Muscle Function 424 FINAL EXAM
The hardest connective tissue which is dynamic and remodels throughout life:
Bone
Synostosis joints
Bone on bone and NO motion Suture bones in sjull
Extensor zones: 2, 3, 4
Boutinere deformity
FLexion of PIP and extension of DIP
Boutonniere
Flexor tendon zones: 2
A1 pulley to the FDS insertion or the distal crease out to the border of zone 1 No man's land to reflext the technical challenge and historically poor prognosis for repair in this area
Dysesthesias
-An unpleasant abnormal sensation, whether spontaneous, or evoked -More nauseating than paresthesias
Stabilizer of the radioulnar joint muscles:
-Anconeus
This ligament encircles the radial head:
-Annular ligament
What is the medial ulnar ligament comprised of?
-Anterior and posterior bundles
Primary restraint for the valgus angle (20-120 degrees)
-Anterior bundle of the medial collateral ligament
Types of support for a painful elbow:
-Arm slings -Arm lapboards or troughs (wheelchair) -Gunslinger orthosis -Neoprene sleeves: neutral warmth and gentle compression or soft dynamic support -Counterforce braces to limit full expansion of the forearm extensor or flexor muscle massess -Wrist splint: in 35 to 40 degrees of extension
Annular pulleys:
A1= MP, cut during trigger finger release A2= largest, midshaft of prox. phalanx A3= distal end of proximal phalanx A4= middle half of the middle phalanx A5= base of distal phalanx
Screen test for MMT
AROM measurement: previous or current which provides an indication of strength review client's chart and history with strength testing funcitonal analysis
What is supposed to be done first- AROM or PROM?
AROM should be done first before PROM more reliable
Splints:
Buddy straps allow one didgit to assist the neighboring digit for greater ROM
Joint structures:
Bursae bones cartilage discs fat pads menisci plates ligaments tendons
Purposes of sensory testing:
-Assess the type of sensory loss -Evaluate and document sensory recovery -Assist in diagnosis -Determine impairment and functional limitation -Provide direction for OT intervention -Determine time to begin sensory re-education -Determine need for education to prevent injury during occupational functioning -Determine need for desensitization
Why are we exploring sensation and pain?
-Assessing the kind of injury what inhibits performance and for opiod and pain meds
Stereognosis
-Assortment of objects and they cannot see
When is the biceps brachii the weakest?
-At full elbow extension
Why is the humerus/ulna/radius a modified hinge joint?
-Because the axis of motion is outside of sagittal plane and includes a little rotation which makes it tricky to mimic the elbow joint
When can most ADLs be performed at the elbow joint?
-Between 30 and 130 degrees of flexion and 50 degrees of each pronation and supination
This muscle is affected by shoulder position and forearm:
-Biceps brachii
Where does muscle wasting, muscular hypertrophy, or muscular imbalance typically occur?
-Biceps or triceps -Forearm extensor wad -Forerm flexor wad -Hyopthenar eminence -Intrinsic Plus Position Inability (lumbricals) -Small finger abduction -Hand shape- Hyopthenar eminence; lack of intrinsic plus positioning -Wartenberg's sign (cant adduct pinky) -Origin of the extensor and flexor wad
Guyon's canal:
-Bony canal formed by the palmar carpal lig. and the hook of the hamate, pisform and transverse carpal lig.
Cubital tunnel:
-Bony canal formed by the ulnar collateral ligament, trochlea and the medial epicondylar groove and is roofed by the triangular arcuate ligament
Lateral ulnar collateral ligament:
-Both secondary radial restraints, combined varus, valgus, and supination stresses
Mobility muscle and work horse of elbow flexors Unaffected by changes in the forearm or shoulder position
-Brachialis
Elbow Flexion ROM, which main muscles?
-Brachialis -Brachioradialis -Biceps Brachii
More activity when the speed is increased
-Brachioradialis
Ecchymosis
-Bruising on the elbow and bicipital rupture
Radial head fractures:
-Can be treated with closed reduction or may require radial head excision
Small finger abduction
-Can they pull their pinky in?
Limb position
-Carrying angle -Excessive varus or valgus elbow
Dislocations of the radius or ulna
-Caused by falling with an outstretched hand
Irritation of the ulnar nerve in the cubital tunnel
-Causes pain, dysesthesias, deformity, dysfunction of grip and pinch strength, fine motor coordination claw hand (MCP extension and IP flexion)
How is the elbow reinforced?
-Collateral ligaments
Fracture: proximal radius
-Common -Occur when an axial load is placed on the forearm in pronation- fall with an outstretched ahdn
Be sure to _________________ in ROM
-Compare contralaterally
Carpal tunnel syndrome:
-Compression of the median nerve at the wrist produces sensory symptoms in the thumb, index, middle fingers and half of the ring finger in the affected side with the greatest change in two point discrimination being found at the middle finger
Cubital tunnel syndrome:
-Compression of the nerve at the elbow as it passess in the cubital tunnel- elbow felxion, wrist extension, shoulder abudction, dislocations, excessive valgus movement, etc.
What is cubital tunnel syndrome:
-Compression of the ulnar nerve in the area of the cubital tunnel
Ulnar nerve compression: MILD
-Conservative tx -Intermittent paresthesias, sensitive to vibration, loss of coordination, positive elbow flexion test, positive Tinel's
Restore mobility:
-Correcting soft tissue and joint contractures that can occur as a result of poor positioning, etc. -Prolonged stretching helps -ROM: tissue elongation -Inelastic mobilization: constant forces -Casting -Dynamic splinting
Touch awareness
-Cotton ball, finger tip, eraser
Fracture: distal humerus
-Could be caused by an outstretched hand while falling
Tests for lateral epicondylitis:
-Cozens -Resistive tennis elbow test -Passive tennis elbow tests
Ulnar neuropathy:
-Cubital tunnel syndrome- mild, moderate, severe
Carrying angle:
-Cubitus valgus angle= shoulder in lateral rotation and elbow extension and forearm supination of 15 degrees (like you are carrying a bucket)
Souter strathclyde: 8 weeks
-D/c nocturnal elbow splint and gentle strengthening
Modifed coonrad morrey: 6 weeks
-D/c splint and sling, AROM for elbow extension, dynamic flexion splint if needed, and strengthening
Souter strathclyde: 6 weeks
-Daytime elbow extension splint may be discontinued by the MD and A/PROM away from the client's slide
Ulnar nerve compression: Moderate
-Decreased vibration, intermittent paresthesias, measurable grip and pinch weakness, positive Tinels and elbow flexion test
Vibration of the skin:
-Detected with a tuning fork
Tactile direction discrimination
-Determine the direction of movement against the skin
Many types of dislocations and fractures:
-Different protocols for each and tendon heals, motion, muscle healing strength back
Being at risk for injury:
-Diminished or lost perceptive sensation or absence of sensation
What separates the ulna from the articulation of the disc?
-Distal Radioulnar joint
Head of the ulnar and ulnar notch of the radius
-Distal radioulnar notch
Completed in a linear plane. Seperation of bone ends
-Distraction
Power of grasp and Pinch strength
-Dynamometer and Pinchometer
Souter strathclyde: 2 weeks
-Edema and scar management, PROM, dynamic splinting prn, NMES for biceps or triceps
What positions the wrist for correctional movements?
-Elbow
Loose hinge, modified hinge joint, weak anteriorly
-Elbow capsule
Anconeus:
-Elbow extension and stabilizer in pronation and supination
Tests for nerve impingement
-Elbow flexion -Tinel's sign -Pinch grip test -Wartenberg's sogn -Froment's sign -Intrinsic plus position
What is the distal radioulnar joint important for?
-Elbow function and wrist function
Varus: excessive
-Elbow goes in and is rare
Chronic mechanical overloading and failed healing of the involved tendon which caused degenerative tendinopathy:
-Epicondylosis
Other muscles for elbow extension (that cross posteriorly)
-Extensor carpi radialis longus and brevis -Extensor digitorum muscle -Extensor carpi ulnaris -Extensor digiti minimi
In sensory tesitng:
-Find the impact of the disease on protective sensation, map of the body and severity of sensory loss, changes in sensory function, etc.
What would happen without sensation?
-Fine motor coordination and manipulative ability is impaired and the amount pf force needed to grasp an object depends on sensory feedback
What position is the elbow fracture splinted in?
-Flexion
Neuropathic pain ____________
-Fluctuates: -ASK: Pain now? Pain at its least? Pain at its worst? -MEASURE OFTEN
Manual muscle testing
-For flexion, extension, supination and pronation In: wrist and hand
Meat chunk on the lateral side of the elbow
-Forearm extensor wad
Meat chunk of the medial side of the eblow
-Forearm flexor wad
Dorsal and palmar radioulnar ligaments
-From the ulna to the radius -Support the distal radioulanr joint and prevent splaying during loading
Close packed position for the Radioulnar joint
-Full supination or full pronation
Is in different planes
-Glide
Meidal epicondylitis
-Golfer's elbow tests
Intrinsic plus position
-Hand, interossei and lumbrical muscles Claw hand deformity?
Biceps Brachii
-Has the largest volume of elbow flexors
More aggressive, used when the focus is stiffness
-Hi-grade
Between the head of the raidus and capitulum
-Humeroradial joint
Joints included in the elbow complex:
-Humeroulnar -Humeroradial -Radioulnar: Distal and Proximal
Between the trochlea and trochlear notch:
-Humeroulnar joint
Extensor mechanism:
EDC tendon (EI and EDM), extensor hood, central tendon, lateral bands that merge into the terminal tendon
What must occur for the PIP and DIPs to simultaneously extend?
EDC= active assistance from the interossei and lumbricals
extends and abducts the PIP joint of the SF due to attachment on the extensor hood
EDM
Extends MP or IF with extensor hood connection extends the PIP and DIP and can extend the wrist
EI
acuity and chronic degeneration presence
EMG
identify peripheral nerve lesions
EMG
identify presence of motor presence that may not be evident after a nerve injury
EMG
track the pace of nerve regeneration to the muscle
EMG
Hyaline cartilage
ENds of bones
Active lengthening of the muscle:
Eccentric contraction
Tension is developed in the muscle where the origin and insertion move apart
Eccentric contraction
Third class lever:
Effort force has a point of application between the axis and the point of application of the resistance force
Stability joints:
Elbow joint, PIP joints on digits, DIP joints
Muscular example of the 1st class lever:
Elbow where the focus is on the triceps and are flexed at 90 degrees while holding a glass of water
Treatment goal of the OFM:
Enable satisfactory engagement in valued roles whether by restored self-performance or directing others
Sensation transmitted to the therapists hand at the extreme end of the PROM that indicates the structures that limit the joint movement
End feel
OFM intervemtopm [rpcess includes:
Enhancing abilities and capacities restoring competence and engaging in what they what to do
Single joint capsule contents:
-Humeroulnar joint -Humeroradial joint -Superior radioulnar joint -Contains everything, connected to the elbow complex
Tests for anterior capsule injury
-Hyperextension
Hand shape for cubital tunnel syndrome:
-Hypothenar eminence and lack of intrinsic plus positioning
What else do occupational therapists determine in evaluations?
-If there is vibration, sustained elbow flexion, frequent distraction on the elbow, sustained wrist extension with digit use, and sustained or consistent intermittent pressure on the elbow
Collateral ligaments:
-Important structures that enforce the elbow medially and laterally and provide stability
When are the Triceps and Anconeus the most efficient?
-In 20 to 30 degrees of elbow flexion
Strength testing
-In flexion, extension, supination and pronation -Wrist -Hand -Grip and pinch
Close packed position for the Humeroulnar joint
-In full elbow extension
Power gripping
-In pronation with wrist flexion (bad?) and with wrist extension
Most tasks occupationally speaking with the elbow:
-Include combined elbow and wrist ROM
Hyperesthesia
-Increased sensitivity to stimulation excluding special senses like vision or hearing
Every time you add a layer (or more risk factors) it ___________ the chance of injury
-Increases
Thermal effects of therapeutic ultrasound:
-Increases extensibility of collagen fibers -Decreases muscle stiffness -Reduces muscle spasm -Alters nerve conduction velocity -Increases metabolism and blood flow -Provides all of the effects of non-thermal ultrasound
Nonthermal effects of therapeutic ultrasound:
-Increases phagocytic activity of macrophages and attracts immune cells to tissue -Increase protein synthesis -Increase capillary density -Regenerate tissue -Heal wounds **no temperature
PROM:
-Initiated at 6- 8 weeks
Moving two point discrimination
-Innervation density of quickly adapting fibers (Different positions)
Static two point discrimination
-Innervation density of slowly adapting fibers and is not moving
These fractures are the most common at the distal humerus:
-Intercondylar and supracondylar fractures in extension which are associated with peripheral nerve injury, etc.
Elbow arthroscopy:
-Investigate the extent of damage to the cartilage of the elbow without making an extensive incision
Medial elbow tendinosis
-Involves the origin of the pronator teres, flexor carpi radialis, and oalmaris longus at the medial epicondyle -Flexor groups of muscles -Repetitive wrist flexion with active pronation
Electrical currents used to deliver drug ions through the skin
-Iontophoresis
Joint mobiliztion indications:
-Joint stiffness -Pain -Capsular tightness -Joint edema or bogginess -Limited AROM or PROM
Types of assessments for the elbow:
-Kinesiology of occupations involving the elbow -Further pain information -Pain quality -Sensory testing -Elbow palpation -Strength testing -Special tests for the elbow
Hand shape and hyopthenar eminence
-Lack of intrinsic plus positioning
Elbow joint mobs Grade II
-Large amplitude movement performed in the resistance free part of the range: large amplitude
Elbow joint mobs Grade III
-Large amplitude movement performed into resistance or up to the limit of the available range: end of the range
When is the movement arm in the biceps brahcii the largest?
-Largest between 80-100 degrees of flexion which equals the greatest torque
Primary radial restraint, protects against varus stress
-Lateral Radial Collateral ligament
Origin of the extensor wad
-Lateral epicondyle
If there is an elbow dislocation, what will be disrupted?
-Lateral radial collateral ligament because it is the primary radial restraint and reinforces the humeroradial articulation and holds the radius in place
Lateral collateral ligamentous complex:
-Lateral radial collateral ligament, lateral ulnar collateral ligament, annular ligament: combined forces with valgus/varus/ and supination
Isometric contractions in the elbow are...
-Less affected by age
Distal biceps rupture:
-Less common than proximal one -Generally carrying a heavy load -Pain at the point of insertion- often bruising -Conservative and post-op repair guidelines exist. -Splinting, a/prom, edema management, strengthening, activity modification
More mobility in the wrist =
-Less stability
Interventions for cubital tunnel syndrome: conservative
-Limit symptom producing activities -Reduce neural tension -Splinting -Anti-inflammatory modalities and iontophoresis -Client education -Strengthening (if necessary)
Posterior bundle of the medial collateral ligament:
-Limits elbow extension -Less significant role in valgus stability -Helps keep joint surfaces in approximation
Is for pain, used in the beginning of the range
-Lo-grade
Edema:
-Location, localized or diffuse? -Ff present would measure circumferentially, -Note the type of edema
Assessment occupational tasks:
-Looking at what you should determine and if there is a high frequency of something -Elbow flexion and extension -Pronation and supination -Prolonged gripping -Wrist flexion and extension -Power gripping
Anterior elbow capsule:
-Loose, large, weak anteriorly and posteriorly and contains folds able to expand to allow for a full range of elbow motion -humeroradial -humeroulnar -radioulnar joints (Superior) -Collateral ligaments
Anesthesias
-Loss of sensation
Elbow fractures: Nonoperative tx
-Maintain stability of the joint and begin protected ROM exercise -Inflammatory or protective phase: stability of the elbow and protective motion exercise, static orthosis -Maturation phase: no precautions for ROM, AROM or PROM exercises, capsular stretches, soft tissue and joint mobs
Joint mobilization
-Manual therapy- massage therapists -Move soft tissue and bones around a joint -Mobilization of a joint in the passive range -Brings joint to the elastic barrier and not beyond -Do not think only of the joint but of all the tissues within the joint
What do collateral ligaments in the elbow include?
-Medial (ulnar) collateral ligament -Lateral collateral ligament complex
Origin of the flexor wad
-Medial epicondyle
Medial elbow tendinosis
-Medial epicondylitis and golfer's elbow -Tendinopathy at the origin of the flexor forearm musculature of the forearm and especially the pronator teres, FCR and PL
What is the purpose of the medial ulnar ligament?
-Medial support for the elbow, primary stabilizer against varus stress
This ligament is at risk for sudden traumatic forces or valgus forces like throwing a baseball and setting a volleyball:
-Medial ulnar ligament
Temperature (looks like a cup of coffee and tests for sensation to see if they sense temperature like frost bite, burns)
-Metal thermorollers
Joint Mobs evidence:
-Moderate support for clients with loss of motion due to joint stiffness but limited high quality literature supporting the use with multiple populations
Humerus/Ulna/Radius:
-Modified hinge joint
Primus PS:
-Most frequently used in OT clinics -Used to simulate ADLS and quantify the movements
What is transverse friction massage followed with?
-Motion and exercise or functional tasks
The recovery sequence of pain:
-Moving touch -Light touch -Touch localization
Age and gender influence what?
-Muscle function
People who are older require more what?
-Muscular force
Does the radius touch the capitulum in extension?
-NO
Types of chronic or acute pain:
-Neuropathic -Nocioceptive
-Burning, tingling, cold, prickling, itching, electric shock, non-pain sensory changes, nerve dysfunction, bugs under the skin
-Neuropathic pain
Bump the elbow: OUCH
-Neuropathic pain
A few assessments for neuropathic pain
-Neuropathic pain scale -Neuropathic pain questionnaire -Neuropathic pain symptom inventory
Where does laxity in the elbow occur?
-Neutral rotation of the wrist
Is the brachioradialis affected by the shoulder?
-No it provides stability
How long should you apply Joint Mobs for?
-No more than 30 seconds
Sharp and achy pain More systemic and visceral
-Nociceptive
Stomach aches, muscle soreness
-Nocioceptive pain
Biceps Brachii (active when?)
-Not active in pronation with limb weight only- load is when the biceps kick in and resistance applied is greater than the limb weight
Visual inspections:
-Observe like the limb position, edema, or ecchymosis
Fracture: Proximal ulna and olecranon
-Occur indirectly from a fall on the outstretched hand with the elbow in flexion or a direct blow to olecrsnon
Brachialis:
-One joint muscle -Acts syngeristically with the long head of the biceps brachii from 0-45 degrees flexion
Complex elbow fractures:
-Open reduction and well secured fixation -Splinted in flexion because flexion has greater functional importance
When the wrist is in neutral is there surface contact?
