Module Three  

D. Prehension.
Prehension (gripping) is an advanced skill in humans, resulting largely from the ability of the thumb to oppose the fingers. Two types of grip are described, ‘precision’ involving the thumb and fingers and ‘power’, involving the whole hand. Thumb opposition in conjunction with movement at other digits is used to execute functional prehension.

A. Adduction and internal rotation.
The patient should be able to reach the lower border of the scapula (~T7 level).

C. Grade 3 (fair). Raising and lowering his arms to the ceiling without resistance is a movement against gravity, without any resistance. The motion of moving up towards the ceiling indicates that this is a full ROM of the upper extremity. When a patient can perform full range of motion without any resistance it is a grade 3.
The most commonly accepted method of evaluating muscle strength is the Oxford Scale (AKA Medical Research Council Manual Muscle Testing scale). This method involves testing key muscles from the upper and lower extremities and grading the patient’s strength on a 0 to 5 scale accordingly:
Flicker of movement
Through full range actively with gravity counterbalanced
Through full range actively against gravity
Through full range actively against some resistance
Through full range actively against strong resistance

B. Determining the best splinting position by handling the child’s extremity and feeling the amount of passive resistance.
This would occur “When handling the joints and feeling the resistance from the child’s muscles, the therapist can determine the most therapeutic position and the location of force application during splint fabrication and strap application”(Coppard, 412) He should take note of the joint angles involved and where pressure is being applied to obtain that position.

A. This would occur during splint fabrication and formation.
C. This would be the final step.
D. This would occur while the therapist is handling the child ( and not at the beginning), as the child is expected to demonstrate dysarthria associated with quadriplegic CP.

Coppard, Brenda M.Lohman, Helene. (2008) Introduction to Splinting: A clinical reasoning and problem-solving approach (2nd Edition). St. Louis : Mosby, pp 406-412.
https://www.cerebralpalsyguidance.com/cerebral-palsy/types/spastic-quadriplegia/

A. Lifting a bag of flour up the 4-step back entry of the bakery from the loading dock. Carrying heavy loads while ascending an incline requires MET Levels greater than 5.0.

B. C and D . Light housekeeping tasks without use of heavy equipment or heavy pushing and pulling, seated BADLs , and standing while writing are well within MET Levels 1.0 to 3.5.

Pass the OT Study Materials – Module 3: https://passtheot.com/met-levels-cardiac-rehabilitation/

D. Clarify concerns and allow them to vent before determining their understanding about the diagnosis and splint order.
It is important to allow the patient and his wife the opportunity to express their emotions and concerns. This helps in establishing rapport in order to develop client-centered goals. The OT practitioner can positively influence the patient’s compliance and motivation and determine the readiness of his family members to help ensuring carryover and support of the patient’s self-maintenance of the splint, precautions, and home exercise program.

A. This would not be therapeutic and client-centered as the concerns must be addressed first.
B. The emotional state of the patient and his wife need to be addressed first.
C. Although environmental modification for therapeutic rapport may be an effective protocol for addressing anxiety, allowing the patient and his wife to speak first would be priority.

Coppard, Brenda M.Lohman, Helene. (2008) Introduction to Splinting: A clinical reasoning and problem-solving approach (2nd Edition). St. Louis : Mosby, p 113.

A. Wash dishes in a seated position.
Washing dishes requires the patient to use both their hands for the task and they can therefore not hold onto a walking aid to help them adhere to their weight bearing precautions, when they need to move along the work surface. Therefore, while the patient is only permitted to partially weight-bear, it is advisable that they complete kitchen tasks from a seated position to reduce the likelihood of them unintentionally taking full weight through their operated limb. This includes tasks such as making a hot drink, cooking and washing up. This is because the patient may be tempted to hold onto the work surface and step sideways without their walking aid, which means they will not be partially weight-bearing on their operated limb.

B. Washing dishes typically requires bilateral upper extremity use.
C and D. Weight-bearing 50% -100% of the body onto the operated leg is contraindicated as partial weight bearing is defined as bearing 30% to 50% of your body weight. Toe touch weight bearing is poorly defined in the research literature, however, in clinical practice, it is commonly described as having the ability to touch the foot or toes to the floor without supporting weight from the affected limb.

B. Active range of motion (AROM).
AROM of all available joints while in the cast, orthosis, or external fixator is vital to edema control and to maintaining tissue length. AROM acts as a pump mobilizing edema through the lymphatic system.
Edema is a natural by-product of trauma, and the development of some edema following injury and surgery is normal and expected. However, moderate to severe swelling that persists is the silent enemy, as it will infiltrate every tissue and alter the normal gliding of joints and tendons. Over time, there can be increased collagen formation and progression from moveable edema to more fibrous protein-rich edema that ultimately turns to scar tissue.

Cooper’s Fundamentals of Hand Therapy Clinical Reasoning and Treatment Guidelines for Common Diagnoses of the Upper Extremity By: Christine M. Wietlisbach.

C. Preventing the development of contractures in the affected extremity. The neurological damage caused by CVA places the patient with hemiparesis at a high risk of contracture development, especially if no active movement is observed. The OTA’s primary objective as she begins treatment should be to provide techniques that will reduce the risk of contracture development. The other techniques listed will also be included over the course of treatment, but contracture prevention is necessary before the OTA can shift the focus of treatment to any of the other objectives.

