adhesive scar tissue Postural instability and misalignment may limit controlled UE reach - why? Joint instability may be observed as loss of arthrokinematics (mechanical instability), excessive movement due to pathological hypermobility (anatomical instability) or inability to control available ROM (functional instability)

Strengthening

Impairments may be due to injury, disease (e.g. muscular dystrophy), neurological diagnoses (stroke), immobilization, lower motor neuron disease (ALS, SCI, peripheral nerve injury) Volitional control of muscles is required for strengthening program

Questions to ask (relevance and importance)

In what ways is this activity important to you? How does engaging in this activity make you feel? In what ways do you need to engage in this activity? Tell me about the experiences you have when engaged in this activity? How has limited ability to engage in this activity affected your life? Your roles? Your relationships with others? How does this activity define who you are?

Biomechanical approach: scope

Incorporates numerous areas of knowledge: Activity analysis Anatomy/physiology Kinesiology: kinetics/kinematics Assumes cause & effect relationship between treatment & outcome Relevance to OT Practice Framework (OTPF) Preparatory methods - exercise, orthotics/splinting Purposeful activity - goal-directed activities within therapeutic context Occupation-based activities - occupational activities within client's own context

Inertia

Inertia is an object's resistance to change in movement - the greater the mass of an object, the greater the magnitude of force needed to move the object

Social interaction skills

Initiating & terminating social interaction Producing social interaction (fluent speech & gestures) Physically supporting social interaction Shaping content of social interaction Maintaining flow Verbally supporting social interaction Adapting to social interaction

Stability of the wrist

Joint Capsule Fibrous outer layer attaches to the radius, ulna and proximal row of the carpal bones The internal layer has a synovial membrane, which secretes synovial fluid which lubricates the joint

Factors influencing joint motion

Joint structure Type of joint - diarthroses vs. synarthroses Type of diarthrosis or synovial joint - hinge, pivot, ball & socket etc. Congruence of joint surfaces Ligament Support External forces Weight of limb Forces from additional loads Gravity Interactions between joints and the external environment Movement at one joint may affect several nearby joints Kinematic Chain: Linkage of a series of joints in such a way that motion at one of the joints in the series is accompanied by motion at an adjacent joint 2 types: closed & open

Glenohumeral joint

Labrum Joint Capsule & bursae Glenohumeral ligaments (3) Coracohumeral ligament Surrounding muscles

Finger MCP ligament support

Ligament support helps to stabilize the joint when MCP moves The collateral ligaments of the MCP's are taut in??? What about the Interphalangeal collateral ligaments? Why is this important?

ROM

Limitations may be due to orthopedic or neurological disease (stroke/hypertonicity), injury (e.g. rotator cuff tear), edema, muscle spasticity, muscle & tendon shortening, joint limitations, prolonged immobilization ROM limitations are the focus of intervention when they interfere with occupational performance: Consider differences between WFL & WNL. Remember that available ROM varies with age, occupation, gender, specific joint & activity levels

Knee motion

MODIFIED HINGE Flexion Extension Rotation (minimal) internal/external

Close-packed position

Maximal contact of articulating surfaces Joint surfaces are in complete congruence Joint capsule and ligaments tight or taut Joint is most stable: no joint play Examples: elbow, knee, and IP extension; MCP flexion; 90 degrees of GH ABD with full external rotation

Ligamentous support

Medial Collateral Ligament (MCL) Anterior fibers limit excessive valgus forces Lateral Collateral Ligament (LCL) Stabilizing force against excessive varus forces Helps stabilize radial head Both MCL & LCL Provide ulnar stability in sagittal plane (Which movements?) Resist longitudinal forces (distraction)

Acitivity analysis: Identify activity demands

Mentally think through the steps Engage in the activity yourself Talk with your client Talk to someone who performs the activity Watch someone perform the activity

Frontal plane:

Movement occurs around the anterior-posterior axis

Thenar eminence muscles

Muscles Include: Abductor Pollicis Brevis Flexor Pollicis Brevis Opponens Pollicis Responsible for positioning the thumb for opposition Median nerve injury will affect all three muscles and therefore limit any type of thumb opposition Thumb Opposition is a combination of what motions?

Synergists

Muscles that ASSIST with an action May be an accessory to the Agonist (NOT the prime mover), OR the Antagonist AND/OR work as a stabilizer (e.g. ankle muscles contracting to stabilize ankles when standing up)

Sternoclavicular joint

Need to know that @ SC joint, Clavicle is more likely to FX with force A/C will likely DISLOCATE Only joint that connects the UE with the thorax Clavicle will fracture rather then dislocate (vs. AC) All movement

Evidence-based practice - how do we choose OT interventions?

Occupation-based activity? Purposeful activity? Preparatory methods? Use available research evidence to inform best practice

Outcomes

Occupational performance Client satisfaction Health & wellness

Evaluation

Occupational profile - client's interests, values, needs, occupational history, daily patterns, goals for intervention

Patellofemoral joint

PATELLA: Convex Anterior; Articular Posterior Anatomic pulley for quads Reduces friction

Hip clinical issues

Pain-Osteoarthritis Osteoporosis Joint replacement Fractures Hip Dysplasia Trendelenburg Sign Post Hip Replacement (THA)

Factors influencing ROM

Patient factors Psychological/psychosocial factors Environment Skeletal Factors Methodological & Measurement Factors

Factors that influence strength

Patient factors Psychological/psychosocial factors Muscle Factors Methodological & Measurement Factors Environment Screen patient/client's strength capabilities

Hip extension-posterior pelvic tilr

Pelvis on femur vs. femur on pelvis, look @ picture on slide

Hip flexion-anterior pelvic tilt

Pelvis on femur vs. femur on pelvis, look @ picture on slide

Planes of motion

Planes in space through which body segments move Are at right angles to each other Help to describe motions of the body/joints Real-life motions occur in these planes infrequently 3 cardinal planes Frontal, sagittal, transverse

Posture and seating considerations

Position: Hip, knee, ankle angles 90 degrees Seat: depth & support Chair back: lumbar support, slight incline Wheelchairs - Sling seat & back - UE use? Options for repositioning & pressure distribution Pelvic tilt? Trunk & UE positioning for function? Child with CP assisting with dressing during OT https://www.youtube.com/watch?v=PiqaiyIBVDs Active Learning: Developing your observation skills as an OT With your team, identify challenges this child is having. Consider the following: What are the goals of this intervention? What are the neurological effects on postural control? UE reach? ADL performance? cognition? Other? How is the OT facilitating occupational performance? Based on your observations, identify 2-3 therapeutic activities you would recommend to address his limitations.

Knee cruciate ligaments

Posterior Cruciate: Restraint against posterior displacement of tibia Anterior Cruciate: Restraint against anterior displacement of tibia Most often injured TEST: Ant-Post drawer test

Scalenes

Primary Unilateral: Lateral flexion (primary), some rotation to the same side (ipsilateral) Bilateral: Flexion cervical spine (limited) Secondary With cervical spine stabilized: Elevate 1st and 2nd ribs (respiration)

Levator scapulae

Primary With scapula fixed: Unilateral: Lateral flexion of cervical spine, rotation to the same side (ipsilateral) Bilateral: Extension of cervical spine Secondary With cervical spine stabilized: Scapular elevation, downward rotation, & adduction Ipsilateral rotation of cervical spine

Finger MP flexion

Primary Muscles Lumbricals (4) Dorsal Interossei (4 bipennate) Palmar Interossei (3)

Endurance, OT treatment

Provide low load, repetitive exercise or activities, gradually increasing duration Guidelines for amount of resistance & maximum heart rate & oxygen uptake differ (~15-40% of repetition maximum for muscle endurance) Treatment activities may include low impact aerobics (swimming, walking) and grading engagement in functional, daily activities by increasing time & intensity of activity demands and monitoring rest period timing (e.g. time between rests, duration of rest) Carefully monitor vital signs, client response to intervention for SOB, quickened respiration, degradation of performance, MET levels

Why do OTs need to understand biomechanics?

Provides a key to understanding levels of independence, effort, efficiency, & safety Helps to identify problems in occupational performance & offer suggestions to improve function Assists in design & modification of adaptive equipment, evaluating safety of home & work environments, & prescribing therapeutic activities

Occupational Profile

Purpose? To understand client's interests, values, needs, occupational history, patterns of daily living, goals for intervention What questions would you ask? What occupational therapy assessments might help with this process?