-Optimal joint surface contact is when the wrist is in a neutral position
Primary rules of force:
Forces come from something touching a segment Anything touching an object becomes a force Gravity touches all objects
Kinetics:
Forces in and on the body to produce stability or mobility are the focus IMPACTS HOW WE FUNCTION: GRAVITY, FRICTION, PRESSURE
Joint design:
Form follows function and the body compensates for what we do functionally
Extracellular matrix helps with:
Fracture healing
Eliminate what for splints?
Friction and shear forces- smooth finishing
Where is the moment arm in a lever located?
From the axis to the effort force
Forces at the hip:
From the top-pressure, gravity through the pelvis Straight down Force going out and inward- dynamic force system Two legged stance= each hip supports 33 % body weight and 2.5-3X more=legs one legged stance Center of gravity shifts
Orinetation of the z axis
Front to back
Motion with the z axis:
Frontal plane
3: gravity resistance
Full AROM against gravity
2: Gravity as resistance
Full AROM gravity eliminated (on the side)
Amount of manual resistance 4:
Full ROM against gravity and moderate manual resistance
FUntionally, the TFCC is considered an _______________________ of the ____________________ joint and ______________ radius.
Functionally, the TFCC is considered an extension of the radioulnar joint and distal radius
The longer the MA, the ________ the torque potential
GREATER
What is the purpose of gait information?
Gain an understanding of normal gait assist movement diagnosis and identify specific causes inform treatment selection evaluate the effectiveness of intervention
Two successive events of the same limb, usually initial contact of the L/E with a supporting surface
Gait cycle
Bottom up approach:
In which capacities, abilities, and skills are assessed before occupaitonal performance -may skip translation of regained abilities to occ. perofrmance
Dysfunction in the biomechanical approach:
Inability to maintain the positions needed for adequate movement
Lumbar pelvic rhythm:
Increase functional motion like the shoulder functional range of motion for the pelvis
In concentric contraction as shortening speed decreases, tension __________________
Increases ******WEIGHT LIFTING
Purposes of the menisci:
Increases congruency of the joints distributes the forces in WB reduces friction within the joint: SHOCK ABSORBER
Name the stages of the stance phase:
Initial contact foot flat midstance heel off toe off
Movement initiation and controls external forces/structures in the body
Internal forces
Intrinsic participation and abducting or adductiong the prox. phalanx to align the fingers with the object so that the extrinsic flexors can provide the gripping power:
Interossei
Clawing at rest demonstrates that the passive tension in the intact EDC muscle exceeds the passive tension in the remaining MP joint flexors and is known as what?
Intrinsic minus position- without the intrinsics to extends the IP joints
Prevents contractures:
Ischiofemoral
Tension is developed in muscle but NO MOVEMENT OCCURS AND THE origin and insertion of the muscle does NOT change position and the muscle length does not change
Isometric contraction
What happens when a fiber is too long or short?
It creates a weaker cross bridge because it misses the optimal length and results in weaker muscle action
What happens to the CoG in an asymmetrical object?
It would fall towards the heavier end
Muscle legnth + Moment Arm=
Joint Torque
Close packed position in joints:
Joint is positioned so that the connective tissue is taut -important so the position of some joints do not shrink
Loose packed position in joints:
Joint is positioned so that there is laxity in the connective tissue
Elements of human motion:
Joint motion and muscle strength
Elements of human motion in joints:
Joint motion which is passive or active on a continuum
WHAT IS THE FUNCTION OF THE ANNULAR PULLEYS?
Keep the flexor tendons close to the bone, allowing only a minimum amount of bowstringing and migration volarly from the joint axes
The change in position over time without regard for the forces that cause the movement (purest form of movement)
Kinematics
Common patterns of ADLs again: Hip extension, knee extension and ankle plantar flexion
Knee extensors contract CONCENTRICALLY to extend the knee and rise from a squat
Common patterns of motion for ADLS: Hip flexion, knee flexion, and ankle dorsiflexion
Knee extensors contract ECCENTRICALLY to control the knee
A muscle with a short moment arm produces a:
LARGER angle of excursion or ROM
the shorter the MA, the ___________ potential we have for torque
LESS
What provides stability for the hip?
Labrum Tendons and muscles joint capsule (with the labrum) Ligaments: iliofemoral, pubofemoral, and ischiofemoral
Contractile forces in Type II fibers:
Large
What happens if you use a little moment arm?
Large range of motion
Strongest collaterl lig. of the PIP joint:
Lateral one on the index finger for pinching
Example of contact force:
Leaning on the elbow: equal force to keep you up
Isometric contraction:
Length is unchanged such as holding a cup in place to take a swig, perfectly balanced
Passive muscle tension:
Lengthening of the muscle beyond the slack length of tissues such as stretching the hamstring muscles
In eccentric contraction, as lengthening speed increases, tension in the muscle __________ and then _________________
Lengthens and then plateaus
What is the total muscle force vector determined by?
Lengths and magnitudes of vectors
Ligaments and tendons injuries require what?
Lengthy recovery times when they require long periods of immobilization esp.
Fiber type:
Less important in muscles than other factors but does play a role
The midcarpal joint contains what for stability?
Ligaments including the transverse capral ligament
Translatory motion magnitude is expressed as what?
Linear displacement measurement in length: millimeters, centimeters, feet and inches
What do the oblique retinacular ligaments do?
Link the DIP and PIP joint motion if the DIP is flexed they become taut and the PIP flexes if the PIP extends they become taut and the DIP extends
Overall, the complex structure of the extensor expansion and the active and passive elements result in what?
Linkage between the PIPs and DIPs
Provide stability or restrict unwanted motion:
-Orthoses can be helpful in stabilizing joints when their integrity has been compromised by an acute injury or chronic disease such as arthritis: stabilization and restriction of mobility can help -Slings, gunslingers, and hinged elbow orthoses can be used to provide proximal stability that may enable improved distal function
standardized tests for dexterity and hand function:
Minnesota Rate of manipulate tests box and blocks purdue pegboard test nine hole peg test jebsen test of hand function
A shorter moment arm generate a smaller:
Moment pr force
Fibrocartilage
More collagen
Muscle size:
More fibers in a physiological corss section results in more muslce force
Amount of motor unit recruitment:
More force, contraction
Muscular example of the 3rd class lever:
Most applicable to muscles throughout the human body
Population with MMT:
Most clients exceptions: change in muscle tone or CNS involvement
Force of Gravity:
Most consistent and influential
Gravity:
Most consistent type of external force and touches everything
Provacative:
Movement that replicated pain
Treatment for Ulnar nerve compression
-Orthoses worn at night to prevent elbow flexion beyond 45 degrees and a elbow pad worn in the day, avoid pressure of the medial elbow, and elbow flexion greater than 90, , nerve gliding, soft tissue mobility, rest the hand
Risk factors for carpal tunnel syndrome
-Overuse of forearm, repetitious elbow movements, pressure, trauma, vibration
Allodynia
-Pain due to a stimulus that does not normally provoke pain -Unusual reaction to the cold, sensory processing, not comfortable, cotton balls are painful, cod on the teeth
Peipheral neuropathic pain
-Pain initiated or caused by a primary lesion or dysfunction in the peripheral nervous system -Force, compression, cutting or something is amiss
Assessing neuropathic pain and sensation:
-Pain scales reviewed in the shoulder section: numerical, visual analog, and pain mapping which are unidimensional or McGill which is multidimensional
Symptoms and movement in lateral epicondylitis:
-Pain weakness disruption in occupations through avoidance or activity modification and particularly with elbow extension and wrist flexion -Resisted wrist extension with elbow extension and forceful motions
Symptoms of medial elbow tendinosis:
-Pain, weakness, disruption in occupations through avoidance or activity modification
Neuropathic pain for carpal tunnel syndrome:
-Paresthesias, diasthesias, anesthesias, in the ulnar nerve distribution etc., weakness and paralysis of the musculature innervated by the ulnar nerve and fingers could be cold, tingly, or drop things
Compression of peripheral nerves
-Pathology and can involve one or several nerves, a smaller or larger extension along the nerve or may spread over time
Rotational motions:
Movements that occur around a Y axis Internal/External rotation External rotation Circumduction Opposition Horizontal abduction Horizontal adduciton Tilt Shoulder girdle elevation and depressipn Hypermobility Hypomobility Passive insufficiency
Translatory:
Moves in a straight line all parts of an object move in the same distance, same direction, and same time
Lunate
Moves the least in flexion and extension
What does most motion involve?
Multiple combinations of the complexity of human motion
Distal radius fracture- Open reduction/ internal fixation etiology
Multiple, FOOSh
Distal radius fraction: nonoperative etiology
Multiple- FOOSH
Splinting core concepts:
Muscle and joint integrity are dependent on movement
What are muscle function factors?
Muscle contractions fiber type Fiber length FIber Arrangement Fiber size
The biomechanical pparoach is the stidu of the relationship between what?
Muscle fuction and how the boyd is designed to for and used in the performance of daily occupations
Conservative treatment for ulnar nerve compression:
-Patient education to limit activities that provoke symptoms -Orthoses for rest and reduction of neural tension -Anti inflammatory modalities to decrease swelling in the closed space tunnel Or surgery: to release the cubital tunnel
Ulnar nerve compression: Severe
-Persistence paresthesias, vibratory perception, abnormal 2 point discrimination, pinch and grip weakness, muscular atrophy, claw hand, Wartnebger's test is positive, Froment sign is positive, Tinels and elbow flexion test is positive
Purposes of the elbow:
-Position the hand for use: Including elevation, length, shortens the upper arm to eat -Provides a platform for loading and force during functioning tasks -Mobility for the hand in space by shortening/lengthening the U/E -Allows the hand to be brought close to the face for grooming or to be placed at a distance -Provides stability for skilled movements
Souter-Strathclyde approach:
-Posterolateral, triceps reflected from ulnar insertion, lateral collateral complex release, radial head excision, hardware implantation, collateral ligament reattached
Modified Coonrad-Morrey approach:
-Posteromedial approach with the ulnar nerve decompression transposition, triceps detachment from olecranon, partial detachment of ulnar collateral ligament, radial head excision, hardware implantation, and triceps reattached
Lateral elbow tendinosis:
-Primarily involves degeneration of the extensor carpi radialis brevis tendon at the lateral epicondyle with the EDC or the ECRL -Causes pain and weakness
Weak elbow flexors that are anterior
-Pronator teres -Flexor carpi radialis -Flexor carpi ulnaris -Flexor digitorum superficialis -Palmaris longus
Annular ligament:
-Proprioception -Joint surface for head of radius during supination/pronation -Anterior/posterior edges of ulnar radial notch
What are the main muscle function factors:
Muscle size Length tension relationship Shorter moment arm and a larger moment arm Velocity of contraction Amount of motor unit recruitment Fiber type
Manual muscle testing, dynamometer, pinchmeter
Muscle strength
Other elements of human motion
Muscle tone, motor planning, coordination, detexerity
Where do Internal forces occur?
Muscle, bone, ligament
What provides stability during gait?
Muscles and soleus
What do you always start with in Orthopedic assessment?
Observation and questions regarding occupations, medical hisotry, pain, etc.
Intervention in the OFM:
Occupation as an end or means
Decision making process:
-Purpose and intent of technique -Direction of movement -Position in the range where technique will be performed -Manner of application of the technique (rhythm and amplitude) -Position of the patient, therapist, manual contacts
Between the head of the radius and radial notch on the ulna:
-Radioulnar joint
This model guides assessment and treatment of persons with physical dysfunction leading to competence in occupational performance and feeling of self-empowerment
Occupational Functioning Model
Hip Joint Pathology: What is the most common painful condition of the hip?
Oesteoarthrisis Degeneration of articular surfaces: Mentioned precautions : body weight or weight bearing
The three domains that roles are split into:
Self-maintenance Self-advancement Self-enhancement
Joint distraction forces
Separation of surfaces
FRICTION FORCE
Shear force moving in opposite direction
Use _______________________ of movement in splinting if possible
Short intermittent periods of movement
A muscle with a short moment arm has to:
Shorten and contract less
The shape of the muscle influences what?
Shortening of the muscle
Treatment for lateral and medial epicondylitisL
-Reduce pain and restore functional strength -Protection -Relative rest -Medication -Orthoses -Modalities to reduce pain -Surgery: if pain persists for 6-12 months
What is the purpose of transverse friction massage?
-Reduces pain and promotes tissue healing -Promotes collagen alignment and fiber lengthening and blood flow
Epicondylitis, insertional tendinopathy or tendinosis?
-Refers to degenerative tendinopathy caused by chronic mechanical overloading and failed healing of the involved tendon
Quadrate ligament- what does it do?
-Reinforces inferior aspect of joint capsule and helps maintain radial head in apposition to notch
Motions and combined motions that would be risk factors for development of the medial elbow tendinosis?
-Repetitive wrist flexion
Provactive motions for lateral epicondylitis:
-Repetitive wrist movement or forceful gripping and static wrist extension- bricklaying, yard work, sewing,
This is optimal for all people:
-Resistance training
Nonoperative tx for radial tunnel syndrome:
-Rest, activity modification, splints, stretching, and anti-inflammatory medication, corticosteroids -Wrist orthosis in 30-45 degrees of extension to enhance function by resting the extensor compartment and will wear this continually in weeks 0-3 -Avoid pronation and supination tasks -Joint protection and energy conservation -Moist heat or other modalities, gentle manual techniques, glides, core stabilization, strengthening
Therapeutic ultrasound:
-Restore and heal soft tissues- heat
Pain awareness (and sees if something is sharp)
-Safety pin
Different syndromes of the radial nerve:
-Saturday night palsy, PIN, radial tunnel syndrome, Wartenberg syndrome
Modifed coonrad morrey: 2 weeks
-Scar management, edema control, NMES of the biceps, hand strengthening
Modified Coonrad-Morrey Surgery
-Semiconstrained
Prostheses types for the elbow:
-Semiconstrained (most common): sloppy hinge, has a connection between ulna and humerus -Constrained (rarely used) -Unconstrained: no connection between ulna and humerus - need good bone and ligaments
Light touch
-Semmes Weinstein Monofilaments
Sensation testing in the elbow for neuropathic pain or sensation:
-Semmes Weinstein Monofilaments -Metal Thermorollers -Safety pin -Static Two Point Discrimination -Moving Two Point Discrimination -Cotton ball, finger tip, eraser -Assortment of objects
Restore mobility of the shoulder, elbow or forearm:
-Serial static abduction splint: scarring -Casts: repositions joints without other stress to tissues -Loss of forearm pronation (radial tunnel syndrome): dynamic forearm rotation splinting
Loose packed position of the elbow:
-Slight flexion (results in elbow dislocation if excessive force is sustained)
Immobilize the elbow:
-Sling: most common -Casts, splints, and hinged braces -Most commonly used: anterior elbow extension splint
Semiconstrained elbow arthroplasty:
-Sloppy hinge- stemmed humeral and ulnar components and allows a few degrees of varus or valgus motion (LINKED)
The PCSA of the Biceps Brachii is ___________?
-Small
Elbow joint mobs Grade I
-Small amplitude movement performed at the beginning of the available range: small oscillations at available range
Elbow joint mobs Grade IV
-Small amplitude movement performed into resistance or up to the limit of the available range: into resistance
Elbow joint mobs Grade V
-Small amplitude, high velocity thrust performed usually but not always at the end of the range
Nerve endings present in the TFCC may result in what?
-Source of wrist pain and an shock absorber: stabilizer for distal radioulnar joint
Purposes of the Medial (Ulnar) Collateral Ligaments
-Stabilizes against valgus torque at medial elbow -Limit extension at the end of elbow extension ROM -Guides joint motion throughout flexor ROM -Provides some resistance to longitudinal distraction of joint surfaces
Purposes of the Lateral Collateral Ligamentous Complex
-Stabilizes elbow against varus torque -Stabilizes against combined varus and supination torque -Reinforces humeroradial joint and helps provide some resistance to longitudinal distraction of the articulation surfaces -Stabilizes radial head, thus providing a stable base for rotation -Maintains posterolateral rotary stability -Prevents subluxation of humeroulnar joint by securing ulna to humerus -Prevents the forearm from rotating off of the humerus in valgus and supination during flexion from the fully extended position
Any muscles shortnening of the forearm?
-Stretch elbows
Surgical interventions for carpal tunnel syndrome:
-Subcutaneous or submuscular ulnar nerve transposition if they are not getting better which involves removing a piece of the flexor wad and putting it under the tunnel to be soft
Acute pain
-Sudden, practical
Elbow joint mobilization techniques:
-Superior radioulnar joint -Downward glide of the head of the radius on the ulna (pushed elbow) -Rotation of the head of the radius on the ulna -Ulnohumeral joint (ulna-olecranon block) -Radiohumeral joint (intra-articular meniscus block) -Common extensor tendon scar
Radioulnar joint ROM: pronation and supination
-Supinator -Pronator teres -Pronator quadratus
Purposes of orthoses:
-Support a painful joint, immobilize for healing, protect tissues, provide stability, restrict unwanted motion, restore mobility, substitute for weak or absent muscles, prevent contractures, modify tone
Tests that are not sensitive to change:
-Temperature, touch, vibration, pain awareness
Radial tunnel syndrome:
-Tenderness over the radial nerve at the proximal or distal edge of the supinator and can be increased by passive pronation or active supination and sometimes coexists with lateral epicondylosis -Pain: deep and achy and present at night -Could be caused by a mass causing the compression, humeroradial joint degeneration, radial head fractures, or compression of the extensor carpi radialis brevis
Difference between tendinitis and tendinosis:
-Tendinitis is acute and tendinosis is chronic
Lateral elbow tendinosis:
-Tennis elbow, lateral epicondylitis -1-3% if population -Tendinopathy at the origin of the extensor wad of the forearm in the extensor carpi radialis brevis
Valgus excessive
-The elbow goes out
Who must you speak with to do elbow joint mobilization?
-The physician to determine whether i tcan be initiated
Anterior transposition:
-The ulnar nerve is moved anteriorly beneath a skin flap or beneath the flexor muscle mass parallel to the median nerve
Clinical use of therapeutic ultrasound:
-Thermal effect for muscle spasms, stiffness, chronic inflammation and to stretch collagen or increase blood flow
Support a painful joint:
-These orthoses are used to help with trauma, nerve irritation or inflammatory conditions and joint instability and are worn all day and night
Reported tendons in tendinopathy look like what?
-Thinning, disruption of collagen fibers, increased vascularity and cellularity and granulation tissue
Oblique cord:
-This keeps the radius and ulnar together, and helps transmit forces
Most sensitive sensory tests:
-Threshold tests which determine the smallest stimuli that can be noticed, like the two point discrimination tests which looks at innervation density
Elbow arthroplasty:
-Total elbow replacement -Happens if nothing else can be done- different kinds and protocols and total elbow replacement
What is the TFCC?
