Lecture Notes on Job Demands Analysis and Hand/Upper Extremity Assessment

Jan 7 Lecture → Job demands analysis (JDA) and functional abilities evaluations Definition ​ Comprehensive approach to quantify the physical, cognitive, and environmental demands of the essential and non-essential tasks of a job Alternative terminology ​ Task analysis, job site analy...

Jan 7 Lecture → Job demands analysis (JDA) and functional abilities evaluations Definition ​ Comprehensive approach to quantify the physical, cognitive, and environmental demands of the essential and non-essential tasks of a job Alternative terminology ​ Task analysis, job site analysis, ergonomic analysis, activity analysis Different uses/users of JDA’s ​ Rehabilitation, insurance, healthcare providers, organizations, RTW plans What details to expect in a JDA ​ Body mechanics ​ Information on physical demands ​ Information on cognitive demands ​ Costs, providers and types ​ Position details ​ Safety, equipment, and training requirements ​ Work environment ​ Accessibility needs and accommodations OT’s use of JDAs ​ Identifying and assessing potential workplace risks ​ Arranging workplace accommodations ​ Preventing physical/cognitive injuries or re-injuries ​ Preparing FAE’s ​ Making RTW plans or arrangements JDA Timeline Original purpose → finding the knowledge, skills, abilities and other characteristics (KSAO) required to perform certain jobs → the process known as JDA lead to the first formal versions of job descriptions → developed and implemented by psychologists using time and motion to create the organization of job tasks and techniques → used to accommodate modern jobs and focus more on job tasks National Occupational classification (NOC) → classification system for occupations in Canada. Creates hierarchical systematic classification system by collecting and analyzing occupational data and labor market data → often used to find ​ Job descriptions ​ Educational and past-experience requirements ​ Job skills required for certain positions  ​ Relating or similar occupations Dictionary of occupational titles (DOT) ​ American version of NOC for those practicing in USA ​ Created to meet demands of growing public employment and increases in standardized occupational information ​ Hopes to address users demands of relevant occupational information Job descriptions for JDA → Can be developed using information collected from the NOC or DOT Job descriptions have the following components ​ A brief description of the key components and responsibilities of the role ​ Explanation of the job in lay/plain terms ​ Provides reviewers a clear understanding of the job ​ Inclusion of the job title ​ Job purpose or overview of the role Physical Demands kneeling Manual dexterity Strength activities Couching Finger dexterity Pull sitting Reaching above shoulder Sustained grip standing Reaching below shoulder Repeated grip Climbing (stairs/ladder) Forward bending while sitting Sustained pinch Walking Stooping Repeated pinch Crawling Lifting Physical demands examples ​ Frequency categories are often used to describe the task demands and have detailed descriptions to allow for accuracy in the job demand analysis ​ Example ○​ 1 = seldom/not daily ○​ 2 = low daily activity / 3h daily Example (JDA - WorkSafeBC) Physical Frequency Duration Distance Height Task demand description Reaching Rare 3 mins N/A 10 ft ceilings Reaching above sustained above to shoulder change bulbs NOC strength category definitions Limited Handling loads 0-5kg (0-11lbs) Light Handling loads 5-10kg (11-22lbs) Medium Handling loads 10-20kg (22-44lbs) Heavy Handling loads >20kg (>44lbs) Cognitive and behavioural demands ​ Memory ​ Attention ​ Recognition ​ Communication ​ Problem solving ​ Critical thinking ​ Time pressures Cognitive and behaivoural demands example Degree of self-supervision required Exposure to emotional situations Degree of supervision exercised Exposure to confrontational situations Deadline pressures (time pressure) Responsibility/accountability required Attention to detail required Reading literacy Performance of multiple tasks Writing literacy Exposure to environmental stimuli Numerical skills Verbal communication Computer literacy Need to work co-operatively with others Need to work under high levels of stress What is NOT included in cognitive/behavioural demands: Topics EXCLUDED from cognitive/behavioural demands: 1.​ Work relationships a.​ Not getting along or experiencing problems with co-worker relationships b.​ Having issues with your superiors, supervisors, or your boss 2.​ organizational/company related factors  a.​ Disputes or disagreements revolving your contract or work term agreements b.​ Company, downsizing, relocation, or restructuring Psychosocial demands → WATCH VIDEO Sensory Demands ​ Hearing → conversations or sounds ​ Vision → near/far. Colour, and depth perception ​ feeling/touch → tactile sensory discrimination ​ Speech → english, comprehension Hazards and risks Hazards → carry the possibility of causing harm or being a danger to someone/something Risks → likelihood or chance of harm and danger FIVE main workplace hazards Biological Chemical Psychosocial Physical Ergonomic → bacteria → chemicals in → workplace stress → vibrations → lifting, pulling, → viruses workplace → workplace → noises pushing, sitting, → health effects due WHMIS/GHS/SDS bullying → heights standing, walking to exposure to → exposure to → confined spaces → lighting plants, animals, chemicals and Equipment and tools insects, birds, and impacts on body humans Jan 9 Lecture - hand and upper extremity assessment, biology and occupation in wound healing: amputation Assessment: listen subjective history ​ Client’s story (2 mins) ​ Mechanism (how?) and time from injury/surgery (surgical details) ​ Initial management/treatment ​ PMHx: ○​ osteoporosis/smoking/diabetes etc. previous injuries/conditions/surgery/mental health ​ Medications ​ Psychosocial issues and red flags ​ Occupational impact and goals (work, leisure, self-care) Enquiring questions “Can you tell me what your main concern(s) is today?” ​ “I have pain (or numbness/tingling)” ○​ Use one finger and show me the area of pain ○​ How long have you had this pain? ○​ Was there a specific incident/injury or was onset gradual? ○​ What makes your pain worse? Better?  ○​ Is your pain constant or intermittent? ○​ Can you rate your pain on a numeric pain rating scale (NPRS) from 0 (no pain) to 10 (worst pain) ○​ How does this affect your ability to perform everyday tasks, work, leisure? ​ “I feel stiffness” ○​ When does it feel stiff? Location? worse/better? ​ “I can’t do…” ○​ Can you show me how you do things now? ○​ What is it that you would like to do? ​ “I feel useless; I don’t sleep at night; I have nightmare” ○​ Ask further enquiring questions such as… Physical examination: OBSERVE ​ Skin condition ​ Edema: mild-severe, boggy (spongy) ​ Surgical incisions: red, yellow, black; sutures ​ Scar: active, hypertrophic, adherent ​ Deformity and posture: finger rotation, malalignment etc. ​ Muscle atrophy ​ Functional limitations ​ Active range of motion if safe to perform ​ Consider how impairment issues might affect work, leisure, self-care and personal goals Physical examination: PALPATE ​ Tenderness ​ Ligament laxity ​ sweating/hyperesthesia (increased sensitivity to touch) ​ Temperature difference ​ Provocative tests (i.e. CMC grind test) ​ Passive motion if safe to perform Depends on diagnosis and healing time frame Physical Examination: MOVE ​ Active and/or passive movement ○​ Shoulder (functional motion) ○​ Elbow (flexion/extension) ○​ Forearm (pronation/supination) ○​ Wrist (flexion/extension; RD/UD) ​ Functional Movement ○​ Composite finger flexion ○​ Tip-top finger motion ○​ Detailed finger ROM ax. Must know what is safe to move AND not safe to move based on healing timeframes (i.e. tendon versus bone healing)  ​ Specific assessment of active and passive range of motion can help you identify which structures are affected ​ This directs treatment decisions Example: AROM < PROM Elbow PROM = 45/140 (extension/flexion) Elbow AROM = 55/135 (extension/flexion) ​ What does this mean? Extension contracture ​ What treatment can you provide? ○​ Splinting, heat, PROM, keep in end range extension while sleeping, maintain maximum PROM end range ​ What functional limitations might she/he/they experience? Strength Testing (if safe..): ​ Modified sphygnomomter (arthritis) ​ JAMAR dynamometer ​ Pinch gauge ​ Manual muscle testing Edema Testing ​ Girth measurements ​ Volumetric measurements Physical examination: examples of peripheral nerve screening of the hand Median nerve: ​ Motor: resisted APB ​ Sensory: assess tip of index Ulnar Nerve: ​ Motor: resisted ADM ​ Sensory: assess pulp of 5th digit Radial Nerve ​ Motor: “victory” sign ​ Sensory: assess dorsum of 1st webspace 10-test for sensation Two-point discrimination (moving, static) Semmes weinstein monofilaments Assessment Tools: focus on function and client goals ​ COPM ​ Patient-specific functional scale Therapeutic Goals ​ Facilitate independence in ADL ​ Facilitate return to valued occupations & roles (i.e. parent, partner, friend etc) ​ Manage pain and edema (may not be able to eliminate pain)  ​ Restore functional ROM ​ Manage scar tissue formation - “functional scar” ​ Restore functional strength and endurance ​ Prevent secondary complications (contractures) Treatment: Pain Management ​ Education regarding hurt versus harm (avoid minimization of pain experience) ​ Cognitive behavioural therapy ​ Participation in valued occupations - may need to modify activities (acute pain versus chronic pain) ​ Active motion - if safe for structure (i.e. tendon injury) ​ Compression (decrease edema) Treatment: Edema Control ​ Tubigrip ​ Elevation ​ Coban tape +/- orthosis ​ Retrograde massage ​ AROM ​ Ice (inflammatory phase) Treatment: restore functional mobility - must be safe for healing structures ​ Graded functional activities ​ AROM and PROM exercises Treatment: Restore soft tissue length-tissue ​ Static progressive splinting ​ Serial static splinting ​ PROM and AROM ​ Functional use Treatment: Restore strength, function and return to occupation, roles Strengthening and functional exercises ​ Restore normal movement patterns first ​ Apply progressive and creative approach ○​ Use meaningful activities ​ Work simulation tasks ​ Encourage graduated return to leisure, self-care activities if safe to do so from a healing perspective Biology and occupation in wound healing: trauma case discussion Wound → a break in the continuity of body structures caused by: ​ Violence  ​ Injury or trauma ​ Surgery Phases of Wound Healing Description Inflammatory phase 3-5 days ​ Increased blood supply brings fibrin to create clotting (‘scab’); edema present ​ White cells (leukocytes, macrophages) engulf microorganisms & cellular debris Therapy implication → often see hand surgery clients 1-3 days post-op Fibroplasia Phase 5-20 days ​ Fibroblasts synthesize collagen and connective (proliferative) tissue - I tensile strength (scar formation) ​ Granulation tissue fills in from the base of the wound Maturation Phase 21 days - 2 ​ Collagen fibres reorganize to I wound strength and years (remodeling) epithelial cells mature - scar tissue forms - remodels ​ Scar is strong but less elastic than uninjured skin - vulnerable to breakdown with excessive stress ​ Week 3: tensile strength is 20% that of uninjured skin ​ Healing continues for approximately 1 year, gradually reaching a maximum of 70% to 80% of irs pre-injury tensile strength From a therapy perspective, goal is to create functional scar particularly if the scar crosses joint(s) ​ Scar massage ​ Edema control ​ AROM & PROM exercises ​ Splinting Impact of edema It is important to control the amount of edema in because excessive, long-term edema contributes to: ​ Increased scar formation ​ Development of tight structures (i.e. ligaments, capsule) ​ Decreased motion (i.e. adherent tendons) ​ Decreased function (ICU positioning) ​ Increased pain and discomfort Phases Therapy Intervention - Edema Management Inflammatory (phase 1) ​ Edema is liquid, soft  ​ Compression, elevation, gentle active motion & massage ​ Excessive heat & exercises is contraindicated Fibroplasia (phase 2) ​ Edema more viscous - excess fluid = exudate ​ Same as inflammatory + lymphatic massage ​ AROM, tendon gliding to minimize adhesions, PROM Maturation (phase 3) ​ remodeling/realignment of collagen - edema can be thick, brawny Goal: functional scar ​ Massage, compression garments ​ ++PROM & AROM to prevent tendon adhesions ​ Orthosis intervention to assist with formation of functional scar and longitudinal remodeling Wound classification ​ Intentional (surgical) versus unintentional (gunshot) ​ Closed (bruise) versus open (puncture) ​ Contamination ​ Colour Wound classification by colour Red Wound Yellow Wound Black Wound Indicates healthy wound with Yellow eschar/slough drainage - Wound contains necrotic (dead) evidence of granulation tissue cleanse gently tissue (new connective tissue, blood vessels) - protect thick/milky yellow tissue Wound requires surgical, comprises dried plasma proteins mechanical, chemical Only requires gentle cleaning and dead skin debridement and protection with a topical antimicrobial agent and/or a Wound requires gentle Once you can see below the moisture retentive dressing cleansing/debridement to necrotic tissue you can make remove non viable tissues decisions about wound intervention (i.e. red, yellow) Dressing to absorb drainage may be required Educate clients regarding signs of infection ​ Increased redness outside the margins of the surgical incision ​ Increased temperature of the wound and area around the wound ​ Increased pain ​ Tracking up the arm - go to ER immediately Three major considerations in wound management ​ Bacterial balance ​ Necrotic tissue = tissue death ​ Moisture balance ​ ​ We need to educate clients regarding these issues Bacterial Balance ​ All wounds contain bacteria ○​ However, a change in wound drainage from clear or serous (some blood) to pus ○​ An unpleasant odour from the wound ○​ An increase in skin temperature and increased surrounding erythema (redness) suggests an infection ​ Superficial infection can be treated with topical agents (polysporin) ​ Oral antibiotics: used for less severe infections ​ Deep tissue infections (cellulitis and bone osteomyelitis) must be treated with systemic antibiotics (IV) Necrotic TIssue ​ Impairs the development of granulation tissue & healing ​ Is a medium for bacterial overgrowth ​ If a wound has an adequate blood supply, then debridement of necrotic tissue should be considered Moisture Balance ​ A wound with too much moisture can damage surrounding tissue causing maceration ​ Maceration slows down wound healing Basic Infection control ​ (a) hand washing ​ (b) use of protective barriers such as () ​ (c) cleaning and/or sterilization of equipment including table surfaces ​ (d) managing wastes, including sharps Sutures: hand washing is allowed with soap and running water ​ Soaking in water is contra-indicated as bacteria may enter through suture sites, causing infection. Advise clients to wait for approximately 3 days post-suture removal before soaking hand/extremity OT Role: other assessment and enabling interventions ​ ROM ○​ What type (passive, active) is safe to perform three weeks post-injury? What factors are you basing your decision on? ○​ Fractures - early AROM safe ○​ Tendon injury - early PROM safe ​ Orthosis fabrication? ​ Scar management (when? examples?) ​ Desensitization ​ ADL & IADL ​ Initiate function and strengthening at appropriate time based on healing timeframe (when?)  ​ Psychosocial issues ​ Other - looking long term Orthoses ​ Static progressive orthosis ​ Static orthosis ​ Serial static orthosis Purpose: protection, correction, assistance Scar management Goal: functional scar ​ Scar massage ​ Scar insert to be worn at night with the orthosis ​ Compression: coban tape, tubigrip, orthosis (flattens scar, desensitization) Progressive desensitization program ​ Massage ​ Textures ​ Immersion ​ Vibration ​ Functional use of affected hand Education: ADL, adaptive equipment, graduated return to activities ​ Education re: hurt versus harm ​ Introduce adaptive equipment if required ​ Modify activities to facilitate independence ​ Monitor and address psychosocial response over time ​ At what stage (number of weeks) during wound healing would you initiate light strengthening? (it depends, 6-8 weeks) ​ What is your rationale (would want a fracture to be healed) Treatment: Restore strength, return to occupation Strengthening and functional exercises ​ Restore normal movement patterns first ​ Apply Progressive and creative approach - use meaningful activities ​ Work simulation tasks ​ Encourage graduated return to leisure activities if safe to do so from a healing perspective Summary ​ Remember to think long-term regarding the enablement of goals that are important for each person ​ Stage of wound healing guides force application (exercises, splints, function, return to work) ​ Educate clients regarding:  ○​ Wound care and simple dressing application ○​ Prevention of maceration ○​ Signs of infection ​ Leads to improved function and return to valued roles Stages of Healing Inflammatory Phase ​ Within seconds, a clot begins to form 3-5 days ​ 24-48h: wound is cleared of bacteria and cellular debris ​ 48-96h: monocytes are transformed to macrophages ​ Macrophages mediate angiogenesis and form fibrous tissue ​ Macrophage-derived growth factors stimulate cells to form immature connective tissue matrix composed of fibrin Fibroplasia Phase ​ Usually occurs on fourth day after wounding 5-20 days ​ Fibroblasts appear in wound bed ​ There are 4 major steps in phase 1)​ Angiogenesis 2)​ Epithelialization 3)​ Granulation 4)​ Tissue formation and collagen deposition ​ Angiogenesis provides new vascular networks ​ Fibroblasts and endothelial cells replace the immature matrix with a collagen-fortified extracellular matrix and form new granulation tissue ​ Fibroblasts are the main cell type responsible for developing granulation tissue 1 to 2 weeks after injury Remodeling or ​ Fibronectin creates a preliminary fiber network maturation phase ​ This network has 2 key functions: as a template for collagen and has 21 days - 2 years a platform for cellular growth ​ As moe collagen is laid down, tensile strength of the wound increases ​ Tensile strength is restored to approx 20% of normal uninjured skin within 3 weeks of injury ​ Healing continues for approx 1 year, gradually reaching a maximum of 70-80% of its pre-injury tensile strength Jan 9 Lecture - Orthosis and Application Guiding Principle of client-centered, Bio-occupational approach to orthosis fabrication ​ Promote client-centered process ​ Enable activity and participation ​ Consider psychosocial factors ​ Consider environmental factors ​ Incorporate biological factors ​ Incorporate biomechanical principles ​ Optimize usability, comfort, convenience and cosmesis ​ Provide choice - collaborate with client Use both Foci ​ Regardless of primary focus of orthosis intervention - biological or occupational - therapists should consistently use both foci because the view through one component of the lens does not give the full picture of the client’s occupational performance issues Types of Orthoses ​ Custom-made ​ Prefabricated (purchased): i.e. fabric/neoprene with or without reinforcements Categories of orthoses based on purpose ​ Protective orthoses ​ Corrective orthoses ​ Assistive orthoses Overall goal: to improve occupational performance and engagement Protective Orthoses ​ Immobilize a joint(s) & promote joint alignment ​ Block joint motion ​ Prevent deformity ​ Stabilize a joint, tendon or fractured bone ​ Protect vulnerable or healing structures Corrective Orthoses ​ Correct joint contracture ​ Correct subluxation of joints or tendons Assistive Orthoses ​ Assist movement of joint during functional activities when muscles are weak or paralyzed ​ Reduce muscle tone of spastic muscles Connective tissue responses to stress ​ Gentle prolonged stress within the elastic range promotes GROWTH of soft tissues via fibroblasts ​ Reduction or removal of tension promotes reabsorption of tissue ​ When tissues are stretched past the normal elastic limit, microscopic tearing of fibers cause inflammation and hemorrhages leading to fibrosis (scarring) of tissues. This can cause a decreased motion and function How varying amounts of stress promote changes in tissue Position of Rest - position of function - Bunnell Ongoing clinical reasoning ​ Client centered ​ Continuous evaluation ​ Dynamic and creative intervention Person ​ Age, occupation, leisure ​ Medical conditions ​ Goals and values Biology ​ Anatomy ​ Stage of tissue/structure healing +/- surgical intervention Disease activity informs decision about whether orthosis is for protection or correction Joint Loose packed position Close packed position (resting) Maintain or lengthen tissues; Protection (i.e. arthritis); less more joint contact (i.e. stiff joint contact joint) Radiocarpal Neutral with slight ulnar Extension with radial deviation deviation (*must be careful about length of time in position - cartilage health, comfort, etc.) MCP - fingers Slight flexion Full flexion MCP - Thumb Midway between Full opposition abduction-adduction and flexion-extension Interphalangeal Slight flexion Full extension Categories of Orthoses based on description  1.​ Non-articular 2.​ Static 3.​ Serial-static 4.​ Static progressive 5.​ Dynamic Nonarticular Orthosis ​ Does not cross a joint and has no influence on joint motion ​ It usually protects a bone during healing through compression (i.e. circumferential stabilizing orthoses = fracture bracing) Static Orthosis ​ Immobilizes one or more joints and is designed to: ○​ Maintain tissue length ○​ Rest injured/inflamed tissues ○​ Promote function ○​ Promote resorption of lax structures such as lengthened ligaments (RA) ○​ Reduce muscle tone Serial static orthosis Immobilizes one or more joints and does the following: ​ Corrects contractures by applying a gentle, prolonged stretch to promote growth of contracted (shortened) soft tissues (i.e. capsule, ligament) ​ Orthosis is serially remolded over time as tissue length changes Static progressive orthosis ​ Corrects joint contractures by applying a gentle prolonged stretched to promote growth (lengthening) of contracted soft tissue ​ An elastic or non-elastic component is attached to the thermoplastic base and is adjusted by small increments, applying a gentle stretch Dynamic Orthosis ​ Applies a passive force in one direction while permitting active motion in the opposite direction using rubber bands etc. ​ It provides a passive assist to substitute for weak or absent motor function due to paralysis (i.e. radial nerve paralysis) Optimal orthoses outcomes include ​ Pain relief ​ Appropriate length of soft tissues for adequate ROM, joint/tendon stability and functional use ​ Protect of vulnerable tissues ​ Enable valued activities and participation in occupations ​ Enhance emotional well-being Guiding principles of the client-centered, Bio-occupational approach to orthotic management ​ Promote client-centered process ​ Enable activity and participation in valued occupations ​ Consider psychosocial factors ​ Consider environmental factors ​ Incorporate biological factors ​ Incorporate biomechanical principles ​ Optimize usability, comfort, convenience and cosmesis ​ Provide choice - collaborate with client Mechanical Principles Surface Area ​ Pressure (P) is defined as the area per unit of area ​ P = Force/Surface area (SA) Ensure orthosis contours to body ​ Mold the orthosis to conform to body contours ​ Contours increases rigidity and strength of the orthosis ​ Good contour decreases pressure caused by the orthosis ​ Appropriate strapping also decreases pressure Level arm ​ Ensure that the location of the straps optimizes the lever arm and joint controlling focus ​ Ensure that the lever arm is long enough to support the limb in the orthosis (i.e. ⅔ length of the forearm) Mechanical Principles ​ Extend forearm trough half-way up sides of limb. Good contour and increased lever arm improves support of limb ​ Extend the orthosis ⅔ length of forearm to increase level arm, thereby improving support of hand/wrist in orthosis ​ Decrease pressure by increasing surface area ​ Mold the orthosis to conform to body contours (increase surface area) ​ Increase rigidity of orthosis with contours ​ Round all corners, including straps and velcro tabs for comfort ​ Flare the proximal weight-bearing edge for comfort ​ Ensure that the location of the straps optimizes the lever arm and joint controlling forces ​ Ensure appropriate width of straps to distribute force over a large surface area Reasons why an orthosis might not be used: ​ Discomfort and pressure ​ Inconvenient - occupational hindrance ​ Unable to easily apply/remove  ​ Lack of comprehension of its purpose or how to use it ​ client/family embarrassed by appearance of orthosis ​ Cultural beliefs ​ Odour ​ Unnecessary restriction of function ​ Poor cosmesis ​ Too heavy LTTs (low temperature thermoplastics) are available as flat sheets with the various choices ​ Different sheet sizes ​ Thicknesses ranging from 1/32 to 6/32 in. (0.8mm to 4.8mm) ​ Solid or with a wide range of perforations ​ Opaque or translucent with heated ​ With or without memory ​ Different degrees or conformability with warm ​ Different degrees of rigidity/flexibility when cool ​ With or without surface coating (affecting self-adherence and surface stickiness when heated) ​ Varying ease of finishing the edges ​ Antimicrobial or not - same price Interventions and enablement ​ Can be use to create ergonomic solutions Guiding principle of client-centered, Bio-occupational approach to orthotic management ​ Promote client-centered process ​ Enable activity and participation ​ Consider psychosocial factors ​ Consider environmental factors ​ Incorporate biological factors ​ Incorporate biomechanical principles ​ Optimize usability, comfort, convenience and cosmesis ​ Provide choice - collaborate with client Jan 10 - Psychosocial impacts of traumatic hand injury Meanings associated with hands ​ Work productivity ​ Socialization ​ Communication ○​ Sexuality ○​ Emotion ○​ “Hand talking”  ○​ Spirituality ​ Independence (financial, personal) ​ Important aspect of body image - sense of self Impacts of hand injury The visible nature of a hand injury can: ​ Change one’s body image ​ Interfere with self-care, productivity, leisure contributing to social isolation ​ Change family/personal relationships (financial stress; feelings of rejection) Myths about adjustments ​ Magnitude of accident/injury dictates magnitude of psychosocial response ​ If they look ok on the outside, they must be OK on the inside ​ Injury to the non-dominant hand is not as significant as injury to dominant hand Issues that may negatively influence recovery and psychological adjustment ​ Inability to perform valued occupations ​ Unsupportive relationships ​ Attribution of responsibility for the injury ​ Pre-injury psychosocial issues and poor coping strategies ​ Litigation and compensation - mixed opinions in the literature regarding impact on adjustment Psychological issues following a traumatic hand injury ​ Flashbacks or nightmares - most prevalent symptoms after injury ​ Anxiety ​ Depression ​ Cosmetic concerns ​ Mood swings ​ Cognitive difficulties ​ Adjustment problems ​ Fear of dying Cognitive symptoms ​ Symptom Initial 3 mo 6 mo 12 mo 18 mo Flashbacks (%) 80.6 74.1 59.4 48.8 39.4 Nightmares (%) 70 30.6 15.9 10.6 9.4 Concentration/ attention 13.5 2.9 8.8 5.3 4.1 Deficits (%) Affective Symptoms Symptom Initial 3 mo 6 mo 12 mo 18 mo Flashbacks (%) 80.6 74.1 59.4 48.8 39.4 Nightmares (%) 70 30.6 15.9 10.6 9.4 Concentration/ attention 13.5 2.9 8.8 5.3 4.1 Deficits (%) Physiological symptoms Symptom Initial 3 mo 6 mo 12 mo 18 mo Startle reaction 37.6 24.1 17.1 11.2 8.2 (%) Phantom 33.5 35.3 30.6 22.4 21.8 sensations (%) Sexual 0 34.1 17.1 15.9 12.4 dysfunction (%) Behavioural Symptoms Symptom Initial 3 mo 6 mo 12 mo 18 mo Startle reaction 37.6 24.1 17.1 11.2 8.2 (%) Phantom 33.5 35.3 30.6 22.4 21.8 sensations (%)  Sexual 0 34.1 17.1 15.9 12.4 dysfunction (%) PTSD Characterized by 3 clusters: ​ Recurrent re-experiencing of the traumatic event ​ Avoidance of trauma related stimuli (i.e. punch press) ​ Persistent hyper-arousal Assessment Tools Impact of event scale (IES) ​ 15 items in two subscales (intrusive symptoms & avoidance symptoms) ​ Reliable and valid instrument for identifying people with distress related to trauma ​ Does not diagnose post-traumatic stress disorder Issues that may influence functional recovery and psychological adjustment ​ Valued occupations ​ Supportive relationships ​ Attribution of responsibility for the injury ​ Pre-injury psychosocial issues and poor coping strategies ​ Litigation and compensation - mixed opinions in the literature regarding impact on adjustment