C. Translucent ring splint turned upside down along DIP, and child-size bamboo chopsticks.
A mallet finger is the term used to describe the deformity produced by disruption of the terminal extensor mechanism at the distal interphalangeal (DIP) joint. Mallet finger is also been referred to as drop, hammer, or baseball finger. The ring splint in this position can provide anterior stability at the DIP joint of a mallet finger. It is inconspicuous, requires little material, and allows for mobility of the PIP and MCP joint to manage utensils. Chopsticks are class-3 lever hand tools. With short lightweight chopsticks, the patient will have more control and requires less force produced to pick up items on the end.

A. Although a plastic tong is less cumbersome for serving food and use applies forces across the hand, a mobilization splint with finger loops attached to the 4th and 5th digit would be more appropriate for an ulnar nerve injury.
B. A hand-based splint is unnecessary and is more conspicuous. A spring-loaded pair of chopsticks would also be obvious.
D. Although silver rings would be appealing, longer heavier chopsticks require more precision and use of intrinsic forces.
.
Coppard, Brenda M.Lohman, Helene. (2008) Introduction to Splinting: A clinical reasoning and problem-solving approach (2nd Edition). St. Louis : Mosby, pp 474-475.
Keogh, J., Sain, S.; and Roller, C. (2012). Kinesiology for the Occupational Therapy Assistant: Essential Components of Function and Movement. Thorofare, NJ: SLACK Incorporated, pp 68-73.

A. Iontophoresis.
Iontophoresis is the application of ionized topical medication through the skin to tissues of the body by the continuous and direct electrical current.  It is used to administer specific medication into the patient’s body, to treat a variety of different conditions. The specific medication that is used in iontophoresis depends upon the goals of treatment. Some medications are used to decrease inflammation, while others are used to decrease calcium deposits in muscle and tendon tissue. Iontophoresis is used for delivery of substances that need local penetration in order to avoid systemic effects, and in cases where oral absorption is variable or contraindicated.

B. TENS- Stimulates nerve fibers and provides symptomatic relief of pain.
C. Fluidotherapy- Superficial heating modality that transfers heat by convection. Dried corn husks or other cellulose material are suspended by warmed circulating air.
D. Neuromuscular Electrical Stimulation (NMES)- Therapeutic muscle stimulation: repetitive simulation to paralyzed muscle to minimize atrophy and maintain range of motion. Activate muscle by stimulating an intact or partially intact peripheral nerve./em>

D. Ambulating to the closet with a front-wheeled walker and retrieving clothes one at-a-time with either hand.
To maintain functional use, it is important for the patient to perform routine self-care tasks and include the affected arm towards the goal of regaining full or functional range of motion. Because light weight-bearing is acceptable, the patient can use a front-wheeled walker and lay the affected arm on the hand grip for stability during ambulation. Using either hand depends on whether the patient is able to use “AROM as tolerated.”

A, B, C. are unsafe and are not appropriate methods of light functional use of the affected extremity at this time.

Early, Mary Beth. (2013) Physical dysfunction practice skills for the occupational therapy assistant (3rd Edition). St. Louis, Mo. : Elsevier/Mosby, pp 56-57.

B. Superficial branch.
Wartenberg’s Syndrome is described as the entrapment of the superficial branch of the radial nerve with only sensory manifestations and no motor deficits. In this condition, the patient reports pain over the distal radial forearm associated with paresthesia over the dorsal radial hand. This should not be confused with Wartenberg’s Sign which refers to the slightly greater abduction of the fifth digit, due to paralysis of the abducting palmar interosseous muscle and unopposed action of the radial innervated extensor muscles.

A. The posterior interosseous nerve (deep branch) is entirely motor. Patients with posterior interosseous nerve syndrome do not present with a sensory deficit.
C. The anterior interosseous nerve (volar interosseous nerve) is a branch of the median nerve that supplies the deep muscles on the anterior of the forearm, except the ulnar (medial) half of the flexor digitorum profundus.
D. The peroneal nerve is a branch of the sciatic nerve, which supplies movement and sensation to the lower leg, foot and toes.

https://teachmeanatomy.info/upper-limb/nerves/radial-nerve/

D. Have the patient put on non-skid footwear before ambulating.
Non-skid footwear including non-skid socks or shoes with traction will reduce risk of falling. The focus of treatment is to promote independence with functional performance of BADLs.

A. This may increase risk for falls.
B and C. These would promote more need for assistance and dependence and downgrades the patient from his current functional level for mobility.

Byers-Connon, S., Lohman, H., Padilla, R. L. (2004). Occupational Therapy with Elders:

C. To improve ease of application and provide mechanical leverage.
Given pain symptoms, the patient can more easily tighten the straps by holding onto the end piece between 2 fingers (other than the thumb and index finger) and rotating the forearm to tighten the D-ring strap.

A. Cognitive function was not mentioned.
B. There are other options of straps that could decrease the weight of the splint.
D. Although edema was not a concern, it may not be expected in this case. Any strap is moveable and can accommodate fluctuating edema.

Coppard, Brenda M.Lohman, Helene. (2008) Introduction to Splinting: A clinical reasoning and problem-solving approach (2nd Edition). St. Louis : Mosby, p 381.

B. Long arm splint.
Radial tunnel syndrome (RTS): Compression of the radial nerve in the proximal forearm resulting in a dull ache and burning sensation along the lateral forearm. With RTS, placing the elbow in extension, forearm in pronation and wrist in flexion along with resisting long finger extension will often provoke symptoms of dull pain or aching and burning in the lateral forearm. Fabricating a long arm orthosis with the wrist in extension, elbow in flexion, and forearm in pronation to neutral rotation is the classic recommended position .

