OrthoRehab Exam 1
Describe how to assess amount of swelling using the figure 8 technique (and practice this with a measuring tape or piece of string, etc.):
(1) on the radial/volar side of the wrist, the beginning of the distal edge of the tape measure was aligned with the distal wrist crease; the wrist crease was operationally defined as the most distal crease on the volar surface of the forearm that is continuous between the tendons of the flexor carpi ulnaris and the abductor pollicis longus (2) the tape measure was drawn in an ulnar direction along the wrist staying proximal to the distal wrist crease until passing over the tendon of the flexor carpi ulnaris; (3) at the level of the tendon of the flexor carpi ulnaris, the tape was directed distal and oblique across the dorsum of the hand, passing over the midpoint of the second metacarpal head with the distal edge of the tape aligned with the radial aspect of the palmar digital crease of the 2nd digit (4) at the palmar crease of the second digit, the tape was drawn in an ulnar direction across the palmar surface with the distal edge aligned with the palmar digital crease of the fifth digit; (5) continuing over the palmar crease of the fifth digit, the tape was drawn back across the dorsum of the hand in a proximal oblique direction, passing over the tendon of the abductor pollicis longus; (6) at the dorsum near the tendon of the abductor pollicis longus, the distal edge of the tape was realigned with the distal crease and directed back to the starting point
Describe how the scalenes, first rib, and clavicle can contribute to thoracic outlet syndrome
- Scalene o If short, tight, or stiff, can squeeze the Brachial plexus - First rib o If scalene tight, pull first rib up, put pressure on brachial plexus - Clavicle o Brachial plexus must go under, so is clavicle depressed, puts pressure on brachial plexus
Explain how to differentiate possible causes of pain ("Clinical Problem Solving"): Pain present with compression but not distraction:
- due to a problem at the joint surface (thinning/loss of cartilage, inflammation in the joint, bone spur)
Explain how to differentiate possible causes of pain ("Clinical Problem Solving"): Pain with AROM and not PROM
- most likely muscle/tendon
How can you tell the difference between joint tightness (joint contracture) and multi-joint muscle-tendon unit tightness (passive insufficiency)?
-Joint tightness: confirmed if PROM does not change despite repositioning of proximal or distal joints -Musculotendinous tightness: confirmed if the PROM of a joint changes with repositioning of adjacent joints that are crossed by that particular muscle-tendon unit; can cause joint tightness
Describe the origin, insertion, and action of each rotator cuff muscle: Subscapularis:
-Prox. attachment: supraspinous fossa; -distal attachment: superior facet of greater tubercle of humerus -movement
What is contracture and what is the treatment?
-caused by collateral ligament tightness, adhesions, or mechanical block -treatment: promote PROM and AROM with same exercises & with corrective orthoses
Describe 4 characteristics of scar that you would assess: -color -size -flat/raised -adhesion
-color: begin deep red and gradually become lighter -size: use a ruler to measure length and width -flat/ raised: use observation and palpation, if scar is raised use terms mild or moderate, if lump under skin: scar and fluid (can be decrease by size and height) -adhesion: observation and palpation, some can be seen during active motion, assess adhesions of skin to underlying tissue by palpation, describe as: mild, moderate, severe
What method is used to decrease scar sensitivity?
-desensitization
What considerations do you need to make if "aggressive therapy" is ordered?
-explain to client that doc wants them to make a lot of progress, but the hand tissues are delicate and can easily be injured, will work to correct the injured tissues and you will make the best progress by providing controlled stress to the correct structures, too much with delay progress. With will aggressively upgrade program and encourage max results
What method is used to decrease functional limitations resulting from a sensitive scar?
-if sensitivity cause functional limitations: protection (padding or silicon gel may help) -padding and gel help facilitate scar maturation
3 points of force are needed to control a joint's movement in one direction
-in order to prevent further flexion at the PIP joint, force would have to be applied at the locations and in the directions shown by the three arrows. Remove any one of these, and you lose control over that joint in the specified direction. ➢ To control joint movement in two directions (e.g., both flexion and extension), six points of control are needed.
What is a "chip bag" and what is it for?