Coping strategies Coping defined: ​ As cognitive and behavioural efforts to manage psychological stress ​ To manage problems that cause stress (problem-focused coping) ​ To regulate emotions caused by problems (emotion focused coping) ​ People respond in different ways to a hand injury depending on how they evaluate the impact of this event on their life and the coping strategies that they use ​ This evaluation of impact occurs continuously and is influenced by personal, cultural and situational factors ​ Coping strategies can assist or hinder adjustment. Therefore ongoing evaluation is essential - client may use a strategy that was initially helpful however long term use may hinder adjustment Coping strategies following a traumatic hand injury Strategy Description Purpose Comparing Comparing to -Alters the threatening meaning of the something worse problem/situation -Some patients experience the real injury as less severe -Facilitates adjustment to new body image -Used by almost everyone Positive Thinking -Similar to comparing -Used to cope with future -Focuses on concerns real or -Purpose is to down-play the imagined situation positive aspects of problem Relying on Strong belief in Personal personal capacity to Capacity manage Distancing Avoiding thoughts Keeps problems at a distance about the future Distracting attention Staying busy Used to manage negative emotions Accepting Accepting the situation the and trying to make the Situation most of it Seeking Seeking help from others or People need emotional Social having the belief that they can and practical support from Support their social network Maintaining Control Maintaining control and Trying to maintain their own not letting others take capacity over Solving Accepting help from others but Believe in own capacity Practical also involved in their own Problem-focused Problems creative in problem solving strategy themselves  Pain Pain killers and elevation Relieving or distraction Actions Active Processing of Analysis of the accident in Conscious attempt to adjust the Trauma order to find an explanation for to a threatening experience Experience how and why it happened Social issues ​ Avoidance of social situations leading to isolation, anxiety ​ Avoidance of public interactions - i.e. going to the store… increased dependence ​ Role changes, failure or loss - i.e. parent must now ask child for assistance with ADL, self-care ​ Financial stress secondary to job or career loss ​ Relationship stress - i.e. spouse (intimacy) Enabling Strategies: ​ Listen - consider the whole person; empathize ​ Facilitate independence in ADL as soon as possible ​ Facilitate return to roles (i.e. parent, worker) by identifying meaningful goals ​ Encourage people to maintain a regular sleep pattern ​ Encourage people to maintain a ‘normal’ social routine to prevent social isolation ​ Ask about changes in behaviours/symptoms - ongoing basis ​ Routinely screen for psychosocial difficulties and refer early ○​ Hand injury support group ○​ Psychological counselling ​ Focus on function and participation in occupation Assessment Tools: PTSD and Social Issues Injured workers survey ​ Brief, easy to administer, validated screening tool ​ Developed to identify patients, with hand injuries, needing further psychosocial assessment and intervention ​ Early intervention is key Injured worker’s survey: questions ​ Has your appetite changed since your accident? ​ Are you sleeping differently since your accident? ​ Do you dream about your accident? ​ Do you ever have sudden feelings like your accident is happening again? ​ Are there any changes in your memory or concentration? ​ Present level of activity - leisure and daily routines PTSD assessment screening tools Impact of event scale (IES) ​ 15 items in two subscales (intrusive symptoms and avoidance symptoms) ​ Reliable and valid instrument for identifying people with distress related to trauma ​ Does not diagnose post-traumatic stress disorder COPM Patient-specific functional scale The adaptation Process “Following severe hand injury, a person’s adaptation evolves over time. The process of developing reasonable hopes for the future involves a balance between limits and possibilities, as they are discovered by the patient through experience” Summary ​ Screen for psychological difficulties on an ongoing basis and refer early (3 months post injury) ​ Monitor coping strategies and address as necessary (maladaptive strategies) ​ Establish goals that are meaningful to the patient ​ Facilitate independence in ADL as soon as possible ​ Facilitate return to meaningful roles as soon as possible ​ Encourage patient to maintain as normal a routine as possible sleep; social; work) Jan 16 Lecture - Enabling Occupation for clients with arthritis Occupational therapy interventions Goal → enable participation in valued occupations ​ Education ​ Energy conservation ​ Joint protection ​ Assessment and provision of adaptive equipment ​ Orthosis intervention: ○​ Protection ○​ Correction ○​ Function ​ Psychosocial support ​ Work, home, activity modification Rheumatic Diseases ​ Osteoarthritis → degenerative joint disease (DJD) ​ Inflammatory arthritis - many are auto-immune diseases ​ Rheumatoid arthritis ○​ Juvenile RA ○​ Psoriatic arthritis ○​ Gout ○​ Scleroderma ○​ Ankylosing spondylitis  ○​ Rheumatic fever ○​ Systemic Lupus erythematosus Rheumatoid Arthritis ​ More than 250,000 Canadians have RA ​ Over 60% are women ​ It is a chronic, auto-immune, inflammatory condition ​ The body’s immune system attack its own joint tissues, bone and occasionally organs ​ Characterized by “flares” (periods of highly intense symptoms) followed by periods of inactivity which is unpredictable ​ Synovial joints commonly affected by RA ​ More symmetrical because it is a systemic condition Criteria for classification of Active RA: need to have at least 4 out of 7 ​ Morning stiffness lasting at least 1h ​ Arthritis in 3 or more joints ​ Arthritis in at least 1 hand joint (wrist, MCP, PIP) ​ Symmetric ​ Rheumatoid nodules - subcutaneous nodules, over bony prominences, or extensor surfaces ​ Positive serum rheumatoid factor (antibodies found in 75% of those with RA - seropositive; sero-negative) ​ Radiographic changes (alignment issues, bony erosions Medications ​ Analgesics - non-narcotic and narcotic ​ Nonsteroidal anti-inflammatory drugs (NSAIDs) ​ Corticosteroids (anti-inflammatory) ​ Disease-modifying anti-rheumatic drugs (DMARDs) (suppress inflammation caused by overactive/abnormal immune responses) ​ Biological response modifiers (suppression of inflammation using genetically engineered antibodies Big picture: Joint issued caused by RA Synovitis (“active joint”) → joint laxity (tendonitis, tenosynovitis) → tendon subluxation → tendon rupture → bone erosion & cartilage loss → HAND DEFORMITY (weakness, muscle atrophy, loss of function & participation Inflammation = itis Synovial membrane joint deformity starts with synovial membrane  1.​ Synovitis = inflammation of the synovial membrane (first sign of joint pathology) & synovial membrane thicken 2.​ Excess synovial fluid produced = EFFUSION (joint fluid swelling) - lax capsule and connective tissue (ligaments) 3.​ Synovial membrane forms pannus grows over cartilage 4.​ Pannus erodes bone and cartilage Result = pain and joint destruction inhibits motion, strength, function & occupational engagement Joint laxity and Tendon Subluxation Joint laxity + ulnar subluxation of extensor tendons (sagittal bands which hold extensor tendons on dorsum of MCP joints become lax) + ulnar pull of flexor tendons (ulnar approach of FDS and FDP held by strong fibrous digital sheath - now lax) + lumbrical and interossei muscle spasm (joint pain can lead to painful muscle spam) + joint subluxation = Laxity of sagittal bands: cross section of metacarpal  1.​ Unimpaired hand - good tendon alignments 2.​ MCP effusion - increased synovial fluid 3.​ Laxity of sagittal bands - ulnar subluxation of flexor & extensor tendons = ulnar drift of fingers Orthosis intervention Anti-ulnar drift orthosis Volar wrist hand orthosis (resting hand orthosis) Disease activity informs decision about whether orthosis is for protection or correction Joint Loose Packed Position Close Packed Position (resting) **maintain or lengthen tissues; more **protection (i.e. joint contact (i.e. stiff joint) arthritis); less joint contact  Radiocarpal Neutral with slight ulnar Extension with radial deviation (*must deviation be careful about length of time in this position – cartilage health, comfort etc.) MCP - fingers Slight flexion Full flexion* MCP - thumb Midway between Full opposition* abduction-adduction and flexion-extension Interphalangeal Slight flexion Full extension* PIP and DIP Joint Deformities Swan Neck Deformity Dorsal migration of lateral bands to the dorsum of the PIP Joint Orthosis intervention to address swan neck deformity Boutonniere Deformity Volar migration of lateral bands of PIP joint Orthosis interventions to address Boutonniere deformity Factors Contributing to Joint Damage: guiding Therapy decisions 1.​ Deformity is more likely to occur when joints are ACTIVE 2.​ Unstable joints more susceptible to joint deforming forces (I.e. gripping) 3.​ Movement may aggravate synovitis and tenosynovitis - but movement is important for synovial fluid circulation, strength and tendon gliding 4.