A. Dorsal blocking splint is used to prevent stress to the flexor tendons following injury or repair.
C. Wrist volar splint with wrist in neutral is typically used to treat Carpal tunnel syndrome.
D. Opponens splint typically used for fractures, injuries, and repetitive motion syndromes of the thumb.

D. The OTA should explain to the patient that paraffin treatments are contraindicated at this stage of her recovery as her surgical scar has not yet healed.
Paraffin should not be used until the scab from an open wound or surgical scar has fallen off. Paraffin can easily seep into open wounds therefore, it is contraindicated when an open wound or surgical site is present. 

A. Pursed lip breathing technique.
B. Positioning techniques.
D. Diaphragmatic breathing.
Pursed lip breathing decreases hyperinflation of the lungs which enables the patient to breathe in more oxygen and reduces dyspnea on exertion.
Positioning techniques such as leaning slightly forwards, elevating the head of the bed, and sleeping propped up on pillows reduces dyspnea with rest.
Diaphragmatic breathing. Often, people with COPD use accessory muscles in their neck, shoulders and back to breathe more than they use their diaphragm. Belly breathing or diaphragmatic breathing helps people with COPD retrain the diaphragm to work better, so they can breathe more efficiently.

C. Myofascial release is a manual therapy technique to improve muscle mobility and reduce pain. 
E. Is a method of measuring a person’s perception of pain.             
F. Accessory muscle use is indicated when a person has trouble moving air out of their lungs normally; this is a compensatory method for poor respiratory function.

Causey, R. (2013). Breathing Easier: Pulmonary Rehabilitation in Skilled Nursing Facilities. OT Practice 18(21), 13–17. http://dx.doi.org/10.7138/otp.2013.1821f2

A. Bend the knees and keep the back straight, when unpacking new books from a box.
D. Maintain spinal alignment when holding the books.
E. Carry the books at chest level with elbows fully flexed.
All three techniques support proper body mechanics. These techniques support the following principles: maintaining the load close to the body, maintaining upright posture, and reducing joint stress by promoting equal distribution along the joints and muscles of the body.

Planning for Lifting and Carrying:
1. Test the weight of the object to be lifted. An easy way to determine if you can lift it without assistance is to try pushing the object with your foot. However, even lightweight objects that are large in size, or cumbersome, may best be handled with assistance.
2. Plan the best way to hold the object to keep it close to your body before lifting.
3. Position your body close to, and directly facing, the object. Place your feet flat on the floor, shoulder width apart, to provide a stable base for your body. To turn directions, use your feet to pivot. Do not twist!
4. Depending on the shape of the object, try to hold it at the sides and bottom, and keep it close to your body. If possible, keep your elbows bent while carrying an object.
5. Use the muscles in your legs as the power for lifting, not the back! Bend the knees, keep the back straight, and lift smoothly. Repeat the same movements for setting the object down.

https://www.spineuniverse.com/wellness/ergonomics/body-mechanics-your-spine-tips-1-3

Early, Mary Beth. (2006). Habits of Health and Wellness, Physical Dysfunction Practice Skills for the Occupational Therapy Assistant (3rd Edition, p 192). St. Louis, Missouri: Elsevier, Mosby Inc.

A. Living situation including available support from others.
C. Typical grooming and dressing habits and routines.
D. Home environment setup including DME.
Discharge planning should be initiated as soon as the patient’s OT intervention begins. Treatment methods are based on the goals which are guided by client factors including the client’s interests and routines. Preparation for discharge includes discussing the patient’s goals towards discharge, mobility and assistive devices, and consideration of caregiver and community support systems. The clinician will keep these factors in mind during treatment implementation.

B, E and F. These serve as a basis for selecting evaluation procedures and provides a guide for approaching the patient’s evaluation.

Early, Mary Beth. (2013) Physical dysfunction practice skills for the occupational therapy assistant (3rd Edition). St. Louis, Mo. : Elsevier/Mosby, pp 57-68.

A. Coordinate exhalation while lifting a filled, small laundry basket
Patients with COPD typically use accessory muscles while breathing with little use of their diaphragm. This results in shallow breathing leading to fatigue in the muscles of the shoulder. Unloading the shoulder girdle by supporting the upper extremities, breathing on exertion, and preventing bending at the hip will allow the patient the continued use of diaphragmatic breathing.
Causey, Renee (2013): Breathing Easier – Pulmonary Rehabilitation in Skilled Nursing Facilities. OT Practice Magazine (Vol 18), p 15.
Radomski, M. & Trombly Latham, C. (2008). Occupational Therapy for Physical Dysfunction (6th ed). Baltimore, MD: Lippincott, Williams & Wilkins, p 1309.

Arm activities are especially demanding for patients with COPD. Some pulmonary rehabilitation programs instruct patients to inhale while raising their arms, whereas others recommend the opposite. A study conducted in 2013, aimed to determine the effect of coordinating breathing with arm movements on the endurance of a lifting task. The results of the study indicated that exhalation during the lift, improved task performance. https://www.ncbi.nlm.nih.gov/pubmed/23370697

C. 3.0-4.0 METs.
MET 3.8
Occupation custodial work: moderate effort (e.g., electric buffer, feathering arena floors, mopping, taking out trash, vacuuming)

2011 Compendium of Physical Activities
https://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/MSS/A/MSS_43_8_2011_06_13_AINSWORTH_202093_SDC1.pdf

A. Auditory biofeedback to the sequence and speed of simulated breath sounds.
Biofeedback facilitates learning. Biofeedback allows the patient to self-monitor and control physiological responses. Auditory biofeedback gives the patient the opportunity to readily observe and monitor how they are performing and make adjustments necessary in order to promote a target response, such as maintaining a slower, deeper breathing pattern. This can be done with a recorded breathing pattern that can be played back.