LCL

Radial - blends with annular Ulnar

Ant. trunk group

Rectus Abdominis: Xiphoid and costal cartilage to pubic bones R and L, separated by linea alba ACTION? Bilateral Unilateral

Types of motion

Rotary motion (angular motion): movement around a fixed axis in a curved path Measure with goniometry Translatory (linear) motion: movement in a straight line Curvilinear motion: movement of an object both around an axis and through space at the same time Includes both rotary and translatory motion How we move our body when performing occupations

Kinematics of the spine

Sacroiliac Joints Nutation - posterior iliac tilt, anterior sacral tilt Counternutation - anterior iliac tilt, posterior sacral tilt Functions Stress relief within pelvic ring, especially during gait, childbirth Stability during transfer of loads between axial skeleton & LEs Gravity & weight bearing through pelvis Ligaments & muscles - static & dynamic forces/loads Malalignment & hypermobility lead to joint stress & pain

Scapulothoracic joint

Scapula is typically between the 2nd and 7th rib Movement is closely tied to AC and SC joints

Thumb movement

Since the thumb is rotated 90 degrees, thumb movement is a little different Thumb Flexion: Thumb movement across the palm Thumb Extension: Return of thumb towards anatomical position Palmar Abduction/Adduction: Movement of the thumb away/toward the palm Radial Abduction/Adduction: Movement of the thumb away/toward the hand Opposition: Unique movement of the thumb to the tip of any finger

Remediation or restoration focus

Structural stability Tissue integrity ROM Strength Endurance

ant compartment

TIBIALIS ANTERIOR Primary: Dorsiflexion of foot Extensor digitorum longus Toe Extensors Dorsiflexion Why is weak dorsiflexion a concern during ambulation?

Post compartment (deep)

TIBIALIS POSTERIOR Primary: inversion of foot Flexor digitorum longus Toe Flexors Ankle Inversion Where is body weight distributed to?

Ankle osteology

Talus Calcaneus Navicular Distal Fibula - Lateral Malleolus - Articular Facet Distal Tibia - Medial Malleolus - Fibular Notch

Subtalar

Talus & Calcaneus Eversion and Inversion

Foot osteology

Tarsals Metatarsals Phalanges Digits 1-5

Rehabilitation Approach: Adaptation & Compensation

Teaching and learning theories inform treatment strategies Therapist must be aware of client's learning style, memory & metacognitive abilities, as well as the context/environment(s) in which activity is performed Consider client's readiness for learning & his/her learning needs Preferred modes of learning (verbal, auditory, "by doing", etc) Client self-efficacy is closely related to performance Theoretical framework will guide type of cues provided Extrinsic vs. intrinsic feedback Constant vs. immediate vs. summary feedback General vs. specific cues "Bandwidth" feedback - given only when performance is NOT within acceptable range Goal: gradually decrease amount of extrinsic feedback, facilitate client's knowledge & use of intrinsic feedback re: his/her own performance

Contribute to large differences between ROM and PROM

Tendon tear/laceration Muscle weakness, deconditioning Pain due to edema or injury Scar tissue Neurological conditions (stroke, SCI)

Carpal tunnel

The Carpal Tunnel Contains FDP- Flexor Digitorum Profundus (four tendons) FDS- Flexor Digitorum Superficialis (four tendons) FPL-Flexor Pollicis Longus (one tendon) Median Nerve Flexor Carpi Radialis travels in the flexor retinaculum (which covers carpal tunnel)

Carpal tunnel structures

The Flexor Retinaculum (also called the transverse carpal ligament) is a strong fibrous structure (limited stretch) that is the roof of the carpal tunnel (released with CTS)

The functional wrist

The mobility of the wrist helps position the hand for performance of grasping, prehension, and manipulation The stability of the wrist helps with transmission of loads involving lifting, carrying, pushing, pulling, and weight-bearing

Antagonist

The muscle that whose contraction is DIRECTLY OPPOSITE to the motion of the Agonist (e.g. agonist: flexors, antagonist: extensors) Why do we need this? (Controlled movement)

Perceived utility

The occupations we engage in define who we are. How does disability affect occupational performance and one's identity?

Thorax

Thoracic vertebrae, ribs, sternum Base for muscle attachments Protection for heart, lungs, viscera Ventilation

Clinical considerations

Those with paralysis or weakened abdominal muscles are at increased risk for choking and lung infection (SCI, ALS, GB, etc.) Aging causes stiffness in the joints and connective tissue in the thorax, reducing expansion

Talocrural

Tibia & Fibula with Talus Dorsiflexion and Plantar flexion

The knee

Together with hip and ankle, supports the body Provides for stability & mobility Functionally lengthens & shortens the lower extremity (LE) Hinge (ginglymus) joint Two joints: Tibiofibular joints Tibiofemoral joint

Tool

Typically used by hands, not disposable and reusable, ex. toothbrush

How do biomechanical & kinematic principles inform OT assessment & intervention?

Understand complexities of physical movement & functional implications Develop skills in range of motion and manual muscle testing (strength) Begin to identify specific, goal-oriented interventions

proximal radioulnar joint

Uniaxial pivot (trochoid) joint Head of radius & radial notch of proximal ulna During supination/pronation, radial head rotates around the annular ligament on capitulum

Distal radioulnar joint

Uniaxial pivot joint Ulnar notch of radius articulates with ulna head During supination/pronation, distal radius moves about ulna

Acromioclavicular joint

Upward & Downward Rotation Rotational Adjustment Motions Susceptible to dislocation (vs. SC)

ROM testing precautions

Use extra care: In presence of infectious or inflamed joint Client is on pain meds or muscle relaxants In areas of marked osteoporosis When assessing hypermobile or subluxed joints When ROM may increase painful conditions In person with hemophilia In regions of hematomas, esp. elbow, hip, knee If bony ankylosis is suspected (Rheumatoid Arthritis) Immediately after soft tissue injury

Spatial-temporal descriptor

Walking speed (normal-3 mph)

Muscles/tendons: wrist extension

What Actions Do These Muscles Perform? What Nerves Innervate them? ECRL (radial n. C6-C7) ECRB (radial n. C7-C8) ECU (radial n. C7-C8)

Muscle/tendons: wrist flexion

What Actions Do These Muscles Perform? What Nerves Innervate them? FCR (median n. C6-C7) FCU (ulnar n. C7-T1)

torque

When you open a door, turn on a water faucet or tighten a nut with a wrench you are exerting a force Torque is produced by this turning force and will produce rotational acceleration Torque differs from force Forces tend to make things accelerate Torques produce rotation Torque is the product of force x moment arm, or distance from fulcrum Example: wrench, jar opener

Movement, context and occupational performance

Why focus on activity analysis in this movement/kinesiology class? Use biomechanical principles to analyze impairments in occupational performance

Scalenes

With cervical spine stabilized: Elevate 1st & 2nd Ribs and Sternum

Adapting task objects

Work simplification strategies Instruction in proper body mechanics Hemi-dressing techniques Slide objects on counter vs. lift Use slotted spoon to remove pasta from hot pot after cooking Foam tubing, Velcro closures Long handled reacher Universal cuff, wrist cock-up splint to provide wrist stability Suction brushes or nail clippers Long straws or adapted, spill proof cups, Button hook & zipper pull Adapted cutting board and utensils (e.g. rocker knife, large handled fork/spoon)

Wrist structures

Wrist Mobility and Stability depend on: Distal Radius/Ulna Carpal Bones Articular Surfaces Extrinsic & Intrinsic (carpal) Ligaments Extrinsic & Intrinsic Muscle-Tendon Units

Newton's 1st Law

an object will remain at rest unless acted on by a force. An object in motion will continue in motion with the same speed and in the same direction unless acted on by an unbalanced force.