​ Rest can reduce synovitis and tenosynovitis - resting splinting? Osteoarthritis ​ Associated with defective articular cartilage and degeneration of the underlying bone. Damaged cartilage stops acting as a shock absorber. Leads to bone-on-bone contact - decreased joint space, ligament laxity, bony spur development, joint deformities ​ Forces (trauma, heavy work, joint instability, obesity) cause abnormal joint loading & increased risk of OA ​ Aging, as aging occurs, cartilage contains less water and fewer chondrocytes thereby decreasing capacity to restore and maintain cartilage ​ Other factors: Gender (post-menopausal), obesity bone density, genetic predisposition, previous joint traumas Joint changes in OA ​ Uneven cartilage & cartilage thinning ​ Development of osteophytes (bone) ​ Sclerosis (hardening) of subchondral bone Osteophytes - OA​ Heberden’s Nodes: ​ Bony growth (osteophytes) of the joint cartilage in the distal interphalangeal (DIP) joints Bouchard’s Nodes: ​ Bony growth (osteophytes) of the joint cartilage in the proximal interphalangeal (PIP) joints Thumb CMC OA (trapeziometacarpal joint) ​ Pain at the base of thumb (decreased cartilage, joint laxity and subluxation) ​ Positive grind test ​ Negative impact on function ​ Orthosis intervention, joint protection and activity modification is helpful ​ Common in women over 50yo Grind test ​ Provocative test to reproduce joint tenderness by axial loading with rotation of the thumb ​ A positive test occurs when client reports pain in trapeziometacarpal region (**must be subjective & objective findings, client story, age etc.) Orthosis Intervention for thumb CMC OA - evidence to support ​ Orthosis intervention effective regardless of degree of pathology ​ Can reduce or eliminate need for surgery ​ Both long and short thumb orthoses reduce pain and subluxation ​ Patients prefer the short thumb orthosis versus long thumb orthosis - provides more function ​ Custom molded CMC orthoses are more appropriate for the acutely inflamed client ​ Offer clients a choice of orthosis based on degree of inflammation and level/typ of activity Other Interventions to assist clients with arthritis ​ Education → condition, anatomy, pain management, sleep management ○​ Evidence supports education that arthritis self management course benefitted participants through reduction in pain, fatigue and health distress, and increased self-efficacy ○​ Improve function through joint protection principles ​ Educational-behavioural joint protection → avoid deforming positions, use largest joints, distribute load, orthoses, adaptive equipment ○​ Study comparing standard joint protection program to an educational-behavioural training found significantly improved joint protection and maintenance of functional ability long term with educational-behavioural approach ​ Adaptive equipment → non-slip grip, larger handles, mobility aids, etc. ​ Exercises → pain free movements; joints not inflamed, need to be prescribed and targeted (ROM/strengthening/stretching) ○​ Moderate evidence to support hand exercises to increase grip, improve function and reduce pain ○​ There is support for aerobic and strengthening exercises to increase grip, improve function and reduce pain ○​ There is support for aerobic and strengthening exercises 3x per week for 30-60min in patients with RA to improve function and fitness ​ Creative problem solving Structural and functional factors: biomechanical stress ​ During lateral pinch, compression force at the trapeziometacarpal surface is 12x that generated at thumb and index finger Summary ​ Base treatment decisions on a critical examination of the relevant literature ​ Integrate this knowledge in a client centered & bio-occupational manner ​ Shape practice around integration of evidence and be creative in collaborative problem solving Jan 21 Lecture - Exploring role of biology and occupation in hand fractures Primary Fracture Healing Every bone in hand heals at a different rate (different type of bone and blood supply) Inflammatory Phase ​ Fracture hematoma clots - creates initial support of fracture 0-5 days gap ​ Inflammatory cells remove necrosed bone and debris & initiate tissue growth ​ This phase has low strength - fails with excessive loads Reparative Phase ​ New capillaries form - nutrition for callus formation 5-20 days ​ Fibroblasts, chondroblasts and osteoblasts synthesize Clinical union woven bone (disorganized - low strength) dependent on specific ​ Initial soft callus is converted to hard callus with appropriate bone healing time stability and loading (can still fail with excessive loads) frame Remodeling Phase ​ Hard callus is mineralized into lamellar bone (stronger) 3 weeks-years ​ Bone remodeling to its normal preinjury state can take years General rehabilitation Guidelines Based on fracture healing for THAT individual, fracture type and bone affected Primary Stage ​ orthosis/cast applied to joints proximal and distal to fracture. 1-6 weeks To be worn at all times unless physician allows for removal for immobilization/early skin care and AROM mobilization stage Secondary stage At discretion of physician 3-6 weeks ​ Discharge immobilization orthosis - key difference from Mobilization stage primarily stage (i.e. clinically healed metacarpal fracture) ​ AROM - safest for fractures, less forceful than PROM ​ PROM (depending on location of fracture, age, pain level etc.)  Tertiary Stage ​ NB: avoid resistive activity/work/ADL/avocational activity until 6-8 weeks fracture is “clinically healed” (versus healed on x-ray) Strengthening stage ​ May require orthosis to increase joint motion ​ Progressive strengthening (light to medium to heavy) ​ 6-8 weeks after cast is technically clinically healed, wouldn’t recommend strengthening after cast as forceful activities can rebreak the bone bcuz too weak Secondary Fracture Healing Factors that delay healing Some agents/conditions may delay healing by disrupting blood supply: ​ NSAID, steroids, cytotoxins (i.e. immune cells, venom), nicotine ​ Diabetes, infection, surgical trauma, crush injuries that impact circulation ​ Age - healing process takes longer as you age ​ Autoimmune disease Motion and Fracture healing ​ Motion is one of the most influential factors in fracture healing ​ The amount of motion across the fracture site will determine the strength and rate of bone healing or failure of healing ​ Compression or weight bearing forces that are intermittent facilitate healing while shear and angular forces have adverse effects on healing (i.e. lower extremity healing) ​ Motion can only be applied if the fracture is considered stable ○​ Determined by doctor making referral ○​ Not in our scope of practice to stabilize a fracture Fracture classification ​ Location on the bone ​ Angle of fracture through the bone ○​ Transverse, oblique or spinal (less stable), longitudinal ​ Number of fragments ○​ Simple of comminuted  ​ Skin open or closed Common: comminuted, avulsion, oblique, transverse - Avulsion = condyle (& other structures, e.g. Tendon) detached - Oblique = bone can slide down and heal shorter -> functional implications - Spiral = bone can rotate (e.g. Finger can heal to cross over other finger) ​ Oblique fracture ​ Broke at an angle ​ Decrease grip strength/power grasp ​ Muscle length does not match bone length ​ Movement of D5 Primary vs. Secondary Bone Healing ​ The type of bone healing depends on the method of fracture fixation ​ Fixation that compresses the fracture and provides stability permits direct bone regrow = primary healing (i.e. internal fixation with plate and screws): this allows for early mobilization directed by the surgeon & therapist ​ When motion is minimized across the fracture gap (i.e. cast), healing goes through fibrous callus repair that is converted to bone = secondary healing Non-operative Treatment Options  ​ Closed reduction plus immobilization (cast/orthosis applied) ​ Appropriate for stable fractures where: ○​ Muscle forces are not likely to displace the fragments ○​ The fracture is not articular (within the joint) and will not be displaced with motion ​ Intra Articular → fracture crosses surface of a joint ​ Extra-articular → fracture does not cross a joint Operative Treatment Options Closed reduction Internal Fixation (CRIF) ​ Percutaneous pins/K-wire fixation to minimize soft tissue trauma ​ Moving two-ends in place placing wires from outside down through the bone ​ Advantages? Not breaking the skin to perform a procedure, no scarring ​ Disadvantages? Limited daily activities, risk of infection, risk of them catching or getting caught on things, can get loose Open Reduction Internal Fixation (ORIF) ​ Fractures that are irreducible by closed manipulation and where early mobilization is essential (for soft tissue gliding) ​ open/closed fractures that are unstable and likely to displace ​ Fixators include k-wire, screws, plates, tension band wires ​ Open procedure ​ Advantages? No open wound or exposed wires ​ Disadvantages? Re injuring, more scar tissue, risk of tendon adhesion Open/closed reduction external fixation ​ External fixator inserted into the bone to maintain fracture alignment until healing is complete ​ Disadvantages: large out rigor outside the body Hand fracture healing Metacarpal ​ 30-50% of hand fractures (i.e. boxer’s fracture) 3-5 weeks ​ Transverse fracture apex is dorsal - intrinsic muscle pull ​ Oblique torque force causes shortening & rotation of bone. Scissoring of finger may occur Metacarpal ​ 15-20% of all hand fractures 3-5 weeks ​ Fracture apex is volar - interossei flex proximal fragment & central slip extends distal portion ​ Complications: PIP joint contracture - bone shortening, tendon adherence Middle Phalanx ​ 8-12% of hand fractures - various displacement patterns 7-12 weeks ​ Healing may take 10-14 weeks in middle shaft due to large amount of cortical bone Distal Phalanx ​ 40-50% of hand fractures  3 weeks ​ Direct blow or crush (tuft fracture) ​ If extensor tendon attachment is involved (mallet deformity) - DIP extension orthotic intervention for 6 weeks 24/7 ​ If inquiry is caused by crush, desensitization if often required to improve tolerance to touch and pressure ​ May fabricate a volar finger orthosis for protection during healing General Immobilization Principle ​ When fabricating an orthosis or cast the general principle is to immobilize the joints proximal and distal to the fracture site ​ If the fingers are involved, immobilize the fingers adjacent to the affected fractured finger Base therapy on healing timeframe of that particular bone ​ Active finger ROM: only safe to perform if fracture is stable ​ Passive finger ROM: only safe to perform is fracture is stable and initial healing has occurred (refer to healing time frame charts) How to clinically assess fracture healing - need to be an experienced clinician Palpate the fracture site ​ ​ Apply firm pressure over the fracture site ​ Ask client to provide a pain rating on a NPRS from 0 (no pain) to 10 (worst pain) ​ Document this pain rating and refer back to bone healing time frame chart ​ Based on two pieces of information you can make a clinical decision about when to initiate PROM and then progress to light strengthening ​ For someone who has other medical conditions or is on medication that can slow bone healing you may decide to delay PROM and/or strengthening for a longer time period ​ If there is ongoing pain or deformity, refer them back to the physician for reassessment Metacarpal Fractures Metacarpal Neck (boxers) Fractures ​ Most common metacarpal fracture ​ Extra-articular; open injuries are common (fist in mouth - potential for infection - effect?) ​ Treatment methods vary (buddy taping, ulnar gutter orthosis, hand/finger based orthosis) ​ Power grip decreases after 30 degrees of dorsal (apex) metacarpal position 1.​ Can you find the fracture? 5th metacarpal midshaft transverse fracture 2.​ How would you describe the position of this fracture? 3.​ If it heals in this position what might be functional impact? Treatment methods ​ Buddy taping ​ Hand based ulnar gutter orthosis ​ Forearm based ulnar gutter orthosis Metacarpal Shift Fracture ​ Classified as transverse or oblique ​ Oblique fractures often lead to rotational deformity of the fingers - why? ​ Rotation of 5 degrees at shaft procedures 1.5cm overlap of digit during fisting ​ Every 2mm of metacarpal shortening results in 7 degree “extensor tendon lag” - why? If you have metacarpal that shortens from sliding or way it heals, it becomes a bit weaker on that side, extensor tendon in muscle is too long for bone, functions but not as strong ​ May reduce grip strength ​ Buddy taping Normal alignment is towards to scaphoid ​ if during early stages of healing you notice that the fingers are scissoring (overlapping) what treatment would you recommend? ​ What treatment timeline do you need to be aware of to address this issue? Proximal and Middle Phalanx Fractures ​ Proximal phalanx fractures tend to be oblique or transverse ​ Middle phalanx fractures are more frequently transverse ​ Spiral and long oblique fractures tend to rotate ​ Transverse and short oblique fractures tend to angulate ​ Proximal phalanx fractures often have volar apex secondary to the pull of the interossei muscles Proximal and middle phalanx fracture management ​ Stable, closed and non-displaced fractures are treated with either dorsal blocking orthosis and/or buddy taping and immediate motion ​ Motion is important to prevent tendon adherence ​ If fracture reduction is not maintained (can only assess on repeat x-ray) then rigid fixation such as ORIF is required Wrist Fractures ​ The radius is most commonly fractured bone ​ ¾ of all wrist injuries are fractures of the radius and ulna ​ ¼ of all fracture visits to ER are wrist fractures ​ Wrist fractures are more common in women, particularly over age of 50 Distal Radio-ulnar Joint - DRUJ ​ Pronation and supination occurs at this DRUJ and the proximal radio-ulnar joint (PRUJ) ​ Stabilized by the triangular fibrocartilage complex (TFCC), a central articular disc and ligament on the ulnar aspect of the wrist Carpal Kinematics ​ There are only two true wrist joints ​ Radiocarpal joint ​ Midcarpal joint ​ Wrist is stabilized primarily by ligaments ​ 50% of flexion & extension occurs at the radiocarpal joint and 50% occurs at the mid-carpal joint ​ Radial and ulnar deviation occurs at radiocarpal joint Force Transmission in Power Gripping ​ Radiocarpal joint transmits 80% of froce ​ Ulnar carpus 20% of froce  ​ Disruption in normal relationship of radius and carpal bones will lead to alternations in force transmission (i.e. 80:20 relationship changes - what structure is affected?) ​ Very important functionally ​ Radius moves proximally during power grip. Flexor and extensor tendons that cross the wrist pull the proximal row against the radius and TFCC ​ This results in compression of the hand on the wrist, forearm and TFCC ​ This can become an issue if the force transmission is altered by a fracture (i.e. 80:20 relationship changes) Types of Wrist fractures ​ Colles fracture → +/- ulnar styloid distal fragment of radius angulates dorsally; apex of fracture is volar ​ Scaphoid fracture ​ Smith’s fracture ​ Barton’s fracture → intra-articular fracture of distal radius ​ Chauffeur’s fracture → fracture of radial styloid ​ Ulnar styloid fracture Fall on outstretched hand = FOOSH injury ​ Same foosh - three different structures affected based on age ​ Radius → elderly, female or high energy injury ​ Scaphoid → more commonly injured in the young person - high energy ​ Ligaments → more commonly injured in working age individuals Relationship between ulna and radius: ulnar variance ​ Normal relationship = ulnar border of distal radius is level with radial border of distal ulna ​ Any different is called “variance”, expressed as positive or negative variance ​ Normal: 0 +/- 1mm ​ Distal Radius Colles Fracture ​ Fall on outstretched hand (FOOSH) in extension ​ Extra-articular, dorsal angulation of distal fragment of radius, with radial deviation/shortening (in uninjured wrist of the forearm, carpal bones, and radius are in a straight line) ​ Up to 50% are associated with an ulnar styloid fracture ​ “Dinner fork” deformity Distal Radius Fracture: ulnar lengthening relative to radius ​ Positive ulnar variance (ulna is too long) leads to a change in force transmission during dripping) ​ 2mm of positive ulnar variance results in 60% force transmission through radiocarpus and 40% through the ulnocarpus (normal relationship is 80% and 20%) ​ Result - irritation/compression of the TFCC and pain Pronation ​ Radius moves proximally causing a relative positive ulnar variance Supination ​ Radius moves distally causing a relative negative ulnar variance Acceptable functional outcome following distal radius fracture ​ 40° Wrist Flexion ​ 40° Wrist Extension ​ 40° Combined Radial and Ulnar Deviation ​ 50° Pronation ​ 50° Supination ​ 75% Grip Strength Outcome Measures Patient Rated Wrist Evaluation (PRWE) ​ MacDermid, JC (1996) Development of a scale for patient rating of wrist pain and disability. Journal of Hand Therapy (9) 178-183 Michigan Hand Outcomes Questionnaire (MHQ) ​ Chung, KC et al. (1998) Reliability and validity testing of the Michigan Hand Outcomes Questionnaire. Journal of Hand Surgery (Am) 23(4):575-587 Disabilities of the Arm, Shoulder and Hand (DASH) ​ Solway, S et al. (2002) The DASH Outcome Measure User’s Manual 2nd Ed. Toronto, ON: Institute for Work and Health Upper Extremity Functional Index (UEFI) ​ Stratford P et al. (2001) Development and initial validation of the Upper Extremity functional index. Physiotherapy Canada 53(4):259-67 Jan 23 Lecture - Enabling Occupation: common hand conditions Common Hand Conditions ​ Carpal tunnel syndrome (example of a nerve compression) ​ Nerve transection: low level ulnar nerve ​ De Quervain’s tenosynovitis ​ Interactive activities focussed on assessment Nerve Compression ​ Er nerve occurring at specific anatomical sites, the mechanism of which combines mechanical pressure and/or ischemia (blood flow to nerve restricted), usually resulting from multiple or repetitive insults to the nerve ○​ E.g., carpal tunnel syndrome, cubital tunnel syndrome, pronator syndrome, peroneal nerve compression etc. Anatomy of a Nerve Endoneurium ​ Around nerve fiber (axon) Perineurium ​ Around fascicle Epineurium ​ Around nerve Classification of Nerve Injury 1st Degree Temporary conduction block (demyelination) ​ With remyelination - recovery in 12 weeks 2nd Degree Axonal Disruption ​ Neural regeneration 1mm/day plus advancing Tinel’s 3rd Degree Endoneurial & Axonal Disruption ​ When axonal regeneration occurs, axons may not reinnervate original end organs ​ **sensory re-education required** 4th Degree Perineurium & Contents Disruption ​ Neuroma present ​ Tinel’s proximal to neuroma but NOT distal to neuroma ​ Surgery: excise neuroma and coaptation of nerve - regeneration 1mm/day 5th Degree Complete nerve transection ​ Required surgery ​ Regeneration 1mm/day Effects of Nerve Compression: guides assessment and intervention ​ Largest diameter nerve fibers are affected first (impaired nutrition/vascular) ○​ Large touch vibration fibers are affected early ​ Large touch/vibration fibres affected early resulting in altered touch/vibration thresholds ​ Changes in 2-pt are late finding due to loss of numerous nerve fibres ​ Early motor changes: muscle aching/pain ​ Later motor change: weakness/atrophy ​ Have to relearn what is normal ​ Feeling goes before motor functioning Staging Nerve Compression: when do you think OT intervention is most effective? Staging Mild Moderate Severe Pathophysiology Reversible ischemic Edema & fibrosis Wallerian block (restriction of (excess fibrous degeneration