B. The patient will have difficulty inhaling while counting aloud. It would be more appropriate to count in silence and/or exhale 4 breaths because exhalation for pursed lip breathing relies on moving air out of the lungs on exhale.
C. It is more appropriate to assume a stabilized forward lean position. However, it does not focus on the breathing pattern.
D. A spirometer measures lung volume capacity and also assesses for presence of airway obstruction. However, it is not an appropriate device to sensitize proper breathing pattern in pursed-lip breathing. Blowing on a tissue would be a better visual biofeedback.

Elizabeth Pyatak, Maggie King, Cheryl L. P. Vigen, Elia Salazar, Jesus Diaz, Stacey L. Schepens Niemiec, Jeanine Blanchard, Katie Jordan, Josh Banerjee, Jagruti Shukla; Addressing Diabetes in Primary Care: Hybrid Effectiveness–Implementation Study of Lifestyle Redesign® Occupational Therapy. Am J Occup Ther 2019;73(5):7305185020p1-7305185020p12. doi: 10.5014/ajot.2019.037317.

B. With right hand, open waist cuff, thread over feet in figure-4, pull to thighs, stand and manage pants over hips while left hand stabilizes waist band.
Proximal humeral fracture most likely occurred at the surgical neck of the upper arm limiting shoulder movements during the initial healing phase. The patient has good trunk control and is able to use her left hand with supervised movement of her left elbow as long as the patient supports her forearm against her body. This would allow her to stabilize the pants with her left hand while she pushes to stand with her right hand and complete dressing. Given her profession, it is likely her balance is within functional range.

A. Bending over would increase the chance of weight-bearing with her LUE which is contraindicated at this time.
C. Managing the reacher with her operated upper extremity would increase the chance of shoulder movement which is contraindicated at this stage of rehabilitation for a proximal humeral fracture.
D. The patient has optimal trunk control with no indication of balance deficits and is able to perform lower body dressing in a seated, unsupported position.

https://passtheot.com/hand-upper-extremity-worksheet/
http://bostonshoulderinstitute.com/wp-content/uploads/2017/03/Post-Fracture-Proximal-Humerus-Rehab-Guidelines.pdf

A. Spring-operated scissors.
Cutting paper and fabric can put a surprising amount of stress on your joints, particularly those in your thumbs. Scissors which have soft-grip handles and spring-action blades that open after each cut, reduces the effort it takes to cut something and easing the strain on your hands.
B. Electric scissors require pushing buttons and maintaining a static grasp to operate them.
D. Embroidery scissors are small, sharp, pointed scissors

B. Put safety first.
C. Consider the benefits of texture.
D. Avoid anything heavy.

What to Look for in RA-Friendly Devices- there are plenty of considerations to keep in mind when looking for products that can help ease RA-related joint strain in your day-to-day life. According to the Arthritis Foundation, here is what you should consider when shopping for products to help you manage your RA:
• Put safety first — consider only those products that you can use as intended comfortably.
• Avoid anything heavy — like cast iron pots or ceramic bowls — which may be difficult to use.
• Think about texture — for example, glassware that has a bumpy exterior may be easier to grasp and hold on to than a smooth surface.
• Consider ease of use — products, for example, that have flip tops, zippers, or large, easy-to-open lids.
• Look for products that don’t require much upkeep or maintenance.

https://www.everydayhealth.com/hs/rheumatoid-arthritis-treatment-management/ra-gadgets/

C. Modify the task by allowing the patient to stand only when necessary to place items beyond her reach.
The goal is for the patient to improve endurance by working on completion of a meaningful task. The patient is demonstrating signs of fatigue with slow movements and need for upper extremity support. Therefore, the patient would benefit from activity modification to make the task less challenging, downgraded to a level that is more tolerable.

A. Termination of the activity would be necessary if the patient demonstrates more severe symptoms such as dyspnoea on exertion or chest pain.
B. The goal is for completion of the task during ambulation with pacing and rest. Wheelchair level is not preferred, and strengthening is not the goal.
D. Using the stationary bike is not the patient’s preferred functional task.

Early, Mary Beth. (2013) Physical dysfunction practice skills for the occupational therapy assistant (3rd Edition). St. Louis, Mo.: Elsevier/Mosby, p 10.

D. Loosen the ace bandage under the splint, check the patient’s blood pressure and contact the orthopedic surgeon.
The patient may be displaying signs and symptoms of acute compartment syndrome of the forearm. This results from internal pressure within the tissues when there is limited space, compromising circulation and function of the contents of that space. The pressure has elevated for some time to reduce capillary perfusion. This is a medical emergency and diagnostic procedures may be required to assess the tissues in the painful area.