Arthritis

at the CMC joint

First class lever

axis is in the middle

Examples of class 2 lever

badge clip, bottle opener, door

Anterior trunk action

bilateral=trunk flexion unilateral=lateral flexion

Temporal descriptors

cadence, stride time, step time

mobility of the wrist: wrist flexion

dorsal glide

third class lever

effort (force) is in the middle

Purposeful activity

goal directed behaviors or activities within therapeutically designed contexts that lead to occupation; practicing slicing vegetables

Spinal curves

kyphosis, lordosis

Role of the patella

lengthen the moment arm of the quads

magnitude

or quantity of the force being exerted

Holistic and Client-Centered

paradigm shift from medical model to biopsychosocial approach

Joint play

play is the non-voluntary movement of one articular surface on another Assessed by therapist's movement of joint If joint is too lax = instability If joint is too tight = restricted movement Joint mobilization: manual technique to restore joint glides necessary for normal ROM

ROM

potential for motion at a joint

Inspiration/expiration

quiet: sedentary, rest, automatic forced: exercise, respiratory disease

CP

spastic gait

Gait spatial descriptors

stride length, step length and width, foot angle

ICF

systems-approach to examining function

Kinematics

the science of motion (without regard for the forces producing motion) Osteokinematics: movement of bones Types of motion Planes & axes of motion Direction of motion Magnitude of motion (ROM) Rate and duration of the motion Arthrokinematics: movement of joint surfaces

Mobility of the wrist: wrist extension

volar glide

Clinical considerations meniscal tear, degenerative joint disease

Meniscal tears Rheumatoid Arthritis Warm, swollen, genu valgum deformity, assistive device in advanced stages Degenerative Joint Disease/Osteoarthritis Pain, muscle weakness, progression of joint limitations, genu varum often develops Knee replacement surgery

Extensor tendon injuries

-Boutonniere Deformity -Mallet Deformity -Swan Neck Deformity Hyperextension of PIP joint Flexion of DIP joint Solutions?

Principles of correct body mechanics

-Keep the shoulders and hips parallel and facing the task. Do not twist the trunk when lifting. -Maintain good balance by positioning the feet shoulder distance apart with one foot forward. -When standing for long periods, reduce pressure on the lower back by placing one foot on a low stool and changing positions frequently. -When sitting or standing, maintain a neutral position in the lower back by tilting the pelvis slightly forward to maintain the natural curve of the spine. Use this neutral back position when lifting as well. -Use the strongest or largest muscles and joints when lifting (e.g., use legs rather than back, palms rather than fingers). -Keep the back upright and bend at the hips and knees rather than bending forward at the waist when reaching for low items. -Push before pulling and pull before lifting. While lifting or carrying, keep the object close to the body. -Avoid rushing. Proper body mechanics are more effectively used when working at a comfortable pace.

Performance skills and PEOP

-What factors influence performance skills required? PEO -Identification of activity demands provides link to performance skills needed: motor, process, social interaction -Skilled occupational performance is influenced by the person's body functions, as well as the activity demands and environmental context in which it occurs

Concurrent force system

2 or more forces acting at a common point of application on an object but in divergent directions Composition of forces: algebraically combine the 2 forces to a net force with a common point of application a2 + b2=c2

parallel force system

2 or more parallel forces act in the same plane These forces are at some distance from each other and some distance from the axis of rotation. When parallel or general forces are applied to the same object, it reacts as a lever: each type of lever has unique properties!

Quadriceps femoris

2 joint muscle Knee Extension (and hip flexion) Common Quad Tendon More force than knee flexors Decelerates knee flexion Knee extension, with hip extension, propels the body forward and upward

Linear force system

2 or more forces act on the same object and in the same action line; produce tension or compression

Finger MCP joints

3 Planes of Movement Articulations between the convex heads of the metacarpals and shallow concave surfaces of the proximal phalanges Motion Flexion/Extension-Sagittal Plane Abduction/Adduction-Frontal Plane

Intercostals

3 layers of muscles between the intercostal spaces "Inner" and "Outer" Inspiration AND Expiration Action controversial INSPIRATION Can elevate a lower rib Increase intrathoracic volume Can stabilize the spaces; muscles contract to stiffen the rib cage EXPIRATION Depress upper rib Decrease intrathoracic volume

ROM

= Arc of motion that occurs at a joint or a series of joints

Posture

= position of head, limbs & trunk & their relationships to each other

Spine ligament support

Anterior longitudinal ligament Limits extension or excessive cervical & lumbar lordosis Reinforces anterior intervertebral discs Posterior longitudinal ligament Limits flexion Reinforces posterior intervertebral discs Ligamentum flavum Limits flexion, high elastin Supraspinous & interspinous Limit flexion, ligamentum nuchae Intertransverse ligaments Limit contralateral lateral flexion & forward flexion

Interosseous membrane

Broad collaginous sheet Binds radius to ulna Attachment for some hand muscles When under tension, provides for transmission of forces between hand and wrist through forearm, elbow, etc. Compression vs. distracting forces

Neck and back extensor group

Back Extensors- Superficial:Trapezius, latissimus dorsi, rhomboids, levator scapula, and serratus anterior. Back Extensors- Deep:Erector Spinae (superficial)spinalis, longissimus, and iliocostalis musclesLong & varied in length - many attach at common tendon near sacrumTransversospinal (intermediate)semispinalis, mutifidi, rotatorescross multiple vertebral segmentsIntertransversarius & Interspinalis (deep)cross 1-2 spinal segments

Vertebral osteology

Body Discs Pedicles Laminae Spinous process Vertebral canal Differences among spinal segments depend on purpose & function of each segment Posterior structures: protect & stabilize spine Anterior structures: shock absorption, weight bearing, mobilize trunk

Motor skills

Body position Obtaining & holding objects Moving self & objects Sustaining performance

Co-contraction

Both agonist and antagonist simultaneously contract

Opposition AT CMC

Combined movement of thumb abduction and flexion 45-60 degrees of medial rotation of the thumb Small finger also helps with opposition through providing a cupping motion to meet the thumb Reposition of the CMC joint returns the metacarpal to it's anatomical position from full opposition (adduction/extension)

Tissue Integrity: Edema

Contributes to impaired ROM (impacting coordination), reduced sensation (nerve compression), pain impacting functional use of limb Causes include intra-articular fluid accumulation around joints, cysts, swollen bursae, injury or trauma Edema can be pitting - thick, slow moving fluid often caused by circulatory stasis

Key cocnepts of biomechanical approach

Controlled movement & strength are needed to perform activities of daily living. "The theory of the biomechanical model concerns the ability to stabilize and move while performing occupations" (Kielhofner, 2009) Concepts that explain the capacity for motion: -Range of motion (ROM) -Strength -Endurance

UE innervation

ELBOW FLEXION Musculocutaneous Radial Median ELBOW EXTENSION Radial PRONATION Median SUPINATION Radial Musculocutaneous

Stability of the wrist cont.

Extrinsic vs. Intrinsic Supporting Structures Extrinsic ligaments attach to radius, ulna, TFCC & carpal bones Intrinsic ligaments connect carpal bones Triangular Fibrocartilage Complex (TFCC) Major stabilizer of distal radioulnar joint Cushions the ulna on the carpus Helps with compressive forces @ wrist See Rybski p. 214 Extrinsic Supporting Structures Palmar Ligaments Palmar Radiocarpal Ligaments Stronger and thicker Dorsal Ligaments Dorsal Radiocarpal Ligament protects dorsal lunate dislocation Guides proximal row movement Active learning: Identify functional activities that require wrist stability

2nd Law equations

Force = mass x acceleration Acceleration = force/mass

Isometric contraction

Force generated by the muscles matches an external force No change in muscle length Crossbridge cycling matches the external force No movement / joint action Typically for stabilizing Functional example?

The spine

Formed by 33 vertebral bones 7 cervical 12 thoracic 5 lumbar 5 sacral 4 coccygeal Vertebral column & ribs functions: Protect spinal cord & internal organs Support head & extremities Transmit loads between extremities Stabilize & mobilize body for hand function & ambulation

Ankle foot complex

Functions: Support weight Control and stabilize leg on planted foot Adjust to irregular surfaces Elevate body (standing on toes) Shock absorption

Post compartment (superficial)

GASTROCNEMIUS SOLEUS (Plantaris) Plantar Flexion 2-Joint muscle

Tissue integrity, OT intervention

Goals are to decrease pain & tenderness, prevent development of chronic inflammation, scar management &remodeling (later stages) Early stage (inflammation phase): rest via orthotics, cold modalities, compression & elevation to decrease inflammation Mid stage - Fibroplasia phase 2-4 weeks: Active ROM, joint mobilization, use caution to not interrupt tissue healing Later stage - Remodeling phase 3-6 weeks up to 2 years: Scar tissue reorganization via stretching, AROM, resistance, e-stim, light compression via Coban, tubigrip, deep friction massage, tendon gliding exercises

Elbow flexion and contracture

How could flexion contracture impact function? Therapy interventions to reduce contracture: Decrease inflammation Position in extension Stretching, joint mobilization Strengthening antagonist (which is?) Most effective intervention is prevention!

