Pedretti Ch. 39 -- Assessment of Grip, Pinch, Edema Flashcards
Nerve Compression and Nerve Regeneration
Sensibility testing performed to assess nerve recovery, return of nerve function after surgical decompression, or efficacy of conservative intervention to reduce compression following laceration and repair
From first 2-4 mos. After nerve suture, axons regenerate and travel through hand at rate: 1 mm/day or 1 inch/month. Tinel’s sign can be used to follow the regeneration
Tinel’s sign
tapping gently along the course of a peripheral nerve, from distal to proximal→ should have tingling sensation in the fingertip [the point at which tapping gives a tingling sensation is where the nerve is approximately compressed/can use to see how much sensory axon grew after nerve repair])
Vibration
Tuning fork is not discrete enough to detect abnormal sensation→ use commercial vibrometers to detect abnormal sensation
Vibration and Semmes-Weinstein test sensitive in picking up gradual decrease in nerve function (with nerve compression with intact nerve circuits)
- Correlated to decreases in potential amplitude of sensory nerve action
Semmes-Weinstein and electrical testing reliable/sensitive tests for early detection of carpal tunnel syndrome and other nerve compression syndromes
Semmes-Weinstein performed at clinic, no discomfort, good screening tool when nerve compression suspected
Touch Pressure
Moving touched tested using pencil eraser end
- Placed in normal sensibility with light pressure (same with light and heavy stimuli) → distal fingertip
- Client says when they feel the stimulus is different
Test constant touch: press eraser in normal area and then distally (and lift up before placement)
Semmes-Weinstein monofilaments: used for assessing cutaneous pressure thresholds
- Either 20 or 5-pack filaments
- Diameter of monofilaments increase and exert force from 4.5 mg to 447 g
- Normal fingertip sensibility: 2.44-2.83 probes
- Apply monofilament perpendicular to skin and just until it bends (larger ones don’t bend so look at skin color to see how hard to apply probe)
- Start in normal range → increasing diameters to see client’s threshold for touch
- 2 out of 3 responses from application necessary to say it has intact sensibility
a. Held for a second, rest for a second, reapplied - Place the monofilaments randomly
Two-Point and Moving Two-Point Discrimination
Discrimination: 2nd level of sensibility assessment
Instruments: bent paper clip (burrs on tip but inexpensive), industrial calipers, Disk-Criminator
1. Device with parallel prongs and distance and blunted ends should give reproducible results
Two-point Test
- Occlude vision
- Normal area of sensation tested for reference with bent paper clips/blunt calipers
- Set blunt calipers 10 mm apart , randomly applied from proximal fingertip → longitudinal with nerves, with 1 or 2 points touching
- Distance decreased until client doesn’t feel 2 points, measure distance
- Normal 2 point discrimination is 6 mm or less
- Give 3-4 seconds between applications and need 4 out of 5 correct responses
Moving two-point test
- Occlude vision
- Normal area of sensation tested for reference with bent paper clips/blunt calipers
- Fingertip supported by table or examiner’s hand
- Set blunt calipers 5 to 8 mm apart , randomly applied from proximal fingertip → longitudinal with nerves, with 1 or 2 points touching
- Correctly identify stimulus 7 out of 8 times, repeated up to 2 mm separation
Two-point values
Two-point values increased with age in both sexes, smallest values in 10-30 year olds
- Women tend to have smaller values than men
- No significant difference between nondominant and dominant hands
Modified Moberg Pickup Test
Sensory function final level: recognizing common objects (ability of hand to perform complex functions by feel)
Used with either median nerve injury or injury to both median and ulnar nerves
Takes 2x as long to perform tests with occluded vision
Test
- 9-10 small objects (ex: penny) are on a table and client puts them in container as fast as they can one at a time while looking at it, timed.
- Repeat with opposite hand with vision
- Repeat with both hands with occluded vision
- Client identifies each object one at a time, with and then without vision
Observe substitution patterns client might use when they cannot see the objects
Edema Assessment
Measure hand volume to assess presence of extra/intracellular edema
Used to determine intervention effects
Use a commercial volumeter: accurate to 10 ml
a. Use the same level surface each time
b. Evaluation
1. Plastic volumeter filled up to the spout
2. Client puts hand in volumeter until it rests gently between middle/ring fingers on the dowel rod
3. Hand remains still until no more water goes into beaker
4. Measure water in a graduated cylinder
Assessing individual finger/joint edema
- Circumferential measurement with circumference tape or jeweler’s ring-size standards
- Make measurements before/after intervention and after thermal modalities or splinting
Grip Strength
UE strength usually assessed after healing phase of trauma (test after they are cleared for full-resistive activities, usually 8-12 weeks after injury)
Recommended for grip strength: standard adjustable-handle dynamometer
- Seated, shoulder adducted, neutrally rotated, elbow flexion 90degrees, forearm neutral and wrist (0-30 degrees) extension, and ulnar deviation (0-15 degrees)
- 3 trials of each hand; mean of 3 trials reported
- Noninjured hand used for comparison, normative data to see strength scores (factors like age will affect strength measures)
Pinch strength
Pinch strength
- Use a pinch gauge (found to be most accurate)
- Two-point pinch (thumb/index), lateral/key pinch (thumb pulp and middle finger), and three point pinch (thumb, index, middle fingertips) evaluated
- 3 trials obtained and compared on both sides
Maximal voluntary effort during grip, pinch, or muscle testing
Maximal voluntary effort during grip, pinch, or muscle testing will be affected by pain in the hand or extremity and note if client’s ability for full force is affected by subjective complaints
Localizing pain symptoms and evaluating the role of pain in recovery is important
Functional Assessment
Assessment of hand function/performance important because physical assessment does not measure client’s ingenuity and ability to compensate for loss of strength, ROM, sensation or the presence of abnormalities
Physical assessment before functional assessment to see how physdys → functional impairment.
