Final Exam - new stuff Flashcards
orthosis positioning
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
What is the difference between dynamic, static progressive and serial casting for mobilization orthosis fabrication?
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
high risk groups for cumulative trauma disorders (CTD’s)
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
commonly used CTD terms
Repetitive strain injury (RSI), occupational cervico-brachial disorder, overuse syndrome, work related disorders, repetitive trauma disorders, regional musculo-skeletal disorders
characteristics of CTD and be able to determine the presence of CTD’s
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
levels of CTD
Level 1 - most severe
Level 2
Level 3 - least severe
appropriate treatment for CTD conditions
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
What is BTE? How is it used?
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
How is work defined when using BTE
Work = Force x Distance
Power = work/time
In relation to BTE = resistance, repetitions, time
What patient populations would the BTE be appropriate for
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
Identify CTDs
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
Symptoms of carpal tunnel
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.
conservative treatment for carpal tunnel
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
surgical management carpal tunnel
open procedure
endoscopic
causes of carpal tunnel
- Entrapment of median nerve
- Injuries
- Arthritis
- Work activities and hobbies
- Associated conditions: pregnancy, birth control, diabetes, thyroid disease, amyloidosis
What is occupational therapy’s role with the management of patients with Lymphedema?
Maintenance: compression sleeve, compression bandaging, self massage, exercise, skin care, prevention and risk guidelines, psychological health promotion
What is the patient’s responsibility when managing Lymphedema?
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
What are the different types of Lymphedema?
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
What is occupational therapy’s role with psychological management of patients with hand trauma?
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
What type of patient responses can occur with trauma?
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.
What are the identified types of flashbacks individuals could experience following trauma?
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
Universal Precautions
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
Radial deficiencies:
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
Syndactyly
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
Arthrogryposis
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
Osteogenesis Imperfecta
Presentation
Brittle bones, scoliosis, wide intra temporal misshapen head with a small triangular face
Muscular Dystrophy:
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
Congenital dislocated hips:
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
Legg-Perthes disease
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
Spinal muscular atrophy (hypotonia)
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
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
Rapid healing (children have strong periosteum), nonunion is rare
Fractures in epiphyseal plates cause complications
Fractures in UE can result in brachial plexus injury
Erb’s Palsy Type 1
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
Erb-Duchenne-Klumpke Type 2
Entire plexus including sympathetic nerve root
Sympathetic nerve root involvement causes Horner’s syndrome (drooping eyelid, small pupil)
Klumpke Palsy Type 3
Lower plexus (C8, T1)
Weakness of wrist and finger flexors → hand looks like ulnar nerve hand (fingers claw in)
Poor prognosis
What occupational therapy goals are appropriate for children with varying neuromuscular disorders?
General OT
Conservative: daily ROM, orthosis
Post nerve graft: sensory retraining, joint compression & weight bearing for proprioception, bilateral motor training
clinical presentation including onset of symptoms in children with neuromuscular disorders
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
MP Arthroplasty: Know post-op precautions
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
Hip Arthroplasty: Know post-op precautions and appropriate adaptive equipment that could be helpful following surgery
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.
Knee Arthroplasty: Know the post-op expected activity level and appropriate therapy interventions
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
Shoulder Arthroplasty: Know post-op precautions
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
De Quervains /Intersection Syndrome: Know clinical presentation and special test corresponding with De Quervains.
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
Elbow Arthroplasty: Know post-op precautions
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
Lateral/Medial Epicondylitis: Clinical presentation
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
Ganglion Cysts/Guyon’s Canal Syndrome: Region of injury
Most commonly occur on the dorsum of the wrist
Wrist Joint Arthroplasty/Fusion: Know the patient population that could benefit from the procedures and expected outcomes following the procedures.
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
Diabetes: Occupational therapy’s role
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