Distal radius and ulna

Important Structures: Lister's Tubercle (separates ECRL from ECRB) Styloid Process of the Radius Styloid Process of the Ulna Distal Articular Surface of the Radius 25 degree tilt toward the ulna Greater ulnar deviation 10 degree tilt toward palm Greater wrist flexion

Levator scapulae

Important role in optimal head & neck alignment Counterbalances tendency for forward flexion of head Overactivity due to poor forward head posture can result in pain/discomfort & muscle shortening

Inspiration

Intrathoracic volume increases Expands the lungs Negative pressure draws in air Quiet (primary) versus Forced (accessory)

Mechanical advantage

Levers differ in their capacity to balance and overcome resistance Mechanical Advantage equals the ratio between Force x Force Arm and Resistance x Resistance Arm MA = F x FA/R x RA

Foot arches

Longitudinal Medial & lateral Transverse

Supplies

May be expendable, ex. toothpaste

Shoulder muscles and functions

May be grouped based on their attachments & joints they affect: Axioscapular & axioclavicular: trapezius, serratus anterior, levator scapulae, pectoralis minor, subclavius, sternocleidomastoid Scapulohumeral: deltoid, supraspinatus, infraspinatus, teres minor, subscapularis, teres major, coracobrachialis Axiohumeral: pectoralis major, latissimus dorsi

ROM assessment includes

Measurement of arc of motion Assessment of joint itself (arthrokinematics) Symmetry between limbs Use of compensatory motions Body posture Muscle contour & proportion Palpation to determine bony landmarks, soft tissue contours, skin temperature etc.

Assessment

Measures core physical functions such as ROM, strength, endurance, and pain. Goniometer for joint ROM Manual muscle testing and weight machines for strength Dynamometer for grip strength, pinch gauge for pinch strength Number of repetitions and duration of a specific movement before fatigue occurs for endurance Pain scales Severity, cause, location Complex and computer driven systems also test muscle strength and endurance. Baltimore Therapeutic Exercise (BTE) Machine

Concentric contraction

Muscle force is greater than resistance - muscle SHORTENS Actin myofilaments pulled toward myosin myofilaments Some part of the body actually MOVES Bones pulled toward each other Crossbridges formed, broken, & reformed in a shortened position Muscle will rotate whichever bony component is free If distal attachment is free it will move If proximal attachment is free it will move

Pinch measurements

Pinches Measured Tip to tip Pinch Lateral Pinch Tripod Pinch Test position: same as grip Shoulder Adducted Elbow flexed to 90 degrees Neutral Forearm Rotation Repeat test 3 times alternating between sides Ideal produces a bell shaped curve

Scoliosis

Postural deformity most apparent in frontal plane but includes frontal & transverse plane deviations Types: Functional Structural Idiopathic Described by location and side of its frontal plane convexity - Example? Treatment?

Brachial plexus

Primary innervation to entire upper extremity Nerve roots C4-T1 Peripheral Nerves: Musculocutaneous Axillary Radial Median Ulnar

Agonist

Primary muscle responsible for the action - the PRIME mover

Anatomical snuff box

Radial Border: 1st dorsal compartment Abductor Pollicis Longus and Extensor Pollicis Brevis Dorsal Border: Extensor Pollicis Longus Tenderness with palpation of the snuffbox could indicate a scaphoid fracture De Quervain's Tenosynovitis Inflammation and/or injury of the 1st dorsal compartment What activities might contribute? Test? Treatment?

Limitations of biomechanical intervention

Reductionistic Cannot assume that gains in ROM, strength & endurance will automatically transfer to functional activities Requires continuous review/revision to ensure relevance to client needs Client-centered focus can be lost Mental health, client factors (motivation) May have minimal consideration of environmental factors

Tenodesis

What happens to your fingers when you extend your wrist? The wrist position plays a huge role on tendon length and passive tension Clinical Significance C6 quadriplegia-near complete paralysis of digital flexors and extension, but does have innervated wrist extension Neumann, Special Focus 8-6

Acceleration

occurs when inertia is overcome and movement of the object begins Acceleration (or deceleration) is the rate of change in velocity/speed

Examples of class 1 lever

scissors, large black paper clip, hammer claw, pliers

Foot muscles

xtrinsics Intrinsics Toe: Flexion/Extension/Abduction/Adduction

MA (mechanical advantage)=

(F x FA)/(R x RA)

Maintain

-Appropriate for persons with degenerative diseases -Goal is to preserve current level of functioning

Biomechanical intervention

-Biomechanical approach requires knowledge and understanding of activity analysis and musculoskeletal functioning -Movement requires muscle activity, joint integrity, intact soft tissue structures -Incorporates knowledge of anatomy, exercise physiology, kinematics & kinetics -Assumes intact cortex & CNS that produce isolated, voluntary muscle control -Diagnoses include orthopedic disorders (fractures, RA), lower motor neuron disorders (Guillain --Barre, peripheral nerve injuries, SCI), hand injuries, burns, cardiopulmonary disease, amputations -Not appropriate for persons with CNS damage (e.g. stroke, TBI) presenting with abnormal muscle tone (spasticity) or lack of voluntary motor control

Center of Gravity

-Center of gravity is a hypothetical point at which all weight of that body/object is thought to be concentrated -Depends on a body's shape and mass distribution -This is the balance point where vertical & horizontal planes meet -The COG does not need to lie within the object -Changes in position produce changes in COG -As we forward flex, the COG does not lie with the body

Biomechanical intervention approach

-Client's capacity to improve in strength, ROM, endurance etc. -Analysis of activity demands and client's potential for active, successful engagement -Consider client factors including cognition, motivation, attitudes -Client safety & needs for immediate success -May contribute to choice of compensatory strategies over remediative interventions requiring longer time course

Prevention

-Designed for clients at risk for developing occupational performance problems -Goal is to prevent secondary consequences of injury or disease (e.g. pressure relief to prevent decubiti, use of arm trough to prevent pain/edema in paretic limb)

Strengths of biomechanical intervention approach

-Emphasis on physical fitness, health promotion & wellness -Adequate ROM, strength & endurance is needed for engagement in life roles & valued activities -A biomechanical approach to activity analysis is beneficial for identifying efficient body positions and physical requirements for activity performance -Standardized assessments are objective and measurable and enable comparison of client performance to "normal" age-related norms: -Goniometry, dynamometry, volumetry (edema measurement)

Compensation

-Goal is to adapt/modify the activity to enable client to use existing abilities successfully to engage in valued activities & occupations -Little expectation for change in client factors & subsequent performance skills

Occupation-based

-Occupations act as therapeutic change agent & facilitate transfer of skills to other contexts -Occupations promote self-exploration & opportunities for meaningful practice -Active engagement in occupation provides feedback for successful performance

OT domains

-Occupations: ADL, IADL, rest & sleep, education, work, play, leisure, social participation -Client factors (e.g. body functions, body structures, values, beliefs, spirituality) -Performance skills (e.g. sensory, motor, communication, social & cognitive skills) -Performance patterns (e.g. habits, routines, rituals, roles) -Context & environment (e.g. cultural, physical, social, temporal, virtual) -Activity demands (e.g. objects, space, social demands, sequencing & timing)

Limitations of biomechanical intervention approach

-Reduction of physical impairments does not automatically lead to improved occupational performance -Focus on client abilities & performance skills is reductionistic -While adjunctive modalities (exercise, orthotics, physical agent modalities) are appropriate as preparatory methods for future occupation-based activities, OT outcomes must be functionally relevant and occupationally-based -Documentation of OT interventions must link biomechanical interventions to functionally relevant outcomes -Biomechanical approach does not incorporate aspects of volition, context, role, environment -Must be combined with holistic OT values concerning life balance, self esteem, self actualization

Line of gravity

-The line of gravity vector passes thru COG towards the center of the earth -Stability is maintained when line of gravity is maintained w/i base of support

Second class lever

2 parallel forces are applied at some distance from the axis A large amount of force is supported or moved by a smaller force The resistance force is applied closer to the axis than the effort force FA (force arm) is always greater than RA (resistance arm) Always have mechanical advantage Examples: wheelbarrow, faucet

Third class levers

2 parallel forces are applied at some distance from the axis The effort force (muscle) is applied closer to the axis than the resistance force Equilibrium: effort torque = resistance torque F x FA = R x RA 3rd class levers reduce the force you apply, but give you greater control and range of motion Most common lever type in the body!

