Musculoskeletal Impairments

Question 1

Five steps in the treatment of contractures:

(1) superficial and deep heat to increase tissue extensibility; (2) slow stretch; (3) static splinting; (4) serial, or progressive, static splinting; and (5) dynamic splinting
Types of splints to reduce soft-tissue contractures (Berger, 2013, pp. 390–407; Flinn & Bailey, 2015, pp. 269–292)
Antideformity (safe position) burn splint: wrist, 20° extension; metacarpophalangeal (MCP) joints, 90° flexion; proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints, 0° extension
Elbow or knee extension splint: positioning in as much extension as possible
Wrist extension splint to prevent wrist drop: functional splint with 45° of wrist extension worn during day
Thumb abduction splint to prevent thumb adduction contracture: splint forms a C bar between the thumb and index web space
Lumbrical bar splints to reduce MCP hyperextension and interphalangeal (IP) flexion contractures: MCPs are splinted to block hyperextension
Resting hand, ball, and cone antispasticity splints: purpose is to decrease tone in the hand and upper extremity
Soft neoprene splints to position thumb and forearm: commonly used with clients with rheumatoid arthritis or cerebral palsy to increase functional use of the hand
Splint to prevent foot drop: below-the-knee splint to keep ankles at 0° for possible future ambulation
Serial casting: use of fiberglass or plaster of paris materials to position clients with increased tone and over time to stretch out soft tissue contractures
Dynamic splinting: may involve metal and loop components; angle of pull needs to be 90° for most effective outcome

Answer 1

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Question 2

Occupational therapy interventions
A. Preprosthetic interventions

1. Training in limb hygiene
2. Wound healing, including whirlpools and massage
3. Limb shrinkage and shaping: The client is trained to wrap the residual limb in an elastic
   bandage to reduce edema and develop a tapered shape. An elastic shrinker or removable rigid
   dressing can be used if the client is unable to perform proper wrapping techniques.
4. Desensitization of the residual limb through weight bearing on various surfaces, massage,
   tapping, and rubbing (Keenan & Glover, 2013, pp. 1162–1164)
5. Maintenance of or increasing flexibility and strength of residual limb to prevent flexion
   contractures of the knees and hips of the residual limb in clients with lower limb amputations
   (Keenan & Glover, 2013, p. 1185)
6. Maintenance of or increasing strength and flexibility of remaining limbs: Clients with lower
   limb amputations need to strengthen the upper body to maneuver a wheelchair and use
   mobility aids and the lower extremities to increase weight bearing (Keenan & Glover, 2013, p.
   1187).
7. Wheelchairs: Clients with lower limb amputations require residual limb support; the large rear
   wheels should be placed further back to counterbalance missing limbs, and the wheelchair
   should have antitippers

Answer 2

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Question 3

Occupational therapy interventions
A. Preprosthetic interventions
1. Training in limb hygiene
2. Wound healing, including whirlpools and massage
3. Limb shrinkage and shaping: The client is trained to wrap the residual limb in an elastic
bandage to reduce edema and develop a tapered shape. An elastic shrinker or removable rigid
dressing can be used if the client is unable to perform proper wrapping techniques.
4. Desensitization of the residual limb through weight bearing on various surfaces, massage,
tapping, and rubbing (Keenan & Glover, 2013, pp. 1162–1164)
5. Maintenance of or increasing flexibility and strength of residual limb to prevent flexion
contractures of the knees and hips of the residual limb in clients with lower limb amputations
(Keenan & Glover, 2013, p. 1185)
6. Maintenance of or increasing strength and flexibility of remaining limbs: Clients with lower
limb amputations need to strengthen the upper body to maneuver a wheelchair and use
mobility aids and the lower extremities to increase weight bearing (Keenan & Glover, 2013, p.
1187).
7. Wheelchairs: Clients with lower limb amputations require residual limb support; the large rear
wheels should be placed further back to counterbalance missing limbs, and the wheelchair
should have antitippers.