-Triangular Fibrocartilage Complex
Articular disc in the wrist is also know as the:
-Triangular fibrocartilage (TFC)
Elbow Joint ROM: extension, which muscles?
-Triceps -Anconeus
Uniaxial pivot/trochoid joint: superior radioulnar
-Ulna/radius
Hypothenar eminence
-Ulnar nerve wasting and nerve damage
Deep heat modality: application of sound waves to ssoft tissue and cause thermal or nonthermal effects and sound having a frequency greater than 20000 Hz
-Ultrasound
Souter-Strathclyde Surgery
-Unconstrained
Unconstrained elbow arthroplasty:
-Unlinked and not hinged: no attachment between the humerus and the unlar components
Detects small changes in sensory perception such as a touch threshold test:
-Use monofilaments
Why is there an carrying angle?
-Valgus angulation of the forearm because the trochlea is projected distally in the medially portion more than the lateral position
Recovery of sensation:
-Varies -Likely if compression is brief -Recovery after total transection of a nerve requires surgery
Tests for ligament injuries
-Varus stress test -Valgus stress tests
This causes vessels to constrict- Rena Syndrome and decreased blood flow with hand, wrist, arm vibration syndrome or total body vibration syndrome
-Vibration
Abduction of the V digit depsite efforts to adduct the digit in the pal down position
-Wartenberg's dign
When does the brachioradialis have more activity?
-With pronated forearm
When is there little surface contact in the wrist?
-With pronation and supination
When would a force used to grip an object be lower or higher than the force needed so objects slip from our hands?
-Without adequate tactile sensation
Rotation at the elbow allows for ________________.
-additional mobility of the hand
Magnitude is measured in
-measured in newtons
Elbow is for _______________, the wrist is for __________________
-postion -correctional movement
Motion required for hip extension when standing
0 degrees with slight extension
Functional ROM at the knee:
0-135 degrees
Most senstive grades:
0-3
Cruciate pulley system:
1- between A2 and A3 2- between A3 and A 4 3- between A4 and A5 (only FDP tendon)
Annular pulley system
1- head of metacarpal 2- volar midshaft of prox. phalanx 3- distal most part of the prox. phalanx 4.- central on middle phalanx 5.- base of distal phalanx
Motion in the transverse plane:
Shoulder: Internal and external rotation hip: internal and external rotation knee: internal and external rotation ankle: internal and external rotation elbow, wrist and hand: supinate and pronate thumb: opposition
What is the purpose of the hip joint complex?
Similar to the shoulder: Supports body height: HAT= heads, arms and trunk Transmit force from pelvis to ground fulcrum for single leg stance provides for locomotion
Thumb ulnar collateral ligament
Skier's thumb which occurs more often than the radial collateral lig. damage and results in thumb instability
Type 1 muscle fibers:
Slow
What muscles maintain balance in static standing?
Soleus
Knowledge of forces:
Some physics: action reaction friction knowledge of the body's center of gravity
Description of forces
Source and recipient
Rate of displacement:
Speed velocity acceleration
Abilities and skills:
Split into motor, sensory, cognitive, perceptual, socioemotional, and cardiorespiratory abilities and skills: related to client factors
Lunotriquetral interosseous ligament:
Stability between the lunate and the triquetrum
Injury to the joint causes:
Stability of that joint to lessen
Muscles where type 1 fibers occur:
Stability or postural muscles
What is the purpose of the tenodesis grasp?
Takes load off the other structures in the wrist and hand
Where is the midarsal joint?
Talus navicular calcaneous cuboid prox: talus and calcaneous distal: navicular and cuboid
OT considerations for Integration:
Teach energy conservation Test appropriate positions and posture
Example of 1st class lever:
Teetor totter or a balance scale
Creep:
Tendency of tissue to elongate over time with consistent force applied thumb sucking
Radial tunnel syndrome:
Tenderness or pain in the dorsal forearm at the proximal or distal portion of the supinator muscle and symptoms increase with pronation and supination
EPL tendonitis
Tendinitis of the 3rd dorsal compartment common in client with RA, trauma or distal radius fracture Remember to evaluate client reports, resisted thumb IP exttension and to test the EPB and MP extension
Active muscle tension:
Tension developed in contractile elements
Concentric contraction:
Tension is developed in muscle where the origin and insertion of the muscle move closer together
Full flexion of the PIP joint will prevent ___________________________________________________
The DIP from being extended
WHat is the most important characteristic of a muscle?
The ability to develop tension and to exert a force on the body lever
Load:
The amount of force applied
Double support time
The amount of time spent with both feet on the ground during one gait cycle: can be increased in the elderly or descreases as the speed of walking increases
Biomechanics:
The application of engineering and phsyical science to the movement of living organisms
PAMs what does this include? What do you need to use these?
This includes cold, heat ultrasound, iontophoresis to use these you need training, certification in states, and formal training is a must
Graded application of force:
Through exercise and occupation can be useful for bone cartilage and tendons and ligament recovery -form follows function and add a little more each time
Femoral neck fractures
Through the femoral head with a compression plate or screw: unstable
Tinel's sign
Tingling, paresthesia or pain by the subject in the area of the thumb, index finger, middle finger or radial one half of the ring finger signal a positive test- CARPAL TUNNEL SYNDROME
What is the purpose of the loose surrounding capsule that happens in the distal radioulnar joint?
To maintain stability
Position in a lengthened position for splinting:
To make it more comfortable and not shortenend to shrink the muscles -consider muscles, ligaments, joint position
Purposes of the biomechanical approach:
To reduce impairment learn new perofrmance skills slow the decline the ability maintain and imporve the quality of life consistency of the approach with the performance context
Compressive external forces:
Approximation of joints, where joints touch creates contact between surfaces Minimum of oe compression force on each contiguous joint segment with each compression force perpendicular to and rected toward the segment's joint surface and opposite in direction to the compression force on the adjacent segment
Syndesmosis joints:
Are fibrous joints with very little motion such as interosseous membranes between the ulna and the radius which cannot be pulled apart
Roles in the OFM:
Areas of occupation in the OTPF -Very broad -constellations of tasks
Example of Moment arm:
Arms of the wheelchair are longer for people with weaker hands because it takes less force to pull on them and make the wheelchair move
Characterized by pain, stiffness, and inflammation in the joints
Arthritis compression can be a big Tx heat for chronic pain cole- acute inflammation moderate ROM
Other tissue structures included in the TFCC:
Articular disc Upper laminae: dorsal and volar radioulnar ligaments Lower laminae: Attaches to the extensor carpi ulnaris, triquetrum bone, base of the 5th metacarpal, and an ulnar collateral ligament
Testing Range of Motion:
Assess complex functional movements during usual functional tasks assess individual joint range of motion
ECU teninopathy:
Associated with DRUJ and TFCC [ain and swelling distal to the ulnar head
where does 50% of wrist motion occur?
At the proximal radiocarpal joint
Reliability and validity of MMT:
Validity: max amount of force that a muscle can exert voluntarily in one effort- kack of evidence for validity (measure torque producing capability) Reliability: based on use of isometric and break testing complete agreement of muscle grades which are low
What is critical to maitaining synovial fluid and tendon nutrition around the pulleys?
Vascular supply: provided by the vincula tendinum
Posterolateral approach:
Avoid hip adduction, external rotation and flexion greater than 90- degrees
Anterolateral:
Avoid hip adduction, external rotation and hyperextension
Valgus stress:
Away from the body
Two types of crutches:
Axillary or Lofstrand
First class lever system:
Axis is between the point of application of effort and the point of application of resistance
Why does the PIP joint extend and then the DIP joints extends?
Because the joints are interdependent and are joined by active and passive forces
Why is the lateral collateral ligament of the PIP joint on the index finger the strongest?
Because the thumb is most likely to oppose the lateral side of the index (creating a varus stress at the PIP joint)
Why does flexion of the DIP joint produce flexion of the PIP joint by a similar complex combination?
Because they link the PIP and DIP expansion
How does joint design differ?
Between mobility and stability
Where are the metatarsalphalangeal joints?
Between the bases of the metatarsal heads and the concave based of the prox. phalanges allow weight bearing extension precedes flexion
Where are the tarsometatarsal joints?
Between the distal row of tarsal bones and heads of the metatarsal bones
Where is the subtalar joint?
Between the talus and calcaneus
The wrist complex as a whole is considered to be ___________ and has how many motions?
Biaxial flexion/extension UD and RD
Example of a third class lever:
Biceps flexing where the axis is the elbow joint, the effort is the point of application of whatever is moving, and the resistance is lifting up the forearm where the little e overcomes the big R fishing rod where the axis is the rod, the effort is where you pull, and the fish is the resistance
What might ulnar negative variance cause?
Too much stress on the radius lunate bone does not like pressure so a lack of blood flow occurs at the bone and causes avascular necrosis Keinbock's disease ABNORMAL FORCE DISTRIBUTION ACROSS THE RADIOCARPAL JOINT WITH POTENTIAL DEGENERATION AT THE RADIOCARPAL JOINT
The strength of the rotary motion that occurs between force couples which are unopposed:
Torque
Contact force:
Touch between 2 objects is a push
Palpation:
Touching and the examination of the body surface to assess bony and soft tissues contours and soft tissue consistency and skin temperatures
Varus stress:
Towards the body
Tensile external forces:
Traction where joints separate and opposite in direction
Arrows that visually illustrate force and both directions and point of application
Vectors
Resultant force:
Vectors on the muscle
Acceleration:
Velocity changes time -go faster
Hand/Wrist based thumb spica
conservative CMC OA treatment
Capitate:
considered the center of wrist motion (Keystone)
Provide what for strength in splinting?
contour
FDP and FDS:
contribute to powergrip
Dorsal capral ligaments:
contribute to stability, especially wrist stability and of the scaphoid during wrist ROM tight in flexion protects the carpals prox. carpals stretch into that during flexion goes diagonnally from the radius to the medial side of the hand (scaphoid to the hamate)
What is the function of the finger carpometacarpal joints?
contribute to the palmar arch system
Deep transverse metacarpal ligament
contributes to stability of the mobil rches during grip functions
Main contribution of the wrist complex:
control length tension relationships in the multiarticular hand muscles and to allow fine adjustment of grip
Dorsal radiocarpal ligament
converges on the triquetrum from the distal radius with attachments along the way TIGHT IN WRIST FLEXION
It is common in rehab that the clinician do what?
correct or minimize pathology provide gait training to develop new habits of ambulation following an injury or dysfunction, leads to gait pathology
Distal phalanx fracture
crushing injury- TUFT fractures Monitor for DOP extensor lag, etc.
ice
cryotherapy, cold packs, ice massage, cold water baths, contrast baths
Where can the ulnar nerve usually be compressed?
cubital tunnel formed by the ulnar collateral lig. trichlea and medial epicondylar groove sensation of the dorsal ulnar hand and volar 5th and ulnar 1/2 of the 4th fingers
Prefabricated vs. custom splints
custom splints are more effective but less comofrtable cumulative trauma- may want to use prefab custom splints are tradiitonally used post operatively
WHat is a proximal row carpectomy?
a procedure to reduce pain and maintain wrist motion the scaphoid, lunate and triquetrum are exercised which allow the proximal end of the capitate to articulate with the lunate foss of the radius This eliminates normal ROM Volar wrist splint, ice, scar management, strengthening, PROM, U/E conditioning
Dynamic splint:
a splint that applies a mobile force, applied with rubber band or springs in one direction while allowing active motion in the opposite direction
OA hand therapy
alleviating symptoms through education on joint protections, adaptive devices, splinting like the thumb spica (CMC)
Shape of the pulleys-
allow finger flexion without pinching of the pulleys while more distributing pressure of the tendon and sheath across the roof of the fibro=osseous tunnels
PT gait goals and focus:
ambulate 60 degrees with a SEC with independence ambulate 100 degrees with a wheeled walker
Step duration
amount of time spent during a single step measurement os expressed as seconds per step
Radial collateral ligaments
an etension of the volar radiocarpal ligament and capsule
When the extrinsic finger flexors and extendors are active without any activity of the intrinsic muslces, the hand assumes:
an intrinsic minus position
Lister's tubercle:
anatomical pulley to turn toward the thumb
Content validity
and it also have torque producing capability of the tested muscles and appears to have content validity
Degree of toe out
angle of foot placememnt and can be found by measuring the angle formed by each foot's line of progression and a line intersecting the center of the heel and second toe
midfoot
ankle middle navicular, cuboid, cuneiforms
the flexor digitorum superfificalis and flexor digitorum profundus pass through a fibrosseous tunnel that is compromised of five transversely oriented _________ pulleys and 3 obliquely oriented _________ pulleys
annular cruciate
Proximal transverse arch
anterior tarsala
In wrist extension the proximal row glides:
anteriorly
Proximal phalanx fracture therapy:
buddy taping, AROM, splint, tendon gliding, blocked motion, PROM, strengthening
SYmptoms of fibromyalgia
burning trigger points pain sleep issues ftigue depression headache numbness no known cause
How does diarthrodial joints improves motion?
by decreasing the forces of friction:
Longitudinal:
calacaneous to the heads of the metacarpals. maintained by the spring of the ligament and plantar aponeurosis
Blocking exercises
can block the Ips to isolate the MPs, etc.
Length of the ulna:
can cause minor problems
ape hand
cannot abduct the thumb or oppose it
Opposition:
circumduction motions for thumb to pinky and permits the thumb to touch other fingers
TFCC injury traumatic and degenerative interventions
client educaiton is central to long arm splinting in FA and wrist in neutral ADL adaptations, social roles consideration, edema management 6 weeks: begin with AROM/AAROM, tendon gliding, neural gliding hourly, imperative due to long immobilization time
Carpal Tunnel Syndrome- conservative Interventions
client education reduce compressive forces (splinting and work modification) tendon gliding iontophoresis cryotherapy strengthening carpal bone mobs
Precautions for MMT:
clients with cardiovascular problems when fatigue can exacerabte problems when overwork can be detrimental to a clients condition
Treatment for Raynard's disease
cold water soaks client eduction avoid cold, contrast baths, compression
Circumduction
combination of flexion, extension, abduction and adduction
Ankle motion restriction:
common following ankle injuries like sprains lack of dorsiflexion, common pathological gait lurching forward, lift heel off ground and move rapidly into terminal stance
Quadriceps weakness:
common with chronic knee injuries, surgery, pain, edmea, non weight bearing characteristics: hyperextension of the knee during the stance phase
Active AAROM PROM exercises
complete in planes of motion used in range of motion testing
Long arm splints
complex distal radius fractures, TFCC
Scaphoid non union
complex, surgical procedures needed and subsequent follow up
Volar plate:
composed of fibrocartilage and is firmly attached to the base of the proximal phalanx. In metacarpophalangeal extension, the plate adds to the amount of surface contact with the large metacarpal head, resists tensile stresses to restrict MCP hyperextension and compressive forces needed to protect the volar surface of the metacarpal head from objects in the palm BLENDS WITH THE DEEP TRANSVERSE METACARPAL LIGAMENT
What is typically used to promote scar softening and maturation in scar management?
compression and desentization
TFC=
comprised of an articular disc in the wrist
Center of Gravity of an object:
concentrated force point
MP joint of the thumb:
condyloid with abduction and adduction and flexion and extension
sagittal bands:
connect on the volar surface of the hood to the volar plates and deep transverse metacarpal ligament
Extrinsic ligaments
connect the carpals to the radius or ulnar proximally or to the metacarpals distally
Intercarpal ligaments
connect to carpal bones and contribute to carpal tunnel
Lower lamina of the TFCC_
connections to the sheath of the extensor carpi ulnaris, triquestrum, hamate, base of the 5th metacarpal through the fibers from the ulnar collateral ligament
Outcomes in the OFM:
satisfactory occupational performance to allow expected discharge, sense of self-efficacy and self-esteem, and prevention of further disability
Radial volar zone
scaphoid SST (watson) carpal tunnel Phalen, Durkins Compression, Tinel's
What is related to ligament laxity in the hand?
scaphoid flexion
tilt
scapula or pelvis: anterior, posterior, in scapula Pelvis: anterior, posterior, lateral
SLAC wrist
scapulunate advanced collapse scapholunatte instability
Productive activities that add to the person's skills or possessions
self-advancement
Contributes to a person's well-being and happiness
self-enhancement
Knne muscles: flexors:
semitendinosus, semimembranosus, biceps femoris, soleus, gastrocnemius, plantaris. gracilis, popliteus
Factors influencing posture:
sensation vision structural integrity and injury environment mismatch between the task and the person's capabilities
Generalized test:
shake, sitting push up, volumetry, dynamometry, goniometry
But a muscle with a long moment arm has to what?
shorten and contract over a longer distance so it has a shorter angle of excursion but has more power
The longer the muscle fiber, the more region it is capable of _____________________
shortening
Motion in the z axis:
shoulder, and hip: abduction and adduction hand: digital abduction/adduction wrist: ulnar and radial deviation
Associated movements in the sagittal plane:
shoulder: flexion/extension elbow: flexion/extension wrist: flexion/extension hand: flexion/extension hip: flexion/extension knee: flexion/extension ankle: dorsiflexion and plantar flexion Thumb: palmar abduction
Orientation of the X-axis
side to side
Proximal row of carpals-
simultaneous flexion of the proximal carpals and extension of the distal carpals during the RD also occurs
Example of closed chain
sitting down on the legs
Contributing factors to fibromyalgia:
sleep distrubance, ppsychological stress, muscle metabolism changes, nervous, immue, endocrine system changes
deep transverse metacarpal ligament
spans the heads of metacaprals and controls the ROM available at each carpometacarpal joint
Hook grasp
specialized form of precision thumb held in moderate to full extension
Velocity of contraction:
speed and direction
De Quervain's tenosynovitis interventions
splint in FA based thumb spica splint, softer splint if needed for funciton PAMs US iontophoresis with dexamethasone Transverse friction massage, soft massage, heat for chronic injury, ice for acute pain free AROM of wrist and thumb, progressive stretching in ulnar deviation, eventual strengthening, ergonomic/work modification
Intersection syndrome interventions
splint in thumb spica splint or wrist in slight extension similar to DeQuervain's change activity use and posture etc.