Force

A push or pull that results from physical contact between 2 objects

Newton's 2nd Law of Acceleration

Acceleration of an object is proportional to the magnitude of the forces acting on it and inversely proportional to the mass of the object If unbalanced forces are applied to an object, it is no longer in equilibrium & the object will accelerate Changes in motion are a direct result of net force exerted

Rehabilitation appraoch to intervention

Activity adaptation Grade activities up or down Energy conservation Ergonomics and prevention OT Interventions often include a continuum of treatment activities that can focus on remediation/restoration and rehabilitation/compensation, depending on client's needs and potential to improve.

Osteokinematics

Angular changes between the bones forming joints Differs from joint to joint due to bony alignments & soft tissues around the joint Visible motion or displacement of the bones (flex/ext, abd/add, etc) Range of motion (ROM) is measured by goniometry ROM can be normal, hypermobile, or hypomobile

Thumb IP joint

Articulation between the middle phalange and distal phalange Hinge Articulation Thumb can typically passively extend beyond neutral to about 20 degrees at the IP joint

CMC of fingers

Articulation of the distal carpal row and the bases of the five metacarpals Non-axial gliding Movements: Flexion and Extension Analyze the stability of the 2nd and 3rd CMC joint compared to the 1st, 4th and 5th CMC joints. What does this combination allow us to do functionally?

Thumb carpometacarpal joint

Articulation of the first metacarpal and the trapezium Biaxial saddle-shaped joint (only saddle joint of body) Both Convex and Concave surfaces Many ligaments surround this joint to help provide support Planes of motion are in relation to the palm Active Learning Name the motions of the CMC joint and demonstrate the motions.

Remediation

Biomechanical Approach to Establish/Restore -Goal is to change underlying structures & body functions limited by disease -Trauma or overuse with intent of improving occupational performance -Intervention delivered in natural context

Posture and gait

Balanced posture reduces muscle activity Posture - changes with aging, effects on gait Visual Inspection Sagittal plane Frontal plane Typically observe from superior to inferior

Grasp

Basic Characteristics Fingers flexed (ulnar more than radial fingers) MP & IP flexion Volar arch (due to movement of CMC articulations) Hypothenar muscles Object is brought toward the thumb and secures it firmly in the palm Thumb flexes over the fingers & pulls towards palm CMC in slight ABD AP forcefully pulls thumb into fingers and object Powerful grasp requires most muscles of wrist and hand

Sternocleidomastoid

Bilateral: Cervical flexion (Cervical Thrust) Unilateral: Rotation to opposite side Lateral flexion to the same side

Rehab approach, client, caregiver education

Body Mechanics Principles: Keep objects/people close to body Wide base of support Push before pulling, pull before lifting Lift with legs, not back, bend knees to squat then stand Use good pacing, lift smoothly Pivot whole body by moving feet Maintain center of gravity close to object/person's center of gravity Use short lever arms for better control

Elbow and forearm osteology

Bones Humerus Lateral & medial epicondyles Supracondylar ridge Ulna Olecranon process Shaft Head Styloid Process Radius Head Styloid Process Shaft Lister's Tubercle

Elbow and forearm osteology

Bones Humerus Lateral & medial epicondyles Supracondylar ridge Ulna Olecranon process Shaft Head (distal) Styloid Process Radius Head (proximal) Styloid Process Shaft Lister's Tubercle

Strengthening, OT intervention

Consider timing of interventions (e.g. not during acute exacerbation of RA or MS), time of day, fatigue level Isometric activities & exercise without resistance can be used to maintain strength when AROM is not possible Resistance activities to INCREASE strength must overload the muscle to the point of fatigue: increased load requires recruitment of more motor units

Knee osteology

DISTAL FEMUR - Medial & Lateral condyles PROXIMAL FIBULA - Attach biceps femoris PROXIMAL TIBIA - Transfers weight across knee and to ankle - Tibial Plateau PATELLA

Health benefits of correct sitting posture

Decrease in ligament strain Decrease in muscular strain and overstretching of back muscles Decrease in intra-disk pressure Healthy spine: reduction in stress on cervical & thoracic spine and shoulder girdle Greater muscle efficiency and reduced fatigue in postural muscles Greater UE ROM for overhead reaching Efficient diaphragmatic breathing -> greater oxygenation and diminished fatigue Improved LE circulation with proper seat tilt and depth Positive self image

Clinical considerations of the hand

Deformities Heberden's nodes (DIP) Bouchard's Nodes (PIP) Finger alignment Fracture Dislocation Tendon Injury Nerve Injury Infection Vascularity

Accessory muscles (forced exhalation)

Depress the ribs Flex the trunk Compress abdominal wall, pushing diaphragm up Decrease intrathoracic volume

Prevention

Designed for clients at risk for developing occupational performance problems Goal is to prevent secondary consequences of injury or disease (e.g. pressure relief to prevent decubiti, use of arm trough to prevent pain/edema in paretic limb)

Contraindications for ROM testing

Dislocation or unhealed fracture Immediately following surgery (tendons, ligaments, joint capsule, skin) Myositis ossificans What is it? A form of heterotopic ossification Osteoblasts form in muscle after injury/trauma Edema after injury proceeds to calcification & osifications; seen in young adults Heterotopic ossification (HO)can impact functional ROM after SCI Benign, conservative treatment includes rest & Immobilization in early stages

Statics (equilibrium)

During equilibrium, two or more forces enable body or object to remain at rest or move at constant speed

Scapulohumeral

During overhead reach, involves combined motions at SC, AC, ST, GH After ~ 30 degrees of abd/flexion 2:1 ratio GH:ST

Neck and back extensor group

Erector Spinae (gross movement) Transversospinal (moderately fine movement) Intertransversarius & Interspinalis (fine motor control) UNILATERAL ACTIVATION = Lateral Flexion BILATERAL ACTIVATION = Spinal Extension

Accessory muscles (forced inspiration)

Elevate the sternum and ribs - increases intrathoracic volume Stabilize lower ribs for diaphragm contraction

Other factors to consider with activity analysis

Environments Physical & social environments Cultural Context Personal Context Temporal Context Virtual Context

Tissue edema, OT intervention

Evaluation includes volumetric & circumferential measurements Interventions include vasoconstriction, compression via ace wrap, Coban, compression garments; elevation & AROM Therapeutic use of cold modalities, retrograde massage

MMT procedures

Explain procedure & demonstrate desired movement Position patient/client so direction of movement is against gravity Instruct to move actively thru full ROM Stabilize proximal segment of joint Apply resistance gradually over 2-3 sec At mid to end range To distal end of segment to which muscle inserts In direction of the "line of pull" of muscle(s) tested Place in gravity-minimal (eliminated) position if unable to move thru full ROM against gravity observe movement Palpate over prime mover for muscle contraction Check for substitution by synergistic muscles, shifting of body etc. Record muscle grade based on resistance tolerated or amount of movement achieved against gravity or in gravity-minimal plane Criteria for grading is same across all ages & conditions Good reliability requires consistent MMT procedures! Reliability concerns: Lack of evidence re: reliability and sensitivity when > Grade 3 Validity concerns: generalizability of MMT to ADL/IADL performance

Strengths of biomechanical intervention

Extensive research support Easy to define and quantify progress Clear communication is possible with other practitioners and clients familiar with the medical model Directly addresses impairments that affect occupational performance Now includes core values of OT: focuses on client-centered capabilities for daily activities

Rehabilitation approach strengths

Extensively used & documented Concepts are easy to explain Intervention is concrete Range of options for treatment is broad and easily matched to client needs Intervention may produce quick results May be reductionistic - why? Analysis is needed to match adaptation to person, environment & occupation Not appropriate for client with cognitive impairments - why? Adaptations must be relevant and meaningful to client (psychosocially, culturally etc) Transfer & generalization may not occur - how could this be improved?

