Final Exam - new stuff

Question 1

orthosis positioning

Answer 1

Safe position / antideformity position 
PIP/DIP extension 0
MCP joint flexion at least 70
Wrist extension 20-30
Thumb in palmar abduction 

Functional positioning / resting
Wrist 10-15 extension
MCP joints 15-20 flexion 
PIPs flexion 20-25
DIPs flexion 10 

Consider bony, nerve, and venous anatomy
Incorporate arches
⅔ of the way down the forearm

Question 2

What is the difference between dynamic, static progressive and serial casting for mobilization orthosis fabrication?

Answer 2

Static: Primarily to support, stabilize, protect, immobilize, prevent contractures, modify tone

Serial static: Splint is remolded or replaced to lengthen tissues, restores mobility

Static progressive: Lengthens tissues via a non-dynamic component (Velcro, turnbuckle), restores mobility. Uses a low load force

Dynamic: Has moving parts (elastic component) to permit, control, or restore movement, can act as a substitute for weak muscles

Question 3

high risk groups for cumulative trauma disorders (CTD’s)

Answer 3

New on the job w/ no major previous exposure to repetitive tasks
After a break from this type of activity (vacation or sick leave)
Older workers (35-55 yo)
Gender, females are 10 x more common than men
Type of work, ex: manufacturing could lead to shoulder pain

Question 4

commonly used CTD terms

Answer 4

Repetitive strain injury (RSI), occupational cervico-brachial disorder, overuse syndrome, work related disorders, repetitive trauma disorders, regional musculo-skeletal disorders

Question 5

characteristics of CTD and be able to determine the presence of CTD’s

Answer 5

Condition in soft tissue structures (tendons, tendon sheaths (tenosynovitis), nerves, muscles or blood vessels, trigger points, myofascial pain, bursitis)
Cause or accelerated by repeated stresses and/or awkward motions
Not caused by a single incident (sprain is a single incident)
Each work activity has the potential to cause micro tears in soft tissue structures
Criteria to determine CTD in the workplace can be tendon or nerve related or both*
Symptoms: pain, numbness, tingling; symptoms lasting more than 1 week and/or occuring more than 20 x in the last year; no evidence of acute traumatic onset; no evidence of systemic disease; onset of symptoms occurring with present job

Question 6

levels of CTD

Answer 6

Level 1 - most severe
Level 2
Level 3 - least severe

Question 7

appropriate treatment for CTD conditions

Answer 7

Management of osis or itis: anti-inflammatory medications; NSAID, corticosteroid
Patient education, activity modification, stretches, splint, icing, proximal exercises to strengthen surrounding muscles, regenerative injections, adhering to restrictions

Rotator cuff tendonitis: NO overhead reaching

Short term treatment strategies:
Goal central sensitization
Acute/sub-acute denervation or peripheral
Goal for muscular or ligament strains
Work on posture and activity modification

Question 8

What is BTE? How is it used?

Answer 8

Used for both assessment (strength and endurance) and treatment (work simulation)
ADLs and IADLs
Can be used in ortho, industrial, and neuro settings
Has various settings for: isotonic (eccentric and concentric), isometric, isokinetic (speed remain the same, but resistance can change), PROM, active assisted ROM

Question 9

How is work defined when using BTE

Answer 9

Work = Force x Distance
Power = work/time
In relation to BTE = resistance, repetitions, time

Question 10

What patient populations would the BTE be appropriate for

Answer 10

Evals: work capacity eval
Treatment: acute or work conditioning
Ergonomic analysis
How: torque control, ratchet switch, height adjustment, work head adjustment, work head position, dynamic and static
Can assess: manual dexterity, handling/grasping, ROM, strength, endurance, effects of vibration, effects of repetitions, work tolerance
Do NOT use for pts with degenerative neurological conditions

Question 11

Identify CTDs

Answer 11

Condition in soft tissue structures (tendons, tendon sheaths (tenosynovitis), nerves, muscles or blood vessels, trigger points, myofascial pain, bursitis)
Cause or accelerated by repeated stresses and/or awkward motions
Not caused by a single incident (sprain is a single incident)
Each work activity has the potential to cause micro tears in soft tissue structures

Question 12

Symptoms of carpal tunnel

Answer 12

Pain, tingling, & numbness in the thumb, index, middle, & radial side of ring finger
Tingling in median nerve distribution
Symptoms are worse at night
Hands feel weak in the morning
Pts drops objects more than usual
Difficulty grasping or pinching objects
Difficulty with tasks requiring dexterity, coordination & strength, such as buttoning a shirt, writing with a pen, or opening a jar lid
The muscles at the base of your thumb are smaller and weaker than they used to be.