Distal radius fracture- Open reduction/ internal fixation interventions
splinting first MD will decide if short or long arm is needed depends on the stability of the fracture and the impact supination and pronation can have on the fracture AROM of the involved and uninvolved joints, edema management skin care scar management target supination add PROM as described in the protocol and strengthening (5-8 weeks)
Distal radius fraction: nonoperative Intervention
splinting when cast is removed, usually around 6 weeks, edema management, AROM- progress to PROM when indicated by the MD, eventual strengthening
Other abnormal end feel sensations:
spring block empty spasm
Stabilization:
stabilize the applicable segments as necessary to provide support while isolating the muscle group to be tested and type of testing -prevents substitute movements
WHat is the function of a precsion grip:
stabilize the object between the fingers and thumb and secure an object so the more prxo. limb segments can move the object
Triangular ligament
stabilizes the bands on the dorsum of the finger
What is the spring ligament?
stabilizes the medial longitudinal arch and supports the head of the talus and talonavicular joint because it is on the calcaneous, naviuclar, and talus
Guarding during descent
stand in front and to the side of client in the area where there is least protection outsie foot on step on which the client will step and the inside foot on the step thst is lower hold the gait belt at the wrist and place the hand against the front of his/her shoulder
Posture types:
static dynamic erect bipedal stance: freedom for the extremities byt increases stess of the bertebral column quadrupedal: distributes weight between the upper and lower extremities
Aligned and maintained body structures: still
static posture
Toe off
the instant at which the toe of the foot leaves the ground usually about 60% of the gait cycle
Stride length:
the linear distance between two successive events that are accomplished by the same lower extrimity during gait: measuring the dinstance from the point of one heel strike of one lower extremity to the point of the net heel strike of the same extremity varies depending on height, leg length, sex, etc.
Ulnar nerve surgery:
the nerve can be transposed
Cadence
the number of steps taken by a person per unit time (sec. or minute) 180 steps per minute: running 80-120: walking
Why do finger tricks occur?
the oblique retinacular ligaments migrate dorsal to the PIP joint axis if hyperextension of the PIP joint occurs and tension in these ligaments porduced by active DIP flexion accentuate PIP extension becayse they function as passive PIP joint extenors
Midstance
the point at which the body weight is directly over the supporting lower extremity, usually about 30 % in
Heel off
the point at which the heel of the reference extremity leaves the ground usually about 40% in
spherical vs. cylindrical grasp:
the spherical grasp has a greater spread of fingers on an object
FInger and thumb positioning in precision:
the thumb is always involved and is positioned to achieve opposition to bring it to pad to pad contact with fingers
what ligaments maintain the proximal transverse arch?
the transverse capral ligament and intercarpal ligaments: flexor retinaculum that attaches to the pisiform and hook of the hamate medially and to the scaphoid and trapezium laterally- which forms the CARAPL TUNNEL
Volar concavity or proxximal transverse arc is formed by what?
the trapezoid trapezium capitate and hamate (distal caprals) and the arch persists when the hand is full opened and is created by the carpals and the ligaments that maintain the arch
Three characteristic of the static grip phase:
the wrist is held in neurtral or extension the fingers are maintained in flexion and abduction or adduction the volar surfaces of the fingers and portions of the palm make foreceful contact with the object
clawing:
the zigzag pattern that occurs when a compressive force is exerted across several linked segments one of which is an unstable segment The proximal phalanx hyperextends on the metacarpal below while the miiddle and distal phalanges flex over it
Flexor tendon zones: TIII
thenar eminence
thenar crease
thenar eminence
Other considerations for MMT:
therapist voice, testing hands gravity grading scale two joint or mutli joint muscle testing
Occupation as a means:
to optimize abilities and capacities and used to change these -occupation holds within itself healing properties that will change organic or behavioral impairments "DOING"
Why must therapists understand muscle biomechanics?
to properly evaluate client's performance and build intervention to address muscle related deficits modify or restore
Why should the immobilization splint place the MCP joints in flexion and IP joints in extension?
to reduce the risk of flexion contractures from shortening of volar plates
When is the biomechanical approach used?
to restore or remediate
forefoot
toes anterior metatarsals and phalanges
Considerations for posture:
traditional assessment techniques as covered thus far visual and objective assessment of functional tasks/workshops
Reliability depends on:
training, practice experience use of strict standardized procedure
Longitudinal arch:
traverses the length of the digits from proximal to distal
Injury to extensor zone 5 and 6:
treated with immobilization
Thickening of the sheath of the flexor tendon:
trigger finger
types of TFCC injuries:
truamatic degenerative- exposure to repetitive compression on the central portion of the complex from weight bearing, overhead lifting and ulnar deviation with force indications: pain and instability
PIPs or thumb IP
true synovial hinge joints with just flexion or extension
Each interphalangeal joint is a ___________________ joint with one degree of freedom, a joint capsule, a volar plate, and two collateral ligaments
true synovial joint
lateral prehension
two adjacent fingers- mostly extended
Biaxial joints
two degrees of freedom (X and Z) F/E and Abduct and adduct condyloid joint and saddle joint
Linear force system:
two or more forces act on the same segment, same plane and same line
The line of Gravity:
gravitaitonal vector that is always vertically down like a plum line
Spherical grip
greater spread of fingers than the cylindrical grip to hold the object
scaphoid:
greatest motion
Box and blocks
gross manual dexterity
volar plate
increases joint congruence and provides stability to the metacarpophalangral joint by limiting hyperextension and providing indirect support to the longitudinal arch
RA:
inflammation of the synovial membraine and can result in swan's neck or boutonniere
Risks of PROM
injurous to tissue, disturb the healing process, increase scar production
Lateral bands
insert into the base of the distal phalanx extensions of the EDC and of the lumbricals and interossei extend the DIP joints
Central band or central slip:
inserts into the base of the middle phalanx, in an extension of the EDC and interossei and extends the PIP joint
Type II muscle fibers:
intermediate
flexion and external rotation
metatarsophalangeal joint
Distal phalanx fractures:
middle and thumb most common and involves damage to nail bed and pulp due to length and use
inversion and eversion
midtarsal
RIng and small finger
mobility like opposing
Most ROM available in the hand
neutral position
Thumb intrinsics: 5
oppoenens pollicis abductor pollicis brevis flexor pollicis brevis adductor pollicis first volar interossei
Thenar muscle control:
opponens pollicis flexor pollicis brevis abductor pollicis brevis adductor pollicis
Muscles of opposition:
opponens pollicis and the abductor pollicis brevis
Pad to pad prehension
opposition of the pad of the thumb and fingers in the distal phalanges two jaw chuck or three haw chuck (tripod) palmar pinch
Types of psychoses:
organic psychosis functional psychosis dementials
What is the purpose of postural control?
orient the body in space, stabilize the head, maintain the CoM over the BoS stabilize the head to allow for visual tasks
cause of median nerve compression:
overuse repetitive motion inflammatory arthritis vibration diabetes kidney disease pregancy obesity and trauma
De Quervain's tenosynovitis etiology
overuse, repetitive tasks, tendon stretching, direct injury, arthritis, diabetes, pregnancy repeated ulnar deviation; ulnar deviation + wrist flexion and thumb use
precision handling:
pad to pad tip to tip pade to side
Intersection syndrome precautions
pain diabetes allergy to anti inflammatory meds, PAMS, RA
TFCC injury traumatic and degenerative description
pain and instability of wrist
De Quervain's tenosynovitis precautions
pain, diabetes, allergy to anti-inflammatory meds and PAMs, RA
Most functional splinting option with the thumb
palmar abduction
6 muscles have tendons crossing the volar aspect of the wrist and are capable of wrist flexion
palmaris longus flexor carpi radialis flexor carpi ulnaris felxor digitorum superfificalis flexor digitorum profundus flexor pollicis longus pass beneath the flexor retinaculum to prevent bowstringing
1: (evidence of contraction)
palpable or observed contraction with no joint motion -stroke victims
longitudinal arch:
passes the length of the digits
Distal transverse arch
passes through the metacarpal heads
Passive ROM
passive ROM requires gentle distraction of the joint followed by passive application of force only used when not contraindicated
Zig Zag deformity:
pathological carpal gliding
middle range
portion of range betweenn outer and inner
OT role in the ankle and foot:
positioning and orthotics energy conservation compensation in and gradual return to IADLs Shoe decisions, referral, neuropathy, pressure, ulcers, gout
Counterclockwise movement:
positive
Carpal Tunnel Syndrome- endoscopic and open release orecautions
post surgical precautions, related to wounds, infections, edema, pillar pain
forceful act of flexion in all finger joints
power grip
skillful handling and placement of an object between the fingers or between the finger and thumb (manipulating)
precision
What is the function of the fascia at the wrist?
prevent bowstringing and icnrease mechanical advantage extensor and flexor retinaculum
Primary goal for clients with back pain:
prevent chronic pain development and assist people in returning to work or ASAP
purpose of the flexor retinacula:
prevents bowstringing
Distal interossei:
produce action at the IP joints and some at the MP joint
Flexion of the DIP:
produce flexion of the PIP by a similar complex combination of active and passive forces because the DIP is flexed by the FDP and a simulataneous flexor force is applied over both joints crossed by the FDP so both DIPs and PIPs have to flex
active insufficiency
produces simultaneous movement of all joints -muslce that corsses two or more joints occurs wehn the muscle produces simultaneous movement
Digital tendon gliding exercises
promote to individual and combined excursion of FDP, FDS, and instrinsic muscles thought to diminish pressure in the carpal tunnel and preventing things from getting STICKY
Index fnger and long finger:
provides stability and does not move much for pinching motions
Concavity formed by the carpal bones:
proximal transverse arch
Walking velocity
rate of linear forward motion of the body, which can be measured in meters or centimeters per second, meters per minute, miles per hours Ex: women walk shorter and faster steps than do men at the same velocity due to height and length
Sources of error for PROM measurements:
reading wrong side, rounding, bias in measurement based on experience, submaximal effort by client, time of day, procedure error
Carpal joints in radial and ulnar deviation:
reciprocol motion of proximal row in RD and UD
Main goals for distal phalanx fractures
reduce edema and pain wound management maintenance of motion of non-involved joints increasing motion increasing strength and increasing function REINFORCE PIN SIT CARE
Initial contact: Stance phase
refers to the instant the foot of the leading extremity strikes the ground. In normal gat, the heel is the point of contact, and the event referred to as heel contact.
three functions of a volar plate:
reinforce each IP joint capsule increase stability' limit hyperextension
direct vascularization of each tendon:
vessels and vincula tendinum
How do the EDC, EI, and EDM extend the MP joints of the fingers>
via their connection to the extensor hood and sagittal bands
Distal radius fracture- external fixation interventions
with external fixator in place, pin care, edema management, AROM of uninvolved joints Upon removal: Patient education regarding pin tract care, edema control, splint immediately (never go from prolonged splint to no splint and there should always be a weaning process) AROM of U/E, scar management, strengthening (6-12 weeks)
High reliability in MMT:
with intrarater is better interrater- range of one whole grade and within one half a grade based on strength of the tester and experience
Splint for trigger digits:
with the MCP extended and use the least restrictive splint
When will double support time increase?
with the elderly
Movement at the radiocarpal and midcarpal joints:
wrist F/E and UD or RD
Functional position of the hand and wrist:
wrist complex in 20 degrees of extension 5 degrees of UD fingers moderately flexed at the MP joints (45 degrees) PIPs 30 degrees flexed DIPs slightly flexed
Opening phase of the power grip
wrist flexion and extension of the fingers to open the hand for grasp of large objects MCPs= fully extended, IPs= always flexed to a certain degree Dynamic phase- concentric muscle contraction Acheived through synergistic muscle action of the wrist flexors/finger extensors Wrist flexors= synergists keeping the wrist in a neutral position or flexion
Carpal Tunnel Syndrome endoscopic and open release interventions
wrist is protected in dression 2 to 23 days, desensitization, work hardening, sensory eval, etc. edema management, splint, scar management, nerve glides (when approved by surgeon) tendon gliding, A/AA/PROM eventual strengthen
moving body and segments
Dynamic posture
Linear velocity:
Meters/sec
inner range
from position of halfway through full range to being fully shortened
Force=
(mass)(acceleration)
Triceps:
-Affected by changes in the elbow and shoulder but NOT the forearm -Maximum isometric torque at 90 degrees elbow flexion -Active in contraction and stabilization
Peripheral nerve damage:
-Affects sensation within the appropriate peripheral nerve distribution
Augmented soft tissue mobilization for lat. epicondylitis:
-Aggressive soft tissue mobilization and instrument assisted soft tissue
Paresthesias
-An abnormal sensation, whether spontaneous or evoked -unpleasant, spontaneous, tingling burning or provoking
Elbow ROM is determined by....
- Number of joints crossed by the muscle (1 or 2) -Physiological cross section area (PCSA) -Location in relation to joint axis -Position of elbow and adjacent joints -Position of the forearm -Magnitude of applied load -Type of muscle action (eccentric, concentric, etc.) -Speed of motion (fast, slow) -Moment arm at different joint positions -Fiber types
Other purpose of tactile sensations:
- To let us know whether the food is warm and whether the bowl is too hot
When does the elbow have the greatest laxity:
-(Or Instability) in 0 to 40 degrees of flexion: loose packed
Interosseous membrane function:
--Transmits forces, stability and splinting, must avoid contraction
When is a splint used for an elbow fracture like sypracondylar?
-0-2 weeks and then it is removed daily for gentle AROM in a hinge splint which can be discharged after 6 weeks
How many degrees of freedom in the humerus/ulna/and radius?
-1 degree of freedom: Flexion and extension
Ulna/Radius degrees of freedom:
-1 degree of freedom: pronation and supination
Functional range of motion and degrees of elbow flexion:
-100 degrees of elbow flexion is needed form functional range of motion
Brachialis: greatest movement arm of more than:
-100 degrees of flexion
Peak movement for the Brachioradialis:
-100-120 degrees of flexion
What is the most functional range of elbow flexion:
-30-130 degrees of flexion
Elbow Joint mobilization is deferred (put off) until radiographic fracture union is evident or ___________ post dislocation
-6-8 weeks post dislocation
Close packed position for the Humeroradial joint
-90 degrees of elbow flexion and 5 degrees of supination
Epicondylitis
-A state of injury and delayed healing caused by inflammation and commonly referred to as tendonitis
Souter strathclyde: 3 days post op
-AROM -Perform with shoulder adducted -Static elbow extension splint between exercise and night
Modifed coonrad morrey: 3-5 days post op
-AROM and PROM initiated -No active elbow extension -Sling between exercise and elbow extension splint for the night
Which type of movement is allowed first in fracture care?
-AROM before AAROM/PROM
Excessive varus and valgus of the elbow:
-Abnormal
Sensory evaluation findings:
-Absent intact or impaired
Sensory perception skills
-Actions or behaviors a client uses to locate, identify, and respond to sensations, interpret or organize and remember sensory events via sensations that include visual, auditory proprioceptive tactile olfactory gustatory and vestibular sensations
Contradindications for Manual Therapy:
-Active Underlying disease process -Unstable fractures -Severe osteoporosis -Long-term steroid or anticoagulant use -Surgical procedures in which the tissue must be protected -Joint hyper-mobility -Conditions with a strong psycho-social component
Types of ROM:
-Active, passive, both if not contraindicated
Nonoperative tx for epicondylitis: (lateral)
-Acute: protection, rest, ice, compression, elevate -Wrist cock up orthosis of 20 degrees of extension could be used -Gentle AROM of the elbow and wrist -Transverse friction massage -Iontophoresis -Chronic: continued control of abusive forces to the forearm and modify intensity or frequency and duration of repetitive gripping or lifting activities -Counterforce brace -Heat, ice, manual therapy, deep transverse friction massage, stretching: wrist flexion, elbow extension, pronation (lateral epicondylitis) or wrist extension, elbow flexion, supination (medial) -Progressive strengthening -Education -Modification of tools -Prevention
Joint mobilization theory benefits:
-Adhesion reduction -Decreased tightness and stiffness -Pain reduction -Increased PROM and AROM
How can muscle contraction occur?
1. Depolarization of muscle fibers 2. calcium triggers the contraction by binding to troponin which activates the binding of actin to myosin 3. Contraction results 4. Connective tissue within the muscle fiber influences contraction which surround the fibers, fascicles, belly, and tendons
What are the muscles involved in gait? (9)
1. Gluetus Maximus 2. Hamstrings 3. Quads 4. Gastrocnemius 5. Tibilais Anterior 6. Soleus 7. Gluteus Medius 8. Tensor fasciae Latae 9. Gluteus medius
swan neck deformity interventions:
A/PROM intrinsic stretching exercises splinting assist is restoring balance fine motor tasks in splints promote balance between the flexors, extensors and intrinsics
Trigger finger release:
A1 pulley is incised Post op care- control swelling, genetle massage for scar management
Strength assessment:
Dynamometers, free weights, cable tensiometer, pinch meters, manual muscle testing and others
Muscle strength
A contuum from none to normal and is measured via manual muscle testing
Example of the second class lever:
A wheelbarrow, where the wheel is the axis, the resistance is the weight on the wheelbarrow, and the effort are the hands
Body weight distribution:
1/2 on heel 1/3 on metatarsals 1/6 on 1st metatarsal pathology of the ankle foot
Flexion needs: Lifting an object from the floor and pullling on a stocking
117 knee flexion
Motion required for hip flexion to tie shoelaces
120 degrees with full motion flexion
Normal angle of inclination:
125
OPtimal wrist splint positioning to prevent deformity
15 to 20 degrees of wrist extension 70 of MP flexion 0 of IP extension thumb position: plamar abduction
Prevalence of digital fracture: proximal phalanx
15-20 %
Reconstruction Model:
1918 by Baldwin
Orthopedic model:
1930 by Taylor
Kinetic model:
1950 by Dunton and Licht
Type of lever for isometric contraction:
1st class lever
Unlike the other CMC joints of the fingers, the first CMC joint of the thumb has how many degrees of freedom?
2 flexion/extension abduction/adduction axial rotation: opposition
How many degrees of motion in the knee?
2 degrees F/Ex/ Int./Ext rotation of the tibia
This extends the MP, PIP and DIP with full contraction, and can extend the wrist
EDC
OPtimal wrist poisition for power grip:
20 degrees of extension 5 degrees of UD in this position and with dynamic activity, the index and middle fingers each absorb 32% of the forces
How much less energy does sitting expend compared to standing?
20% less
Flexion needs: ____________ of tibial rotation are needed for most functional activities.
25 degrees
What type of lever pairs with eccentric contraction:
2nd class lever: setting the cup down- biceps are eccentric and triceps are concentric
The handgrip of a walker or ambulation aid should be __________ of elbow flexion when the client stands upright?
30 degrees or have the ulnar stylid be in line
Partial weight bearing
30% of body weight
Motion required to ambulate:
30-10 hyperextension 5 degrees med and lat. rotation 5 degrees ab/adduct leg moves in and out
Prevalence of digital fracture: Metacapral
30-35% boxer's fracture
Concentric contraction results in which lever?
3rd class lever where the biceps brings a cup to the mouth
Grasp is least powerful with the wrist in:
40 degrees flexion
Prevalence of digital fracture: distal phalanx
40-50 %
Most to least mobile fingers
5,4,2,3
Contraction and shortening of a muscle fiber is approximately how much of its length?