Extrinsic thumb extensors

Extensor Pollicis Longus Extensor Pollicis Brevis Abductor Pollicis Longus

Postural alignment: line of gravity

External Auditory meatus/odontoid process (ear lobe) Cervical vertebrae Shoulder joint Mid Trunk Lumbar Vertebrae bodies Posterior to hip joint (Greater Trochanter) Anterior to knee joint Anterior to lateral malleolus

Flexor tendon support

Fibrous Digital Sheaths Pulleys Bands of tissue that keep the tendons in place A1 Pulley - pulley most often released with a trigger finger/thumb Digital Synovial Sheaths Deep to the pulleys, this sheath provides nutrition and lubrication to the tendons Tenosynovitis-Inflammation of the tendon/synovial membrane

ROM concepts to think about for the hand

Finger AROM/PROM are typically measured dorsally The fulcrum should be over the joint The "larger" arm of the goniometer is proximal Measurement is always over the bone not the tendon Opposition is measured in centimeters from the tip of the finger/thumb to the DPC (distal palmar crease) Active vs. Passive Motion PROM is typically > than AROM Patient Handling Strategies Stabilize the proximal joint segment you are testing Be aware of substitutions PROM: Stabilize Proximal Segment & Provide Force to distal segment End Feel Hard, Firm, Soft

Finger movement

Finger Flexion/Extension (sagittal plane) Finger Abduction/Adduction (frontal plane) Middle finger is the reference for abduction/adduction Middle finger movement side to side is call radial/ulnar deviation

Tibiofemoral joint

Flexion & Extension (sagittal plane) 130-150 degrees of flexion 5-10 degrees of hyperextension Internal & External rotation (transverse plane)

Elbow motions and functions

Flexion/extension Supination/pronation Important for positioning of hands/fingers in space Permit height & length adjustments during reach Rotation of forearm allows hand to face/mouth Elbow joint assists shoulder with force distribution & UE stabilization for power & fine coordination Elbow contractures/restrictions in ROM can significantly impede functional reach

Coordination, OT intervention

Focus of intervention depends on theoretical approach (e.g. biomechanical vs. motor control/learning after stroke) Repetitive activities & exercises to provide opportunities to practice accurate, controlled movements Focus is on smoothness, speed, appropriate rhythm & muscle tension Ways to grade coordination activities? Consider activity demands (e.g. object size, distance from person, degrees of freedom controlled, etc). OT intervention may occur in collaboration with pharmacological interventions (e.g. Parkinson's Disease)

Biomechanical (remediation) vs. rehabilitation (compensate/adapt)

Focuses not on the client factors like biomechanical approach but the performance in areas of occupation -the process between the two is fluid, not linear

moment arm and angle of application

For any given muscle the moment arm is greatest when the line of action of the effort force by the muscle is applied at 90 degrees to its lever, or as close to 90 degrees as possible This 90 degrees is the angle of force application, not the joint angle

Friction

Friction is a special type of resistance force related to Newton's 3rd Law Dependent on the net forces between 2 objects when moving one object on another Friction has no magnitude unless an external shear force is applied Force of friction is parallel to contacting surfaces and opposite to the direction of potential movement or shear force

Activity analysis

Generic description How an activity might be done typically

Compensation, rehabilitation approach

Goal is to adapt/modify the activity to enable client to use existing abilities successfully to engage in valued activities & occupations Little expectation for change in client factors & subsequent performance skills Function To maintain self & others To advance oneself thru work, learning To enhance self thru self-actualizing activities Expected outcomes Learning of new skills or use of devices Maintaining or improving QoL Prevent disability Enhanced self efficacy Improved adaptation to occupational challenges Methods: Changing the task via: Adapted task methods or procedures Adaptive task objects, adaptive devices, orthotics Changing the context via: Environmental modification Caregiver, family education Mobility adaptations Disability prevention For this individual, how has feeding been modified? What contextual modifications may be provided to optimize occ performance?

Performance patterns

Habits - tendencies to respond in consistent ways in familiar environments or situations; automatic behaviors/actions Routines - patterns of activity that provide structure for daily activities Rituals - actions with cultural, spiritual or social meaning Roles - one's social & cultural context sets expectations for role behaviors

Biomechnical intervention areas

Hand therapy Work hardening: sitting tolerance, standing tolerance, task completion, quality Ergonomics: fitting workplace conditions and job demands to the capabilities of the working population Prevention Cumulative trauma (back injuries, carpal tunnel syndrome)

MMT contraindications

Healing fracture Post tendon or nerve repairs Post chest/heart/lung surgery Initially post myocardial infarction History of bone metastasis Post recent neck/back surgery Check MD orders before testing!

How is activity analysis used for evaluation and intervention?

Intervention Outcomes - OTPF Occupational performance Health & wellness Participation Prevention Quality of life Role competence Well-being Occupational justice

Contraction types

Isometric Contraction Concentric Contraction Eccentric Contraction

Hamstrings

Knee Flexion (and hip extension) Internal and External rotation Less force than knee extensors Decelerates the tibia at the late swing phase during gait

Equipment

Larger, supports the activity, Machine, appliance or set of objects to equip Ex. sink

Politeus

Lateral condyle of femur to posterior tibia "Unlocks" the knee from full extension into flexion Produces slight inward rotation of tibia at beginning of knee flexion

Linear force system

Linear or translatory movement is observed in a linear force system All parts of an object move the same distance at the same time Friction & shear force can affect this linear or translatory movement

Axes of motion

Lines around which movement takes place Body segments rotate around these axes Axes are perpendicular (at right angles) to the planes

Kinematics of the spine

Lumbopelvic (LP) Rhythm - important for normal mobility/lifting Trunk flexion initiates in lumbar spine, followed by anterior pelvic tilt & posterior movement of sacrum (counternutation) Trunk extension initiates by posterior pelvic tilt, anterior sacral movement (nutation) followed by lumbar spine extension Limitations in hip flexion and lumbar mobility significantly affect LP rhythm In presence of osteoarthritis or hip instability, increased compression forces may lead to pain or accelerated degeneration.

Kinetmatics of the spine

Lumbopelvic Rhythm Pelvis moving on femur (closed chain) What is happening at pelvis, lumbar spine? Effects on intervertebral disc? What factors affect health of discs & neural tissues & LP rhythm? Poor alignment of axial skeleton increases deforming potential of gravity Posture Poor body mechanics when lifting Aging

Joint kinematics

MCP Joints The head of the Metacarpal is not completely round Flexion stretches the dorsal capsule and collateral ligaments This stabilizes the joint, which is useful for grasping IP Joints Phalange heads are more spherical, therefore tension on the collateral ligaments is relatively constant with movement The closed packed position of the IP joints is extension, because of the stretch placed on the palmar (volar) plates

Collateral ligaments

MEDIAL LATERAL Limit movement in frontal plane A. Genu Valgum (knock-knee) B. Genu Varum (bow-leg)

Strength of the hand

MMT Grip Strength Demonstrates grip force in pounds of force Isometric contraction Adjustable hand—Most people peak on Rung II or Rung III Test Position Shoulder Adducted Elbow flexed to 90 degrees Wrist in neutral position Repeat test 3 times alternating between sides Ideal produces a bell shaped curve https://www.youtube.com/watch?v=frcNPiLnWRo

Tip to tip pinch

Makes the "O" Abnormalities APL muscle weakness = unable to stabilize CMC joint against pull of FPL Intrinsic weakness (ape thumb) Arthritic changes lead to inability to position CMC Long fingernails Compensation? Alteration of other joints i.e. hyperextension or hyperflexion of MCP joint of thumb

Hand innervation: ulnar nerve

Medial half of the Flexor Digitorum Profundus Hypothenar Muscles Flexor Digiti Minimi Abductor Digiti Minimi Opponens Digiti Minimi Palmaris Brevis Medial two lumbricals All Palmar/Dorsal Interossei Adductor Pollicis

Hand innervation: median nerve

Median Nerve Flexor Digitorum Superficialis Lateral half of Flexor Digitorum Profundus Flexor Pollicis Longus Muscles to the Thenar Eminence Flexor Pollicis Brevis Abductor Pollicis Brevis Opponens Pollicis Lateral two lumbricals What functional tasks are difficult with a Median Nerve Injury?