-incorporated into orthotic regimens to maximize lymphatic flow and minimize stiffness and adherence that otherwise would worsen as a result of edema -cotton stockinette bag filled with small foam pieces of various densities -used in lymphedema treatment
What interventions are generally appropriate in each stage of tissue healing? -inflammation -fibroplasia -maturation
-inflammation phase: right after for a few days; immobilization (often advised); -fibroplasia phase: 4 days after and lasts 2-6 weeks; AROM and orthotics -maturation(remodeling) phase: may last years; resistive exercises, monitor for inflammatory response, dynamic or static orthoses
Describe 5 aspects of pain that are important to assess:
-level of pain: pain scale -location of pain: have them point to the area of pain -type of pain: describe the pain (throbbing, aching, sharp, stabbing, shooting, burning, hypersensitive to light touch -frequency or cause of pain: constant or intermittent, what causes the pain -duration of pain: how long have they had the pain
What is the difference between pitting and brawny edema?
-pitting edema: made up of large amounts of free fluid in the tissue that can be displaced by pressure, leaving a pit that slowly fills back up when pressure is removed -brawny edema: firmer edema, cause by interstitial fluid becoming clogged and preventing it from moving easily
Describe the origin, insertion, and action of each rotator cuff muscle: Infraspinatus
-proximal attachment: infraspinous fossa of scapula -distal attachment: middle facet of great tubercle of humerus -Movement: lateral rotation
Describe the origin, insertion, and action of each rotator cuff muscle: Supraspinatus
-proximal attachment: subscapular fossa -distal attachment: lesser tubercle of humerus -Movement: medial rotation and adduction
Describe the origin, insertion, and action of each rotator cuff muscle: Teres Minor
-proximal attachment: superior part of lateral border of scapula -distal attachment: inferior facet of greater tubercle of humerus -Movement: lateral rotation
What are Blocking exercises and when are they used
-proximal support is provided to promote isolated motion at a particular site; exert more force than nonblocking exercises -use for clients with AROM or PROM limitation o Using AROM to improve PROM o Active stretch: pushing into resistance o Immobilize everything proximal to joint and all of the force will go to the joint you want § Want DIP flexion, only allow FDP movement at DIP
What does the quadragia effect tell us about orthopedic occupational therapy?
-quadragia effect: interconnectedness of digits -restricting movement in one finger (holding pointer in extension) reduces movement for all other fingers (hard to flex other fingers) -clients can be limited in motion in areas not originally injured-EVALUATE BEYOND THE INJURY
Describe 6 aspects of a wound that are important to assess: -size -depth -color -drainage -odor -temp
-size: length and width, trace wound for future comparison, DO NOT touch wound with ruler unless sterile -depth: measure with sterile cotton swab -color: red, yellow, or black. Many have a combo of the 3 and progress through stages of the colors - red: moist and heathy granulation tissue, pinkà re, prerequisite for wound healing -yellow: soft and sticky slough (necrotic tissue), creamàyellow, slough in the wound is increased infection risk -black: semifirm to hard eschar (necrotic tissue that is dry and adheres to wound bed, leather-like appearance, greyàblack, eschar increases infection, doesn't let wound heal and must be removed. -drainage: quantify the amount and color of drainage -clearàlight pink: normal in small amounts -cloudy thick drainage (yellowàtan): possible infection -thick (green, brown, tan, or yellow): never normal and indicated infection -odor: note any odor, unpleasant odor typically = infection, sweet smelling odor can also = infection -temperature: compare tissue around the wound with temp of unaffected area, warmer tissue around could= infection
List some observations that a clinician might make regarding a patient's edema:
-skin becomes shiny and tauter with loss of wrinkles or joint creases -document appearance of the skin -shiny, dry, partial or ful loss of joint creases, color of skin (redness, bluish, or pallor)
What is lag and what is the treatment?
-unable to actively extend the PIP joint as far as is possible passively; caused by adhesions, disruptions of musculotendinous unit or weakness -treatment: promote active movement (blocking exercises, tendon gliding exercises, place and hold exercises, dynamic or static orthoses can be helpful
When planning treatment interventions, what must a therapist know in addition to the patient's limitations in ROM, strength, and ADL?