50 to 60% or the sum of sarcomeres
100 degrees of forearm rotation in pronation and supination:
50/50= half and half
How much wrist ROM is needed to accomplish most ADLs?
54 degrees flexion 60 extension, 40 ulnar deviation, 17 radial deviation
ADLs
54 degrees of flexion 60 extension 40 UD 17 RD
Center of gravity is location where:
6 inches above the pubic symphysis
Center of mass (center of gravity) location:
6 inches above the pubic symphysis
How long is movement restricted with a hip replacement?
6 weeks
Max torque at _______ of flexion in the knee extensors
60 degrees of flexion
Motion required to climb stairs
70 flexion
Motion requires to donn jeans and slacks
70 flexion
Full weight bearing:
75-100%
Prevalence of digital fracture: middle phalanx
8-12 %
The body is thus supported by only one limb for nearly _______ of the cycle
80%
Postural dysfunction: low back pain
80% often accompanied by psychological responses #1 cause-postural stress other: stenosis, fracture, tumor, infection, arthritis
Flexion needs: Climbing stairs
83 degrees
Motion required for hip flexion to sit
90 degrees
Flexion needs: Sitting in a chair
93 degrees
Flexor tendon zones: TII
A 1 pulley to the IP joint
Anything touching an object becomes what?
A FORCE
Thumb CMC joint arthroplasty
A common location for arthritis implant, trapexiectomy or soft tissue reconstruction Common: LRTI The trapezium may be trimmed but is usually exervised and the base of the first metacapral is resected Ligamentous stability: augmented by passing part of the FCR through a drill hole in the first metacarpal and then suturing it back on itself
The center of gravity demonstrates:
A connection with balance in motion
Gravity touches:
ALL OBJECTS
Motions that occur at the radiocarpal joint:
ALL motions: flexion, extension, ulnar deviation, radial devation, pronation and supination
SOme comon interventions used in the biomechanical approach:
AROM and PROM graded excersise activities Myofascial release E stem and ultra sound Stretching and splinting for protection and joint stability sensorimotor physical agent modaalities manual techniques
Extensor zones: 1
EDC inserts and mallet finger occurs
Finkelstein test
Abductor pollicis longus and EPB tenosynovitis: Dequervain's
In the OFM, independence in roles is dependent on what?
Abilites and capacities
What is the difference between an ability or a skill?
Ability: A general trait and is a combination of endowed talents and acquired skills skill: The ability to use one's knowledge to effectively and readily execute performance and enables goal achievement under conditions with consistency and economy
Arthrokinematics
Accessory motion or movement of the joint surfaces in relation to one another
Law of action-reaction
Action and reaction are opposite and equal An action of a force produces an equal reaction in the opposite direction upon an object *** balancing forces
What did Taylor use for treatment of joint and muscle dysfunction in the orthopedic model?
Activiites
Smaller units of goal-directed behavior that comprise tasks -bring together abilities and skills in a functional context
Activites
A core component of the OFM assessment process:
Activity analysis -as well as the context and environment
Testing of MMT:
Actually perform it and ends with a conclusion on grading
Conversely, overuse of joints can lead to:
Acute or chronic injury
Proximal interossei:
Affect the metacarpophalangeal joint alone
Strength is influenced bY:
Age gender type of muscle contraction muscle size (cross secitonal area) contraction speed (tension increases and concentric contraciton speed decreases) previous training effect joint positiong time of day muscle temperature fatigue
Fibers change with.....
Age and we adapt to what we are doing
A muscle whose role is to produce a desired motion at a joint
Agonist
Rotary:
All parts of the object revolves around the center of rotation movement around a center of rotation
Assessment in the OFM:
Always top down
The direction of pull involved in muscle force vectors:
Always toward the center of a muscle
Angle of inclination:
An angle made by the head and neck of the femur that occurs in the frontal plane between an axis through the head and neck and the longitudinal axis of the shaft.
Law of Inertia:
An object remains at rest or moves in a straight line until external force acts upon it
Other factors affecting muscle function:
Anatomy of origin and insertion Number of joints Passive insufficiency Sensory receptors
Structures to consider for alignment:
Ankle: neutral Knee: full extension Hip or pelvis: neutral or no ant. and post. tilt Lumbosacral/sacroiliac joints: 30 degree angle between L5 and the top of the sacrum Vertebral column (curves and normal/gentke curves( Head (anterior or forward)
Example of a concurrent force system:
Antagnoist and agonist muscles: unbalanced and push back
Muscles that produce opposite movement to the desired motion:
Antagonists
Posterior lateral stability:
Anterior and posterior bundles of lateral collateral ligament and annular ligaments
Ilio and pubofemoral:
Anterior total hip
What is torque or the moment of force?
Application of force at a distance from the center of rotation AMOUNT OF FORCE WITH ROTARY MOTION
How would one fix an intertrochanteric and femoral neck fracture?
CLosed reduction: bed rest, traction, early mobilization internal fixation: pinds, nails, scres, plates and rods
THUMB CMC clinical applicaitons
CMC OA or arthritis
Z deformity
CMC adduction, MCP hyperextension, IP joint flexion
Finger joints
CMCs MPs PIPs DIPs
active shortening of muscle:
CONCENTRIC CONTRACTION
Higher energy cost, decreased rate of ambulation
CP
Neurologic gait:
CP, Parkinsons, cerebrovascular accident, hemiplagia, ataxia
What is the general term to describe complex fractures of the wrist and hand?
CRUSH injuries
Wrist cock up splint
CTS, radial fractures
What triggers muscle contract?
Calcium
An active contraction of a dorsal interossei volar interossei and lumbrical muscle alone does what?
Can extend the PIP nd DIP completely because of their direct attachments to the central tendons and lateral bands
Function in the biomechanical approach:
Capacity for movement in the bones, joints, muscles, tendons, nerves, heart, lungs and skin as demonstrated by ROM, strength, and endurance for phsyical abilities and perofrmance skills needed in role relecant behavior inclides stabilty of joints with positioning
Flexor tendon zones: 4
Carpal tunnel where the flexor tendons lie under the transverse carpal ligament- injuries to the median and ulnar nerve
Synchondrosis joints:
Cartilaginous connection which allows for little motion and occurs between the ribs and sternum
Connective tissue is composed of:
Cells that are fixed or transient
Anatomical pulleys:
Change the direction of the force and add mechanical advantage to produce more torque
Example of an anatomic pulley:
Changes the direction of the force from the joint axis and adds mechanical advantage
Open and closed chains relate to joints in whcih way?
Changing the function of a joint will change another joint in the chain -positioning to eliminate the impact one joint has on another
active contraction of the EDC:
Createas tension on the sagittal bands of the extensor mechanism, pulls bands proximally over the MP joint and extends the proximal phalanx
What if short intermittent periods of movement are not possibe?
Due to fractures, move the surrounding joints that are not immobilized
Pain characteristics:
Chronic or Acute: Neuropathic or Nocioceptive
Capacities
Client factors and what we want to build in an intervention potential attributes that contribute to functioning once developed into abilities and skills basis of performance
Active range of motion
Clients move the joint with their own muscles
Where did the OFM originate from?
Clinical practice with persons with physical limitations and was created by Catherine Trombly Vining and was used in the OTPF
Direction of displacement:
Clockwise and counterclockwise
If the agonists and potential antagonists contract simultaneously:
Co contraction
Ligamentous or soft tissue support in the knee
Collateral ligaments: med or lateral cruciate ligaments: Anterior or posterior menisci muslces= 7 flexors or 4 extensors
Human motion:
Combination of translatory and rotational force
General displacement:
Combines translatory and rotary: HUMAN MOTION
Joint compression:
Comes together by a push the two forces that cause joint reactions
First step of orthopedic assessment:
Communicate to the patient your rationale for performing the physical assessment and the component parts of the assessment process as these are carried out: speak slowly and consicely and ask if you can touch them
Effective interaction with the social and physical environments to facilitate independence and is determined by the client
Competence
What does the effect purpose and meaning of engagement in activites influence accoridng to the biomechanical approach?
Compliance, effort, fatigue, and improvement in movement capacities
Total muscle force vector:
Concurrent force system that cumulatively applies force to a bone
Ligaments:
Connect bone to bone
Tendons:
Connect muscle to bone and transmit forces
Myotendinous junction:
Connection between muscles and tendons
Tendon:
Connects muscle to bone and allows for limited extensibility and is not stretchy
Immobilization when necessary should what?
Consider optimal positioning to deter muscle shortening and connective tissue changes
Dynamic contraction and tension:
Consider the length tension relationship AND force velocity
Kinetic friction force:
Constant as long as it is moving and overcomes the static friction force: moving a fridge
Satisfaction
Content and happy with the outcome/ reached the goal
All that influences any aspect of human functioning, including physical social personal temporal and situational influences, as well as familial and cultural beliefs and practices
Contexts
in the OFM, satisfying occupational engagement requires enabling what?
Contexts and environments
Muscular example of the 2nd class lever:
Controversial: standing on one's toes
Pathological increase in the medial angulation between the neck and shaft
Coxa valga greater angle: stress on head brings the vertical weight ebaring line closer to the shaft- decreases the stability of the hip
pathological decrease in angle of inclinaiton of femur:
Coxa vara lesser angle, stress on neck decreased angle between the head and neck Increases stability Closer to 90 degrees
Bursae:
Cushions with synovial fluid
Finger tricks:
DIP flexion with PIP extension
Valgus stress test
Damage to the collateral ligament and excessive gapping
Varus stress test
Damage to the collateral ligament and excessive gapping
Intersection syndrome vs. De quervains:
De Quervain's: first dorsal compartment with APL and EPB Intersection syndrome:repetitive wrist motion and tensosynovitis of the second dorsal compartment involving the tendons of the extensor carpi radilias brevis and extensor carpi radialis longus as they pass deep to the APL and EPB
Forearm based thumb spica splint
DeQuervain's, EPL tendonitis, CMC arthroplasty
Goals of interventions for epicondylitis and tendinopathy:
Decrease pain, restore flexibility and strength- increase occupation but for lateral epicondylitis: none were found to be gold standards
Increase the area of force application of a splint to:
Decrease the pressure on the underlying soft tissue
Benefits of optimal sitting posture:
Decreased ligament, muscle strain, decreased overstretching of back muscles less pressure of discs and less fatigue and more ROM in upper body, better breathing
Angular velocity
Degrees/sec
FOrmation and direction of ligaments:
Depends on functional needs -the way that they form and strengthen depends on what we need to do
Magnitude of force
Depends on the object and slipperiness or roughness of surface
Positioning:
Desired position of the MCP and IP joints and the integrity of the extensor digitorum in extending the MCPs and lumbricals in creating a grip position is essential
Length of a muscle's moment arm:
Determines the distance and amount of shortening in a muscle
Isokinetic exercise:
Development of testing an exercise equipment that provide for manipulation and control of some of the variables that affect for muscle function like when the angular velocity of bony compartments is present and kept constant by a mechanical device throughout a joint ROM the muscle facicles do not shorten: the resistance is directly proportional to the torque produced by the muscle at all points in the ROM The magnitude of the torque of the resistance increases proportionately
An articulated joint filled with synovial fluid
Diarthrodial Joint
Which joint allows for motion?
Diarthrodial joints
CVA and adult hmeiplagia:
Differences due to disordered motor control lack of voluntary muscle control weakness interference from abnormal muscle tone and muscle stiffness and disorganized postural control asymmetrical gait between involved and univolved extremities choppy, inefficient gait
Fatigue:
Dimished response of muscle to generate force that may be due to a lack of energy stores, Oxygen, and buildup of lactic acid or the inhibitory influencs that cause a decrease in conduction impulses
Role of the PT in gait:
Directly assess gait, determine walking goals, implement interventions to modify, adapt or improve gait COMPLETING A WHOLE GAIT ANALYSIS
contraindications for AROM and PROM and AAROM
Dislocation or unhealed fracture COntraindicated by surgery or other injury -there are many of these so pay attention to protocal Ossification
Skier's Thumb
Disruption of the ulnar collateral ligament of the thumb MP joint occurs with acute radial deviation Treat: hand based spica splint, strengthen, lateral pinching
Goniometer mobile arm:
Distal joint
DRUJ
Distal radioulnar joint
Which joints are included in the wrist?
Distal radioulnar joint Radiocarpal joint Midcarpal joint
Wrist is a functional unit of:
Distal radius and ulna Eight carpal bones proximal metacarpal ones soft tissue structures: Instrinsic and extrinsic ligaments that link carpal bones together
Distal radioulnar joint location:
Distal radius, distal ulnar, palmar radioulnar ligaments and interosseous membrane
Flexor tendon zones: 1
Distal to the FDS insertion
Frontal plane:
Divides the body in anterior and posterior halves
Transverse plane:
Divides the body in top and bottom halves
Static friction force:
Does not move: like 2 objects laying on a table
What does the femorotibial joint consist of?
Double condyloid joint. not a stable congruent joint, obliquity or angle
The complex of external factors and circumstances or structures that inhibit or facilitate occupational functioning (physical or social)
Environment
USe parallel forces t establish what in splinting?
Equilibrium
OFM Process:
Evaluation, planning, treatment, re-evaluation -identify the problem -intervene -evaluate the result
Examples of Magnitude
Examples: mass, time and length
Which muscles group is strongest in the knee?
Extensor
facilitates or restricts movement
External forces
Types of forces:
External or internal
Defining of forces:
External or internal forces
Extrinsic flexors of the fingers:
FDP and FDS FDS= PIP joints FDP= MP, PIP and DIP joints MP joints= more torque from the FDS PIP joints= more torque form the FDP because the FDS is under the FDP
predominantly flexors of the fingers:
FDS and FDP
R-A-E
FIRST CLASS LEVER
Scaphoid fracture nonoperative etiology
FOOSH as it blocks hyperextension of the wrist
scaphoid fracture
FOOSH or wrist radial deviaiton
TFCC injury traumatic and degenerative etiology
FOOSH, TFCC avulsions from ulna radius or carpal bones thinning of the TFCC genetics arthritis
What is a common injury that occurs at the TFCC?
FOOSH- Fallen on an outstreched hand injury
THA after surgery precautions
Failure to maintain precautions during healing- may result in hip dislocation
Hip fractures:
Femoral Neck Intertrochanteric fractures Subtrochanteric fractures
Three joints in the knee
Femorotibial: Medial and lateral (obliquity of the femoral shaft) femoropatellar
Angular motions:
Flexion Extension Hyperextension Abduction Adduciton Shoulder elevation
What motions are allowed at the loose surrounding capsule?
Flexion Extension at the end of bones Pronation Supination
US Torque measured in:
Foot-pound
Determines whether an object is at rest or in motion Determines how much does soemthing weighs, or how far or fast it will it go
Force
Shear force:
Force that has an action line parallel to a contacting surface and that affects movement between joints: direction is opposite to the potential movement: parallel
Concurrent force system:
Force vectors act in the same plane but not the same line- perpendicular
pelvis on femur and femur on pelvis
In abduction
ROM measurement uses:
Goniometer placement and demonstration of AROM and PROM measurements
Chronic pain:
Gradual, slow onset, long term, idiopathic
External forces types:
Gravity, compression, tensile reaction, shear:
What happens if you use a greater moment arm?
Greater strength and torque
Extrinsic finger flexors:
Gripping strength and force
Individual or group muscle testing:
Group: gross strength testing like elbow flexion and extension individual: testing individual muscles that contribute to a motion or motions like biceps brachii
What does the OFM do?
Guides the evaluation and treatment of persons with physical dysfunction leading to competence in occupational performance
Chains of action sequences that are so learned that the person does not have to pay full attention to do them: involuntary
Habits
Extensors:
Hamstrings Gluteus maximus gluteus medius post. adductor magnus muscle piriformis glut. max
Jebsen test of hand function
Hand function-simulated ADLS
Types of end feel
Hard soft firm capsular stretch
A/PROM: proceed with caution if:
In painful conditions infection or inflammed Masks medication and takes medicaiton to relax muscles because they may not respond appropriately Bone integrity is questionable Hypermobile or sublexed joint If testing will increase pain Hemophilia Hematoma Soft tissue disruption Newly healed fracture Prolonged immobilization
What may be attributed to the linkage between the PIPs and DIPs?
Oblique retinacular ligaments
WHy is biomechanical approach benefical?
Helps us design an intervention to reduce or improve underlying impairments in ROM, strength and endurance to engage in other occupations defines musculoskeletal problems and allows for a common language with other professions: find out what was happening diagnositcally assists in assistive device or orthotic desgin and appropraite recommendation uses measurement tod ocument client imitial impairment and progress
Hemiparetic gait
Hemiplagia/CVA
step length shortened on involved side and increased double support time in the stance phase which results in increased time on the involved limb
Hemiplagia/CVA
Not as stable yet extremely mobile:
Hip and shoulder joint
What is the close packed position of the hip?
Hip extension with slight abduction and medial rotation
Roll:
Hip- like a ball
Magnitude of displacement:
How big it is
closed packed position:
How tight is the contraction and the CT? SPLINT in close packed
The anatomical structure of a joint influences what?
How we use the joint ex: ball and socket shoulder joint
Cartilage:
Hyaline elastic fibrocartilage
What must happen in order for kinetic friction to occur?
IT MUST BE GREATER THAN STATIC FORCE
Evaluation in the OFM:
Identify the roles tasks and activities the person wants to do or needs to do -analyze their performance -identify inadequate performance -identify impaired abilities or capacities that contribute to inadequate performance and assess the level of impairment with assessment tools -identify environmental/contexual enablers or hindrances -interpret assessment data
Long finger flexion test
If the DIP does not flex but the PT. can flex the PIP joint, then only thr FDP tendon or nerve is compromised if the PT. cannot flex the DIP OR the PIP then the FDP and FDS tendons and nerves are compromised
How does the shape of the muscle influence shortening?
If the muscle contains parallel fibers it will shorten more than a muscle with pennate fibers
Strongest ligament and is tight which limits extension and adduction:
Iliofemoral
What can occur in the central dorsal zone?
Lister's tubercle scapholunate interval lunate base of 3rd metacarpal capitate resist for ECRB, ECRL, EDC
Visual assessment:
Look at the client's posture and see if it is consistent with the numbers: Integral part of joint ROM and muscle strength -Facial expression symmetrical or compensatory motion body posture muscle contours body proportions color condition crease of the skin
Contractile force in type 1 muscle fibers:
Low but they do not tire as fast
Active components of the extensor mechanism:
Lumbricals and interossei- intrinsics
Distal palmar crease
MCP flexion
APL and EPB tendon gliding:
MIMIC FINKELSTEIN'S gentle motion and pain free
More sacromeres in a muscle results in:
MORE SHORTENING
Cylindrical grip:
MP flexion and UD pints the fingers towards the thumb
Extensor zones: 5
MP heads joint
Overall in approaching or holding the position of the MP flexion and IP extension, both pIP and DIP insertions of the interossei muscles contribute to:
MP joint flexion
What happens if an isolated contraction of the EDC results?