and blood supply) connective tissue) axon loss (axon degeneration) Symptoms Sensory changes Sensory changes Persistent sensory (tingling, numbness) (tinling, numbness) changes - loss of are intermittent and are intermittent and sensation dependent on progressive. Positive position provocative tests (tinel’s, phalen’s) Tinel tests vibration Sensation Decreased vibration Increased vibration Abnormal 2-pt  threshold = increased threshold = decreased discrimination perception of vibration perception of Changes because during testing vibration during testing nerve is not working properly and sending messages, nerve endings in fingertips not functioning Motor Mild weakness of Weakness may be Muscle wasting and affected muscles noted (i.e. CTS - thenar weakness. Nerve muscles) demyelinated & fibrosed Treatment Often resolves with Conservative treatment: Surgery required, may Interventions conservative treatment temporary relief surgery provide partial relief of (i.e., orthosis, activity often required symptoms modification) May not fully recover Treatment guidelines Conservative Conservative measures Surgery measures: activity/job for 3 months & surgery modification, orthosis, if above fails NSAIDs, steroids Basic Assessment ​ Listen - want to know issue to know what to assess ​ Look ​ Feel ​ Move **must know what is safe to move** Assessment: Listen - subjective history ​ Client’s history ​ Mechanism and time from injury/surgery (surgical details) ​ Initial management/treatment (prolonged use of a sling: shoulder issue & age etc.) ​ PMHx: ○​ osteoporosis/smoking/diabetes etc. ○​ Previous injuries (MVA: potential neck issues) ○​ conditions/surgeries ○​ Pre-injury MH issues ​ Medications ​ Occupational performance goals (work, leisure, self-care, roles) Clinical Examination: Peripheral Nerve Compression Goals ​ Location site(s) of compression ​ Determine severity - guides treatment ​ Impact on valued occupations ​ Figure out where it is happening and how severe it is Assessments components  ​ history/symptoms - hand dominance, occupation, leisure, ergonomic issues, PMHx, time since symptoms began, aggravating activities, MVA ​ Impact on occupational performance ​ Observation ​ Screen for proximal nerve compression (neck) ​ Sensibility evaluation - 2 pt discrimination, monofilaments ​ Provocative testing (i.e. Tinel, Phalen) ​ Motor testing (i.e. CTS - APB) Simple Screen of Neck Range of Motion ​ Perform RoM of neck ○​ If no increase tingling in fingers at neck RoM, problem is more distally ○​ If increase tingling in fingers with neck Rom, problems may be in neck ○​ Exploration, does it happen when sleeping ​ Does neck movement reproduce symptoms of nerve compression distally? ​ For example, does the individual feel tingling in the hand when their neck moves through neck range of motion as per above? If yes, what does this tell you? ​ What additional questions might you ask? General Principles for Sensibility Testing ​ Quiet Area - takes lots of concentration for person and feeling is very light ​ Demonstrate test first on intact area ​ Eyes must be closed to avoid visual clues, or use a shield ​ Avoid giving feedback when testing ​ Support hand with therapy putty to prevent motion during testing ○​ Prop against pillow or theraputty Sensibility evaluation: Semmes weinstein monofilaments: threshold test ​ Point at which the stimulus is perceived ​ Altered first with nerve compression (refer to ‘staging’ nerve compression chart) ​ The filaments are applied three times to the same area - a yes response (1 out of 3 applications) - can give a check if they get it the first time ​ Sensibility can be mapped on a hand drawing to monitor change over time ​ At early stages touch changes first Interpretation - Semmes-Weinstein Monofilaments Filament Colour Log Scale Value Sensory Level Green 2.83 Normal Blue 3.61 Diminished light touch Purple 4.31 Diminished protective sensation Red 4.56 Loss of protective sensation Red-Orange 6.65 Residual deep pressure Sensibility Evaluation - 2-pt discrimination → test of innervation density ​ Reflects number of nerve fibers innervating a specified area = innervation density ○​ Decrease with nerve compression over long period and nerve laceration ​ This decreases with nerve laceration and severe nerve compression ​ Therapist randomly applies one or two points to the finger tip (hand is supported) ○​ Apply fo 1 full second, hand is supported so there is no proprioceptive feedback ​ Spacing of two points varies from 2mm to 20mm ​ Client reports one or two points (2 out of 3 times) Interpretation for 2pt discrimination → norms suggested for 2pt discrimination Moving 2-point discrimination Static 2pt discrimination ○​ 2-3mm = normal ○​ 2-6mm = normal ○​ 4-6mm = fair ○​ 6-10 = fair ○​ 7-9mm = poor ○​ 11-15 = poor Moving disk on finger along fingertip, What we do when we grab something, measuring functional ability or moving fingers holding plate (statically pinching) when touching objects Hand not supported in this figure Median Nerve ​ Pronator syndrome ​ Anterior interosseous syndrome (AIN) ​ Carpal tunnel syndrome ​ Palmar cutaneous branch of median nerve Carpal Tunnel Syndrome What is it? Compression of the median nerve in the carpal canal resulting in pain, tingling and numbness in the median nerve distribution Median nerve distribution is thumb, index, middle and radial half of ring Causes? Fracture, diabetes, pregnancy (fluid retention and occupies space that the nerve requires), repetitive motion, vibration, positioning during activities or work or sleep Clinical examination (refer to clinical examination up) Provocative Nerve Tests (mild to Tinel’s Test moderate stage) Positive with early compression, change in vibration threshold Phalen’s Test Making space in carpal canal small putting pressure on nerve Interventions ​ Orthosis intervention, at night? ○​ Relieve intra-carpal tunnel pressure, maximize blood flow to median nerve ○​ Neutral = 2.5mmhg ○​ Flexion = 21 mmHg ○​ Extension = 30mmHg ​ Modify work postures, tool handles to minimize sustained grip/pinch in intrinsic plus ○​ Lumbricals move into carpal canal and occupy space) ​ Ergonomic assessment & mods ○​ Increase diameter of tool ​ Education re: positioning and nerve compression Non-conservative treatment ​ Corticosteroid injection into the carpal canal ​ Surgical release of the trans carpal ligament ○​ Internal neurolysis or epineurotomy Ulnar Nerve Compression ​ Where is the ulnar nerve root most commonly affected by compression ○​ Elbow?? ​ What symptoms are typically experienced? ○​ Tingling, numbness ​ What ealy compression provocative nerve tests would you use during eval? ○​ Two - vibration & tensioning of the nerve A person is referred to you with a left low ulnar nerve transection (complete laceration at the wrist) following a knife injury 1.​ What does this mean from a physical perspective? (feeling, movement) a.​ Losing sensation in little finger and ulnar half of ring finger 2.​ What muscles are affected in the hand? a.​ Hypothenar (ADM,FDM, ODM) b.​ Intrinsic muscles of hand i.​ Ulnar hlaf and adductor intrinsic muscles 3.​ What part of the hand no longer has sensation? 4.​ What does this mean functionally? a.​ Person is in claw like position, not functional for grabbing objects 5.​ Think about potential OT roles in this situation a.​ Make orthosis that mimics the lumbricals Potential OT Roles ​ Education re: anatomy, impact of injury functionality & safety issues related to impaired sensation ​ Orthosis design, rationale and wear & care schedule ​ Discussion regarding adaptation/compensation/modification ​ Appropriate home exercise/activity program - to strengthen muscles Peroneal Nerve Compression ​ Feel around fibular head Acute Tendinopathy = Tenosynovitis (itis = inflammation) Can be caused by ​ Rheumatologic disorder (inflammation) ​ Bacterial infections (puncture wound) ​ Can be associated with repetitive movement (active muscle contractions & stretching over bony surfaces i.e. “tennis elbow” ​ Prevalence increases with age, comorbidities (diabetes, rheumatologic disorders) and exposure to forceful repetitive movement Dequervain’s Tenosynovitis ​ Entrapment of the tendon sheath of the APL and/or EPB tendons at the radial styloid process (first dorsal compartment) ​ There may be swelling and pain occurs with thumb abduction, extension, flexion ​ Age: 30-55 years ​ Women : men = 4:1 Evaluation History ​ Injury, systemic condition, vocation, leisure activities, symptoms, activity aggravation Impact on occupational participation ​ Information guides treatment - be specific Objective assessment ​ Pain assessment (location, intensity) ​ ROM, grip/pinch strength ​ Clinical features (anatomy, swelling etc.) ​ Provocative tests (finkelstein’s & resisted thumb MCP extension) ​ Screen for other conditions Evaluation - Provocative Tests Resisted thumb extension ​ MCP positive if pain is produced Finkelstein test ​ Place client’s thumb into palm, wrap client’s fingers around thumb and passively move wrist into ulnar deviation ​ Excruciating pain around radial styloid = positive test Screen other conditions ​ OA (wrist or thumb CMC)  ​ Fractures (scaphoid, radius) ​ Intersection syndrome ​ Wartenberg syndrome ​ ​ (some of these can co-exist with de quervain’s) Evaluation: Intersection Syndrome ​ Radial wrist pain ​ Crepitus with wrist motion ​ Inflammation and swelling ○​ ~4cm proximal to lister’s tubercle Mechanism ​ Friction between 1st and 2nd compartment tendons (APL/EPB and ECRL/B) Provocative test ​ Pain with resisted wrist radial deviation Evaluation: Wartenberg’s SYndrome Clinical findings ​ Radial wrist pain not dependent on thumb motion ​ Paresthesia over dorsum of 1st webspace