-what structures are restricted -how restriction affect function -target treatment to particular tissues
List the structures in each of the 6 dorsal wrist compartments
1:EPB, APL 2:ECRL, ECRB 3:EPL 4: ED and EI 5:EDM 6:ECU
What part of the hand is the "immobile central segment" (called the "fixed unit of the hand" in Kinesiology) that you must control in order to control wrist motion?
2nd and 3rd metacarpal
Describe how to perform the following grip tests, and the purpose of each type of grip test: standard
3 trials on the second handle-width setting, use the average as the test result
Orthosis Fabrication: use of heat gun
A heat gun can be very useful for spot heating areas that are difficult to dip in the splint tank. A heat gun is also useful for heating sticky back Velcro for better adhesion. A pinpoint nozzle can help focus the heat with lightweight materials like Orfilight. A heat gun can start materials on fire, so use caution!
What is wrist tenodesis and how can it be used functionally?
Action of: wrist extension producing finger flexion OR wrist flexion producing finger extension In nerve injury: tenodesis is harnessed by orthoses to provide function
Name at least two techniques for donning the body-powered prosthesis and describe them.
Coat method: residual limb is inserted into the socket while the harness and axilla loop dangle behind back. Sound hand reaches around the back and slips into the axilla loop, Pullover method: prothesis positioned face up, places residual limb in the socket and threads the opposite arm through the harness, person raises both arms above head, allowing axilla loop to slide down to the axilla and harness to be positioned
Describe the role of the OT in the orthotic fabrication process.
Design and construct orthosis Orthotics falls under preparatory method: splints and used to enhance participation in occupation
What trim lines are needed for full MCP joint flexion in an orthosis?
Distal trim lines that fall proximal to the MP crease
Volar Wrist Hand Finger Orthosis (Resting Pan Orthosis) Dx: Rx: Material:
Dx: CVA with UE spasticity Rx: Resting Pan Orthosis, wrist in 0° of extension, 0° deviation, fingers in comfortable longitudinal arch, appropriate distal transverse arch (continued through the phalanges), and thumb in comfortable palmar abduction (not end range). Material: is North Coast Medical Solaris, 1% perforated, with 4 orthoses per 18" x 24" x 1/8" sheet, CushionStrap strapping, and Velcro Extra Sticky Back Hook. -or- Performance Health Rolyan Ezeform, 1% perforated, with 4 orthoses per 18" x 24" x 1/8" sheet, R-Securable strapping, and self-adhesive Velcro hook.
Volar Wrist Hand Orthosis (Wrist Cock-up Orthosis) Dx: Rx: Material
Dx: S/P ORIF distal radius fracture Rx: Wrist Cock-up Orthosis, wrist in 20° of extension, 0° deviation, fingers and thumb and fingers fully free to move. Material: is North Coast Medical "Clinic," 1% perforated, with 6 orthoses per 18" x 24" x 1/8" sheet, CushionStrap strapping, and Velcro Extra Sticky Back Hook.
Describe the axis of motion of forearm rotation, and discuss how it affects the fit of an orthosis.
Elbow and distal forearm, axes of rotation center of radial head and capitulum Pronation: ulnar styloid moves laterally and radial styloid medially Supination: ulnar styloid moves medially Midline lines drawn in supination shift dramatically in pronation If the forearm is not pronated before the orthotic material is set, the trim lines will be high on the radial border and low on the ulnar border
Define the terms friction, torque, and stress.
Friction: when one surface impedes or prevents gliding of a surface on another Torque: measure of force that results in rotation of lever around an axis Stress: resistance to any force that strains or deforms tissue
List the motions used to operate the body-powered prosthesis.
GH flexion Scapular abduction or adduction Shoulder depression or elevation Chest expansion Elbow flexion
Properties of thermoplastic orthotic material: Thickness
Generally, the thicker the material, the stronger it is. Thicknesses range from 1/16" (1.6mm) to 1/12" (2mm) to 3/32" (2.5mm) to 1/8" (3.2mm) to 3/16" (4.2mm).