MP joint hyperextension IP joint flexion= clawing
Muslce tension equals:
Magnitude of the muscle force
Reliability in PROM:
Make sure to place the axis and arms of the goni appropriately every effort needs to be made to make th epatient feel comfotable the same goni by the same tester at the same time Intrarater over interrater The reliability varies upon joint assessed AROM= more reliabile
Deformity resulting in damage to extensor tendon at DIP joint
Mallet finger
Minnesota rate of manipulation test:
Manual and gross motor dexterity
Mechanical advantage:
Measure of the mechanical efficiency of the lever system
MMT validity:
Measurements have to be accurate to be a valid representation of muscle strength for a diagnosis and prognosis -general lack of evidence to demonstrate validity in MMT -criterion related validity has ebeen compared to measures obtained with HHD Content validity: MMT measures torque producig capabilities of muscles
PROM and AROM Validity:
Measures what it is supposed to in degrees (content) and uses criterion validity to compare the scores to an accepted standard The scores must be accurate to plan treatment and test the effectiveness of the treatment Universal Goni has high content validity but criterion has not been established
A muscle positioned at its larger moment arm is said to be at:
Mechanical advantage with strength
Early motion is desirable with splints if:
Medically stable
Localize the nerve lesion
NCS
characterize cause of lesion
NCS
determine severity and prognosis
NCS
facilitate surgical planning
NCS
monitor nerve regeneration
NCS
Can the EDC alone extend the IPs?
NO
Does the tibia move on the femur?
NOT IN WEIGHT BEARING only on knee flexion and open chain motion moves approx. 30 degrees each of IR and ER
MMT reliability:
Needed to detect a true change in strength Studies used to assess the relaibility are ased on isometric or break testing techniques Interrator reliabilty with complete agreement on muscle grading is low Intrarater an dinterrater reliability within range of one whole muscle grade and interrater reliability within one half a grade is high Intratester is better: use the same therapist, at the same time, and using the same muscles, and same position witht he same protocal Stabilization of the muscles Merit in using MMT if limitations are kept in mind Limited by the strength of the examiner Not sensitive to grades 4-5 More sensitive to grades 0-3 May need to be supplemented with quanititative means: dynamometer Not equivalent to linear measurements Training and experience are important follow a strict protocol
Clockwise movement
Negative
How would you measure nerve function?
Nerve conduction studies and EMG
Close packed position of the scaphoid and capitate
Neutral complete wrist extension proximal carpals move as one unit on the radius and TFCC ligaments tight in full extension= full close packed position
Force units=
Newtons and pounds
Non weight bearing:
No weight whatsoever
Intertrochanteric fractures
Non weightbearing: 4-6 months below the neck of the femur and open/internal fixation, nail to fix Women over 50
What to feel for in PROM:
Normal limiting factors normal and pathological end feels Capsular and noncapsular patterns
hard end feel
Normal: painless abrupt hard stop to movement when bone contact bone abnormal: has pain or could be a bony grating sensation when rough surfaces go past each other
In RD/UD:
Note the glide of the carpal bones
Connecting kinesiology and orthopedics to the occupational focus of our profession:
OFM
Immobilization should be done when?
ONLY NECESSARY because tissue can shrink
What did Licht and Dunton help define in the kinetic model?
OTs role within health sciences *established activity analyses
Uniaxial joints:
One degree of motion: flexion and extension (X) pivot joint and hinge joint
Open and closed chains:
One joint may affect another- you have to cure everything
Forces at the hip:
One legged stand: 2.6 X bw slow walk 1.6 X b.w. fast 3.3 X BW run 5 X BW crutches .3 X BM stairs 2.5 BW 3 X BW
open chain to closed chain
Open: flexed closed: extended
Joint tensile forces:
Opposite pulls on the same object: equal in magnitude, opposite in direction, applied parallel to the long axis
Where should the cane be held?
Opposite side of painful condition of the hip NON painful side
Length tension relationship:
Optimal sarcomere length so there is a maximum number of cross bridges
Psychoses:
Organic cause vs. chronic pain client departs from reality hand disorders can result in a manifestation of the injury
What type of clients the biomechanical approach is used for:
Orthopedic disorders (amputations and hand injuries) Lower motor neuron disorders Burns Cardiopulmonary disease
What is the difference between a neurological gait and orthopedic gait?
Orthopedic gait correction is MORE simple
Rotary movement of the bones in space during joint motion:
Osteokinematics
Extracellular matrix:
Outside cells and is part of the Connective tissue -most of the volume of the tissue and determines the tissue's function
What requires EDC tension?
PIP extension
Boutonniere deformity non operative description
PIP is flexed and DIP is hyperextended lateral bands displace volarly force imbalance affects the PIPs and DIPs
Active or passive flexion of the DIP joint will normall initiate flexion of the _____________________________
PIP joint
active or passive flexion of the distal interphalangeal joint will normally initiate flexion of the ______
PIP joint
Middle phalanx fractures
PIPJ collateral ligament or PIPJ dislocation closed, nondisplaced, stable: fixed with buddy tape, AROM< edema control, protective orthosis, PROM, resistive exercises
Complex regional pain syndrome
Pain from an U/E injury, other NO PROM for intervention- control the pain
Why will a muscle with parallel fibers shorten more than pennate fibers?
Parallel fibers are longer and also produce a greater ROM
Shear or tangential external forces:
Parallel to the surface
At risk for L/E contracture and changes ability of the L/E to load
Parkinson's
What is dorsal to the deep transverse metacarpal ligament?
Sagittal bands on each side of the metacarpal head that connect the volar plate to the extensor digitorum communis tendon and extensor expansion These help stabilize the volar plates to the 4 metacarpal heads
Retinacular link ligaments
Pass anterior to the PIP joint axis and posterior to the DIP axis
What is the mechanical advantage of hand muscles?
Passive insufficiency and tenodesis grasp
What assists the central band and lateral bands to relax and release the extensor influence at the PIP so it can flex when the DIP is flexed?
Passive tension in the transverse retinacular ligament
Femoropatellar joint:
Patella purpose because it protects ant.knee and provides mechanical advantage of the quad ligament
______________________ in a normal sequence while rolling the walker
Patient walks
Evaluation in OFM:
Plan in collaboration with the family and person and establish short-term goals and long-term goals of successful role functioning
Force vectors:
Point of application on the object acted upon
Effort:
Point of application- such as the distal attachment (insertion) or proximal attachment (origin)
Purpose of the wrist "unit:"
Positions the hand (for grasp and dexterity) Increases the mechanical advantage of the hand muscles
Drawer sign:
Positive when ant/post displacement is possible
In wrist flexion the proximal row glides:
Posteriorly to allow tipping of the distal row
Ilio and ischofemoral ligaments:
Posterolateral total hip
What causes lunat einstability:
Pressure increases at the tip of the lunate bone
Increase the force arm by lengthening the splint to:
Prevent undue pressure on the edge of the splint
Passive insufficiency:
Prevents full ROM at joints that muscle crosses over
What is manual muscle testing?
Procedure for the evaluation of the function and strength of individual muscles and muscle groups based on effective performance of a movements in relation to the forces of gravity and manual resistance
Goniometer stationary arm:
Proximal joint
Where does the FDS split to either side of the FDP tendon so it can rejoin beneath the tendon to insert on the middle phlanx?
Proximal phalanx
Extensor zones: 6, 7, 8
Proximal to the MP EDC and EI run through here
What allows the palm and digits to conform to the shape of an object and assist with functional grasp?
Proximal/distal transverse arch and longitudinal arch
Carpal tunnel nonoperative other interventions:
Proximal: Long arm splint, cryotherapy, allow elbow and wrist AROM, nerve gliding, minimize pronation, use a wide grip, etc. Distal: wrist orthosis 3 to 4 weeks in neutral, avoid prolonged wrist flexion and extension, forceful grip or vibration
What does the radiocarpal joint consist of?
Proximally: radius, disc and pisiform Distally: scaphoid, lunate, and triquetrum bones
Categories of psychological based hand disorders:
Psychoses Neuroses Psychological problems
Limits hip abduction and ext. rotation:
Pubofemoral
Spin:
Pure rotary movement but does not have to be in the full circle
WHere do Type IIX fibers occur?
Quads and biceps
Knee extensors:
Quads: rectus femoris, vastus medialis, vastus intermedius, vastus lateralis
What is Magnitude?
Quantity of a force, amount
Joint destruction caused by an inflammatory process and results in pain stiffness or degenerative changes
RA
swan neck deformity etiology
RA, temrinal tendon injury spasticity intrinsic tightness volar plate injury fracture ligamentous laxity post surgical complication
Motion with the x axis occurs in which plane?
Sagittal plane
Location of the midcarpal joint:
Scaphoid, lunate and triquetrum between the proximal carpals
Optimal posture
Segments are aligned vertically
Self and care of the familiy
Self maintenance
Goniometer
ROM
Assessment in the biomechanical approach:
ROM and flexibility Strength Endurance activity analsis Structural stability Tissue integrity Coordination Edema
In ulnar deviation, the proximal row glides:
Radially
Joint motion:
Range of motion (active or passive) with a goniometer
Rotary motion magnitude is expressed in what?
Range of motion expressed in degrees, rotate
How is joint motion measured?
Range of motion with goniometry
What determines mechanical advantage?
Ratio of the moment arm of the effort force (elbow to DA) to the moment arm of the resistance force (rest of forearm)
Disadvantages of the biomechanical approach:
Reductionistsi and focuses on performance skills: overlook life satisfaction Focus on the physical: lack of consideration for motivation, context, role, and environment You cannot always assum that ROM, Strength, and endurance will automatically lead to functional activities and occupations
Developed capacities:
Reflect the organization of first level capacities into more mature, less reflexive and voluntary responses -more complex, form abilities and skills, develops in therapy through occupation as a means ex: fine motor skills and pinching (which derive from automatic release or reflexive grasps)
Second class lever:
Resistance force is between the axis and the point of application of the force
Scapholunate interosseous ligament:
Responsible for wrist stability because it stabilizers the scaphoid Thumb sits on the scaphoid Scaphoid instability
Superficial fascia:
Right under the dermis and is loose tissue which allows for mobility of skin
Types of arthrokinematics:
Roll slide spin
Unopposed force couples:
Rotary motion
Torque movement outcomes:
Rotary movement which occurs from force couples that are unopposed
Elastin
Rubber like and stretchy
A-R-e
SECOND CLASS
Mobility joints:
SHoulder, wrist, thumb CMC joint, MP finger joints
Forces come from:
SOMETHING TOUCHING A SEGMENT
Three cardinal planes where displacement in space occurs or where movement can happen around the axis
Sagittal Transverse Frontal
In the OFM what does life role comptetency result in?
Self-efficacy self-esteem life satisfaction
What are the major phases of the gait cycle?
Stance and swing phase
Therapist posture:
Stand with your head and trunk upright and feet shoulder width apart and knees slightly flexed and with one foot in fron of the other, the stance is in line of the direction of movement and maintain a broad base of support to attain balance
Collagen
Strength and functional integrity and resisted to tensile forces
Organic substrate:
Structural and physiological foundation for movement, cognition, perception, emotions, CNS organization, integrity of the skeletal system ex: body structures
Is the knee joint unstable or stable?
Structurally unstable and ligaments, tendons, or muscles make it stable
What is the Triangular Fibrocartilage Complex?
Structure compromised of the radioulnar disc and fibrotic attachments that provide the primary support for the distal radioulnar joint
What joint does the midtarsal joint follow?
Subtalar joint link between the hindfoot and forefoot it adds to supination and pronation and compensates for the forefoot
Assumptions of the biomechanical approach:
Successful human motor acitivty is based on phsycial mobility and strength purposefu; activities are prescribed to remediate the loss of ROM, strength, and endurance actiivites can be graded progressively to meet pariticular demands participation in acitivites involved repeated specific graded movement ot improve function If ROM strength and endurance are regained then the client can use the prerequisite skills to regain functional skills Rest and Stress: the body needs time to heal and gradulla yadd stress to the musculosekeltal and cardiovascular systems for normal function
Injection injuries
Suction hose, any subtance that is injected into the limb
Touchdown or Toe Touch Weight Bearing:
Surgical limb 10-15%% of body weight
When the foot is NOT in contact with the floor, which makes up 40% of the gait cylce
Swing phase
Inflammation:
Swollen muscles
Decreased arm swing, inability of pelvis to contribute to gait, and decreased limb advancement stooped posture., festinating gait (progressive increase in speed with shortening in stride length) propulsive gait hard to turn direction
Symptoms on parkinson's disease
Joint types:
Synarthroses or diarthroses
Muscles that help the agonist perform the desired action:
Synergists
What might ulnar positive variance cause?
TFCC impingement possible
ulnocarpal ligament complex
TFCC the ulnolunate ligament and ulnar collateral ligament
A-e-R
THIRD CLASS
PROM and AROM reliability
The arms and axis must be placed appropriately for accuracy Environmental factors: time of day, temperature of the room, type of goni used, training and experience of the tester: same tester and goni and time of day each assessment Patient factors: If they feel comfortable, pain, faitgue, feelings of stress or tension Intrarater reliability is higher than interrater in the universal goni AROM is more reliable than passive ones (exceeds it) The same position should be used each time Experience of the tester plays a big role in ROM measurements
What happens when segments or mass are altered:
The center of mass may change
Intervention in the OFM is dependent on:
The client's needs, roles, wants
Where is the talocrual joint?
The distal tibia and fibula meet the talus
Where is the moment arm located?
The distance perpendicular from the joint axis to the force vector
Which arm is bigger in a second class lever system?
The effort arm is always bigger than the resistance arm
Velocity is determined by:
The fiber type and length
zFirst level capacities:
The function and foundation of movement, cognition, perception and emotional life which is based on the organic substrate -reflex based motor actions ex: reflexive grasp
Occupation as an end:
The goal of therapy and the outcome -a higher level of functioning and reaches the desired outcome
Orienting the foot in space:
The knee shortens the leg for toes to clear and shortens or lengthens leg for functional gait
The wider the base the support......
The less likley to displace the line of gravity and the object is more stable
What does the optimal length of the sarcomeres forms?
The maximum number of cross bridges for contraction
The more complex a joint.......
The more affected the joint by injury, disease etc.
Plyometric exercise:
The muscle and tendon complex is stretched before a forceful concentric contraction and the stretch immediately before the concentric contraction helps produce a much greater torque during the concentric contraction
What does shortening of a muscle depend on?
The number of sarcomeres in the muscle itself
Efficacy
The perceived capability to perform a behavior or complete a task and belief in personal competence
Moment arm:
The perpendicular distance between forces that produce a torque (moment of force)
What is a moment arm again?
The perpendicular distance from the muscle attachment to its point of rotation or the joint acis
In the Third class lever, which arm is larger?
The resistance arm is larger than the effor arm
What we do affects _____________________________.
The structure of the joint ex: Pitching on the right arm your whole life pregnacy changes joints
Top down assessment:
The therapist determines what roles and tasks the person was responsible for in life before the accident or diseases, what they expect to be, want to be, responsible for in rehabilitation, etc. *Occupational profile -assess competence to accomplish roles
Environment and context
The who what where and when: Where occupations take place and enhances or hinders occupational performance and can be highly adaptable -better in a natura environment
Passive range of motion:
Therapist moves the joint
What is isometric tension?
There is a point of optimal isometric tension which is a stability point and is perfectly balanced
What is the issue of clockwise and counterclockwise movement?
These are not useful clinically because they depend on the perspective of the viewer
Increased flexion of the MP joint, what happens to the collateral ligaments?
They become taut
The major requirements of clients if they will be using the biomechanical approach:
They must be free to move and be relatively free of pain -need muscle control, motivation and an intact CNS
What are nerve conduction studies and EMG?
They rank second in importance only to careful history and neurological examination for acurate and localizing diagnosis of nerve entrapments and disorders of the peripheral nervous system ordered by the MD neurophysicologist
Deep fasciae:
Thick fasciae with collagenous fibers attached to muscles and bones
Which lever is mechanically disadvantaged?
Third class lever
USe a 90 degree rotational force with splints instead of:
Translational forces
Slide:
Translatory
Types of displacement:
Translatory Rotary General
Motion with the y-axis occurs in which plane?
Transverse plane
Gluteus medius gait:
Trendeleburg gait
The lateral bands are interconnected dorsally by a triangular band of fibers known as the ______________________________
Triangular or dorsal reticular ligament
An example of a disability that can happen at the annular pulley:
Trigger finger repetitive trauma or flexion to the tendon results in the formation of nodules on the tendon and thickening annilar pulley nodule gets caught and requires passive extension to unlock the stuck flexed position
Compression
Tubogrip tubipad compression gloves, coban compressive dressing
Three types of distal phalanx fractures:
Tuft fractures: nail bed or pulp injury shaft fractures: longitudinal or transverse Articular fractures: may include avulsion injuries of the distal flexor or extensor tendon (mallet finger)
Therapy for distal phalanx fractures
Tuft: protective orthosis, wound care ofr nail bed, AROM, densentization, wean off splint, resistive exercies shaft:full time use of a protective splint, desensitization AROM, passive ROM, stregthening
Torque:
Turns a lever around the axis of rotation and is a product of force
Force couple:
Two forces equal in magnitude, opposite in direction, parallel, and applied to the same object at different point
Joint reaction forces:
Two or more forces cause contact between contiguous surfaces
Composition of forces:
Two or more forces combined into one force
Double support:
Two periods of double support, occuring between the time one limb makes initial contact and the other one leaves the floor and toe off
5 factors in Kinematics:
Type Location Direction Magnitude Rate
This muscle fiber has greater endurance with sustained activity:
Type 1 fibers
What type of muscle fibers does mobility muscles likely include?
Type II muscle fibers
Fast muscle fibers:
Type IIX
These fibers fatigue fast
Type IIX
Kinematic variables:
Type of motion Location of motion in space direction of motion magnitude of motion Velocity or acceleration of change in motion
Friction forces:
Type of shear force
Force increases with what movement of the wrist:
UD
Ulnar negative variance
Ulna= too short in relation to distal radius
Ulnar dorsal zone
Ulnar head DRUJ DRUJ stress/glide Piano key test TFCC TFCC shear test Triquetrum Lunotriquetral ballotment test
Diarthrodial joint subcategories:
Uniaxial Biaxial Triaxial
Validity in PROM:
Uses criterion related validity to assess the accuracy of the instruments for assessing joint angles or positions
Thumb CMC joint
Very mobile 2 degrees of movement like F/E and Abduct or adduct
How would you measure edema?