Question 13

conservative treatment for carpal tunnel

Answer 13

Splinting; for positioning when sleeping & in the daytime splint if the symptoms persist during ADL activities. Splinting reduces swelling. Can be off the shelf (less effective, but less restrictive) or custom made
Medications, injections of corticosteroids
Ergonomics: rest wrist and hands from repetitive activity intermittently, alternate tasks to reduce pressure on the wrist, delegate tasks that aggravate to co workers or family members, modify and change daily activities that aggravate
Patient education

Question 14

surgical management carpal tunnel

Answer 14

open procedure

endoscopic

Question 15

causes of carpal tunnel

Answer 15

• Entrapment of median nerve
• Injuries
• Arthritis
• Work activities and hobbies
• Associated conditions: pregnancy, birth control, diabetes, thyroid disease, amyloidosis

Question 16

What is occupational therapy’s role with the management of patients with Lymphedema?

Answer 16

Maintenance: compression sleeve, compression bandaging, self massage, exercise, skin care, prevention and risk guidelines, psychological health promotion

Question 17

What is the patient’s responsibility when managing Lymphedema?

Answer 17

Pt needs to buy in and know it is not a quick fix; it will require a permanent lifestyle change to manage/reduce the lymphedema
Maintenance and self-management: compression sleeve, compression bandaging, self-massage, exercise, skin care, follow prevention and risk guidelines, watch for cellulitis/ scratches

Question 18

What are the different types of Lymphedema?

Answer 18

Primary Lymphedema
Lymphedema Congenitum: clinically present at birth (10-15% of primary lymp.)
Lymphedema Praecox: present w/ onset of puberty (75-80%)
Lymphedema Tardum: appears after 35 yrs (15-20%)
Secondary Lymphedema: cancer treatment #1 cause of lymphedema in the US; trauma/burn, infection, scar tissue formation, lymphatic system blockage, chronic venous insufficiency, filariasis (#1 cause worldwide) , radiation therapy

Question 19

What is occupational therapy’s role with psychological management of patients with hand trauma?

Answer 19

Facilitate physical and psychosocial recovery
Treat the whole person
Educate patient on normal reaction to traumatic injury
Identify symptoms that may indicate the benefit of psychological intervention and referral
Coping interventions

Question 20

What type of patient responses can occur with trauma?

Answer 20

Cognitive
Flashbacks (most common)
Nightmares
Concentration/attention difficulties
Affective
Anxiety, depression, disgust, irritability, hostility, cosmesis concerns
Psychological
Startle reaction, phantom series, sensations, sexual dysfunction
Behavior
avoidance, denial, gaze aversion, drug/alcohol abuse, marital distress

After three months, these signs should subside.

Question 21

What are the identified types of flashbacks individuals could experience following trauma?

Answer 21

Relay – Like watching on video tape, great detail
Good prognosis
Appraisal – Like snapshot image
Variable prognosis
Projected – Flashbacks of events that never occurred
Poor work return prognosis

Question 22

Universal Precautions

Answer 22

Protection from bodily fluids 
Avoid needle stick 
If it is ‘wet’ wear gloves if needed 
Washing hand 
Wearing eye protection 
When doing laundry wear gloves 

What to do with needle prick: 
Flush with water right away 
Report right away 
Evaluate source (patient)
Baseline testing 
Follow up with results 
Learn patient’s results

Question 23

Radial deficiencies:

Answer 23

absence of all or part of the radius, hand displaced radially, thumb may be missing, if present thumb is stiff

Presentations
Type 1: Deficient distal radial epiphysis
Type 2: Deficient distal and proximal radial epiphysis
Type 3: Present proximally (partial aplasia)
Type 4: Completely absent (total aplasia), most common
Surgical management
Pollicization: Makes the index finger into a thumb

Question 24

Syndactyly

Answer 24

webbing of the fingers, associated with Apert syndrome
Presentations
Simple: only skin involved
Complex: bones are fused
Surgical management
Surgically corrected at about 4 years of age