Describe how to perform the following sensation tests: Touch/Pressure threshold test:
Green Normal light touch threshold 1.65 to 2.83 Blue Diminished light touch 3.22 to 3.61 Purple Diminished protective sensation 3.84 to 4.31 Red Loss of protective sensation 4.56 to 6.65 Untestable Unable to feel largest monofilament —" Step 1: describe test to client Step 2: support client's hand on a rolled towel to prevent the fingers from moving with touch Step 3: occlude the client's vision with a screen/folder Step 4: instruct client to respond with "touch" each time touch is felt Step 5: begin with the largest monofilament in normal category, proceed to larger is no response Step 6: for small monofilaments (size 1.65-4.08) the filament needs to be applied for 3 trials. One correct response to 3 trials is considered correct, all larger monofilaments are applied only one time for each trial Step 7: begin distally and move proximally Step 8: apply the monofilament perpendicular to the skin until the monofilament bends. Apply slowly (1-1.5 seconds) to skin, hold for 1-1.5 seconds, lift slowly (1-1.5 seconds Step 9: record on a hand map that monofilament size that the client correctly perceives
Name at least four postsurgical factors that can interfere with prosthetic training and rehabilitation. How is each factor managed?
Hypersensitivity: desensitization with soft textures moving to rougher textures Phantom limb pain: isometric exercises, analgesics, acupunctures, electrical nerve stimulation Phantom limb sensation: myoelectric prosthesis Neuroma: steroid injections, redirect nerve into padded area, tie nerve ending,
Define the "golden window" and identify its importance in upper extremity amputation rehabilitation.
Implement comprehensive exercise program to maintain and increase ROM and strengthening- 30 days of never fitting
In what position should the therapist fabricate an orthosis for a patient who is acquiring these deformities after trauma?
Intrinsic-plus position (wrist neutral, MP flexed, IP extended, thumb abduction with opposition)
Why is tip prehension considered to be a dynamic prehension pattern rather than static?
Necessary for picking up a pin or coin IP joint of thumb and DIP and PIP joints of finger are flexed to facilitate tip-to-tip prehension, it shifts from Tip to palmar (tip=touching thumb to pointer tip)
Orthosis Fabrication: bonding
Non-coated thermoplastic material can be bonded to itself by first dry-heating it with a heat gun, then pressing the pieces firmly together.
How can translational forces reduce the effectiveness of an outrigger? (Think vectors!)
Outrigger has to have a 90 degree angle in order to avoid translational force, if finger moves at all, 90 degree angle changes , undermines effectiveness of orthosis because it shortens lever arms
What is extrinsic extensor tightness?
PIP and DIP flexion is limited when the MP joint is passively flexed; passive composite digital flexion is more limited with the wrist flexed than with the wrist extended
Properties of thermoplastic orthotic material: solid/perforated
Perforated materials allow for some air exchange and less maceration of the skin. They are also easier to cut in a straight line with a knife! 1% Perf is standard for most 1/8" thick materials; Orfit comes microperforated as well. Too much perforation results in rough orthotic edges that are irritating to the client.
Name the three major nerves that supply the hand and describe their sensory innervation patterns.
Radial: dorsal radial side of hand up to the midline of ring finger Median: palmar radial side and dorsal tips of index and long Ulnar:palmar and dorsal ulnar side of hand
Describe the motor and sensory innervations of the following nerves: Radial: Ulnar: Median
Radial: muscle the originate from lateral epicondyle Ulnar: flexor muscles on the ulnar side Median: flexor muscles on radial side
Describe the three different purposes of orthosis fabrication.
Restriction: limit joint ROM but don't completely stop motion Immobilization: fabricated for protection to prevent injury, rest to reduce inflammation, of to ensure proper healing Mobilization: increase limited ROM or to restore function
Name three ADLs that should be addressed immediately after amputation.
Self-feeding Toileting Oral hygine
Properties of thermoplastic orthotic material: Working time
Some materials harden very quickly once removed from heat, while others stay soft for several minutes. Short Working Time - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Longer Working Time Orfilight, Technofit -->TailorSplint, Orfit -->Polyform Ezeform Aquaplast
Properties of thermoplastic orthotic material: Coated
Some materials have a non-stick coating that keep it from sticking to itself. Unfortunately, the non-stick coating also keeps self-adhesive Velcro from sticking to these materials as well. You can use solvent to remove the coating, but solvent carries some significant hazards (cancer, infertility, highly combustible). If you can smell the solvent, you are getting too much exposure. When using uncoated materials like Orfit, add dish soap or liquid hand soap to the water in the splint tank to keep it from sticking to itself too much.