Volumeter and digit circumference gauge
Why are these kinematics concepts important?
We need to know when human rotational and translational motion is normal and when pathology has disturbed normal kinematics
closed chain:
When BOTH ends of a segment or set of segments are constrained in some way and not free to move in space
Law of acceleration:
When a force acts on a moving object its rate of acceleration is poroportional to the force, and its direction of the force -the larger something is, the faster you have to push
open chain:
When one end of a segmnet or segments is free to move in space
What is the stance phase?
When some part of the foot is in contact with the floor, which makes up 60% f the gait cycle
Line of gravity when standing vs. sitting down:
When the line of gravity is between the feet but is perpendicular to the trunk and limbs when lying down
Ulnar positive variance:
When the ulna is long in relation to the distal radius
What is the tenodesis grasp?
When the wrist extends, the fingers flex and while the wrist flexes the fingers extend WHich is helpful to grasp and sustain grasp of objects
When NOT to use the biomechanical approach:
When they are not cognitively aware -for clients with impairments in the CNS that may result in lack of voluntary control Ex: psychological spinal cord injuries RA, inflammed joints PArkinsons Acute care
How are wrist movements coupled during dynamic tasks?
Wrist RD occurs with maximal wrist extension UD occurs with maximal wrist flexion
Approach
Wrist extension finger flexion adduction fingers close around the object and FDP is critical in free closing of hand
Most important motions for function
Wrist extension and ulnar deviation
FCR tendinopathy
Wrist flexion and associated with arthritis of the scaphotrapeziotrapezoid joint
Axes of movement:
X Y Z
Does the center of mass vary at all?
YES -may vary with weight, distribution
Active assistive range of motion:
You assist the patient move
Kinetics includes;
a defining of the forces (gravity as external) a description (source and recipient) And knowledge of some physics ( action-reaction, friction, and knowledge of the body's center of gravity)
What does the TFCC function as?
a load bearing disperser and radioulnar stabilizer for FA rotational tasks
shoulder girdle elevation
elevation of scapula and lateral end of clavicle in a cranial direction
intrinsic thumb muscles
abductor pollicis brevis, opponens pollicis, flexor pollicis brevis, adductor pollicis, and first volar interossei muscle
open reduction and internal fixation:
accurate, stable reduction with rigid fixation together with an early motion program stability achieve can allow early motion in the first 2 weeks and other therapy includes scar and edema, active exercises of the wrist in E/F, RD and UD, supination, pronation Splint and AROM of uninvolved joints, edema and scar management, wean off the splint and start AROM immediately after removing it (5-8 weeks and 9-12 weeks)
What needs to be present for the IP joints to extend?
active contraction of one or more intrisnic finger muscles active contraction of the EDC or passive stretch of the EDC muscle created by MP joint flexion resulting from an active contraction of the intrinsics
Pain
acute- hold off on muscle movement
factors that affect gait:
age gender level of activity variables related to injury, weakness, specific diagnosis
What is the purpose of the sagittal bands?
aid in stabilization at the volar plates and hood of the MP joint help prevent bowstringing of the extensor mechanism during the MP joint extension transmit force that will extend the proximal phalanx responsible for centralizing the extensor the EDC tendon over the MP joint
Grading:
apply little or no resistance
CMC osteoarthritis:
arthritis of the trapeziometacarpal joint (CMC) or adjacenet joints of the thumb thumb pain at the CMC joint, positive grind test, achy wrist more common in women than men conservative or surgical management options
Dynamic relationship between joint surfaces:
arthrokinematics
When using a cane what rule should we use:
ascend leaving with the uninvoled foot or descend leading with the involved foot with the good
Assessing motion: AROM and PROM
ask for permission expose area assess normal range on contralateral limb position patient limt substitute movements stabilization only in PROM assess PROM and End feel ROM measurement
Role of the OT in gait:
assist the PT/reinforce principles taught by physical therapists Enhance functional and SAFE gait mobility in daily task engagement: like the kitchen, bathroom, community mobility Contribute to team's understanding of gait patterns, functional use, etc.
Distal transverse:
at heads of metatarsals
How many joints do knee flexors cross?
at least two for mechanical advantage
Where is trigger finger most common?
at the A1pulley, FDS or in the thumb (FPL) most common digits: thumb, ring, middle finger snip the pulley: conservative, splint around proximal phalanx
Retinacular ligaments:
attach to the collateral ligaments and pass anterior to the PIP joint axis and posterior to the DIP joint axis tension increases as the PIP is extended PIP extension may contribute to initiate DIP extension through passive tension in the oblique retinacular ligaments the contribution of PIP extension to DIP extension via these ligaments may be significant only during the first half of the DIPs return from flexion
Non operative mallet finger etiology
avulsion rupture laceration of tendon at base of distal phalanx
Common metacarpal fracture
boxer's fracture fracture of the 5th metacarpal common when striking something with a closed fist and can be treated with closed reduction or surgically (fibrocast 6-8 weeks)
Why is the midcarpal jpint ot an anatomical unit?
because it does not form a single uninterrupted articular surface
the purpose of the deep transverse lig. from:
becoming slack through volar migration and has pulley effect on distal tendons
Desensitization:
begin with textures that the client can tolerate and add more that may be uncomofrtable return to more comforting textures apply bilterally when possiblefint
Early swing phase:
begins once the tow leaves the ground and continues until midswing or the point at which the swinging extremity is under the body: initial swing
Subtrochanteric fractures
below trochanter traction with open reduction and internal fixation: screw or plate
claw hand
benedicting sign MP extend and IP flex affects the 4th and 5th fingers and no instrinsic plus position
Guyon's canal:
between the volar and palmar carpal ligament, hook of hamate, pisiform and tranverse carpal lig.
MP joints
biaxial/condyloid- flexion and extension and abduct or adduct
Disadvantages to sitting:
blood flow decreases, build up of waste, mechanical stress, ankle and knees are 90
Structural integrity and injury:
bony contours, ligamentous laxity, muscle tone muscle tightness, pelvic angle, joint position and mobility and neurogeneic outflow or inflow
Stairs without handrail:
both feet placed at the edge of the stairs ascend place cane with involved foot bring involved foot and cane u to step with/ uninvolved foot
Phalen test
carpal tunnel syndrome: tingling or numbness in the median nerve distribution of the fingers like the thumb index middle fingers or the lat. aspect of the ring finger
Reverse phalen test:
carpal tunnel syndrome: tingling or numbness in the median nerve distribution of the fingers like the thumb index middle fingers or the lat. aspect of the ring finger
Longitudinal arches
carpals and each pf the 5 rays MCP joints MObilie or fixed
each digit has a ___________________ and ____________________ joint. Each finger has two ____________________, the _________________________________ nd _____________________________________________ and the thumb has only one.
carpometacarpal joint metacarpophalangeal joint interphalangeal joints proximal interphalangeal distal interphalangeal
How can RA cause swans neck?
cause portective spasms to interossei causing MCP flexion during finger extension
Sitting:
central component to a healthy workstation Requires 20% less energy than standing
Boutonniere deformity etiology
central slip injury at middle phalanx ruptures avulsions lacerations closed trauma burns RA Dupuytren's Contracture Congential
proximal phalanx fractures:
challenging like the middle phalanx intraarticular fractures surrounded by flexor and extensor mechanisms and other soft tissue damaged as well conservative or surgical
General neuropathic gait: differences in people with CP
changes in amplitude, timing, phasing of muscle activity coactivation of muscles instead of reciprocal inhibition and smooth muscle phasing
hand based psychological problems
chronic pain problems reflex sympathetic dystrophy neuromas phantom limb pain occ. chronic hand pain congenital deformities
Most common U/E tenosynovitis:
de quervain's Education on avoiding wrist deviation, built up handles, FA based thumb spica
MIddle Phalanx fracture
decreased PIP and DIP ROM Isolated FDS exercises are important
Carpal Tunnel Syndrome- conservative precautions and contraindications
decreased tunnel size, increased tunnel contents, neuropathic conditions, inflammatory conditions, congenital porblems Limit compressive forces (wrist flexion, work change) observe sensory loss and pain
As the object size increases, the total grip strength ____________
decreases
Gait training goals of the OT
demonstrate modified independence in kitchen mobility transporting items demonstrate safe bathroom mobility and transfers with minimal cues independent with transitional movements and use of walker in 5 days.
Psychosocial problems:
depression, anxiety,
Non operative mallet finger description
description of the terminal tendon, lack DIP extension
Dupuytren's disease
development of tendon-like cords in the ring and small fingers pathological change in the fascia causes contracture caused by over active cellular process in the fascia or hand
Proximal palmar crease
ends at the hypothenar eminence
What is the hip at risk for?
dislocation when the hip is flexed and adducted with legs crossed
Raynaud's disease or phenomenon
disorder of the blood vessels, brief periods of narrowing of the blood vessels cause paresthesias, anesthesias, considerations: vibration, prolonged grip, cold w
Velocity
displacement per unit time in a given direction linear: meters/sec Angular: degrees/sec
Speed:
displacement per unit time regardless of direction
carpometacapral joints:
distal carpal row and the bases of the second through fifth metacarpal joints
full flexion of the Proximal interphalangeal joint will prevent ____________________________________
distal interphalangeal joint from being actively extended
Flexor tendon zones: T1
distal phalanx
Flexor tendon zones: 3
distal portion of the transverse carpal ligament to the distal palmar crease or the distal end of the carpal tunnel to the A1 pulley includes lumbrical muscles
Proximal carpal arch
distal row of carpals and proximal row capitate= keystone fixed
The adjustable positions of the first fourth and fifth metacarpal heads around a fixed second and third metacarpals form a mobile _____________________________ at the level of the metacarpal heads that augments the fixed proximal transverse arch
distal transverse arch
Sagittal plane:
divides the body in right and left halves
Stabilization in MMT
done before testing at the site of attachment
This extends the IP joints if the IF LF and RF due to attachments on the extensor mechanism
dorsal and palmar interossei
The upper laminae of the TFCC-
dorsal and volar radioulnar ligaments with attach to the ulnar head and ulnar styloid
DISI wrist
dorsal inercalated segment instability scapholunate instability dorsiflexion instability
Brief period when both feet contact the ground
double support
Dr. CUMA
drop wrist- radial nerve Claw hand- ulnar nerve median nerve- ape hand
Phases of the swing phase:
early swing midswing late swing
External fixation therapy:
edema control, ulnar gutter orthosis to support the mobile transverse arch for patient commfort AROM, PROM weeks 6-12: fixator is removed and a splint can be used- slower process than internal fixation
Types of interventions:
edema management rest ice compress elevate massage, PAMs
Distal radius fraction: nonoperative precautions
edema, pain, fracture
Distal radius fracture- Open reduction/ internal fixation precautions
edema, pain, infection, scar adherance because of the fixation in early motion (within a week) is usually possible
Ulnar nerve compression conservative treatment:
education, splint to reduce swelling, anti inflammatory
What is the most common site for ulnar nerve compression?
elbow
WHat do both the NCS and EMG measure?
electrical potentials generated by nerves and muscles
General intervention for OA RA and fibromyalgia
ergonomic methods like changing movement patterns. no heavy lifting, protect the joint, broper body mechanics, work simplification, fatigue management compression gloves, wrist splints to reduce torque during heavy tasks, MCP splints, FInger and thumb splints
Pronation:
eversion, dorsiflexion, abduction too much pronation leads to flat feet
In joints......
everything influences everything: components and what the body is for- all things influences all things
What is friction force?
exists on an object whenever there is a contact force on that object
MMT process:
explain/permission/instruction screen test- applying resistance -may include Active ROM -assessment of normal stength if possible choose group or individual muscle testing patient position- isolate muscles stabilization- site of attachment testing grading- start at 3
Non operative mallet finger intervention
extend it in splint for 8 weeks to and then gradually decrease splint use client educaiton custom based splint two splints: One dorsal DIP extenion splint for the day and one volar DIP extension splin for the night prevent skin breakdown wound care and edema management
concentric muscle contraction to _______ and clear toes from ground
extend knee
The most vital function is _______ and must be presevered for positioning and in exercise/activity
extension
What motion is most conducive?
extension and radial deviation
Active extension of the PIP joint will normally be accompanied by ____________________
extension of the DIP joint
active extension of the PIP joint will normally be accompanied by the:
extension of the DIP joit
Dorsum musculature:
extensor carpi radialis longus and brevis, extensor carpi ulnaris extensor digitorum extensor idnicis extensor digiti minimi extensor pollicis longus extensor pollicis brevis abductor pollicis longus under the extensor retinaculum
Finger extensors:
extensor digitorum communis, extensor indicis, extensor digiti minimi with merge into the extensor expansion @ the MP joint
Non operative mallet finger precautions
extreme pain, edema, tape allergy, wound or skin breakdown once splinting begins: if the DIP flexes at all, there will be a disruption in the extension tendon has to be extended for 8 weeks
FUnctional movements from flexion to extension in the wrist:
from full flexion to extension dovemement initiated at the distal carpal row and metacarpals by wrist extension distal carpals glide on the proximal carpals
Sitting optimal alignment:
feet supported on the floor, neutral IR/ER, slight abduction of the hips pelvis, slight lumbar lordosis, slight thoracic kyphosis, slight cervical extension back supported arms supported immediately Head: midline, eyes, facing forward Plumb line: head, vertebral column, pelvis
Pulleys
fibrous digital sheath
purdue pegboard
fine motor dexterity measures how to pick up, manipulate, place pegs in holes with speed and accuracy
nine hole peg test
finger dexterity
These wreak havoc on the extensor mechanism and surrounding tissues or structures:
finger fractures
Boutonniere deformity interventions
first priority: PIP extension splint and this may be static or static progressive or serial casting A/PROM- MP, PIP, DIP joints maintain ROM of all uninvolved joints Joint mobs as needed eventual function tasks
Because these are not used clinically, direction of displacement is dependent on these anatomic rotations instead:
flexion and extension abduction and adduction internal (medial) rotation and external (lateral) rotation
Hip motions:
flexion and extension: sagittal abduction or adduction: frontal med or lat. rotation: transverse
What motions is the radiocarpal joint conducive to?
flexion and ulnar deviation of the wrist
Froment's sign
flexion of the DIP joint in the thumb is indicative of adductor pollicis muscle paralysis and ulnar neuropathy
Motions of the midcarpal joints:
flexion, extension, ulnar deviation, and radial deviation functional movement and moves as a single unit
extrinsic thumb muscles: 4
flexor policis longus, extensor pollicis brevis, extensor pollicis longus, and abductor pollicis longus
The only muscle responsible for thumb IP flexion?
flexor pollicis longus
Extensor is more than________________
flexors
Flexor tendon zones: 5
flexors musculoteninous junction
MP blocking splint:
for trigger finger
What affects alignment?
force, position, and posture
Boxer's injury or Metacapral fracture therapy:
forearm based orthosis wound care, edema management, full IP joint motion, ROM of uninvolved joint, early AROM, strenghtening
Functional position for hand and wrist
forearm in midposition 10 degrees of UD 20 degrees of wrist extension MPs=slightly flexed and abducted Thumb= abducted and in slight opposition IPS and DIPs are flexed (increase flexion from index to last digit)
Proximal transverse arch:
forms the carpal tunnel capitate is the keystone
Trunk in parkinson's
forward flexed kyphotic deformity compromises trunk strength and flexor and extensor groups Hip, knee, ankle, and trunk motions are all reduced
Distal radius fraction: nonoperative deacription
fracture
Tap/percussion test
fracture
compression test
fracture
Amt. of manual resistance: 5:
full ROM against gravity and maximal manual resistance
What is Dupuytren's linked to?
genetics, alcoholism, COPD, hypothyroidism, smoking
Massage
gentle- no harder than you would pet a kitten follow lympathic flow
CP weakness
gluteus max, gluteus med., quads, gastrocnemius, anterior tibialis
Abductors
gluteus minimus and medius
Capsular stretch
hard arrest to movement with some give when the jooint capsule or ligaments are stretched: involves the joint capsule and is limited within
Scaphoid fracture nonoperative precautions
healing depends on the location proximal pole > 20 weeks (high degree of nonunion) distal pole= 8-10 weeks waist=12 weeks edema, pain, nerve injury, tendon injury, stability of fracture, delayed union or nonunion
Hindfoot
heel posterior talus and calcaneous
Strength in Type IIX fibers:
high but endurance is low
Velocity in type II fibers:
higher
What does the carpal tunnel contain?
median nerve, nine extrinsic flexor tendons for the fingers and thumb
swan neck deformity description
hyperextension of the PIP and flexion of the DIP lateral bands displace dorsally and the tension to extend the DIP joint is diminished
Tendinitis:
ice, compression, elevation, rest, PAMS, anti inflammatory, splints AROM
Flexors acting upon the hip:
iliopsoas, rectus femoris, tensor fascia latae, sartorius Function to bring the swinging limb forward during ambulation
Carpal Tunnel Syndrome- conservative
impaired sensation in the radial 3.5 digits, thenar clumsiness, weakness of the lumbricals of the IF and LF
Carpal Tunnel Syndrome- conservative etiology
impingement of the median nerve in the transverse carpal ligament decreased blood flow diminished axonal transport and degeneration will occur eventually
CMC arthroplast:
implant insertion or soft tissue reconstruction
When is the CMC thumb joint close packed?
in abduction and adduction and flexion
Elastic cartilage
in ears and more elastin
When is abduction and adduction most restricted at the hand?
in flexion of the mcp joint
Over estimate scores:
in grades 4 and 5
All types of canes are held ________________________ to keep the COG over the uninvolved stringer leg and allow for normal swing pattern
in hand on opposite side of weak leg
Sequence of the power grip:
open the hand position fingers bring the fingers to object maintain the static phase
fibrocartilage, extensor mechanism, volar plate, collateral ligaaments
interphalangeal joints of the finger
clawing of the hand:
intrinsic band hand
When the lumbrical and interossei muscles contract together without any extrinsic finger muscle activity the muscles produce flexion and IP extension:
intrinsic plus
Proximal phalanx fracture:
intrinsic plus position for spliniting, digit based extension, avoid joitn flexion contractures
Supination:
inversion, plantarflexion and adduction botH the subtalar and the midtarsal joints provide 1/2 of the eversion and inversion if the feet
Patterns of grip depend on:
involvement of thrumb, degree of ROM, finger position, amt. of digitopalmar contact area
Ulnar nerve compression
irritation of the nerve at the level: pain dyesthesias deformity and dysfunction of grip and pinch strength claw hand
Other questions for clinicians:
is the CTS or another entrapment present? severity precise localization atypical features or concurrent disorders neurophysiological findings explain the patient's symptoms or signs, or are they are least consistent with them?
single support time
is the amount of time that elapses during the peirod when only ONE EXTREMITY is on the supporting surface in the gait cycle so the other leg is offf of the ground
MMT position
isolating muscles
how can RA cause Boutonnniere deformity?
it can disrupt the positioning of the extensor tendon central slip and lateral bands at the PIP joints, allowing the Boutonniere deformity to develop
Muscle strength
max amount of tension or force that a muscle or muscle group can voluntarily exert in one maximal effort- when type of contraction, limb velocity, and joint ROM is specified
What did Baldwin used in the reconstruciton model?
joint motion and muscle strength measurement: used for WWII soldiers and musculoskeletal injuries
OTs should seek to decrease what in RA?
joint pain and inflammation, protect joints, maintain ROM, prevent deformity, increase function, and slow disease progression
MP arthroplasty:
joint replacements of the MP joints, flexible implants rather than a true joint, common in people with RA due to ulnar drift and MCP joint subluxation, extensive therapy required post op.
