Chapter 11 Biomechanical Approaches Evaluation and Intervention Flashcards

1
Q

Biomechanical Frame of reference

A
  • focuses on the range of motion, strenth, and endurance required to perfom an occupation
  • used to treat patients with lower motor neuron deficits and orthopedic problems
  • this approach is most effective when used in compbinaton with other OT treatment approaches with the focus on the client’s engagement in meaningful occupations and desired purposeful activities.
  • Example of settings - hand clinics, work programs, physcial medicine and rehabilitatin, ergonomic programs
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2
Q

Types of ROM

  • Functional ROM
  • AROM
  • PROM
  • AAROM
  • Finger ROM
A
  • Functional ROM - ROM needed to perform functional movements (reach top of head, small of back)
  • AROM - active ROM (contractile structures) movement produced by one’s own muscle
  • PROM - Passive ROM (noncontractile structures) movement produced by an external force
  • AAROM - active assisted ROM, movement produced by one’s own muscles and asssested by an external force.
  • Finger ROM - total active motion (TAM) and total passive motion (TPM).
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3
Q
  • WFL
  • WNL
A
  • WFL - ROM is functional
  • WNL - achieves normal ranges (recorded with specific degress)
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4
Q

MMT testing grading system

  • 5
  • 4
  • 4-
  • 3+
  • 3
  • 3-
  • 2
  • 2-
  • 1
  • 0
A
  • 5 :Normal. the part moves through full ROM against gravity and takes maximal resistance
  • 4: Good. the part moves through full ROM against gravity and takes moderate resistance
  • 4- : Good minus. the part moves throught full ROM against gravity and takes less than moderate resistance
  • 3+ : Fair plus. the part mvoes throught full ROM against gravity and takes minimal resistance before it breaks
  • 3 : Fair. The part moves throught full ROM against gravity and is unable to take any addes resistance
  • 3- : Fair minus. The part moves less than full range of motion against gravity
  • 2 : Poor. The part moves throught full ROM in a gravity-eliminated plane with no added resistance.
  • 2- : Poor minus. The part moves less than full ROM in a gravity-eliminated plane.
  • 1 : Trace. Tension is palpated in the muslce or tendon, but no motion occurs at the joint.
  • 0 : Zero. No tension is palpated in the muscle or tendon.
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5
Q

Edema

  • description
  • Types
  • evaluation
A
  • description - body’s resonse to injury where the fluid from the blood stream moves to the interstitial tissue. can be localized or diffuse
  • Types -
    • pitting - acute
    • brawny - chronic
  • Evaluation - tape measure, compare extremities, or measure using volumeter. Significant change in edema would be more than 10 ml
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6
Q

Testing sensation

  • Spinal cord injuries
  • peripheral nerve injuries
A
  • Gereral Sensory testing
    • Demo test with vision, then occulud vision for actual testing.
    • Test uninvolved side first
  • SCI - test proximal to distal
  • Peripheral nerve injuries - test distal to proximal following dermatomes.
    • assess for nerve involvment. Order of return: Pain, moving touch, static light touch, and touch localization
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7
Q

Type of Sensory Testing

  • Light touch
  • localization
  • pain
  • temperature
  • stereognosis
  • moving two point discrimination: disk-criminator or caliper
  • static 2 point discrimination: disk-criminator or caliper
  • Proprioception: position sense
  • Kinesthesia
A
  • Light touch - cotton swab person responds “yes” or “touched”
  • Localization - with person’s vision occluded touch an area, then with vision, point to area touched
  • Pain - person responds sharp or dull when touched, vison occluded
  • Temperature - test tubes, person responds hot or cold
  • Stereognosis -recognition by touch (second set of identical common objects shoudl be used for individuals with expressive aphasia
  • Moving 2 point discrimination - applied proximal to distal on finger tips in a horizontal orientation. starts with points 5-8mm apart. person responds with the number of points they feel “one” or “two”. Normal is 2mm
  • Static 2 point discrimination - test begins at 5mm.applied to finger tips in a longitudinal orientation. person responds with the number of points they feel “one” or “two”. Normal is 5mm.
  • Proprioception - poisition sense. Therapists positions involved extremity, person duplicates position with contralateral extremity.
  • Kinesthesia - Movement sense. Therapists moves segment or involved extremities with eyes occluded. person responds “up” or “down”
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8
Q

