Exam 2 Flashcards
What type of heat transfer is US
Conversion
3 types of US
Diagnostic
Therapeutic
Surgical
How deep does therapeutic US go
2-5 cm
What is US most commonly used for?
deep heating and biophysical effects
what type of tissue does US travel best through
Dense material
Ligaments, tendons, joint capsule, scar tissue etc.
What does frequency of US determine
depth, wavelength and temperature
1 MHz
goes deeper 2-5 cm
slower absorption
long wave length
3.3 MHz
shower wavelength
quick absorption
reaches only 2 cm
What is the effective radiating area
The inner portion that propagates sound
What is the beam non-uniformity ratio with US
the middle of transducer has the highest peak and the outside has less
Continuous mode for US
100% duty cycle
sound energy is constant
thermal effects
Pulsed Mode for US
10, 20, or 50% duty cycle
minimizes thermal effects
Thermal effects of US
increase metabolic rate for tissue healing
elevate motor and sensory nerve conduction (pain reduction)
Reduces spasm
Vasodilation
increased ROM
what is ultrasound not ideal for heating?
Muscles
how to increase thermal effects of ultrasound
Increase duration and/or increase intensity 1.5 watts/cm
non-thermal effects of US
increased skin and cell permeability
increased cell degranulation
increase phagocytic activity
increased rate of protein synthesis by fibroblast
Enhances wound healing
Clinical applications of non-thermal US
Edema
pain control
wound healing
Trigger points
Documentation of US
Frequency
Intensity
Duty cycle
time
location
transmission medium
Pt tolerance
results
phonophoresis
delivery of medicated lotion via ultrasound
“upgraded ultrasound and downgraded iontophoresis”
What level does TENS and Iontophoresis reach
sensory level
Contraindications for electrical modalities
cardiac pacemakers/ electronic implants
over carotid sinus
near venous or arterial thrombosis
over areas of indwelling phrenic nerve or urinary bladder stimulators
Direct current
continuous unidirectional flow of electrons
alternating current
uninterrupted bilateral flow of electrons
pulsed current
when electron flow is interrupted for milliseconds or microseconds
can be either AC or DC
Types of pulsed waveform
mono-phasic
biphasic- 2 phases with current flow in both direction
polyphasic
amplitude/intensity of wave form
distance the impulse rises above or below a baseline
duration of waveform
length of time to complete one wave
modulation of waveform
changes made in one or more aspect of the current (duration or amplitude)
Subsensory level of stimulation
no nerve fiber activation
no sensory awareness
sensory level of stimulation
non-noxious paresthesias
tingling
cutaneous A-beta nerve fiber activation
What level of stimulation do we typically stay in during TENS
Subsensory and sensory
Motor level of stimulation
strong tingling and pins and needles
muscle contraction
A-alpha nerve fiber activation
Noxious level of stimulation
strong
uncomfortable paresthesia
strong contraction
A delta and C fiber activation
Pulse duration/ width
length of time between beginning and end of all phases in a single pulse
commonly set to 50-150 usec for TENS
what does pulse duration determine?
Which types of fibers are stimulated
Short-sensory (less than 100)
longer- motor (more than 100)
longest-pain (more than 200)
What does frequency determine
type of muscle contraction that occurs
1-20 pps (subsensory and sensory)
20-40 (necessary for muscle contraction)
50-80 (creates tetany with significant fatigue
what is the average intensity that is tolerated?
35-80 mA
What is intensity responsible for
level of sensory and motor response
number of fibers being stimulated
What is TENS utilized for?