DIP or PIP fusions
joints are fused decisions based on extent of tissue damage pack with bone fragments, pin, hold for 8-10 weeks, can still be unstable stability at each of the joints is necessary for functional use of the hand
function of the annular pulley:
keep flexor tendons close to one, allow a minimum amoint of bowstringining and migration volarly from the joint axis
pad to side prehension
key grip key pinch lateral pinch thumb is mor adducted and less rotated pad of the thumb and side of the index finger least precise
Mass of objects=
kilogram and slug
Proximal joint surface of the radius:
lateral radial facet medial radial facet articulates with the lunate TFCC- articulates with the triquetrum
What might a person do to compensate for ankle motion restriction?
laterally move the hip, increase knee flexion or circumduct the limb during swig no clearance by toes
Descending stairs:
lead with involved foot, place hand near hips of involved limb step with uninvolved foot and bring it to the involved foot and sensory step
Specific principles of ascending stairs with handrail:
lead with the unvolved foot place uninvolved hand closer to the hips of involved limb raise leg to same step
Tendon gliding:
maximizes total gliding and differential gliding of the digital flexor tendons at the wrist
Metacapral fracture
may require fixation
Precision steps:
open, position, approach fingers.
Eccentric muscles in the knee contract to ______ and slow down motion against momentum for the heel strike (initial contact with the ground)
lengthen
Neuroses
less severe than psychoses psychological reaction to stress
Distal carpal arch
level of the MC heads third metacapral mobile
LRTI Common:
ligament reconstruction and tendon interposition after resecting the trapzium
What provides stability during the static standing?
ligaments and the center of gravity
Grades of 5
limited by strength of examiner
Step length
linear distance between two successive points of contact of opposite extremities heel strike of one leg to the heel strike of the opposite one
scaphoid
links proximal and distal rows and is important for stability Most motion of carpal bones: flexion and exension source of common injruies
Extreme flexion or extension-
little ulnar or radial deviation available
Principles for all lifts:
load should be close to the body so it does not offset the COG, semi squat add handles for unstable loads maintain slight lumbar lordosis face the slope or uneven surfaces lift in the sagittal plane
Digital fracture: WHat should you consider?
location mechanism of injury degree of disruption fracture type soft tissue involvement client age general health
What is used to rest the ECU, DRUJ and the TFCC in an TFCC injury?
long arm splint with the elbow flexed and the wrist in neutral restore AROM of the flexor and extensor compartments and diminish joint stiffness Tendon glides PROM: start with pronation and supination strengthening weight bearing training/ADLs
Arches of the foot:
longitudinal, proximal transverse at anterior tarsals digital transverse
knee motion restriction
loss of motion results in the initial contact occurring in the midfoot region rather than the heel results in a shortened stride
Thumb radial coll. lig
opening a jar and results in pain during adducted activities
Middle phalanx fractures
lowest incidence closed, nondisplaced, stable-buddy taping
Extend the PIP of the IF LF and RF by the extensor hood attachments
lumbricals
What muscles insert into the extensor mechanism?
lumbricals and interossei
What are the characteristics of Trendeleburg gait
lurches toward the injured side to place the COG over the hip dropping of pelvis on unaffected side at heel strike of affected foot lateral trunk flexion to ipsilateral side might use assistive device to enable more normal gait or includes myopathic gait
backward falls:
maintain stance and press forward up against upper trunk or pelvis and assist the client to regain his balance if unable to maintain the client in standing, instruct client to release the cane and grasp the handrail and lean forward allow client to lean against the body or sit on the thigh or maneuver the client toward the loft
MAJOR GAIT PURPOSES
maintain support of the head U/E, and trunk> prevents L/E collapse Maintain upright posture and balance control the foot trajectory for clearing the ground and placing the heel or toe generate activity substantial to propel the body forward absorb energy for shock absorption and stability, or slow down or halt forward velocity
Injuries to extensor zones 1 and 2:
mallet deformity which follows disruption of the terminal extensor tendon and manifests itself in extensor DIP lag
gliding mechanismis of the flexor Reinacula, bursae, digital tendon
mechanisms for finger flexion
Position of CP:
more hip adduction flexion and med. rotation increased knee flexion during stance forefoot strike lack of dorsiflexion
NCS:
more important in diagnosing nerve entrapments and i juries, percutaneous electrode placement, can test sensory OR motor nerves and square wave stimulus is delivered at different points in the nerve
Scaphoid fracture nonoperative
most common carpal fracture distal pole- 10 % proximal pole 10 to 20 % waist 70-80 %
Describe the hip joint complex:
multiaxial ball and socket joint 3 degrees of freedom
What are gait differences in people with ataxia due to?
multiple disorders: MS cerebellar mibrain spinal disease chronic alcoholism CP
Full range of muscles:
muscle changing from full stretch to max. shortening
Outer range
muscle in full stretch to a position halfway through full range
Active insufficiency:
muscle produces simulataneous movement at all joints it corses and reaches such a short position that it no longer has the ability to develop effective tension
PArkinson's
muscle rigidity resting tremor bradykinesia akinesia all phases of gait cycle
evaluation and psychological issues
must be vigilant in monitoring and recording physical and psychological behaviors inquire about how the client is feeling take a careful history use physical examination repeatedly to establish patterns notify physician make appropriate recommendations for other referrals
Deep transverse ligament
near the flexor retinaculum and is incised during a carpal tunnel release
Keinbock's disease
necorisis of the lunate- everything crumbles
Using a walker precuations:
never oull on the walker when moving push up and on the armrests of the chair do not carry or hold items in his/her hands while using the walker
0: Ievidence of contraction)
no contraction by palpation or observation
Wrinkle test
no wrinkling indicates denervated tissue
TFCC injury traumatic and degenerative precautions or contraindications
nonoperative first 6 weeks: avoid motion and weight bearing
Pelvic motion and tilt:
normal, post. or ant. ant: hip flexion and the sacrum moves away post- brings the symphysis up and the sacrum moves closer to the femur
Soft end feel
normal: body surfaces come together a soft compression of tissue is felt adnormal: a boggy sensation that indicates synovitis or edema
firm end feel
normal: firm or springy sensation that has some give when muscle is stretched abnormal: springy or a hard arrest to movement with some give- indicates capsular or muscular shortening
Grades 4 or 5
not sensitive to strength changes in higher grades
Interventions for posture:
occupation based treatment with emphasis on proper body mechanics, energy conservation and adaptations as needed build endurance through the use of activities of daily living work closely with phsyical therapist or athletic trainer can specialize then the preparatory techniques of OT look like PT
Foot flat: stance phase
occurs after intiial contact at 7 % of the gait cycle: first instant when the foot is on the ground
Late swing
occurs after midswing when the limb is decelerating in preparation for heel strike and is known as terminal swing
Midswing
occurs approximately when the extremity passes directly beneath the body or form the end of acceleration to the beginning of deceleration
horizontal abduction
occurs at shoulder and hip when it is in 90 degrees abduction or flexion
Co contraction:
of muscles can help provide stability to a joint and represent a form of synergy
Adductors:
pectineus adductor brevis adductor longus adductor magnus gracilis muscles
Self esteem
perception of self and self concept that can be positive or negative
Types of neuroses:
personality disorders anxiety neuroses panic attacks PTSD adjustment disorders symptom magnification malingering factitious disorders clenched fists, unexplained swelling, sores that will not heal and bizarre posturing somatization neurosis somatization syndrome conversion neurosis psychogenic pain disorders hypochondrias
MD ordered and interpreted tests
physician exams' diagnostic imaging radiography----Xrays Routine special views
Distal radius fracture- external fixation precautions
pin care!!!!!!!!!!!!! edema, fracture infection
Unstable distal radius fracture fixation:
pin fixation, pins and casting, external fixation, open reduction and internal fixation
Pinch strength
pinchometer tip, lateral or 3 jaw chuck
Ulnar volar zone
pisiform hook of hamate tinel guyon's canal FCU ECU subluxation and windshield wiper test
Endoscopic release:
places a small skin incision outside of the palm to decrease palmar incision tenderness
Orthopedic conditions in gait:
quadriceps weakness knee motion restriction ankle motion restriction gluteus medius weakness
drop wrist
radial nerve palsy
What is in the radial dorsal zone?
radial styloid scaphoid 1st CMC grind test 1st dorsal component Finkelstien test RDSN: Tinel Intersection syndrome
Orientation of the hand:
radial to ulnar dorsal to volar medial to lateral proximal to distal
FUll radial deviation
radiocarpal and midcarpal joints are close packed
Volar extrinsic ligaments:
radiocarpal and ulnocarpal ligaments
Volar radiocarpal ligaments:
radioscaphocapitate radiolunate radioscaphulunate ligaments
Distal radius fracture- Open reduction/ internal fixation
radius fracture and often the ulna too
guarding during ascent
remain behind and to the side of the client hold the gait belt use a wide base of support with one foot on on step on which the client standing
Muscle endurance
repeated contractions against resistance
Intersection syndrome etiology
repetitive wrist and thumb activities
Displaced and unstable middle phalanx fractures:
require surgical intervention and OTs to see post op
Losss of balance on forward falls:
restrain the client unable to maintain client in standing
Forward falls:
restrain the client by gently and fimrly pulling on the gait belt and shoulder move closer to client and maintain your stance as you who assist him/her regain their balance and stand erect if unable to maintain standing position, instruct to reach off the handrail and lower the client to the stair
backward falls loss of balance
restraint the client by pulling froward and move closer to the client while minimizing stancne, regain her/his balance unable to maintain: instructs client to release the cane
Criterion validity in MMT:
results have been compaired to HHD
deep to the deep transverse metacarpal ligament
sagittal bands that connect each volar plate extensor expansion
Contraindications in MMT:
same as AROM and PROM with inflammation and pain presence
What are active components in the extensor mechanism?
the dorsal interossei and volar interossei and lumbrical muscles which may also contribute to the central tendon and the lateral bands
Trigger finger:
stenosing tenosynovitis of the digital flexor Stenosis at the A1 pulley and tenderness with pain with reisisted grip and painful catching or locking of the fingers splinting: MP neutral to prevent digital flexion
Three different gaits for canes:
step to gait cane together gait cane first gait
Types of lifts:
stoop squat freestyle trunk kinetic load kinetic
Torque:
strength of rotary motion
Kinesiology:
study of muscles and body movmement:
pronation and supination:
subtalr
Hyperextension of PIP and flexion of DIP
swans neck
Nonsynovial joints with little movement:
synarthrodial joints
De Quervain's tenosynovitis
synovitis of the first dorsal compartment of the wrist EPB and APL
Distal to the extensor hood:
the extensor digitorum splits into three bands Central, Terminal, Lateral
In order to produce interphalangeal extension, the extensor digitorum communis muscle requires the assistance of two intrisnic muscle groups that also have attachments to what?
the extensor hood and lateral bands
Dorsi and plantar flexion
talocrural
five joints at the ankle joint:
talocrural subtalar midtarsal tarsometatarsal metatarsophalangeal
flexion and extension
tarsometatarsal
Ligaments in the Thumb CMC are _____ in abduction or adduction
taut
PIPs or thumb IP collateral ligaments:
taut in F/E important for stability radial more likely to be injured
ACL cruciate ligament:
taut in extension prevents ant. displacement of the tibia on femur (with knee flexed)
PCL
taut in flexion prevents post. displacement of tibia on the femur (with knee flexed)
Joint capsule of the MP joint
taut in flexion and lax in extension
COllateral ligaments of the MP joints
taut in flexion which limits abd-adduction
Stance time
te amount of time that elapses during the stance phase of one extremity in a gait cycle: think initial contact with the ground
Intervention in the biomechanical approach
teaching new skills behaviors or habits or modifying performance skills and patterns change the biological, phsyological, or neurological process to decrease pain or impairments by doing certain tasks
Extensor pollicis longus tendinopathy:
tendinitis of the extensor pollicis longus reveals pain and swelling at the Lister's tubercle
WHat is all included in the extensor mechanism?
tendons of the EDC extensor hood central tendon' lateral bands that merge into the terminal tendon triagnular ligament sagittal bands dorsal retinacular ligaent dorsal interossei volar interossei lumbricals oblique retinacular ligaments
Intersection syndrome
tenosynovitis of the 2nd dorsal compartment ECRB and ECRL pain, edema, crepitus, 4-6 cm proximal to the Lister's tubercle weak pinch and grip
instrinsic ligaments
that intercpmmect the carpals themselves and are also known as intercarpal or interosseous ligaments within the synovial fluid
tip to tip prehension
the IP joints of the finger and thumb must have range and force to create nearly all flexion most precise tip pinch pincer pinch
When the EDC, interossei and lumbricals contract at the same time:
the MP joint will extend with torque that exceeds that of flexion
However, if one or more of the intrinsics contractions without the EDC, what happens?
the MP joint will flex because the intrinsics pass volar to the mp joint axis and passive tension assists with active intrinsic muscles
Stride duration
the amount of tume it takes to accomplish one stride: synonymous with the gait cycle
Why can't the DIP joint be extended actively when the PIP joint is fully flexed?
the central tendon is being stretched and the increasing tension pulls the extensor hood distally which releases tension in the lateral bands and this releases tension in the terminal tendon at the distal phalanx but it completely eliminates any extensor force at the distal interphalangeal joint
distal to the extensor hood, the EDC at each finger splits into three bands:
the central tendon= base of the middle phalanx two lateral bands= rejoin the terminal tendon to insert into the base of the distal phalanx
extensor pollicis longus tendinopathy:
third dorsal compartment: common in patients with RA or with direct injury or distal radius fracture could be treated with a solit, PAMs, corticosteroids, deep friction massage, isometric exercises
Main function of the extrinsic thumb muscles:
to extend the thumb back near the palm
Triaxial joints
three degrees of freedom (X Y Z axes) All movements plane and ball and socket joints
Thumb arthoplasty interventions:
thumb spica cast, and then later fitted to a FA based thumb spica splint, AROM of the CMC at 4-6 weeks, edema control, pain management, AAROM, strengthening
Therapy for UCL and RCL tears of the thumb
thumb spica splint, strengthening ingrip and pinch In incomplete tears you can use buddy staps
Ligaments in the radiocarpal joint:
ulnar and radial collateral anterior and posterior
optimal range to maximize grip strength output
ulnar deviation
ulna is short in comparison with the radius
ulnar negative variance avascular necrosis of the lunate- kienbock's disease
ulna is long in comparison to the radius
ulnar positive variance distal radial fracture
In radial deviation, the proximal row glides:
ulnarlly
Characteristics of gait in ataxia:
uneven step length irregular width absent rhythm high stepping relationship between the stance and swing phases is altered absent arm swing
What is an ulnar head resection?
unload ulnocarpal articulation and often radioulnar articulation performed due to pain at the DRUJ and the ulna is reshaped or resectioned to relieve pain Therapy typically includes a long arm splint and then transferred to a wrist splint, strengthening, AROM exercises in wrist flexion and extension
External fixation:
unstable unreduceable, extra articular distal radius fractures, displace intra artciular fractures that can be reduced by percutaneous means and highly comminuted distal radius fractured that are reduced openly, fixed with pins
Boutonniere deformity precautions
untreated can lead to MP hyperextension, further damage, monitor skin integrity when splinting RA, burns, diabetes, steroid use prevent extensor tendon rupture, reduce pain and swelling, prevent pIP joint flexion contracture, prevent lateral band subluxation, prevent ligament contracture
Orientation of the Y-axis
up and down
Simultaneous MP PIP and DIP flexion
use all available extensor mechanism slack
Joint mobs
use with caution and only when not contraindicated indicated with ligament shortening due to immobilization and other injuries wrist distraction with ant. post. glide PIP joint distraction with ant. post. glide
client positioning with MMT:
used to isolate specific muscles or muscle groups full outer range with slight tesnion patient comfort
Grip and strength measurement
uses a dynamometer position: elbow flexed to 90, shoulder adducted, forearm neutral and wrist between 0 and 30 of extension and up to 15 of UD
Scaphoid fracture nonoperative interventions
usually casted tendon fliding and AROM for fingers and uninvolved joints edema management cast post cast removal AROM of wrist once cast is removed PROM when fully healed and ordered by MD strengthening when permitted
EMG:
usually necessary to provide complementary information, needle electrode inserted into the muscle, records electrical activity on the need insertion, spontaneous activity in the resting muscle and motor unit potentials with voluntary contraction
WHen does the center of gravity change?
with body positon and movement *** goes towards the heavier end
VISI wrist
volar intercalated segment instability volar rotation of the scaphoid and lunate with extension of the triquetrum with lunotriquetral instability
Intrarticular middle phalanx fractures
volar or dorsal dislocation common challenging due to likely disruption of soft tissue structures PIP joint is most likely to lose motion Intervention: dependent on consideraitons mentioned earlier and communicating with MD to understand mechanism of injury
Flexor gliding mechanisms of the MP joint review:
volar plate longitiduinal fibers of the MP joint capsule Deep transverse MP ligament FDP tendon FDS tendon' digital tendon sheath A1 annular pulley
swan neck deformity precuaitons
volar plate laxity intrinsic tightness dynamic imbalance systemic or neurological conditions
FCU tendinopathy
volar ulnar side of the wrist with pain around the pisiform avoid writ flexion and UD
example of an open chain
waving hands in the air like you just don't care
Trendelenburg gait
weakened gluteus medius primary injury to muscle or secondary due to other issues
What is the knee joint functions of?
weight- bearing Mobility (rotational) shock absoprtion gait raise and lower the body in space orient the foot in space
Extensor mechanism summary
when the PIP extends, the DIP extends DIP cannot actively extend with PIP flexed when the DIP actively flexes the PIP actively flexes
Step width
width of walking base and may be found by measuring the linear distance bewtween the midpoint of the heel of one fooot and the same point on the other foot
When shoudl you use ice?
with an acute injury for vasoconstriction to prevent inflammation