A. This will add pressure to an already-compromised area.
B. This would be a more appropriate intervention to neuropathic pain, such as CRPS.
C. This modality is contraindicated for this condition

Chandraprakasam, T., & Kumar, R. A. (2011). Acute compartment syndrome of forearm and hand. Indian journal of plastic surgery : official publication of the Association of Plastic Surgeons of India, 44(2), 212–218. doi:10.4103/0970-0358.85342
https://www.ncbi.nlm.nih.gov/pubmed/14503155
https://www.choosept.com/symptomsconditionsdetail.aspx?cid=a373249d-d523-4eb7-90b0-b252f164f405

B. Acknowledge her concerns and redirect the patient onto a neutral topic.
It is important for a patient with anxiety to express her concerns, confront her fears, and release stress. The clinician’s role in maintaining a therapeutic relationship is by allowing patients to come to terms with their conditions, manage their symptoms, and carry on with their meaningful tasks by gradually turning their attention to a more constructive topic.

A. The problem with missing the bus is not because of a time management problem. It is related to anxiety.
C. The focus of action should be on gradual redirection, not encouraging discussion regarding physical symptoms.
D. It is important to report the patient’s behavior to the OTR®. as she may be experiencing an exacerbation of her symptoms, but the question is asking what NEXT, in the group situation.

Early, Mary Beth. (2009) Mental Health Concepts & Techniques for the Occupational Therapy Assistant (4th Edition). Baltimore, MD.: Walters Kluwer, pp 290-291.

B. Replace the Velcro straps with shoelaces and shoelace locks, and apply stickers of her favorite animal or cartoon characters. This would prevent her from removing the splint. The cartoon design is fun and appealing and she is more likely to keep the splint on, to show the design to her peers and loved ones.

https://www.mitchmedical.us/extremity-splinting/splinting-the-pediatric-patient.html

C. Suggest he sit on a tall kitchen stool at the sink while washing the dishes. Sitting down to complete a task is an energy conservation technique. By sitting down at the sink, the man can conserve his energy and still wash his dishes himself. The other answers suggest that the man find an alternative to washing his own dishes.

D. Teach the patient a variety of joint protection strategies for grooming.
It is important to deal with the patient’s pain first. Teaching the patient joint protection techniques and strategies will help eliminate the pain.

D. “I wake up in the morning and rush to get my clothes on, brush my teeth, and make breakfast. Then I am exhausted.”
Waking up in the morning and attempting to do all those activities will cause the patient to become short of breath and tired. It is important to educate the patient about energy conservation, pacing, and slowing down.

A. Ultrasound. The bones of children and adults share many of the same risks for injury. But because they are still growing, a child’s bones are also subject to a unique injury called a growth plate fracture. Growth plates are areas of cartilage located near the ends of bones. Because they are the last portion of a child’s bones to harden (ossify), growth plates are particularly vulnerable to fracture. An epiphyseal injury therefore affects the growth plate of the bone. Since the patient is 12 years old, his growth plates are active and any treatments that could affect that growth should be avoided. Ultrasound which is a deep heat modality has been shown to interfere with active growth plates and the use of ultrasound over growth plates is therefore contraindicated.

D. A flail arm splint. This type of splint is designed to support the entire arm and facilitate some functional movement that is initiated at the shoulder.
Flail arm splint provides the needed stability at both the shoulder and elbow for functional positioning of the hand.
For patients who have sustained a flail upper limb as a result of a brachial plexus lesion, functional splintage in the form of the flail arm splint is recommended. The full flail arm splint is basically a skeleton of an upper limb prosthesis. It fits around the patient’s arm and enables them to lock the elbow in one of five positions. By protracting their unaffected shoulder , they can operate various terminal devices, thereby increasing his functional capabilities.
https://journals.sagepub.com/doi/abs/10.1177/030802268604901008?journalCode=bjod

D. Volar or dorsal.
Volar means the palm of your hand. Dorsal means the back of your hand. A wrist cock-up splint can be fabricated with either a volar or dorsal design. Volar wrist cock-up splints are more commonly used. Dorsal wrist cock-up splints are used when a patient’s condition prevents the use of a volar wrist cock-up splint.

The OTA should assess the patient using the Borg Rating of Perceived Exertion during ADL tasks. The OTA needs to know the patient’s current level of ADL ability, including how much energy the patient feels he is exerting during tasks. The Borg Rating would give the OTA this information. The OTA should also monitor oxygen levels during any activity, but this will tell the OTA when the patient needs to rest, not what his current ADL ability is. Nursing staff may not allow the patient to perform ADL tasks by himself and his family might not know about his current ADL status.

C. To support the humerus after a nondisplaced fracture. A humeral fracture brace supports all or a portion of the upper arm following a fracture of the humerus. Most commonly, a humeral fracture brace is used to support the humerus as a part of conservative management of a nondisplaced fracture.

D. Osteogenesis Imperfecta. This congenital disorder is characterized by brittle bones that are prone to fracture. Children with this disorder are born with a deficiency in type 1 collagen that causes defective connective tissue or the inability of the body to make connective tissue.

B. Compensatory technique to resume ADLs.
Rehabilitation for a patient with a fractured humerus typically involves a team approach, including physiotherapy and OT. 
The main and unique treatment goal of OT in this situation, is to help the patient regain independence in his ADLs. In order to achieve this, teaching the patient new ways to perform these tasks (compensatory techniques) is usually required. For the patient to be able to perform his ADLs with ease, controlling his pain may be necessary. It is also important to maintain the patient’s muscle strength and range of motion, of the structures around his immobilized humerus as immobilization can result in tissue shortening. If a physiotherapist is not involved in the patient’s care, then the OTA would have to address this, as well