Coordination/Dexterity assessments

  • Purdue Pegboard
  • Minnesota Manual Dexterity Test
  • 9 Hole Peg Test
  • Informal assessment of coordination should include
A
  • Purdue Pegboard - Test of fingertip dexterity and assembly job simupation. Score the number of pins that are placed on the board in 30 seconds. Assembly score is the number of parts assembled during one min.
  • Minnesota Manual Dexterity Test - tests of gross hand and arm movements. Placing tests measures rate of hand movements. Turning test: measures rate of finger manipulation. Score the time it takes to complete board.
  • 9 hole peg test - measure finger dexterity. Score is tiem for each hand to place 9 pegs in square board and remove them. (Purdue Pegboard is performed because it’s unilateral and bilateral)
  • Informal assessment of coordination -
    • fine motor - observation of routine task performance, manipulation of various sized objects, handling money, handwriitng, cuttin gfood, buttoning etc.
    • gross motor - observation that inclue gross motor movments, tossing a ball, reaching into cabinets for ites, dressing etc.
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9
Q

Intervention

Increasing Range of Motion

  • Passive ROM and passive stretching
  • Active ROM
  • Precuations
A
  • Passive ROM and passive stretching -
  • Active ROM - should be performed wwhen PROM is breater than AROM.
    • tendon gliding exercises - differentiates tendon movment and increases tendon excursion
    • blocking exercises - used to isloate indiviaul joint motion
    • Purposeful ADL, crafts, games and sports. emphasize functional use preparatory wall walking, AROM, cane axercises, etc.
  • Precautions - Myositis ossifican may result from over stretching
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10
Q

Intervention

Increasing strength

  • Isometrics
  • Isotonic
A
  • high resistance, low repetitions
  • type of contracitons
    • Isometric - Contraction without movment. Sometimes can produce more foreceful contractions.Isometrics are contraindicated for persons with hypertention and cardiovascular problems as they can increase blood pressure and heart rate!
    • Isotonic - contraction wtih movment. eccentric = lengthening, concentric = shortening
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11
Q

Interventions

Increasing Endurance

A
  • work at 50% of maximal resistance or less
  • increase repetitions and duration, not resistance.
  • use energy conservation methods
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12
Q

Interventions

Edema Reduction Techniques

A
  • Elevation - extremity placed above the heart. contraindicated if individual has circulation problems.
  • retrograde massage - assists the return of blood and lyphatic fluids to the venous system, stroking is applied in centripetal direction, massage performed with extremity elevated.
  • Compression garments - prevents re-accumulation of fluids folliwng retrograde massage (isotoner glove, stockinet with elastic, ace wraps, custom made compression garments, coban wrap)
  • Coldpacks - effective when combined with elevation, need to monitor vasular status.
  • contrast bath - Alternate immersing the hand in warme and cold water.
  • Containdications/Precautions - Heat. infection, grafts or wounds, vascular damage, unstable fractures, Congestive Heart failure (CHF)
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13
Q

Interventions

Scar Management

A
  • ROM - early mobilization programs are most effective,
  • Massage - circular and friction massage.
  • Compression - coban for digits, isotoner glove for the nad and tubigrip for the upper extremity
  • Scar pad with compression (otoform, elastomer, topigel are common scar pads)
  • Splinting to prevent contractures resulting from scar
  • Edema control (especially in acute phase)
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14
Q

Interventions

Sensory Training

  • Desensitization
  • Sensory re-education
  • compensation
A
  • Desensitization - s/p surgery - begin in peripherphy of the scar as tolerated work over scar, massage, textures, vibration, fluidotherapy
  • Sensory re-educaiton - Massage, textures, vibrations, three phase desensitation kit
  • compensations - educate on using hands with visual cues. avoid using hands when vision is occluded. observe safety precautions.
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15
Q