Properties of thermoplastic orthotic material: Drape/stiffness:
Some materials have more "drape," that is they will conform to the hand contours just by the influence of gravity (if you have positioned the patient so that gravity works for you). Other materials are stiffer and require the therapist to do more work to form the contours. Less Drape - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - >More Drape Ezeform -->Orfit, TailorSplint -->Polyform
Properties of thermoplastic orthotic material: Memory
Some materials spring back to their original shape when re-heated; this property is called memory. Less Memory - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -> More Memory Polyform, Ezeform --> TailorSplint--> Orfit
Properties of thermoplastic orthotic material: ❖ Resistance to stretch:
Some materials stretch easily, while others take a bit of effort to stretch. Less Stretch - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -> Easily Stretched Ezeform -->TailorSplint--> Orfit --> Polyform
Describe how to assess amount of swelling Using circumferential measurement (practice):
Step 1: apply tape measure around area to be measured Step 2: tighten lightly Step 3: record circumference. Note where tape was placed for example 4 cm proximal to radial styloid and distal ulna, proximal phalanx or PIP joint
Describe how to assess amount of swelling Using a volumeter
Step 1: fill calumet with room temp water to point of overflow Step 2: position the hand so that the palm faces the client and the thumb faces the spout of the volumeter. Keep hand as vertical as possible and avoid contact with he side of volumeter Step 3: lower hand slowly into the volumeter until dowel in volumeter is firmly seated between the middle and ring fingers, collect displaced water in beaker, hold hand still until water stops dripping Step 4: pour displaced water from collection beaker into the graduated cylinder for final measurement Step 5: repeat previous steps if you would like avg. results Step 6: compare the vol. to that of the other hand and determine a relative normal for the individual, the difference between the two extremities is most valuable info MDD: 10 ml
Describe how to perform the following sensation tests: Static two-point discrimination:
Step 1: instruct client to respond to each touch, with vision occluded, by saying Note that the client should be instructed to say "One prong," "Two prongs," or "I can't tell," with "I can't tell" counting as an incorrect response. (Moberg, 1991) Step 2: support the client's hand to avoid movement of fingers when touched by the points, puttly commonly is used for support Step 3: occlude the vision, begin at 5 mm, touch clients fingertip with 1 or 2 points randomly applied Step 4: force of touch pressure is just to the point of blanching, in longitudinal direction to avoid crossing digital nerve innervation in finger Step 5: increase or decrease the distance between the two points, if client is unable to discriminate two points at 5 mm, increase distance, if client can discriminate decrease distance, determine smallest distance Step 6: begin distally and work proximally from fingertips to distal palmar crease 7/10 resposes for a score
Orthosis Fabrication: Stockinette
Stockinette can be applied to the extremity before forming an orthosis to improve patient comfort. This is especially important when splinting a child or geriatric parient or when splinting a burn patient. Two or three inch stockinette works well. Some materials (Ezeform) feel hotter and retain heat longer, so stockinette is more necessary for these materials. ➢ Some patients will prefer to wear stockinette under their orthosis all the time for comfort, usually with larger splints.
Discuss the impact of the residual limb status on successful fitting and operation of an upper limb prosthesis.
Swelling, allodenia and shaping of residual limb all affects fitting
Orthosis Fabrication: tracing patterns onto thermoplastic
The neatest way to do this is with a scratch awl. Other methods include using a ballpoint pin (depending on the brand, the ink may be easily removed with an alcohol wipe), or using a china marker or grease pencil. In any case, be sure to cut away or remove your markings for a clean look.
Orthosis Fabrication: splint tank temp
The temperature of the water in your splint tank should be around 170°, minimum of 160° and maximum of 180°. The water in your splint tank can cool rapidly when the cover is off, so please keep the cover closed when not accessing the tank. Keeping more (deeper) water in the tank will slow the rate of cooling when the cover is off.
What is the purpose of a shrinker?
To decrease edema and promote optimal limb shaping
What is the commonly accepted position for a resting orthosis (also called "safe position")?