D. Median nerve
The median nerve originates from the lateral and medial cords of the brachial plexus, and has contributions from ventral roots of C5, C6 and C7 (lateral cord) and C8 and T1 (medial cord).
The median nerve is the only nerve that passes through the carpal tunnel. The median nerve predominantly provides motor innervation to the flexor muscles of the forearm and hand as well as those muscles responsible for flexion, abduction, opposition, and extension of the thumb. The median nerve also provides sensory innervation to the dorsal aspect (nail bed) of the distal first two digits of the hand, the volar aspect of the thumb, index, middle, and half of the ring finger, the palm, as well as the medial aspect of the forearm.Carpal tunnel syndrome is the condition that results from the median nerve being compressed in the carpal tunnel. 

 https://www.ncbi.nlm.nih.gov/books/NBK448084/

B. Lift a towel and place it on a towel rack.
A grade of Fair plus (3+) means the patient can move through full ROM against gravity and can tolerate slight resistance. The patient should be able to lift the towel as it provides slight resistance to movement. The other activities provide more resistance than what the patient will be able to tolerate at this grade.

D. Anergia
Anergia is a condition in which an abnormal lack of energy is observed. The lethargy and fatigue that the patient displays are consistent with this term. Following are the definitions of the terms offered in the other choices:

Anosognia- a deficit of self-awareness, a condition in which a person who suffers a certain disability seems unaware of the existence of his or her disability.

Dyspnea- shortness of breath or breathlessness is the feeling or feelings associated with impaired breathing.

Open Reduction Internal Fixation (ORIF) involves the implementation of implants to guide the healing process of a bone, as well as the open reduction, or setting, of the bone itself.

B. 4 – Minimal Contact Assistance. At this level, the patient can perform 75% or more of the task, but may need incidental assistance such as help adjusting clothing, applying toothpaste, etc.

C. Isotonic contraction.
Isotonic- intention to move.
Isometric- intention to hold.
Isotonic contractions generate force by changing the length of the muscle and can be concentric contractions or eccentric contractions.
A concentric contraction causes muscles to shorten, thereby generating force.
Eccentric contractions cause muscles to elongate in response to a greater opposing force.
Isometric contractions generate force without changing the length of the muscle.

Sensory re-education helps patients to interpret sensory impulses through graded sensory stimuli.

A. Lymphedema.
Lymphedema is a condition of localized fluid retention and tissue swelling caused by a compromised lymphatic system, which normally returns interstitial fluid to the thoracic duct and then the bloodstream. Though incurable and progressive, a number of treatments can ameliorate symptoms. Tissues with lymphedema are at risk of infection.

A. PROM and resistive exercises.
Acutely, inflamed joints should be rested to prevent exacerbation of symptoms. Avoid stretching in acute cases. For non-inflamed joints, active or active-assisted stretching of all major joints is essential to prevent contracture formation and maintain the current range of motion to perform activities of daily living. When the patient experiences an exacerbation and the joints are acutely inflamed then only isometric exercises should be done. Avoid excessive stress over the tendons with stretches and avoid resistive movements.

https://www.hopkinsarthritis.org/
https://www.physio-pedia.com/Rheumatoid_Arthritis

C. Moderate assistance needed. A level 3 on the Functional Independence Measure (FIM) for bathing and grooming indicates that this patient requires moderate assistance and completes 50%-74% of the task.

B. The patient should not perform resistive exercises to increase strength.
RA: Maintaining AROM is a PRIMARY recommendation in order to prevent deformity. PROM and resistive exercise is contraindicated.

D. The phase would be the rehabilitative phase.
The ultimate goal of occupation-based hand therapy is to ensure that the rehabilitation process promotes healing while also enabling clients to perform meaningful activities both in the clinic and in their daily lives. This approach fosters positive outcomes for clients, including enhancing their satisfaction with the therapy experience and results, maintaining their ability to engage in desired roles within their family and the community, and most importantly, experiencing quality of life as they define it.
https://www.aota.org/About-Occupational-Therapy/Professionals/RDP/hand-therapy.aspx

A spherical grasp.This grasp is used when the fingers need to be shaped around the object in order to grasp it. In a spherical grasp, all of the fingers and the thumb are adduced around the object, and the fingers are spread apart. The palm of the hand is often not involved.Two ulnar digits are supported in greater extension to allow a more open hand posture.

C. Swan neck deformity
Hyperextension of the PIP and flexion of the DIP due to rupture of terminal ending lateral slips of extensor digitorum communis tendon OR rupture of flexor digitorum superficialis OR flexor tendon injury

C. NMES.
NMES is a safe, low-frequency current that excites the nerves that innervate desired muscles, causing contractions, blocks pain pathways & reduces swelling and edema. NMES strengthens muscles in a different way than active muscle movements. Often NMES is positioned based on the angle of pull, from the origin to the insertion along the bulk of the muscle fibres.
A. TENS is typically applied over a surrounding area of pain (i.e., more client-specific).

C. Tenodesis (grasp).
Tenodesis grasp and release is an orthopedic observation of a passive hand grasp and release mechanism, affected by wrist extension or flexion, respectively.

C. Cylindrical grasp
A cylindrical grasp is used to hold objects such as a glass, hammer, or a railing.

D. Isometric exercises.
Isometric exercises are contractions of a particular muscle or group of muscles. During isometric exercises, the muscle doesn’t noticeably change length and the affected joint doesn’t move.

D. Ape hand deformity is the result of a median nerve injury at the elbow and/or proximal forearm. The injury results in the inability to abduct the thumb and limitations to flexion of the MCP joints, resulting in an “ape hand” appearance.