Shoulder muscle functions

Motions at GH & ST joints involve both dynamic stabilization and mobility Compare location & role of proximal stabilizers.. Originate on spine, ribs, cranium Insert on scapula & clavicle, including: Serratus anterior Trapezius With location & role of distal mobilizers... Originate on scapula & clavicle Insert on humerus or forearm, including: Deltoids Teres Major

Sagittal plane:

Movement occurs around the medial/lateral axis

Horizontal plane:

Movement occurs around the vertical/longitudinal axis

Hypothenar muscles

Muscles Include: Flexor Digiti Minimi Abductor Digiti Minimi/Quinti Opponens Digiti Minimi Palmaris Brevis Help to raise and "cup" the ulnar border of the hand ABductor Digiti Minimi can also abduct or spread small finger to increase control with grasping Ulnar nerve injury will completely paralyze the hypothenar eminence Decreased sensation of small finger Decreased cupping and raising of ulnar border of hand

Newton's 3rd Law

Newton's Law of Action & Reaction: for every action there is an equal & opposite reaction When one object applies a force to a 2nd object, the 2nd object "reacts" by simultaneously applying a force equal in magnitude & opposite in direction to the 1st object Everything that touches an object will exert a force on the object All forces occur in pairs, when 2 objects contact they exert force on each other

Active and passive insufficiency

Occurs in muscles crossing 2 or more joints Active Insufficiency - inability of a muscle to shorten enough to pull the limb through full ROM Every muscle's capacity to shorten depends on the length of its fibers Agonists cannot contract fully if in their shortest position Passive Insufficiency - inability to move thru entire available ROM because of passive restrictions from opposing soft tissue/muscles Antagonists are stretched and limit movement of agonists

IP joints

One degree of freedom: Flexion/Extension PIP and DIP joints Compare the extension of the MCP to the IP joints. What do you notice and Why? If the IP joints were the same, how would that affect function?

Postural analysis-sitting

Optimal sitting posture: Pelvis - slight anterior pelvic tilt Trunk - slight lumbar lordosis, thoracic kyphosis, cervical extension LE - neutral internal/external rotation, slight hip Abduction, 90 degrees of flexion at hips, knees, ankles UE - elbows slightly forward of shoulders, forearms supported, hands toward midline Head - Midline, eyes facing forward Functional Task Position Center of gravity shifts in direction of activity

Osteokinematics and arthrokinematics

Osteokinematics (physiologic movements) The manner in which bones move in space Flexion, Extension, Abduction, Adduction, Rotation Visible Motion Planes of motion and Axis of rotation and degrees of motion Arthrokinematics Relative motion of the articular surfaces Necessary for movement, but cannot be isolated voluntarily Joint play and mobilizations (roll, slide, spin) Accessory motions (compression, distraction, shear, etc.)

Palpations of the hand

P=Pisiform Personal Hammer FCU Insertion H=Hook of the Hamate Baseball players or Bike Riders Trapezium Saddle Shaped to help with thumb Mobility Bone that causes pain with CMC OA S=Scaphoid Tubercle Scaphoid Bone Most common carpal bone to fracture Limited blood supply (proximal pole) Scaphoid is the link between the two carpal rows Scaphoid and Lunate play a major role in wrist mobility

Respiratory muscles

PRIMARY Diaphragm - 60-80% of work during inspiration Intercostals Scalenes

Elbow flexion

PRIME MOVERS: Biceps brachii Brachialis: "workhorse" Brachioradialis ALSO: Pronator Teres Flexor Carpi Radialis Flexor Carpi Ulnaris Extensor Carpi Radialis Longus

Forearm pronation

PRIME MOVERS: Pronator quadratus (primary) Primary pronator of radioulnar joint without help and in slow, unresisted movements Deep: not palpable Pronator teres (secondary) Not active during slow, unresisted pronation Contracts during rapid or resisted pronation Considered a secondary pronator Innervations? Pronator quadratus - Median C8-T1 Pronator teres - Median C6-C7

Capsular patterns

Pathological conditions of joint capsule lead to patterns of ROM restrictions at the joint May lose PROM & AROM at ends of range in all motions - see Rybski Ch. 3, Table 3-9

Pinch

Precise ability to hold and/or manipulate small objects Radial side of hand (Thumb, IF, MF) Thumb holds object to stable IF or MF or Both CMC of thumb (contributes to mobility) CMC of digits (provides stability) What are the functional implications of the inability to pinch?

Controversy of biomechnical intervention

Professional ethics concerns regarding scope of practice Risk of diversion away from occupational interventions and client-centered care Medical Model of Disability vs. Social Model of Disability Best when paired with other systems-based approaches in OT Consider context & occupational performance!

Forearm articulations and mechanics

Proximal Radioulnar Joint Uniaxial pivot (trochoid) joint Uniaxial pivot joint Head of radius & radial notch of proximal ulna During supination/pronation, radial head rotates around the annular ligament on capitulum Distal Radioulnar Joint Ulnar notch of radius articulates with ulna head During supination/pronation, distal radius moves about ulna

Expiration

QUIET-passive Diaphragm relaxes Ribcage constricts Decreased intra-thoracic volume Lung pressure increases Air is forced out Note: The diaphragm does NOT actively force air out- relaxes during expiration!

Ant. trunk group

Rectus Abdominis Internal/External Obliques Transverse Abdominis Physiologic Functions of Abdominal Muscles: Supporting and protecting abdominal viscera and increasing intrathoracic and intra-abdominal pressures.

Activity demands

Relevance & importance to client (occupation-based activity analysis!) Objects & their properties Space demands: physical environment Social demands: cultural context Sequence & timing: specific steps Required actions: performance skills needed Required body functions: physiological functions needed to perform activity Required body structures: limbs, organs etc.

Establish/restore

Remediation: optimizing capacity for motion Increase strength Increase ROM and endurance Reduce edema OT interventions may involve preparatory activities - e.g. strengthening exercises to achieve goal of improved functional performance OT directed biomechanical interventions also may use functional activities to reestablish or restore ROM, strength and endurance vs. rote exercise Research Evidence?

Force effects

Repetitive strain Injuries Ulnar Drift What Activities of Daily Living contribute to Ulnar Drift of fingers? What are some activity modifications? Musicians = small muscles, high force, awkward positioning Tendinopathy Stress = (Force/area) Amount of force applied to an area Hook Grasp Stress on joint increases from Proximal to Distal Pinch Contact during pinch occurs over very small area, leading to very large stresses Joint Protection Education, Splinting, Modalities, Strengthening

Coordination

Smooth, rhythmical, well-timed, coordinated movement involves many systems (e.g. motor, sensory, visual, cerebellum, extrapyramidal) and is observed during UE activities, gait, speech (e.g. dysarthria) What diagnoses have you learned about in Conditions that contribute to impaired coordination, impacting occupational performance?

Structural stability, OT intervention

Strengthening weak structures Limiting excessive or abnormal joint mobility Kinesiotaping to prevent injury and provide stability without restricting movement How might you use these treatments in natural contexts to optimize functional performance?

Hand innervation radial nerve

Supinator ECRL ECRB ECU Extensor Digitorum Communis Extensor Digiti Minimi Extensor Indicis Extensor Pollicis Longus Extensor Pollicis Brevis Abductor Pollicis Longus

Functions of the hand

Support Manipulation Repetition and blunt typing, scratching Continuous and fluid sewing, writing Prehension used during grip and pinch Power Grip (i.e. using a hammer) Spherical grip (i.e. baseball) Lateral (key) pinch Precision pinch (i.e. stringing a needle) Hook Grip (i.e. holding purse or briefcase

Changes in muscle: injury

Tendon fatigue Bursae inflammation (bursitis) Nerve compression Decreased ROM & max. voluntary contraction (MVC) Decreased coordination Delayed-onset muscle soreness (DOMS) Soreness 2-3 days after eccentric work Rhabdomyolysis

Thumb (CMC) movement

Thumb Abduction Opens the web space of the thumb to grasp objects During abduction the convex articular surface of the 1st metacarpal rolls palmarly and slides dorsally on the concave surface of the trapezium Full abduction elongates the Adductor Pollicis Muscle

Thumb CMC movement

Thumb Flexion and Extension Brings thumb across palm and back into place Flexion: Metacarpal rotates medially Concave surface of the metacarpal rolls and slides in an ulnar (medial) direction Extension: Metacarpal rotates laterally Concave surface of the metacarpal rolls and slides in a radial (lateral) direction

Thumb metacarpal

Thumb is oriented almost 90 degrees medially (i.e. internally) compared to the other digits Prehension depends on the thumb and its intersecting orientation with the other digits This orientation allows the thumb to sweep across the palm All prehension requires the thumb to interact with the fingers Think of 3-4 situations or patterns of movement that might cause injury or fractures to thumbs

Ligaments (ankle/subtalar)

Tibiofibular ligaments -Medial collateral ligament (MCL)(deltoid) Broad, very strong (rarely tears) -Lateral collateral ligament (LCL) -Anterior talofibular (injury) -Posterior talofibular (injury) -Calcaneofibular -Superior & inferior extensor retinacula (anterior) -Superior & inferior peroneal retinacula (posterior)