acute and chronic pain management
How is TENS beloved to decrease pain
by counter-irritant theory
creates a signal to counter pain that a person is feeling
Elements of TENS
Pulse duration - less than 150 is short
Frequency- Greater than 8- is high
amplitude is determined by patient
precautions of TENS
narcotic pain med usage
unclear diagnosis
general E-stim precautions
Contraindications for TENS
Driving
MG or MS (rapid fatigue)
Contralaterally- transthoracically
Children
Documentation for TENS
treatment parameters
electrode placement
Pain description
Change in occupational performance or biomechanics components
Conventional TENS
High rate
sensory
most commonly used for acute pain
effect doesn’t last ling
patient feels pins and needles
Motor TENS
low rate
sub-acute or chronic pain
Effects last longer
patient feels thump
Iontophoresis
Delivery of ions into body for therapeutic purposes
E-stim for medication delivery
Need referral and prescription
Causes of soft tissue injuries
minor and persistent repetitive trauma
Direct blunt trauma
Sudden uncontrolled and excessive overuse
What is a contusion
a region of inured tissue or skin in which blood capillaries have been ruptured
Early and later stage of contusion
Early- erythema
Later- swelling and loss of function
tx for contusion
prevent tissue form further injury
compression wrapping
MICE
Definition of a strain
damage of some part of contractile unit of muscle caused by overuse or over stress
Where does a strain occur
the weakest link of the muscle tendon unit
3 degrees of strain from lowest to highest
mild pulling without tearing
damage to a portion of the junction
complete rupture of the junction
Tx for acute strain
RICE for at least 1 week
muscle is vulnerable to re-injury
Later warm-up, stretch and resume activity as long as there’s no pain
Tx for chronic strain
High risk for re-injury so prevention is key
Gradually build ip activities including closed chain
Strain
involves ligamentous attachment
usually sudden
minor tears and hemorrhage without loss of joint stability
Grading for strain
similar to sprain
mild damage to complete ligament rupture (ACL tear)
tx for strain
protect ligament from stretch
gentle movements that maintain joint motion but do not reach full stretch
increase strength of surrounding musculature in case ligament is not back to full strength
Occult
occurs only when the joint is stretched or stressed, otherwise stable
no Pain or symptoms
Subluxation
joint loses some stability but maintains joint contact
3 degrees of joint instability
occult
subluxation
dislocation
Dislocation
joint stability is in jeopardy and the joint surfaces are not in contact
Late effects of dislocation
after 4 weeks
joint stiffness
recurrent dislocation
post-traumatic arthritis epically if further damage to capsule
When is immobilization always necessary
dislocation and sometimes subluxation
Effects of immobilization on soft tissue
stiffness and weakness of CT
loss of extensibility
atrophy and adaptive length changes in muscles
loss of fibers/shortening of fibers lead to contracture
How much stretch should you bring a client in for immobilization
some stretch but not into new pain
submaximal
olecranon bursitis
inflammation of olecranon bursa
caused by trauma or prolonged pressure on elbow
tx for olecranon bursitis
rest, avoid pressure on elbows, custom padding
Lateral epicondylitis
tennis elbow
insidious onset of pain over extensors felt at lateral epicondyle
aggravated by wrist flexion/extension with pronation or supination and gripping
Tests for lateral epicondylitis
Cozens test and Mill’s Test
Cozens test
provocative test
elbow stabilized by thumb
patient makes a fist and prints, radially deviates and extends wrist
Clinician resists wrist extension
Mill’s Test
passive elbow extension and wrist flexion
What tendons/muscles are most commonly effected during lateral epicondylitis
extensor digitorium
Extensor carpi ulnaris
tx for Lateral epicondylitis
stop doing what makes it hurt
NSAIDS
US
compression brace
activity modification
What muscles are involved for medial epicondylitis
pronator tires and flexor capri radialis
sometimes FCU and PL
Medial epicondylitis cause
throwing athletes
repetitive trauma
Testing for Medial Epicondylitis
resistive wrist flexion with pronation
elbow extension with passive wrist extension
decreased grip strength
What should be ruled out when testing for medial epicondylitis
UCL rupture
Cubital tunnel syndorme
Tx for medial epicondylitis