Answer 3

Q

Question 4

Fibromyalgia
Occupational Therapy Intervention

Client education to avoid pain triggers and manage stress
Gentle regular aerobic exercise, gentle daily stretching, strengthening activities, cognitive–behavioral therapy, alternative medicine (e.g., acupuncture, hypnosis)
Sleep hygiene techniques
Myofascial release and trigger point treatment, massage, relaxation exercises, biofeedback
Progressive strength training
Fatigue, stress, and pain management; pacing activities; work simplification and energy conservation techniques
Memory aids
Modification of activity or environment

Answer 4

q

Question 5

Occupational therapy intervention (Deshaies, 2014, pp. 429–451)
A. Five steps in the treatment of contractures: (1) superficial and deep heat to increase
tissue extensibility; (2) slow stretch; (3) static splinting; (4) serial, or progressive, static
splinting; and (5) dynamic splinting

Answer 5

Q

Question 6

Contractures
B. Types of splints to reduce soft-tissue contractures (Berger, 2013, pp. 390–407; Flinn &
Bailey, 2015, pp. 269–292)
1. Antideformity (safe position) burn splint: wrist, 20° extension; metacarpophalangeal (MCP)
joints, 90° flexion; proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints, 0°
extension
2. Elbow or knee extension splint: positioning in as much extension as possible
3. Wrist extension splint to prevent wrist drop: functional splint with 45° of wrist extension worn
during day
4. Thumb abduction splint to prevent thumb adduction contracture: splint forms a C bar between
the thumb and index web space
5. Lumbrical bar splints to reduce MCP hyperextension and interphalangeal (IP) flexion
contractures: MCPs are splinted to block hyperextension
6. Resting hand, ball, and cone antispasticity splints: purpose is to decrease tone in the hand and
upper extremity
7. Soft neoprene splints to position thumb and forearm: commonly used with clients with
rheumatoid arthritis or cerebral palsy to increase functional use of the hand
8. Splint to prevent foot drop: below-the-knee splint to keep ankles at 0° for possible future
ambulation
9. Serial casting: use of fiberglass or plaster of paris materials to position clients with increased
tone and over time to stretch out soft tissue contractures
10. Dynamic splinting: may involve metal and loop components; angle of pull needs to be 90° for
most effective outcome

Answer 6

Q

Question 7

_____________ is a syndrome consisting of widespread pain affecting the entire
musculoskeletal system (Moorehead & Cooper, 2014, p. 170).
B. Symptoms include widespread soft tissue pain, nonrestorative sleep, fatigue, inability
to think clearly, paresthesias and joint swelling, depression, and anxiety.
C. Diagnosis includes excessive tenderness in at least 11 of 18 trigger points on the body.

Answer 7

Fibromyalgia

Question 8

Fibromyalgia
Occupational therapy evaluation (Moorehead & Cooper, 2014)

A. Daily activity log: baseline record of engagement in daily activities for client
(Moorehead & Cooper, 2014)
B. Canadian Occupational Performance Measure (Law et al., 2014): Occupational profile of
client
C. Pain assessments: establishment of baseline pain and documentation of improvements
or regression of pain levels after occupational therapy treatments (Moorehead &
Cooper, 2014)

Answer 8

Q

Question 9

Fibromyalgia
Occupational therapy intervention (Hammond, 2014, pp. 1215–1218)

A. Client education to avoid pain triggers and manage stress
B. Gentle regular aerobic exercise, gentle daily stretching, strengthening activities,
cognitive–behavioral therapy, alternative medicine (e.g., acupuncture, hypnosis)
C. Sleep hygiene techniques
D. Myofascial release and trigger point treatment, massage, relaxation exercises,
biofeedback
E. Progressive strength training
F. Fatigue, stress, and pain management; pacing activities; work simplification and energy
conservation techniques
G. Memory aids
H. Modification of activity or environment

Answer 9

Q

Question 10

Types of hip fractures (Lawson & Murphy, 2013a, pp. 1076–1078)
1. Femoral neck fractures can be caused by slight trauma or rotational force; they occur most
commonly in women with osteoporosis who are older than age 60.
2. Intertrochanteric fractures result from a direct blow to the area between the greater and lesser
trochanter; they occur mostly in women younger than age 60.
3. Subtrochanteric fractures result from a direct blow to the lesser trochanter; they are most often

Answer 10

Q

Question 11

Types of hip replacement and associated precautions (Lawson & Murphy, 2013b, p. 624)
1. Posterolateral approach: no hip flexion greater than 90°; no internal rotation; no adduction of
affected hip joint
2. Anterolateral approach: no external rotation; no extension; no adduction of affected hip joint

Answer 11

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Question 12

Role of the occupational therapy assistant in hip replacement (Coppard et al., 2012, pp.
302–305; Lawson & Murphy, 2013b, pp. 628–636)
1. Complete an occupational profile with the client and family or caregiver.
2. Provide home safety recommendations.
3. Offer education and reeducation regarding hip precautions, including bed mobility, proper
transfer techniques, home modification recommendations, ROM restrictions, and positioning to
perform ADLs.
4. Emphasize maintaining or increasing joint motion.
5. Increase strength of surrounding musculature.
6. Emphasize increasing independence in ADLs and IADLs using prescribed precautions, safety
techniques, and compensatory strategies.
7. Prescribe and instruct the client (and family or caregiver, as necessary) in use of adaptive
equipment.
8. Use physical agent modalities (PAMs) as appropriate to the practitioner’s level of training and
in compliance with specific state regulations (e.g., some states require occupational therapists
to obtain a PAM certification).