Boutonniere (Buttonhole) Deformity: clinical presentation of flexion at the proximal interphalangeal (PIP) joint and hyperextension at the distal interphalangeal (DIP) joint.

Swan Neck Deformity: clinical presentation of PIP hyperextension, with DIP flexion of the finger.

Wrist drop: as a result of damage to the radial nerve, active wrist and finger extension is inhibited.

D. Osteogenesis Imperfecta.
Osteogenesis Imperfecta (OI) is a group of rare disorders affecting the connective tissue and characterized by extremely fragile bones that break or fracture easily (brittle bones), often without apparent cause. It is the most common heritable disorder of connective tissue. Besides being associated with brittle bones, the following features are also linked to OI: Blue sclerae, dentinogenesis imperfecta (disorder of tooth development), increased joint mobility, short stature, and hearing loss. The visual system is also commonly affected in patients with OI. Ocular and visual pathway problems reported include corneal disorders, glaucoma, retinal detachment, optic neuropathy and others. Four main types of OI have been identified. OI type I is the most common and the mildest form of the disorder. OI type III is characterized by extremely fragile bones, multiple fractures, and malformed bones. Multiple fractures are often present at birth. This is the only disorder which would account for Todd’s physical appearance, especially at birth.

A. Cerebral Palsy is a group of disorders caused by damage that occurs to the immature brain as it develops. Signs and symptoms appear during infancy or preschool years. In general, cerebral palsy causes impaired movement associated with abnormal reflexes, floppiness or rigidity of the limbs and trunk, abnormal posture, involuntary movements, unsteady gait, or some combination of these.
B. Osteoporosis is a progressive condition in which bone density is lost, or there is insufficient bone formation, thereby weakening the bones and making them more susceptible to fractures. Although much more common in older adults, especially women in menopause and after, osteoporosis can also occur during childhood. Most often, osteoporosis during childhood is caused by an underlying medical condition, called secondary osteoporosis.
C. Muscular Dystrophy- Congenital muscular dystrophies (CMD) are extremely rare neuromuscular disorders with onset at birth or early infancy, characterized by hypotonia, delayed motor development, and progressive weakness. The clinical presentation is variable and can affect other organs, including the eyes, brain, lungs, and heart.

C. Test for ulnar nerve dysfunction (palsy).
Ulnar nerve: clawing and sensory loss of 4-5 fingers – problems with finger adduction and bringing little finger to opposition – claw hand, flattened metacarpal arch, and Froment’s sign (pull paper from fingers to test the adductor pollicis muscle), lose power grip and pinch strength – MCP flexion block splint.

In more detail:
Froment’s sign is a physical examination of the hand to test for palsy of the ulnar nerve which results in reduced functionality and muscle weakness of the pinch grip. It tests the strength of the adductor pollicus of the thumb, which is innervated by the ulnar nerve and is weakened in ulnar nerve palsy. Froment’s sign is an observable sign that correlates with the complaint of a weakened ability to pinch normally between the first and second digits. This sign is sometimes elicited by asking the patient to grasp a piece of paper between the thumb and index finger.

B. 6-8 weeks post surgery.
Humerus fracture: Non-displaced or displaced, fall on outstretched hand
Fx of Greater tuberosity: rotator cuff injury
Fx of Shaft: radial injury, wrist drop

• If shoulder stability achieved by ORIF, can begin AROM and AAROM (pain-free) by 7-10 days
• 6-8 weeks: Isometric exercises, wall-climbing, pendulum (contraindicated if UE edema), non-resistive exercises
• Once bone union: progressive, resistive shoulder exercises

D. Resting hand splint. This patient is demonstrating signs and symptoms of RA. RA is a chronic inflammatory disorder that can affect more than just your joints. In some people, the condition can damage a wide variety of body systems, including the skin, eyes, lungs, heart and blood vessels. Signs and symptoms of rheumatoid arthritis may include:
– Tender, warm, swollen joints
– Joint stiffness that is usually worse in the mornings and after inactivity
– Fatigue, fever and loss of appetite
– Rheumatoid arthritis and depression commonly occur together. Although this is known, people with rheumatoid arthritis often aren’t screened for depression, so it may not be diagnosed or treated.
Intervention for RA:
Decrease pain and swelling, maintain ROM/strength/endurance.
Use resting hand splint night/day for jt. protection, assistive devices as needed, PAM’s (inflamed joints may exacerbate with heat, ice may be better).
Gentle AROM/PROM
Positioning, functional activities as tolerated, isometric exercises

https://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/expert-answers/rheumatoid-arthritis-depression/faq-20119780

Thumb spica splint
A thumb spica splint is used to immobilize the thumb and provide support. Example: De Quervain’s

D. Prevent re-accumulation of fluids post retrograde massage.
Compression Garments:
·  Prevent re-accumulation of fluids post retrograde massage
·  Types: Isotoner gloves, Tubigrip (elastic stockinette), Ace wraps, Coban (wrapped distal to proximal) for edema in digits while exercising/ADL, but avoid too much tension.

C. Dorsal blocking splint.
A dorsal blocking splint is used for flexor tendon injury repair to keep the hand and wrist flexed because if the patient extends their wrist and fingers, it could tear the repair by overstretching it. It is used to limit the amount of active and passive finger extension and thereby prevent possible tendon rupture following surgical repair. The exact wrist and finger joint placement may differ among the various post-op protocols.