similar to lateral epicondylitis
Tinels sign
tingling or prickling sensation elicited by tapping injured nerve trunk
if positive nerve, if negative tendon
symptoms of overuse syndromes of muscles
vague diffuse pain
cramping
fatigue
loss of strength and control for an extended period of time
tx for overuse syndromes of muscles
rest until symptoms subside
modalities to decrease pain
progressive exercise and strengthening programs
Where is compartment syndrome most common
volar compartment
When does compartment syndrome occur
sustained excessive pressure develops in one of the 3 forearm compartments following acute trauma
Signs and symptoms of compartment syndrome
Significant swelling
severe pain not relived with immobilization
tense to palpation
Tx for compartment syndrome
rest
modalities
progress to exercise
faciotomy if blood is not getting to hand
Tendonitis and stenosing tensosynovitis
inflammation of tendons leads to fibrosis
structures become thick, unyielding and restrictive to tendon excursion
tendon will not be able to slide through sheath/retinaculum
tx for tendonitis
initially conservative
edema management
gentle exercise
Dequervains tensosynovitis
most common stenosing tensosynovitis
inflammation of APL and EPB at the level of the radial stolid in 1st compartment
When does DeQuervains Tensosynovitis occur
with repetitive ulnar deviation and grasping
or repetitive use of the thumb
Symptoms of DeQuervains Tensosynovitis
pain, stiffness, and weakness of pinch
What test shows DeQuervains Tensosynovitis
finkelsteins test positive
Finkelsteins test
passive stretching of extensor thumb tendons
Clinical brases wrist in ulnar deviation and then passively flexes thumb across palm
Dorsal thumb pain will be present
tx for DeQuervains Tensosynovitis
stop doing what motion causes pain
thumb spica splint
rest from activities
modalities
gentle stretching and thumb
Intersection Syndrome
involves 1st and 2nd dorsal compartments
signs and symptoms of intersection syndrome
point tenderness 3 fingers proximal to the wrist joint
squeaking on A&PROM
pain during flexion or extension
Where is intersection syndrome compared to DeQuervains
proximal
What tests for intersection syndrome
negative Finkelsteins test
Tx for intersection syndrome
similar to DeQuervains but no dumb splint
Trigger Finger
painful snapping as FI tendons suddenly pull through a tight A1 pulley
can occur during fl or ext
What comes first A1 stenosis or tendon thickening in trigger finger
either one
Most common occurrences of trigger finger
thumb, mid, ring
women
DM or RA and other tendonitis
tx for trigger finger
limit snapping/ tendon excursion for a bit of time
modalities ot help decrease swelling
TFFC injury causes
traumatic or degenerative
falls
rotational injuries
repetitive axial loading
Symptoms of TFCC causes
ulnar wrist pain
clicking
credits with forearm rotation, gripping or UD
Tx for TFCC injury
brace
injection
Gentle AROM, don’t want to stretch too far
surgery
UCL of Thumb sprain
gamekeepers/skiers
occurs with values stretch
stability of MP by adductor aponeurosis, AP, UCL and the solar plate
Eval for UCL of thumb sprain
valgus stretching testing with MP 30 degrees of flexion
30-35 degrees of RD indicates complete rupture requiring surgery
Tx for UCL of thumb sprain
partial tear: 3-4 weeks of immobilization then some AROM but no stretch
Dupuytrens Disease
gradual thickening and tightening of fascia under the skin in he hand
Genetic origin of Dupuytren’s Disease
Northern European s
more men than women
5th decade
1signs of Dupuytrens Disease
nodule in palm near DPC and in line with ring finger
continues to get tighter and tighter
Indications of Dupuytrens Disease that do not require tx
nodule, MCP joint contracture less than 30 degrees
Indications for tx for Dupuytrens Disease
finger joint contracture
MCP flexion more than 30
PIP flexion contracture of 15
DIP hyper extension
Contracture or tightness in the thumb
Most common Radial collateral ligament sprain of fingers
PIPJ
What are radial collateral ligament sprains vulnerable to
flexion contracture
What does untreated PIP collateral ligament injury lead to
stiff and painful
lack of PIP ROM
Tx for “itis” vs sprain/injury
“itis”= RICE
Injury/sprain= immobilization then MICE
Ganglion cyst
soft-fluid-filled cyst attached to or near joint capsule, tendon, or tendon sheath
palpable mobile mass
Who is more likely to get ganglion cysts
women
Symptoms and signs of ganglion cyst
cosmetic
pain
weakness if it gets too big
