Therapeutic Exercise Chapter 19

B. Avoid strong gripping motions that require wrist extension, radial deviation of the wrist, and ulnar deviation of the fingers.

A patient with RA of the hands and wrists is experiencing an acute flare of the disease. To protect the inflamed joints and minimize deforming forces on the hands and wrists, you should teach the patient to: A. Avoid all activities with the hands until there is no pain. B. Avoid strong gripping motions that require wrist extension, radial deviation of the wrist, and ulnar deviation of the fingers. C. Exercise the hands in functional ways such as wringing out a dishrag under warm water. D. Stretch the extrinsic finger tendons across all the joints simultaneously to gain mobility and counter contractures.

B. No history of chronic synovitis.

Prerequisites for successful PIP arthroplasty include all of the following except: A. Adequate bone stock. B. No history of chronic synovitis. C. Intact neurovascular system. D. Functioning flexor/extensor mechanism.

B. Gentle muscle setting (isometric/static) exercises used during the early phase of rehabilitation after, for example, a tendon repair, whereby an involved finger is placed passively in a particular position (by the therapist or by the patient using the sound hand); the patient then is asked to try actively to hold the position without assistance.

"Place-and-hold" exercises are: A. A form of dynamic exercises in which the patient actively moves through a series of hand positions to prevent tendon adhesions. B. Gentle muscle setting (isometric/static) exercises used during the early phase of rehabilitation after, for example, a tendon repair, whereby an involved finger is placed passively in a particular position (by the therapist or by the patient using the sound hand); the patient then is asked to try actively to hold the position without assistance. C. A form of isometric exercise in which the therapist places a finger in a particular position and then asks the patient to hold the position as manual resistance is applied to the contracting muscle. D. A form of stretching exercise in which a patient is asked to perform an isometric contraction of a muscle-tendon unit against low-intensity resistance followed by relaxation and elongation of that muscle.

D. Progressive resistance exercise.

During the subacute stage of soft tissue healing after injury and repair of the flexor tendons of the hand or forearm, each of the following is an important intervention except: A. Scar management with pressure on the scar. B. Tendon-gliding exercises. C. Gentle prolonged stretch. D. Progressive resistance exercise.

A. Zone I is where the flexor digitorum superficialis (FDS) tendon inserts; if the tendon avulses, the patient will be unable to flex the DIP joint.

Each of the following descriptions of the flexor zones of the hand and forearm is correct except: A. Zone I is where the flexor digitorum superficialis (FDS) tendon inserts; if the tendon avulses, the patient will be unable to flex the DIP joint. B. Zone II, known as "no-man's land," is where the extrinsic flexor tendons (flexor digitorum superficialis and profundus) lie in close proximity; range-limiting adhesions that prevent tendon gliding are likely to develop in this area after injury and repair. C. Zone III is in the palm of the hand; injury in this area can damage the lumbricales and interfere with MP flexion. D. Zone IV includes the carpal tunnel; the extrinsic flexor tendons can adhere in the tunnel following inflammation.

C. For functional grasp after PIP arthroplasty, more flexion of the PIP joints of the index and middle fingers is necessary than flexion of the ring and little fingers.

Each of the following is correct about PIP arthroplasty, associated soft tissue reconstruction, and postoperative management except: A. Because correction of a boutonnière deformity during PIP arthroplasty involves a central slip-splitting approach, it is important to postpone resisted PIP extension exercises for at least 6 to 8 weeks. B. When initiating ROM of the PIP joint after PIP arthroplasty, stabilize the MP and DIP joints in neutral. C. For functional grasp after PIP arthroplasty, more flexion of the PIP joints of the index and middle fingers is necessary than flexion of the ring and little fingers. D. After PIP arthroplasty that included correction of a swan-neck deformity, emphasize PIP flexion and DIP extension more so than PIP extension and DIP flexion.

C. To perform these exercises, the therapist passively moves the patient's fingers into five different positions in a particular sequence.

Each of the following is true about flexor tendon-gliding exercises except: A. Maintain or develop free gliding between the FDS and FDP tendons. B. To perform these exercises, the patient actively moves the fingers into five different positions. C. To perform these exercises, the therapist passively moves the patient's fingers into five different positions in a particular sequence. D. Maintain or develop free gliding between the FDS and FDP tendons and adjacent bones.