B. Dyspnea.
Dyspnea = SOB. Despite its prevalence, the descriptions of dyspnea vary from patient to patient and no single definition encompasses all its qualitative aspects. Typically, it is defined as a feeling of shortness of breath or an inability to take a deep breath. The American Thoracic Society defines it as “a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.” Many overlapping mechanisms account for descriptive terms used in the medical literature, such as “air hunger,” “chest tightness,” and many others.
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/pulmonary/dyspnea/

C. Yoga in a warm to hot room. Gentle movement and stretching is best and a warm room as a modality will help loosen the muscles. Yoga has many forms. Of course poses that would be harmful to the back would not be recommended. Sitting in a chair will not help the patient’s pain.

C. Power grasp.
A variation of cylindrical grasp, used when extra force is required. The thumb helps to stabilize the shaft of the tool rather than opposing the fingers. The greater the effort to control an object with a power grasp, the greater the potential for injury.

B. MCP blocking splint, also called a lumbrical blocking splint. The photo reveals what is referred to as a claw hand deformity (intrinsic hand deformity). This deformity results from compression or injury to the ulnar nerve, which innervates the intrinsic muscles of the hand. The ring and little fingers are extended at the MCP joints and flexed at the PIP joints, resembling a claw. PROM, joint mobilization to reduce contracture, splinting, therapeutic activity, adaptations for grip, are examples of appropriate intervention.

A. Built up handle or foam tubing. Providing a built up handle on the fork will give the patient more grasping surface, compensating for the deformities in her fingers. Built up handled utensils reduce stress on the finger joints. The soft, built-up foam handles spreads the fingers so that they don’t have to close completely around the utensil. Holding the utensil in this position reduces the stress on the joints, allowing the patient to grasp it more easily.

D. Tenodesis splint.
A patient with a C6 injury typically has head, neck, shoulder, arm and wrist movement. He can shrug his shoulders, bend is elbows, pronate/supinate his forearms, and extend his wrists. A Tenodesis Splint is an ideal splint for a C6 quadriplegic patient or anyone with wrist extension strength but no finger strength. As the patient is able to achieve wrist extension, he can utilize the tenodesis grasp pattern. The tenodesis grasp is the natural flexion of the fingers when the wrist is extended, and extension of the fingers with wrist flexion. This natural movement pattern allows the patient to grasp an object. Although this movement is present, it is often weak and may need to be supported with a tenodesis splint. This splint stabilizes the thumb and holds the fingers in slight flexion. When the wrist is extended, the static line attached to the wrist cuff pulls the finger MP joints into flexion, creating a fingertip pinch ability and gross grasp ability. Some tenodesis splints are simple and provide just enough support to enhance the natural movement of the hand while others may be more elaborate with moving parts to provide increased grip strength.

https://www.st-lukes.org/uploadedFiles/Patients/Patient_Care/

A.Sitting: self-feeding.
Sitting: self-feeding, wash hands/face, bed mobility.

A. Active exercises to all extremities in supine position.
Exercises permitted at Stage I (1.0-1.4 MET) :
Bed mobility, transfers, reading, table games, can exercise all extremities in supine and only neck and lower extremities in sitting. Sitting- Self-feeding, washing hands, table games, light handwork.
https://passtheot.com/met-levels-cardiac-rehabilitation/

B. Reading. RECREATION: reading, radio, table games (noncompetitive), light handiwork.

D. Sitting in a chair near the bed with water and supplies on the bedside table. Stage 2 activity restrictions allow patients to sit up as tolerated. Slow walking is allowed for brief periods but standing is not allowed until stage 3. Based on this, the patient would be allowed to transfer to a chair near the bed and complete his hygiene routine with all supplies set up for him on the bedside table.

A. No isometrics.
MET levels are used to ensure that the activities do not exceed the patient’s activity tolerance. At stage 2, a MET level of 1.4 to 2.0 MET is permitted.
Exercise:
Sitting: active exercise to all extremities, progressively increasing the number of repetitions
NO ISOMETRICS

A. 1.5 – 2.0 METS. MET levels are used to ensure that the activities do not exceed the patient’s activity tolerance. At this MET level, slow walking is allowed. The patient may also exercise all extremities but no isometric or strengthening exercises are allowed.
Stage 2: 1.5 – 2.0 METs.
– The patient may exercise all extremities but NO ISOMETRICS or strengthening exercises are allowed.
– AROM to all extremities, progressively increasing number of repetitions.
– Walking at slow pace in room, as tolerated.

C. Performing light housework in sitting. (2.0 – 3.0 met level, Stage 3). The only task that this patient is permitted to perform falls between 2.0 to 3.0 Met levels. The only task that falls within this range is performing light housework in sitting which expends 2.0 – 3.0 METs and corresponds to Stage 3 – Cardiac Rehabilitation.
At this at this stage, the patient is only able to perform his ADLs while seated. He can only stand up briefly, for short periods.
A. Grooming in sitting (1.4 – 2.0 met level, Stage 2). This is not challenging enough, as the most Mets the patient would expend, would be 2.0 and the target is 2.0-3.0
B. Showering in standing (3.0 – 3.5 met level, Stage 4)
D. Grooming while standing at the sink (3.0 – 3.5 met level, Stage 4)

STAGES OF CARDIAC REHAB & CORRESPONDING MET LEVELS

B. Gripping a pillow.
Symptoms associated with ulnar nerve injury include:
• loss of sensation, especially in the ring and little fingers
• loss of coordination in the fingers
• pain
• tingling or burning in the hand
• hand weakness
• weakness that worsens with physical activity
• loss of grip strength
The ulnar side of the hand plays an important role in hand strength