Question 25

Arthrogryposis

Answer 25

congenital contracture in two or more areas of the body.
Presentations
Stiffness, limited ROM
Shoulders adducted & internally rotated, elbows fixed in extension and forearm pronation
Normal intellect

Question 26

Osteogenesis Imperfecta

Answer 26

Presentation

Brittle bones, scoliosis, wide intra temporal misshapen head with a small triangular face

Question 27

Muscular Dystrophy:

Answer 27

inherited recessive gene most common in males. Progressive degeneration and weakness of the skeletal muscles.
Presentation
Symptoms begin at varying ages but likely will not be obvious until 36 months
Children initially seem normal, but they can’t keep up
Weakness and falling, respiratory failure, cardiomyopathy
UE shoulder problems, then elbow, then hand function

Question 28

Congenital dislocated hips:

Answer 28

hip instability
Presentation
Babies show very little visible signs. Look for legs with different lengths and uneven skin folds
Causes vary
Can usually be corrected with a Pavlick harness (worn 1-2 months) if caught at birth

Question 29

Legg-Perthes disease

Answer 29

Presentation
Knee pain is usually first complaint (even though it is a hip disorder)
Osteochondrosis: degenerative changes in ossification centers of epiphysis
Flattening of weight bearing surface of the hip
Treated in broomstick cast
Disruption of blood flow to the head of the femur, the bone dies

Question 30

Spinal muscular atrophy (hypotonia)

Answer 30

Progressive muscle wasting and decreased mobility
Presentation
Proximal muscles and respiratory muscles affected first
Chronic progressive degeneration
Weakness, low tone, atrophy
Rapid decline, many die by age 2, life expectancy of 10 years

Question 31

What are common musculoskeletal injuries in children? What is the etiology and healing expectations of children who have experienced fractures? Which area of the bone can cause complications when fracture

Answer 31

Rapid healing (children have strong periosteum), nonunion is rare
Fractures in epiphyseal plates cause complications
Fractures in UE can result in brachial plexus injury

Question 32

Erb’s Palsy Type 1

Answer 32

Upper Plexus (C5, C6, C7) (UPPER plexus– kid in picture has their hand up)
Waiter’s tip
Mild: only involves supraspinatus & infraspinatus
Extensive: involves deltoid, external rotators (infraspinatus & teres minor), and elbow flexors (biceps, brachialis, and brachioradialis)
Most common with an estimated 75% of babies having full recovery
OT
Orthosis (shoulder: 90 ER, 75 abd, 10 flexion) (elbow: 60 flexion) (wrist: neutral) (hand: safe position).
PROM & bilateral activities as function returns

Question 33

Erb-Duchenne-Klumpke Type 2

Answer 33

Entire plexus including sympathetic nerve root

Sympathetic nerve root involvement causes Horner’s syndrome (drooping eyelid, small pupil)

Question 34

Klumpke Palsy Type 3

Answer 34

Lower plexus (C8, T1)
Weakness of wrist and finger flexors → hand looks like ulnar nerve hand (fingers claw in)
Poor prognosis

Question 35

What occupational therapy goals are appropriate for children with varying neuromuscular disorders?

Answer 35

General OT
Conservative: daily ROM, orthosis
Post nerve graft: sensory retraining, joint compression & weight bearing for proprioception, bilateral motor training

Question 36

clinical presentation including onset of symptoms in children with neuromuscular disorders

Answer 36

Stretch
Injury varies according to the amount of stress. Causes nerve compression.
Usually recover within 1-2 years with nearly complete function
Neuroma
Injury involves scar tissue compressing nerves
May require surgery
Rupture
Nerve torn at several locations
Surgery and therapy required
Avulsion
Nerves are pulled from the spinal cord
Requires extensive surgery and possible muscle transfer

Question 37

MP Arthroplasty: Know post-op precautions

Answer 37

No MCP flexion past 45 degrees for 1st 6 wks
Avoid lateral stress
No passive flexion beyond 85 degrees
(check these)
Resting hand splint worn at night; dynamic extension splint worn during the day; can pull radially to protect from ulnar drift

Question 38

Hip Arthroplasty: Know post-op precautions and appropriate adaptive equipment that could be helpful following surgery

Answer 38

Posterior: more common. Precautions: 
No hip flexion beyond 90 degrees
No hip adduction (keep legs apart)
No trunk rotation
No hip IR

Anterior: less common. Precautions: 
No hip extension
No leg crossing
No sleeping on stomach
No hip ER
Or, there may be no precautions. Ask your surgeon. 