C. If a tendon lesion occurs in zone V, PIP and DIP extension is disrupted, but MP extension remains intact.

Each of the following is true about lesions of the extensor tendons of the wrist and hand except: A. A mallet finger is a lesion of the extensor mechanism of the DIP joint and is managed nonoperatively with an orthosis for positioning in full extension. B. A lesion of the central tendon (central slip) of the extensor hood, if untreated, will result in a PIP flexion contracture and boutonnière deformity over time. C. If a tendon lesion occurs in zone V, PIP and DIP extension is disrupted, but MP extension remains intact. D. A laceration of the extensor tendons in zone VII can cause a wrist flexion deformity and requires surgery to repair the lesion.

D. It is used more often after extensor tendon repair than after flexor tendon repair.

Each of the following is true about the use of early controlled motion after tendon repair in the hand and forearm except: A. When ROM exercises are initiated, they are performed within a protected range to minimize the risk of excessive stress on the repair site and gapping of the repaired tendon ends. B. It has been shown to increase the tensile strength of the scar at the repair site more effectively than the use of prolonged immobilization after a surgical repair. C. It is thought to improve synovial fluid diffusion, thereby improving tendon nutrition and promoting tendon healing. D. It is used more often after extensor tendon repair than after flexor tendon repair.

C. Application of an orthosis should be avoided in the rheumatoid hand because it promotes loss of joint mobility.

Each of the following is true regarding management of the patient with RA of the hands except: A. Progressive resistance exercise is contraindicated so long as there are signs of inflammation. B. Principles of joint protection and energy conservation are integral components of patient education to reduce deforming forces on involved joints and reduce excessive fatigue. C. Application of an orthosis should be avoided in the rheumatoid hand because it promotes loss of joint mobility. D. With MP joint deformities, forceful pinch and grip exercises are contraindicated.

C. Rupture of the central band (central slip) of the extensor hood mechanism, causing the lateral bands to slip in a volar direction at the PIP joint

What is the biomechanical cause of a Boutonnière deformity? A. Overstretching of the volar plate (palmar plate) and bowstringing of the lateral bands of the extensor hood mechanism B. Volar displacement of the extensor carpi ulnaris tendon, causing a flexion force at the wrist joint C. Rupture of the central band (central slip) of the extensor hood mechanism, causing the lateral bands to slip in a volar direction at the PIP joint D. Overstretching or rupture of the collateral ligaments of the metacarpophalangeal (MP) joints

D. The need to perform high-load, high-impact occupational tasks postoperatively

Which of the following is a relative or absolute contraindication for wrist arthroplasty despite debilitating pain in the wrist region and diminished hand and upper extremity function from advanced arthritis? A. Significant, arthritis-related, ipsilateral limitation of motion of joints proximal and distal of the wrist B. Subluxation or dislocation of the radiocarpal joint C. Previous arthritis-related arthrodesis of the opposite wrist where arthrodesis of both wrists would potentially reduce, rather than improve, function D. The need to perform high-load, high-impact occupational tasks postoperatively

B. After MP arthroplasty and removal of the postoperative compression dressing, a dynamic orthosis with an outrigger is worn to maintain the MP joints in full extension when the fingers are relaxed but allow active MP flexion within a limited range and unrestricted interphalangeal (IP) motions.

Which of the following is a true statement about MP arthroplasty and postoperative management of the fingers? A. Repair of ruptured extrinsic finger flexor tendons often is coupled with MP joint replacement arthroplasty for the patient with RA and chronic tenosynovitis. B. After MP arthroplasty and removal of the postoperative compression dressing, a dynamic orthosis with an outrigger is worn to maintain the MP joints in full extension when the fingers are relaxed but allow active MP flexion within a limited range and unrestricted interphalangeal (IP) motions. C. If a patient has an ulnar drift deformity of the fingers, use of a dynamic orthosis is contraindicated postoperatively. D. Use of a static orthosis has been shown to be an ineffective alternative to a dynamic orthosis for improving ROM and function after MP arthroplasty.

C. After CMC arthroplasty, the thumb is immobilized in palmar abduction.

Which of the following is a true statement about carpometacarpal (CMC) arthroplasty of the thumb and postoperative management? A. For a patient with erosion of the articular surfaces and subluxation of the CMC joint, joint replacement arthroplasty with prosthetic implants is a far more common procedure than trapezial resection/tendon interposition arthroplasty with ligament reconstruction. B. A longer period of immobilization of the thumb is required after total joint arthroplasty with prosthetic implants than after trapezial resection/tendon interposition arthroplasty with ligament reconstruction. C. After CMC arthroplasty, the thumb is immobilized in palmar abduction. D. A priority in a postoperative exercise program is to gain active radial adduction combined with palmar adduction of the thumb (sliding the thumb across the palm) as early as possible.