tx for ganglion cyst
Temporary immobilization and strengthen
3 parts of cardiac rehab
exercise counseling and training
education for heart-healthy living
counseling to reduce stress
post pacemaker precautions
Standard sling for L UE for 24 hrs
No exercise to involved shoulder for 4-6 weeks
No shoulder flexion/abduction greater than 90 degrees for 4-6 weeks
no lifting more than 5 lbs
use minimal weight bearing
Sternal Precautions
avoid unilateral shoulder flexion greater than 90 degrees
avoid bilateral and unilateral shoulder abduction greater than 90 degrees
No lifting/pushing greater than 10 pounds
don’t want traction of sternum
1st area of consideration of cardiac recovery
monitoring progression of early mobilization and activity
OT role in 1st steps of cardiac recovery
want early mobilization but in structured and monitored way
need to find a balance of too much or too little movement
method of monitoring exertion/energy expenditure
MET- monitors energy, metabolism
RPE or BORG- how much is being exerted
Vital signs
MET
measures the oxygen or calorie consumption is during specific activities
1 MET generally is equal to the resting metabolic rate
Can be used in conjunction to where they are in rehab
Want to help individuals understand their energy expenditures
Using MET to determine activities
each activity has a MET value that correlates
individuals only have so much energy in the day so MET values can be used to determine what can be done during the day
BORG
Has to do with what person perceives/ how they feel
Rating scale of 6-20 to correlate with heart rate range 60-200
In phase 1 of rehab RPE should not exceed 11-13
When should the BORG scale be used
when used in conjunction with vital sign monitoring
helps patients be more in tune with their body and when they feel overexterion
recommendations for Phase 1 of cardiac rehab
Intensity: RPE below 13 or HR below 120
Duration: intermittent sessions lasting 3-5 minutes, 20 minutes total
Resting periods: as patient wants, lasting 1-2 minutes, shorter than time of activity
Frequency: 3-4 times per day for 1st to 3rd days
Methods for monitoring progession of early mobilization
MET levels as an index for profession
BORG scale in conjunction with vital signs to help patient become more intone with body and know when they need to stop activities
Pre/post vital sign ,monitoring
2nd area of consideration for cardiac rehab
cognitive factors
Cognitive factors of rehab patients
Non surgical: premorbid changes, ischemic hypoxia after MI, decreased perfusion
Complications of cardiac surgery: Type 1- stroke, TIA, Type 2- delirium and post op cognitive dysfunction due to decrease in O2
3rd area of consideration for cardiac rehab
Psychosocial factors
Psychosocial factors during cardiac rehab
Depression
anxiety
perceived decreased quality of life
Heart-focused anxiety
a specific fear of cardiac-related stimuli and sensations because of their expected negative consequence
Instrument for screwing depression/anxiety in cardiac population
Beck depression inventory
Areas of focus for education during cardiac rehab
energy conservation
tips for coping with stress or anxiety
tips for managing cognitive impairments
Phase 1 of cardiac rehab
Acute inpatient hospitalization
Vital signs
patient and family education
improve ADLs
Discharge to phase 2 at MET 3.5
Phases of cardiac rehab
Acute inpatient hospitalization
outpatient rehabilitation
community exercise and support programs
Phase 2 of cardiac rehab
outpatient
activity tolerance
improve ADLs
Graded exercise program
improve ability for occupational roles and work
phase 3 of cardiac rehab
No more therapy
less intensive monitored exercise programs
nutrition programs
senior community programs
Purpose of workplace assessments
prevent injuries
promote comfort
safety and productivity
Workplace assessment inputs
Workers
Supervisors
Employers
not just looking at what they are doing but also looking at policies and standards
2 components of workplace assessments
Clearance
Reach
Clearance of workplace
sufficient headroom, legroom and elbowroom in the work area
posture
Designed for largest user
Reach in workplace
location of controls and materials accessed to perform job tasks
looks at posture and repetitive motions
designed for the smallest user
Reach envelope
Want most used objects within 10 inches
want least used things within 20 inches
past 20 inches is high risk for injuries
Visual requirements in workplace
Head position
locations of visual cues, object placement, information placement