Adaptive equipment: sock aid, raised toilet seat, reacher, grab bars in bathroom, abduction pillow and angled cushion seat

Note: precautions vary b/t facilities/ surgeons.

Question 39

Knee Arthroplasty: Know the post-op expected activity level and appropriate therapy interventions

Answer 39

Weeks One-Two
WBAT
Keep wound clean

Weeks 3-6
No rapid flexion
No impact activity

Weeks 6-12
LIft no more than 50lbs
30-50 lbs is okay, if not repetitive
Maintain activity lifestyle but no do not over do it

Treatment could include
Standing endurance while performing ADLs 
Walking endurance while performing ADLs 
Energy conservation 
Pain management

Question 40

Shoulder Arthroplasty: Know post-op precautions

Answer 40

Phase One
Wear sling for 3-4 weeks
Avoid hyperextension when supine, 6-8 weeks
NO shoulder AROM, IR, ER, driving (for 3 weeks)
Do not support body weight
Do not soak wound

Phase Two 
Occurs around 4-6 weeks 
Use sling for sleep 
Avoid hyperextension when supine 
Avoid AROM AG 
No lifting, jerking
Do not support body weight 

Phase Three 
Introduce moderate strength training
No heavy lifting (3kg) 
No  sudden pushing/lifting
No jerking 

Phase Four
Advance strength stage
Avoid anything that puts stress on anterior capsule
Gradual strengthening is okay

Question 41

De Quervains /Intersection Syndrome: Know clinical presentation and special test corresponding with De Quervains.

Answer 41

DeQuervain’s Tenosynovitis

• Inflammation of APL and EPB
• Presents with pain at radial styloid

Intersection Syndrome

• Inflammation where ECRL and ECRB ‘intersect’ over APL and EPB
• Pain presents 2-4 cm proximal to radial tubercle

Special Tests for DeQuervain’s and Intersection Syndrome
-Finkelstein’s Test

Question 42

Elbow Arthroplasty: Know post-op precautions

Answer 42

Elbow in posterior soft splint in 60 degrees of flexion
No lifting objects > 1 lb
No excessive stretching or sudden movements, especially extension
Avoid valgus/varus stress to elbow
No UE weight bearing with involved side	
No UE pushing against resistance 	
No end range elbow flexion	
Watch out for ulnar nerve injury

Question 43

Lateral/Medial Epicondylitis: Clinical presentation

Answer 43

Medial Epicondylitis (golfer’s elbow)  
Caused by trauma to common flexor tendon 
Involves…
PT (pronator teres) 
FCR
PL (palmaris longus) 
FDS
Avoid: 
Wrist flexion 
Pronation 
Valgus Stress 

Lateral Epicondylitis (tennis elbow)  
Degeneration of wrist extensors involving attachment to lateral epicondyle 
ECRB is most commonly affected 
Avoid 
Repetitive use of muscles

Question 44

Ganglion Cysts/Guyon’s Canal Syndrome: Region of injury

Answer 44

Most commonly occur on the dorsum of the wrist

Question 45

Wrist Joint Arthroplasty/Fusion: Know the patient population that could benefit from the procedures and expected outcomes following the procedures.

Answer 45

Arthrodesis-bone fusion
Used for people with post-traumatic arthritis (radiolunate/scaphoid lunate)
After surgery…
Wrist is casted for 6 weeks
Cannot pick up anything heavier than a pencil/pen
Do not weight bear
Typically for the younger population

Arthroplasty-total joint replacement 
Used with people with RA or OA 
After surgery…
Casted 4-6 weeks 
Do not lift more than 11 lbs for 4-8 weeks 
Typically in the older generation

Question 46

Diabetes: Occupational therapy’s role

Answer 46

Type I vs Type II
What parts of body are affected/risks

OT’s Role 
Lifestyle Change (diet and exercise) 
Skin Scans 
Patient education 
REAL program 
Amputation management if applicable to patient 
Pain management
Edema measurements  
Scarring 
Mobility 
Sensation 
ADL
Transfers 
Mirror box therapy