ROM intervention

Treatment goal/intervention depends on cause of ROM impairment What would your OT treatment be for ROM due to shortened tissues? Edema? Pain? Maintaining AROM & PROM What is wrong with this sentence in your text (see Rybski p. 321)?? "If active ROM is normal and active ROM is limited, the focus is on active assisted ROM (AAROM)." Movement through full available ROM is essential for maintenance of ROM Treatment options include Codman pendulum exercises (e.g. post rotator cuff surgery), PNF patterns, functional movement patterns during daily tasks, continuous passive motion (CPM), self ROM exercises Increasing ROM Apply stretch force beyond current ROM to elongate collagen fibers in soft tissues Stretch can be applied actively, passively, statically or dynamically Manual passive stretch moves limb to the point of maximal stretch or few degrees past point of discomfort. Provide heat prior to stretch to improve tissue extensibility and decrease muscle-tendon stiffness. Stretch is held 15-60 secs Stretch force should be slow, sustained and well tolerated by client/patient

Carpal bones

Two Rows: Proximal row: approximates with radius Scaphoid, Lunate, Triquetrum, Pisiform Lateral to Medial Distal Row: approximates with metacarpals Hammate, Capitate, Trapezoid, Trapezium Medial to Lateral

ligament support finger

Volar Plate Very thick ligament on the volar MCP and IP's of a finger Joins two bones together Reinforces the joint capsule Prevents hyperextension Susceptible to injury with a hyperextension force Tearing or spraining the ligament Intraarticular fractures

occupation-based activity

client-centered activities, collaboratively chosen by client and therapist that are relevant to the client in the expected environment

Moment arm

distance between fulcrum and the line of action of the force (not the point of application of the force). the perpendicular distance from the line of action of each force to the axis of motion. Internal force External force Given a constant force of muscle contraction, the torque generated by a muscle is greatest at the point of joint range of motion at which the moment arm is the longest

Gravity

exerts a constant (vertical) force on all objects and affects body stability and movement

Rehabilitation approach

focus is compensation & adaptation NOT remediation. Focus is on client's remaining strengths/abilities. Maintain Modify

Resistance

is applied in direction of line of pull of tested muscle(s)

Strength

is the ability of muscles to produce tension, also defined as maximum tension produced under voluntary effort.

Endurance

is the ability to sustain effort

Magnitude muscle on bone

is the amount of force exerted by the muscle on the bone, denoted by the length of the vector If contraction of muscle was less forceful, vector would be shorter

Action line

is the direction the force is acting at, either toward the source or away from source

Action line muscle on bone

is the direction the muscle is pulling the point of application toward

Muscle strength

is the force or torque produced by a muscle during maximal voluntary contraction (MVC) Directly related to tension produced by muscle

Point of application

is where the force acts on the object Named by the source of the force followed by the object acted on: e.g. muscle on bone, gravity on arm

Point of application muscle on bone

is where the muscle attaches to the bony part it is moving

Biomechnaical approach

primarily a remediation approach to therapy, but some strategies can fall under maintenance or prevention -change underlying structures that are limited by disease, trauma, etc. understanding that gains will lead to improvement in occupational performance -focuses on intersection b/w motion and occupational performance

Systems-orientated approach

provides structure for examining effects of contextual factors on functioning and disability

Second class lever

resistance is in the middle

Kinesiology

the study of forces and the active/passive structures that are involved in human movement Anatomy Biomechanics Kinetics: the study of forces acting in and on the body producing stability or mobility

If in equilibrium

the sum of forces applied to the object equals zero Only forces that have a point of application on an object contribute to equilibrium on that object

Endurance

two components: Cardiovascular - circulatory & respiratory systems supply oxygen needed to continue task Muscular - is the ability to maintain a force over time or for a set number of repetitions without fatigue

Preparatory methods

used to prepare the client for occupational performance; ROM, sensory stimulation,

Kinetics

- forces acting in and on the body that produce stability or mobility Internal forces - muscular forces applied to move body External forces - gravity & forces acting on the body

Performance skills

-Goal directed actions that are observable as small units of engagement in daily life occupations" (AOTA, 2014, p. S7) -Performance skills are learned & improve over time Steps to an activity require single or multiple performance skills -Performance skills are observable - differ from body functions -Activity analysis involves assessment of the performance skills required to complete the activity -Evaluates the activity vs. client/patient Example: Performance skill: grips Body Functions: muscle power, joint mobility, joint stability

First class levers

2 parallel forces are applied on either side of an axis at some distance from that axis, creating rotation of the lever in opposite directions Effort arm may be greater than, smaller than, or equal to the resistance arm Equilibrium: Effort Force (F) = Resistance Force (R) Force arm = FA Resistance arm = RA F x FA = R x RA

Remediation biomechanical approach to establish and restore

Goal is to change underlying structures & body functions limited by disease Trauma or overuse with intent of improving occupational performance Intervention delivered in natural context Structural stability Tissue integrity ROM Strength Endurance

Rehab approach, changing the physical environment

Home: Safety checklist or OT/PT home visit to assess space for ease of mobility, bathroom accessibility, height of bed, chair, clutter, lighting, thresholds, doorway width, entrance to home, ramps, community mobility & accessibility Client & Caregiver Education: Aim is to prevent disability & injury and enhance client safety Education may address proper body mechanics, joint protection, safety for sensory loss, etc. Consider learning style and needs of client & caregiver; engage in active problem solving to develop self-management skills and facilitate transfer of learning to novel situations Facilitate client's ability to direct his/her own care whenever possible Body Mechanics Principles: Keep objects/people close to body Wide base of support Push before pulling, pull before lifting Lift with legs, not back, bend knees to squat then stand Use good pacing, lift smoothly Pivot whole body by moving feet Maintain center of gravity close to object/person's center of gravity Use short lever arms for better control

Joints of pelvic girdle

Lumbosacral Sacroiliac (2) Sacrococcygeal Pubic symphysis HIP (2) 3 degrees of freedom (DOF) Labrum, synovial capsule, ligaments

Arthrokinematics

Movement of one joint surface in relation to another with one surface a more stable base Arthrokinematics at a specific joint depend on the shape of the articular surface Type of motion can be roll, slide (also referred to as glide), or spin

Eccentric contraction

Muscle lengthens Actin myofilaments pulled away from myosin myofilaments Bones pulled away from each other Crossbridges formed, broken, and reformed in a lengthened position Occurs when a muscle actively resists or brakes motion created by an external force such as gravity or manual resistance ex. sit down in a chair, lowering box to table, Active learning: what muscle & type of contraction occurs when lowering barbell during elbow extension?

Forearm supination

PRIME MOVERS: Supinator Deep: difficult to palpate Requires assist from biceps during resisted motions Most efficient when elbow extended Biceps brachii Strongest supinator with elbow flexed at 90° Also assists with quick, resisted supination with elbow flexed Innervations? Biceps - Musculocutaneous C5-C6 Supinator - Radial C5-C6

Elbow pronation/supination ROM

PROM - Normal end-feel? Pronation Supination ROM Testing procedures Palpate landmarks Goniometer Alignment Stabilization & position are essential! Beware of substitutions!! Measurement: Pronation 0-75° Supination 0-85°

Patient positioning

Positioning affects: tension in soft tissues muscle length Standard procedures enhance reliability within & between testers- Consistency is key!! Test all motions in one position before moving to another (prone, supine, sitting)

Postural changes as a result of sitting

Sedentary Osteoporosis Weakening of vertebral bodies Collapse Kyphosis Anterior trunk muscles shorten Forward head

Accessory respiratory muscles

Sternocleidomastoid Pectoralis major and minor Trapezius Abdominals Quadratus Lumborum Serratus posterior Latissimus

Shoulder complex bones and joints

Sternum Clavicle Scapula Humerus Sternoclavicular Acromioclavicular Scapulothoracic Glenohumeral

Gait-walking, steping or running

and sensory inputs to generate appropriate motor actions How do neurological diagnoses affect these processes (e.g. stroke, MS, TBI)? Major Tasks of Walking Gait: Maintain support of head, arms, & trunk, prevent collapse of LEs Maintain upright posture and balance Control foot trajectory to achieve safe ground clearance and heel/toe landing Generate biomechanical energy to maintain/increase forward velocity Shock absorption & stability or decrease forward velocity

Hip angles

angle of inclination: normal: 120-135 Coxa vasa <120 Coxa valga >135