visual input should be directly in the line of sight
Placement of equipment in workplace
postures and motions
are objects too high or too low
is equipment too far away leading to extensive extension
Seated workstations
Ergonomic chair- height adjustable, lumbar and thoracic support, seat pan length
Desk/surface height- low height at 90 degrees
Standing workstations
surface height, clearance and posture should be assessed
Flooring and mats
can be really hard on back to stand all day on hard floor
Workplace intervention
start with problem list
include recommendations and education then follow up
promote neutral posture and change layout of work surfaces
Work place intervention for group
OT as a consultant at community level or company levels
Seddon Classification
Neuropraxia
Axonotmesis
Neurotmesis
Neuropraxia
damage to myelin but axon is still intact
impacts conduction
Axontmesis
Axon and myelin is damaged
Neurotmesis
Full nerve is damaged
Problem of nerve with PNI
divided into proximal and distal segment
distal segment undergoes degeneration
What is required for recovery after full severance
Extension of proximal segment back to distal
orientation of proximal segment to distal, needs ot find its way back
Anatomy fo nerve fiber
axon encased by endoneurium
nerve fibers bundled into fascicule encased in perineurium
many fascicule are embedded in epineurium
Sunderland classification
1- myelin damage
2- axon damage
3- endoneurium damage
4- entire fascicle/perineurium damage
5- entire nerve including epineurium is damaged
Seddons vs Sunderland
Neurapraxia=Grade 1
Axonotmesis- Grade 2
Neurotmesis= grade 3, 4, and 5
Metabolic conduction block
caused by compression
Temporary
6-12 week recovery
severe falling asleep with sensory and motor impairment
Recovery signs start with itching, shooting pain, and then parenthesis
Neurapraxia/Sunderland Type 1
complete motor paralysis
minimal sensory loss
complete recovery
short term focused intervention
Axonotmesis/ Sunderland Type 2
Transection of axon
complete motor paralysis and sensory loss
usually complete recovery
moderate intervention
Neurotmesis/ Sunderland type 3
often a traction injury
complete motor and sensory loss
surgery may be required
incomplete recovery
moderate intervention
Neurotmesis/ Sunderland type 4
Complete motor and sensory loss
Surgery recommended
nerve may not be able to locate distal end on its own
incomplete recovery
long-term intervention
Neurometsis/ sunderland type 5
complete motor and sensory loss
surgery mandatory
never complete recovery
long-term intervention
2 phases of nerve response
Disintegration of the axon and breakdown of myelin sheath (wallerians)
neuronal regeneration (extension and orientation)
Wallerian degeneration
occurs distal to level of injury
distal end shrinks and collapses
fascicle gets smaller
When can nerve response begin
at grade II
Rate of recovery of nerve
1-3 mm per day after initial latency period of 3-4 weeks
Techniques of nerve repair
Epinerual repair- stitching segments together
group fascicular repair
nerve grafting
Nerve conduit
What is classic posture when referring to a PNI
resting/active hand posture
all 3 nerves have this, if individual has it you can rule in nerve injury
Radial nerve injury
high injury often caused by humeral fracture- will effect upper arm all the way to hand
Classic hand posture- wrist drop
Radial nerve innervates extensors
Median nerve injury
cannot flex digits on medial side and no wrist flexion depending on location of injury
Classic posture- benediction during active fist (only ulnar side flexes)
Ulnar nerve injury
intrinsics in digits and wrist flexion is effected
classic posture: ulnar claw deformity at rest of lesion is at wrist
Tx for PNI
Immobilization based on what nerve is injured
preserve unaffected joints and muscles
slow lengthening of repaired nerve segment
entrapment vs injury
there is not typically a full loss of sheath with an entrapment
getting compressed for some reason
Radial Nerve Palsy
injury to radial nerve at level of humerus
often follows humerus fracture
What are symptoms of radial nerve palsy
absence of all wrist and finger extensors and supination
loss of sensation at the dorsoradial aspect of the hand
Tx for radial nerve palsy
wrist extension splint while healing
strengthening as motor function returns
Radial Tunnel syndrome
compression as the nerve lies against the capitulum by the ECRB
Symptoms of radial tunnel syndrome
sensory only!!!