Mechanism ​ Entrapment of superficial branch of radial sensory nerve between BR and ECRL during pronation Provocative tests ​ Positive Tinel test over radial sensory nerve ​ Elbow extension + hyperpronation + wrist ulnar flexion causes numbness & tingling over dorsoradial aspect of hand (tensioning the nerve) General Treatment Approaches for acute tendinitis Orthosis intervention ​ To rest tissues - as acute symptoms resolve, flexible orthoses or taping may be used to provide support until no longer required ​ Determine wearing schedule based on symptoms and life demands: ++ education Ergonomic assessment and modification ​ Work, leisure, life roles Modalities and exercise ​ Eccentric vs concentric - beyond scope of discussion today Orthosis intervention Rationale ​ To rest APL and EPB with thumb in functional position ​ Volar based long thumb spica orthosis ​ Wear 6 weeks, full time ​ Wean to semi-rigid or soft orthosis Education ​ Anatomy & mechanism of de quervain’s ​ Orthosis wear & care schedule - rationale ​ Educate regarding compensatory movements while wearing orthosis ​ Pain management (ice, heat, rest, hurt versus harm education) ​ Appropriate home exercise program ​ job/activity modification Activity Modification ​ Through discussion with the client, assess aggravating activities ○​ Client may being in photos, equipment etc. ​ Reduce task frequency and duration ○​ Modify based on your interview and analysis ​ Diversify work activities ​ Alter sports or work technique ​ Modify tools ○​ i.e. ergonomic keyboard, tools with pistol grip ​ Use larger joints Exercise ​ AROM & PROM ○​ Need to consider healing time frames and presence/intensity of pain ​ Stretching - same as above ​ Tendon gliding - APL & EPB ​ Strengthening ○​ Eccentric - need to carefully apply to UE Sensory receptors and perception Nerve fiber type Receptor Perception slowly-adapting Markel cell Constant touch Pressure Semmes-weinstein monofilaments - threshold; static 2pt - innervation density  Slowly-adapting Ruffini end-organ Constant touch Pressure Lateral stretch Quickly-adapting Meissener corpuscle Movement Vibration 30hz - threshold; moving 2pt discrimination - innervation density Quickly-adapting Pacinian corpuscle Movement Vibration 256hz - threshold Movement 2pt - innervation density Chronic Tendinitis = Tendinosis Tendinosis ​ There are no inflammatory cells present, therefore treatment will be different ​ Assessment will tell you whether the person has an acute or chronic condition based on how long they have had symptoms and what those symptoms are ○​ Chronic = greater than 3 months ​ >40 you begin to suspect “osis” vs “itis” Jan 24 Lecture - Flexor Tendon Injuries Goal of Flexor Tendon Rehabilitation ​ Maximize tendon excursion in order to achieve full finger composite flexion and extension and return to valued functional activities (self-care, leisure, school, work)**** ​ Focus on exercises because there are specific protocols to follow Flexor Pulley system A5 - DIP joint A4 - middle phalanx A3 - PIP joint A2 - proximal phalanx A1 - MCP joint Need to know if pulley was injured, if so, provide protection for 12 weeks Which pulleys are most important? Importance How can we protect pulley during active motion? Do we need to protect pulley during PROM? ​ No muscle contraction so not pulling against the pulley Tendons not close to bone will stick out against skin and finger will not bend well Flexor Tendon Zones Zone 1 Distal to insertion of FDS Zone 2 From proximal part of A1 pulley to insertion of FDS Location of “no man’s land” Problem area where FDP goes between distal ends of FDS Everything gets attached to each other We need to ensure functional scarring and limit tendon adhension Zone 3 From distal end of transverse carpal ligament to proximal end of A1 Pulley Zone 4 Area at transverse carpal ligament (carpal tunnel) Zone 5 From musculotendinous junction of flexor tendons to proximal border of transverse carpal ligament  ​ Therapy principles different based on zone of injury ​ Zone 2: “no man’s land” is most difficult to successfully rehabilitate ​ Goal: prevent tendon adherence and promote tendon gliding Goals of surgical repair ​ Provide the tendon with strength to withstand early motion (passive and/or active) ​ Offer minimal resistance to tendon gliding ​ Repair tendon to promote function Factors to consider before deciding on therapy approach ​ You need to review the OR note to provide safe and effective treatment ​ Mechanism of injury (i.e. saw, knife, etc) ​ Date of injury and tendon repair (critical to decision making regarding therapy) ​ Location of injury (relates to zone) ​ Percentage of laceration (50%, 100%) ​ Quality and type of repair (frayed tendon) ​ Other associated injuries (i.e. fracture, nerve, pulley) ​ ***client factors (age, general health, home/work demands, MH status etc.) Suture stand number relates to strength of repair, which affects therapy decisions Suture strength is related to # of strands that cross tendon repair (2-strand, 4-strand, 6-strand repair) 2-strand = passive motion protocol ​ Surgeon goes across between tendon ends twice 4 and 6-strand = active motion protocol (plus passive exercises) Top = 2-strand 2nd from bottom = 4-strand Bottom = 6-strand General Guidelines to Follow - consider literature, surgery type and client Suture Type Week 1-3 Week 4-6 Week 6-8 8-12 2 - strand repair Passive mobilization PROM plus specific Graduated Progressive Protocol active tendon gliding strengthening, strengthening exercises. Add tendon and increased No active because functional use. will tear apart** blocking exercises at gliding, blocking At 12 weeks, 5-6 weeks. Address exercises and light unrestricted long flexor tightness. ADL use. 4 - strand repair Early AROM Protocol PROM plus specific Graduated Progressive (perform PROM for active tendon gliding strengthening, strengthening the exercises. Add tendon and increased functional use. purpose of blocking exercises at gliding, blocking At 12 weeks, improving joint 5-6 weeks. Address exercises and light unrestricted motion and long flexor tightness ADL use. decreasing work of tendon) 6 - strand repair Early AROM Protocol PROM plus specific Graduated Progressive (perform PROM for active tendon gliding strengthening, strengthening the exercises. Add tendon and increased functional use. purpose of blocking exercises at gliding, blocking At 12 weeks, improving joint 5-6 weeks. Address exercises and light unrestricted motion and long flexor tightness ADL use. decreasing work of tendon) Immobilization Immobilization PROM plus specific Graduated Progressive when client is a active tendon gliding strengthening, strengthening child, is unable exercises. Add tendon gliding, to understand and increased blocking exercises at blocking functional use. instructions exercises and light etc. 5-6 weeks. Address At 12 weeks, long flexor tightness ADL unrestricted use. REMINDER - phases of healing Phases of Description Healing Inflammatory ​ Increased blood supply brings fibrin to create clotting Phase 3-5 days (‘scab’); edema present ***therapy implication – often see hand surgery clients 1-3 days post-operatively Fibroplasia Phase ​ Fibroblasts synthesize collagen and connective tissue - î 5-20 days tensile strength (scar formation) (proliferative) ​ Granulation tissue fills in from the base of the wound Maturation ​ Collagen fibres reorganize to î wound strength and epithelial Phase cells mature - scar tissue forms - remodels 21 days - 2 years Week 3: tendon strength decreases – CAUTION (how would you (remodeling) educate clients regarding this issue? How does this information affect therapy decisions?) Benefits of early protected mobilization (AROM & PROM) ​ Improves tendon excursion = gliding ​ Decreases tendon adhesion formation ​ Improves clinical and functional outcome Factors to consider before deciding on a therapy approach ​ You need at least a 4-strand repair in order to perform early active finger range of motion ​ As therapists, we must know this information before initiating a therapy program otherwise we could cause tendon rupture (too much force), tendon adherence (too little force), gap scar formation (tendon lengthening) ○​ Review OR note and discuss with treating surgeon Therapy: Immobilization ​ Complex injuries ​ “Complicated” patients or patient situations ​ Based on previous chart, when would you begin AROM and tendon gliding ○​ 1-3 weeks for 4 and 6-strand, 4-6wks for 2-strand ** Case example ** ​ Alex is a 56 year old RHD gentleman who was cutting frozen chicken when his knife slipped and lacerated his right small and ring fingers at the proximal phalanx level. ○​ Zone 2 laceration ​ He is referred to you at one week following surgery for fabrication of an orthosis and therapy  ​ Based on the OR note, what is your therapy plan? What other structures do you need to protect? How would you do this? What education would you provide to Alex? ○​ Anything above and below the laceration? ○​ Early active ROM and PROM (dependent on OR note) ○​ Protection A2 with external support for 12-weeks only during active range Operation Note: ​ 4-strand repair of FDS of the right small and ring fingers ​ Ring finger A2 pulley was repaired ​ The digital nerves were intact. What if it was a 2-strand repair? ​ Only PROM no AROM in the first 1-3 weeks Decrease Tendon “work of flexion” (WOF) ​ Active ⅓ fist as early as possible based on surgical repair strength (day 3 post-op to week 4) - ensures low force on tendon AND ensures that tendon actually glides ○​ If swelling occurs, use coban tape ○​ Full fist is too much force and could rupture tendon repair ​ Position within orthosis: wrist neutral or extended; MCP joints flexed to 15-30 d