Wrist in 25-35 extension, MP joints in 60-70 degress of flexion, PIP and DIP 10-35 extension
What is the typical deformity position of the hand and wrist due to edema after injury?
Wrist: flexion MCP: hyperextension PIP and DIP: flexion thumb: adduction
Describe the following concepts: PROM
ability of the joint to be moved through its normal arc of motion while relaxed, motion provided by outside source. Limitation indicate joint problems, tightness of muscle/tendon group opposing the motion
controls training
achieve smooth movement of the prosthesis with minimal delay, joint protection, energy conservation and work simplification
functional training
applies concepts for controls and use of prosthesis for automatic, spontaneous, smooth movements
use training
apply mechanics of operation to activities
static progressive orthoses:
apply mobilizing force using nonmoving parts such as monofilament, Velcro and screws o Promote motion o Increase PROM o Client changes positioning of the orthoses when it starts to feel loose to take advantage of increase length § Screws, Velcro,
Describe the following assessment tools for vascular changes: Modified Allen's Test
assess status of blood supply within hand through the ulnar and radial arteries of wrist -to perform: place firm pressure over radial and ulnar arteries just proximal to wrist crease, have client make a fist and open repeatedly until palm turns white, instruct client to relax, release pressure from one side, record color return time, repeat process and release opposite artery, record time. Normal is 5 seconds or <, can compare to opposite extremity
Describe the following assessment tools for vascular changes: observation
assessment of color and trophic changes in hand, increased levels of white, blue or red are most common, trophic changes (textures of skin and nail): can occur from sympathetic nerve or vascular issue
Describe the following assessment tools for vascular changes: surface temp
compare forearm to fingertip temp, if forearm is at least 39 deg F warmer than fingertip, may indicate vascular compromise -raynauds: measure temp of fingertips after being in warm room for 30 minutes then immerse in ice water for 20 seconds. Should return to body temp within 10 minutes, will not do this with Raynauds
Describe how to perform the following grip tests, and the purpose of each type of grip test: Rapid exchange
examiner rapidly moves the dynamometer, alternatice from clients right to left hands for 10 tirals each hand, thought to prevent voluntary control of grip strength by client
Describe the following concepts: TAM (and be able to calculate it):
full arc of active motion of digits, measure as the total flexion of all 3 finger joints, subtracting any loss of full extension (MP+PIP+DIP flexion) - (MP+PIP+DIP extension loss) = TAM Example: AROM MCP +35/85, PIP 0/110, DIP -5/65 would have a TAM of 255°
What are Place and hold exercises and when are they used
gently perform AAROM to position finger, then ask client to sustain position comfortable while releasing the assisting hand -when PROM is great than AROM o Works of excursion of FDS and FDP and a little bit of strengthening o Without so much tension on muscle tendon unit o Typically done after tendon repair o Want to get gliding but don't want a lot of tension so use this o Passively place in full flexion and once placed they try to hold it there
What is the one grasp pattern that does not include the thumb?
hook grasp
static orthosis,
immobilize tissues, prevent deformity, prevent contracture of soft tissue, provide a substitution for lost motor function o Doesn't move and no moving parts o Not stretchy or springy o Can use to compensate for lost motion, to provide support if they cannot themselves o Mostly to immobilize o Often used to prevent contracture in someone with spasticity
Describe the various orthosis designs and their purposes. mobilizing to remodel scar tissue and reduce contracture
increased by application of deep heat modality before orthosis application, three-point for flexion contracturs, loop splint for IP joint extension contracture, outriggers for metacarpophalangeal extension contracture
prosthetic training wearing schedule
initially: 15-30 minutes 3x a day
Describe the various orthosis designs and their purposes. Immobilizing for pain reduction:
is injury from acute sprain or chronic, full-time or intermittent (intermittent=light weight, well aerated), what structure needs to be immobilized
Explain how to differentiate possible causes of pain ("Clinical Problem Solving"): Limited joint motion because of pain and pain present with distraction but not compressions:
ligament or joint capsule being stretched with distraction
Describe the concepts of tissue growth
living cells will sense strain and collagen fibers will be actively and progressively absorbed and laid down again with modified bonding patterns with no creep or inflammation
What are Differential tendon gliding exercises and when are they used