aching in the prox/distal forearm with wrist flexion and forearm rotation
night pain
point tenderness 4-5 cms distal to lateral epicondyle
pain with resisted supination and MF extension
Radial tunnel syndrome treatment
activity modification
nerve glides
PIN syndrome
compression of the nerve between the two heads of the supinator
PIN syndrome symptoms
paralysis of ECU, EDC, EDM, and EI
Loss of MP extension of digits and full thumb extension
median nerve entrapment syndromes
Pronator syndrome
AIN syndrome
Carpal Tunnel Syndorme
Pronator Syndrome
compression between two heads of pronator teres
Symptoms of pronator syndrome
pain in volar forearm
no night pain or paresthesias
parenthesis in digits and thenar eminence
positive tingles over pronator tunnel
2 special tests for pronator syndrome
pronator teres test- resisted pronation with the gradual extension of the elbow, if there’s pain then +
Resisted middle finger flexion- compression at FDS fibrous arch
Pronator syndrome treatment
Elbow splint
activity modification
modalities
nerve glides
AIN Syndrome
Compression as it branches off the median nerve
Symptoms of AIN
Motor symptoms only
Paralysis of FDP of digits 2 and 3 and the FPL
Pain with resisted pronation
paralysis of PQ
AIN treatment
PROM
Elbow splint or thumb IP flexion splint
Carpal tunnel syndrome symtpoms
numbness
nocturnal pain and paresthesias
positive tinels and phalens at wrist
Sensitivity to cold
positive berger test
Carpal tunnel treatment
splint
activity modifications
nerve and tendon gliding
modalities
Ulnar nerve compressions
Thoracic outlet
cubital tunnel
Guyon tunnel
Thoracic outlet syndrome
compression of the brachial plexus and subclavian vessels
Tx for TOS
rest
pain modalities
nerve glides
gentle massage
Cubital tunnel syndrome
Compression at elbow from leaning on it
Sx of cubital tunnel
numbness and tingling along ulnar forearm and hand
pain at medial aspect of elbow esp. with extreme elbow flexion
Tests for cubital tunnel
Positive elbow flexion test
positive tinels at elbow
Positive froments sign
Positive Wartenbergs
Cubital tunnel treatment
Elbow pad, activity modification
modatilies
edema control
nerve glides
Guyon Tunnel syndrome
Ulnar nerve at wrist
repetition
ganglion
pressure
fascia thickening
Symptoms of guyon tunnel syndrome
pure sensory, pure motor or both depending on level
decreased pinch and power grip
pain over volar waist and 5th digit
GTS tests
+ froments
+ wartenbergs
GTS treatment
work/activity modification
modify hand position, wear padded gloves
nerve glides
What is the first goal for the healing process of the wound
infection control if present
3 phases of wound healing
Inflammation
Proliferation
Remodeling/Maturation
Inflammatory phase of wound healing
Contain exudate, reduce edema, remove dead tissue, promote granulation
Length= 1-10 days
Goal is to be able to manage wound care on own or with caregiver
Proliferation phase
stimulate angiogenesis, promote epithelialization, protect wound, maintain a moist environment
Length: 3-21 days
Remodeling phase
Educate on pressure relief, skin inspection, mobilize soft tissue
Length= 3 weeks-2 years
Red wound
what we want to see
cellular activity- oxygen and nutrients
Therapeutic goals protect/ keep moist
Yellow wound
Slough, biofilm
cellular activity- fibrin
Therapeutic goals- remove yellow
may or may not heal with further intervention besides cleaning
Black wound
Necrotic tissue
must be removed or healing wont occur
no cellular activity
Types of wound closure
Primary closure- staples, stitches, glue
Secondary closure- no intervention, healing on its own
Delayed primary closure- primary closure after surgery
Types of scar
Soft- how we want scars to heal
Hypertrophic- raised red rigid
Keloid- spread beyond wound boundaries
Contracture- very tight that restricts motion
Scar management
compression garments, wear 23-24 hours for a year
massage
silicone/gel inserts
ROM
Thermal agents