Inteventions

Improving Coordination

A
  • begin with gross motor activities and drade up to fine motor activities.
  • select activities in which ROM required is withing the person’s reach and yet challenging
  • fous on acuracy and speed, begin with slow gross movements and gradually progress to faster precise movements.
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16
Q

Interventions

Energy Conservation and Work simplification

A
  • Plan rest period during daily routine
  • schedule tasks for the day, week to alternate and balance heavy and light work tasks
  • organize tasks - gather all necessary items and equipment before begining tasks
  • avoid multiple trips to obtain items, use utility car, walker bag, backpack
  • eliminate tasks that are non-essential
  • delegate tasks that are beyond one’s capacity,
  • combine tasks
  • sit to complete tasks
  • Organize items so that they are easy to reach and convenient.
  • use adaptive equipment to avoid bending and stooping
  • use electrical appliances to decrease personal effort
  • rest before fatigue sets in . intermittent rest during and activity is more effective than resting after exhaustion has occurred.
17
Q

Intervention

Joint protection

  • Maintaining Joint ROM
  • ” muscle strenth
  • Use strongest and largest joint for task completion
  • Utilizing joint in most stable/functional position
  • Avoid holding joints in position or sustaining muscl econtracitons for extended periods
  • avoid positions of deformity
  • Precautions and contraindications
A
  • Maintaining Joint ROM - use maximal ROM during ADLS
  • Maintaining muscle strenth - utilize maximal strenth during daily activities.
  • Using stronest and largest joint for task completion - use knees and hips for lifting, push large items that need to be moved rather than pulling, carry bags on forearm rather than wrist.
  • Stable/functional position for joint -Stand directly infornt of item to be reached for, rather than to the side, keep wrist and fingers in proper alignment.
  • avoid sustained musle contractions - use adaptive equipment, take breaks
  • avoid deformity -perform movements in the direction opposite the potential deformity, use ergonomically designed equipment
  • precautions - do not start an activity than cannot be immediately stopped. recognize discomfort, which can be an indicator of possible damage.
18
Q

Body mechanics Principles and methods

A
  • do not move items that are too heavy, slide or push object along surface instead of lifting it
  • directly face object to be lifted
  • keep object close to body when lifting and carrying
  • bend at the knees
  • breathe while lifting
  • do not rotate trunk
19
Q

Splinting types

  • Static
  • Dynamic
A
  • Static -has no resilient components and immobilizes a joint or part
  • Dynamic - includes a resilient component (elastic, springs etc) designed to increase PROM or to augment AROM
20
Q

Purpose of splinting

A
  • rest,
  • prevent deformities, and contractures
  • , increase joint ROM,
  • prodtct boine, joint, and soft tissue
  • increase functional use
21
Q

Hand Splinting standards

A
  • Maintain arches of the hand
    • proximal transverse arch
    • distal transverse arch
    • longitudinal arch
  • Do not impinge upon creases of the hand
    • distal and proximal palmar creases
    • distal and proximal wrist creases
    • thenal crease
22
Q

Mechanical principles of splinting

_*know/avoid positions of deformity_

A
  • decrease pressure (rounded edges, long splint base
  • use sling applied with 90degrees of pul
  • use low load to increase duration
  • maintain 3 point pressure versus circumference
  • avoid position of deformity (wrist flexion, MCP hyper extension, IP joints flexed, thumb adducted
23
Q

Appropriate splinting positions

  • Resting position
  • safe position
A
  • Resting position
    • wrist: 10-20 extension
    • MCP: 30-45 flexion
    • IP: 0-20 flexion
    • Thumb: abducted
  • Safe position
    • Wist 20-30 extension
    • MCP 50-70 flexion
    • IP in extension
    • Tumb abducted and extended
24
Q