Answer 12

Q

Question 13

True changes in structure or mechanics of the lower back can result in the following
conditions:
1. Sciatic pain: when the nerve is trapped by a herniated disc
2. Spinal stenosis: narrowing of the intervertebral foramen
3. Facet joint pain: inflammation or changes of the spinal joints
4. Spondylosis: stress fracture of the dorsal to transverse process
5. Spondylolisthesis: slippage of a vertebra out of position
6. Herniated nucleus pulposus: stress tearing of the fibers of a disc, causing an outward bulge
pressing on spinal nerves
7. Compression fracture: vertebral osteoporosis

Answer 13

Q

Question 14

Standards of body mechanics (Grangaard, 2013, p. 1099; Jacobs, 2008, pp. 173–190)

1. Maintain a straight back; minimize lumbar lordosis.
2. Bend from the hip.
3. Avoid twisting.
4. Maintain good posture.
5. Carry loads close to body.
6. Lift with the legs.
7. Lift with a wide base of support.
8. Lift in the sagittal plane.
9. Lift slowly.

Answer 14

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Question 15

Semisquat: safest lift for the back; ideal for heavy loads (e.g., clients)

2. Squat: alternative to the semisquat when space is limited; often preferred by people with LBP
3. Stoop lift: used only for light loads (<20 lb)

Answer 15

Q

Question 16

LBP
Rehabilitation should aim for the following outcomes: 
1. Reduction of pain
2. Use of back stabilization techniques
3. Use of adaptive equipment
4. Incorporation of body mechanics
5. Incorporation of ergonomic techniques
6. Ability to adapt learning to future applications

Answer 16

Q

Question 17

Cancer
Medical Treatment

Chemotherapy
Definition: use of toxic chemicals to kill cancer cells
Side effects: alopecia, fatigue, anemia, diminished hearing or vision, peripheral neuropathy, thrombocytopenia
Precautions: use of a mask because of compromised immunity; restricted diet because of yeast infection in the mouth; screening for anxiety, depression, and fatigue; extra care to avoid dropping things; monitoring for excessive bleeding
Radiation
Definition: use of radioactive material to kill cancer
Side effects: burns
Precautions: assistance to maintain joint ROM while avoiding pulling the burned skin, use of water-based ointments
Surgery
Definition: removal of cell, tissues, or organs
Side effects: varied, depending on the surgery (e.g., lymphedema with mastectomy)
Precautions: refraining from bathing the area until staples or sutures removed, prevention of dependent edema
Hormone therapy
Definition: use of hormones to decrease estrogen, which can increase the spread of some cancers
Side effects: menopauselike symptoms, including hot flashes and mood swings
Precautions: monitoring of room temperature and client mood
Immunotherapy
Definition: use of medicine to block or heighten immune system response
Side effects: skin welts
Precautions: avoidance of scratching the skin
Combinations of the above treatments

Answer 17

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Question 18

Cancer
Occupational Therapy Intervention

Vary, depending on type of cancer, medical stability, and phase of treatment
Can be helpful in many areas:
Training in energy conservation, fatigue management, and activity and exercise tolerance to manage the side effects of medical treatment
Independence and safety in ADLs and IADLs
Adaptive equipment and assistive technology
Psychosocial support, including education in realistic expectations for recovery
Caregiver training and support
Compensatory cognitive strategies
Sensory education and desensitization
Scar management
Wheelchair seating and positioning
Fall prevention and home safety
Lymphedema treatment after radical mastectomy
Physical agent modalities
End-of-life care

Answer 18

q

Question 19

Osteophytes or bone spurs may develop on the edge of the bone (Beasley, 2014, p. 457).
Bouchard’s nodes on the ___ joints
Heberden’s nodes on the ___ joints