mainstay of most home exercise programs, easy to perform and promote motion effectively -standard for conservative management of carpal tunnel syndrome and release; clients with hand or wrist stiffness o Trying to get FDS and FDP to slide past each other freely o If trauma FDS and FDP can get stuck, and causes issues and neither will really move o Finger straight àfull fist o Finger straight à flat fist o Finger straightà hook fist § Get most gliding
Describe the various orthosis designs and their purposes. immobilizing for positioning
maintain hand functional position, sometime at end range to prevent contractures
Explain how to differentiate possible causes of pain ("Clinical Problem Solving"): Pain with PROM:
more likely joint problem (tightness, ligament injury, cartilage injury, inflammation)
Describe the following concepts: AROM
motion at joint caused by a voluntary contraction. Limitation can result from weakness of muscle, loss of tendon continuity, tendon adhesion, tendon inflammation/constriction, decreased mechanical efficiency, disrupted nerve supple
Describe the approach -biomechanical
o Bottom-up § What does client have not have, etc. o Work your way up from smallest piece
describe the FOR - Biomechanical
o Has to do with biomechanical factors o Remember the 8 things to consider** o Trying to fix or make better some underlying deficits, which will result in better Occ. Performance o At home exercise program
Describe the FOR -rehabilitative
o Not trying to make impairment better o Trying to compensate for impairments § Assistive tech, enviro modifications, compensatory activities
What should you do for every session for documentation?
o Take measurement before session even starts o Take another measure at very end
Describe the approach -occupation-based
o What do they need to do that they can't? o Start at top and work down § Occupation that must do o Then modify and adapt from there
Describe how to perform the following grip tests, and the purpose of each type of grip test: five level
one trial on each of the 5 handle-width settings. This test is used to determine a bell curve when gaphed. Strongest grips is almost always the 2 or 3 handle setting, weakest grip normally occur at most narrow and widest setting. If flat line or up-down-up: possible client didn't give max effort
What is intrinsic tightness?
passive PIP and DIP flexion is limited when the MP joint is passively extended or hyperextended
What is extrinsic flexor tightness?
passive composite digital extension is more limited with the wrist extended than with the wrist flexed
Describe the following assessment tools for vascular changes: Capillary refill test
place pressure on distal portion of volar finger until tissue turns white, normal capillary refill time is <2 seconds, compare with same digit on opposite hand
Describe the concepts of elasticity
point of tissue elongation where pain is felt, if elastic limit is met creep occurs
Describe the concepts of stress relaxation
position the tissue at the end range of its elastic limits and hold it static for short periods and then to relax and repositions
Serial static orthoses:
position tissue for lengthening and are remolded at intervals o Promote motion o Increase PROM o Wear static orthosis, wear for a while, then OT makes a new one/remolds to take advantage of increased motion § Typically place towards end of motion
what are functional activity exercises and when are they used
practicing or simulating relevant activities in the clinic and can reinforce this -incorporates gains made from exercising into functional UE use at home
Describe the following concepts: TPM (and be able to calculate it):
same process as TAM but measured passively (helpful at documenting presence of adhesions
Describe how to perform the following sensation tests: Light Touch Localization:
step 1: describe the test to the client. Client is open his or her eyes and point to the location the touch was felt after stimulus was given step 2: provide a light touch stimulus to an area. Place dot on the hand map where the stimulus was placed step 3: following client respons, if touch was felt in another place than given, draw an arrow pointing to the location the client flet touch from the location given. If the client did feel touch where given, draw dot alone.
What are resistive exercises and when are they used
strengthening and improve excursion of adherent tissue; explain load safety (lower load, higher reps) -client has to be medically cleared (be careful with fractures, tendonitis, or at risk for degenerative joint changes)
Describe the concepts of tissue creep
stretching phenomenon of the skin, result of slippage of short collagen fibers on one another within the tissue, some ruptures and some slide
documentation comparing before to after -After better than before:
they improved, intervention worked
dynamic orthoses:
uses moving parts such as rubber bands or spring wires, to apply a gentle force o Replace motion that client doesn't have for some reason o Springy or stretchy component o Move in direction that can move well and spring will move them into position they cannot
What group of muscles arise from the lateral epicondyle?