A. Manual stretching techniques to restore full ROM of the wrist during the final phase of rehabilitation

Which of the following is least appropriate after arthroplasty of the wrist? A. Manual stretching techniques to restore full ROM of the wrist during the final phase of rehabilitation B. Active wrist flexion/extension (greater emphasis on extension) and forearm pronation/supination (greater emphasis on supination) as soon as the immobilization device can be removed for exercise C. Low-intensity (about 1 lb) dynamic resistance exercises of the wrist and hand during the intermediate and late phases of rehabilitation D. Use of the hand for light functional activities at about 3 months postoperatively

C. May involve the use of a dynamic dorsal blocking orthosis with elastic bands attached, allowing limited active finger extension and providing passive finger flexion

Which of the following is true about regimens that employ customized orthoses and early controlled motion after flexor tendon repair in zone I, II, or III? A. May involve the use of a dorsal tenodesis orthosis that allows full active extension of the wrist and MP joints B. May involve the use of a dynamic dorsal blocking orthosis with elastic bands attached, providing full passive extension of the fingers and allowing limited active flexion of the fingers C. May involve the use of a dynamic dorsal blocking orthosis with elastic bands attached, allowing limited active finger extension and providing passive finger flexion D. May involve the use of a volar tenodesis orthosis that allows full ROM of the wrist while maintaining the fingers in full extension

A. Swan-neck deformity.

You are evaluating a patient with rheumatoid arthritis (RA) of the hand and wrist. You notice several deformities, including hyperextension of the proximal interphalangeal (PIP) joints and flexion of the distal interphalangeal (DIP) joints of digits 2, 3, and 4. This deformity is called: A. Swan-neck deformity. B. Heberden's deformity. C. Boutonnière deformity. D. Saddleback deformity.

B. Maintain joint mobility and decrease pain by using grade I or II joint-oscillation techniques.

Your patient has a 5-year history of RA. There are no obvious deformities, but during this current exacerbation of the disease, the wrist and MP joints are swollen, red, tender, and warm. There is generally decreased range of motion (ROM), pain during joint motion, and increased pain at the end of the available range of each joint. An appropriate short-term goal and intervention is: A. Minimize deforming forces by maintaining ROM with gentle, passive stretching to the involved joints. B. Maintain joint mobility and decrease pain by using grade I or II joint-oscillation techniques. C. Increase muscle length by using contract-relax (hold-relax) techniques. D. Control pain by imposing continuous rest and using orthoses on the wrists and hands.

D. Have the patient move actively from the full fist position of the hand to the hook fist position.

Your patient has an "extensor lag" of the MP joint. The exercise of choice to remediate this problem is which of the following? A. While stabilizing the IP joints of one finger in extension, passively extend the MP joint of that finger. B. Have the patient move actively from the straight fist position to the tabletop position of the hand. C. Have the patient move actively from the full fist position of the hand to the tabletop position. D. Have the patient move actively from the full fist position of the hand to the hook fist position.

A. It is possible to extend the MP joint passively through the full range of extension, but full active MP extension is not possible, owing to weakness of the extensor digitorum.

Your patient has an "extensor lag" of the MP joints. What does this suggest? A. It is possible to extend the MP joint passively through the full range of extension, but full active MP extension is not possible, owing to weakness of the extensor digitorum. B. Posterior (dorsal) sliding of the proximal phalanx on the head of the metacarpal is restricted. C. Full passive MP extension is not possible. D. It is possible to extend the MP joint passively through the full range of extension, but full active MP extension is not possible, owing to weakness of the lumbricales.

B. Begin tendon-gliding exercises to minimize the formation of range-limiting adhesions.

Your patient sustained a laceration of the palmar aspect of the fingers in zone II ("no-man's land") of the hand. The patient subsequently underwent a repair of the lacerated tissues. During the subacute (moderate protection) phase of healing, it is critical to: A. Keep the fingers immobile because there is poor circulation and therefore poor healing in this area. B. Begin tendon-gliding exercises to minimize the formation of range-limiting adhesions. C. Initiate maximum-level resistance exercises of the extrinsic flexors to regain normal strength of the injured muscle-tendon unit. D. Limit exercise to passive ROM to protect the healing tendons.