Answer 19

PIP

DIP

Question 20

Osteoarthritis
Occupational Therapy Evaluation

Occupations that rely on lower extremity flexibility and strength should be evaluated for clients with knee or hip OA. IADLs that require walking, standing, squatting, and balance are potentially problematic. Rest and sleep may be disturbed by pain. Job analyses for clients who are workers may be necessary. The effect of OA on play and leisure activities should be explored.
The main client factors affecting participation are pain and joint changes such as instability, loss of motion, weakness, and fatigue.
Clients with OA should be screened for cognitive and psychosocial deficits.
Although OA does not directly affect cognition, symptoms such as pain, sleep disturbances, depression, and medications can all have an effect on attention span, short-term memory, and problem-solving skills.
Psychosocial deficits include fear of pain, changes in body image, perception of self as a sick person, continuous uncertainty about the course and progression of the disease, sexual dysfunction, altered roles, and loss of income because of the inability to work.
Current coping strategies should be assessed, particularly if OA is a chronic disorder (Deshaies, 2013, pp. 1011–1013).
Clients with OA-related THR and TKR should be assessed for their understanding of precautions; transfer abilities, bed mobility, and ability to change body positions; and lower extremity dressing (Coppard et al., 2012, pp. 302–306; Lawson & Murphy, 2013, pp. 1082–1088).
THR precautions should be taken to avoid dislocation of the operated leg (Lawson & Murphy, 2013a, p. 1078; Lawson & Murphy, 2013b, p. 625).
Posterolateral approach: no hip flexion greater than 90°; no internal rotation; no adduction (crossing of legs or feet)
Anterolateral approach: no external rotation, no adduction (crossing of legs or feet), no hip extension
TKR precautions include not putting a pillow under the knee while in bed; resting feet on the floor when sitting to increase ROM; wearing an immobilizer as instructed; and avoiding kneeling, squatting, or twisting the knee (Javaherian-Dysinger & Pavlovich, 2012, p. 294; Lawson & Murphy, 2013b, pp. 626–627).
Hand function related to thumb mobility may be severely restricted by pain and instability. OA of the thumb CMC joint should include an assessment of thumb joint ROM and stability (Beasley, 2014, pp. 460–461).
The occupational therapist can provide consultation regarding environmental modifications to the home to improve access and reduce fall risk.
A driving evaluation should be performed.

Answer 20

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Question 21

Osteoarthritis
Occupational Therapy Interventions

Physical agent modalities—for example, superficial heating agents such as paraffin, fluid therapy, hot packs, microwave packs, hydrotherapy, and electric stimulation—can be used to reduce pain and increase ROM (Beasley, 2014, p. 460).

Exercise includes therapeutic exercises designed to promote client needs and tolerances (Deshaies, 2013, pp. 1021–1023).
AROM exercises are encouraged; PROM is used only if AROM is precluded.
Isometric or isotonic strengthening exercises can be performed to tolerance. Low-impact aerobic conditioning exercises can increase flexibility, strength, endurance, and cardiovascular fitness.
Pinching exercises may be contraindicated with CMC joint instability because of stresses on the joint.

Spica splints may be prescribed to provide stability to the CMC joint during pinching activities (Beasley, 2014, pp. 462–463).

Occupation-based retraining can include adaptations or modifications to accommodate or compensate for pain, stiffness, decreased ROM, and instability. These adaptations and modifications may include devices with built-up or extended handles.

Clients with THR and TKR should practice transfers, bed mobility, ADLs, and IADLs while maintaining precautions.

Education topics should include symptom management, disease process, principles of joint protection and fatigue management, and available community resources.
Principles of joint protection and fatigue management are as follows (Coppard et al., 2012, p. 308; Deshaies, 2013, pp. 1029–1031; Harrell, 2013. pp. 581–584):
Respect pain.
Maintain muscle strength and joint ROM.
Use each joint in its most stable anatomical and functional plane.
Avoid positions of deformity.
Use the strongest joint available.
Ensure correct patterns of movement.
Avoid staying in one position for long periods.
Avoid starting an activity that cannot be stopped immediately if it becomes too stressful.
Balance rest and activity.
Reduce force and effort.

Answer 21

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Question 22

__________ is a progressive condition characterized by low bone mass or density and deterioration leading to bone fragility and pathological fractures, particularly of weight-bearing bones.

__________ is a reversible weakening of the bone and is a precursor to osteoporosis.

Answer 22

Osteoporosis

Osteopenia

Question 23

__ is a progressive synovitis (inflammation of the synovial membrane) of the diarthrodial joints that can lead to destruction of ligament, tendon, cartilage, and bone. Joint swelling from excessive synovial fluid combined with enlargement of the synovium and thickening of the joint capsule leads to weakened joint capsules and distended tendons and ligaments. Uneven distribution of biomechanical forces on weakened ligaments and tendons can lead to permanent deformities of the joint (such as swan neck deformities of the fingers; Deshaies, 2013, p. 1007).

Answer 23

RA