Precautions and education

A
  • check skin condition before and after making spling
  • educate wearer to check skin when donning and doffing and care of splint
  • educate wearer to understand purpose, function, and limitation of splint
  • teach proper techniques for donning and doffing splint
  • provide functional training in us of spling in rol activities.
  • reevaluate use of splint periodically
25
Q

splints for common diagnoses

  • Brachial Plexus injury
  • Radial nerve palsy
  • Median nerve Injury
  • Ulnar nerve injury
  • Combined median ulnar injury
A
  • Brachial Plexus - Flail arm splint (holds arm close to body)
  • Radial nerve palsy - “saturday night palsy”; damage to radial nerve; may get wrist drop. dynamic wrist, finger, & thumb extension splint
  • Median nerve injury - Opponens splint (thumb spica), C-bar (hand in C position), or thumb post splint
  • Ulnar nerve Injury - dynamic/static splint to position MPs in flexion
  • Combined median ulnar injury - dynamic MCP flexion splint or figure of eight (loop around finger joints)
26
Q

Splints for common diagnoses

  • Spinal cord C6-C7
  • Carpal Tunnel syndrome
  • Cubital tunnel syndrome
  • DeQuervains
  • Skier’s thumb
A
  • Spinal cord C6-C7 - Tenodesis splint
  • Carpal Tunnel syndrome - wrist splint in 0-15 extension (positioned in neutral)
  • Cubital Tunnel syndrome - elbow splint positions at 30 degrees of flexion
  • DeQuervains - median nerve repetitive stress injury; pain/tingling along thumb side of wrist & difficulty gripping; positive Finkelstein’s Test.thumb splint, includes wrist, IP joint free
  • Skier’s thumb - hand based thumb splint (UCL)
27
Q

Splints for common diagnoses

  • CMC arthritis
  • Ulnar drift
  • Flexor tendon injury
  • Swan neck
  • Boutonniere
A
  • CMC arthritis - hand based thumb splint
  • Ulnar drift - Ulnar drift splint
  • Flexor tendon injury - Kleinert or Duran dorsal protection splint (dorsal block splint so fingers can’t extend very far)
  • Swan neck - silver rings or buttonhole splint (to prevent hyperextension of PIP joint)
  • Boutonniere - silver rings or dynamic PIP extension splint (to prevent flexion of PIP joint)
28
Q

Splints for common diagnoses

  • Arthritis
  • flaccidity
  • Spasticity
  • Muscle weakness (ALS, SCI, Guillain-Barre)
  • Hand burns
  • ulnar nerve laceration
A
  • Arthritis - functional (C shaped) or safe splint, depending on stage
  • Flaccidity - resting splint
  • Spasticity - spasticity splint (fingers abducted, thumb abducted) or cone splint
  • Muscle weakness - balanced forearm orthosis (BFO), deltoid sling/suspension sling
    1) mounts to wheelchair
    2) individual MUST have shoulder or trunk movement
  • Hand burns - Wrist 15-30 degrees extension, MCP 50-70 degrees flexion, and IPs in full extension
  • Ulnar nerve laceration - deformity: claw hand; flattened metacarpal arch; + Fromment’s sign
  • Functional loss: loss of poet grip; decreased pinch strength MCP flexion block splint
29
Q

Physical Agent Modalities

  • Superficial heat
  • cryotherapy
  • whirlpool
  • electrical stimulation (functional eletrical stimulation FES, neuromuscular electrical stimulation NMES, transcutaneous electrical nerve stimulator TENS)
  • ULTRASOUND
  • CONTRAST BATHS
A
  • Preparatory intervention that compliment the primary OT intervention methods.
  • Superficial heat - releives pain, increases tissue extensibility (increases ROM), assists with wound healing
  • Cryotherapy - relieves pain, controls edema, decreases abnormal tone, facilitates muscle tone.
  • Whirlpool - cleans and debrieds open infected wound, temperature does not reach therapeutic range to use as a heat modalitiy.
  • electrical stimulation - Relieves pain, decreases swelling, stimulates and strenthens muscles, stimulates denervated muscle
  • Ultrasound - relieves pain, decreases inflammation, increases tissue extensibility (increases ROM), decreases adhesions
  • contrast baths - Reduces edema
30
Q

Contraindications/Precautions of PAMS

A
  • Cancer
  • pacemaker
  • pregnancy
  • Cognitive impairment
  • sensory impairment
  • vascular impairment
  • ultrasound is never used over a growth plate!!