wrist extenders
What group of muscles arise from the medial epicondyle?
wrist flexors
documentation comparing before to before Before 1 worse than before 2:
· HEP is working · Could add more to HEP
documentation comparing before to before Before 1 same as before 2:
· HEP may not be doing anything · Didn't do HEP · Doing HEP wrong o Ask to see them do the HEP for you
documentation comparing before to before Before 1 better than before 2:
· HEP not working · That aren't doing HEP · HEP not doing right · Something made them worse o Figure out WHY
Documentation comparing before to after -after worse than before
· Intervention was not good and do not do that again
documentation comparing before to after -after the same as before
· didn't get better · Could do it again a few more times · Not do that intervention
Orthosis Fabrication: aeration of splints
❖ Aeration of splints I tend to use perforated material for all splints, as it allows some air circulation. Some patients tend to sweat more, and you'll need to add more air holes with a punch (TA445-2) or drill. Drilling results in rough hole edges that you then need to smooth out, so I prefer using a punch when possible.
Orthosis Patient Instructions
❖ Always provide written instructions for your patients (see attached example) ➢ If you are in a hospital or residential facility, these instructions should be posted in the patient's room (along with a photo of the proper application), added to the nursing care plan, and put in the medical record. ❖ The patient's skin should be monitored for pressure spots. ➢ A stage I pressure sore can occur in hours. ➢ If sensation is impaired, or the patient is not able to independently monitor their skin, check the skin after 30 minutes of orthosis application. If ok after 30 minutes, then check every 2 hours for the first couple days.
Principles for orthotic fabrication:
❖ Curved surfaces give strength: Be sure to contour all parts of your orthosis for maximum strength ❖ Cover ½ the circumference of the extremity with the orthosis: 1/2 the circumference give plenty of strength. An orthosis that covers more of the circumference will often migrate, as there is inadequate surface area for the strapping. ❖ Larger orthoses lead to less skin breakdown: A larger orthosis will distribute the force over a larger area, resulting in less force per area. The orthosis should cover 2/3 of the way up the forearm for a forearm based orthosis—a shorter orthosis will dig into the forearm and be uncomfortable. ❖ Rounded corners are better: ➢ Rounded inside corners increase durability ➢ Rounded outside corners increase comfort ❖ Rounded edges are better: Rounded edges increase comfort and decrease the chance for skin breakdown. Always make sure your edges are smooth and rounded. ❖ 3 points of force are needed to control a joint's movement in one direction ➢ In the picture shown to the right, in order to prevent further flexion at the PIP joint, force would have to be applied at the locations and in the directions shown by the three arrows. Remove any one of these, and you lose control over that joint in the specified direction. ➢ To control joint movement in two directions (e.g., both flexion and extension), six points of control are needed. ❖ Strap width and edema Strapping can sometimes prevent the lymphatic flow of edema out of the extremity. Using wider straps will mitigate this problem. ❖ Contour orthosis to accommodate bony prominences Be sure to allow enough room for bony prominences (e.g., ulnar head, radial styloid, etc.). You may need to create extra room as swelling decreases. ❖ Circumferential splints must allow for edema changes If there is a part of your orthosis that is circumferential (e.g., a thumb hole), be sure to make it big enough to allow for edema changes throughout the day.
Orthosis Fabrication: cutting thermoplastic material
➢ Initial cuts in 1/8" thick material are done with a utility knife (e.g., T5532-79). Score the material halfway through, and then bend on the scored line to pop the pieces apart or cut again with the pieces bent away from each other. Never cut towards your hand! ➢ Warming material before you cut it with a scissors makes for an easier cut. Save your hands--you'll need them for a long time! ➢ You want to have a good pair of scissors for cutting material, and make sure you keep them sharp. I like the Super Shears (TA371-5) for cutting warm soft material. I use the Fiskars Softouch Shop Shears (TA371-7) for cutting thin OT 621 Clinical Reasoning: Orthopedic Rehabilitation 2 Orthosis Fabrication CUW Michael Borst OTD, OTR, CHT Page 7 of 9 materials (e.g. Orfit) cold. The Fiskars All Purpose Snips (T7275) are nice for cutting precisely when making gutter splints. ➢ Use a separate scissors f
