Module Three

A. 4-6 weeks.
One passive shoulder exercise often prescribed during shoulder rehabilitation is called the pendulum or Codman exercise. It’s used to facilitate passive range of motion of the joint, and doesn’t require a muscle contraction.

REHABILITATION GUIDELINES FOR PROXIMAL HUMERUS FRACTURE – ORIF
PHASE I (1-3 WEEKS) DATES:
Rehabilitation Goals
• Protect repair
• Minimize pain and swelling
• Maintain ROM of surrounding joints
• Prevent adhesive capsulitis
• Minimize cardiovascular deconditioning
Precautions
• Sling at all times or per MD
• No AROM, lifting, pushing, pulling x 6 weeks
• No ER > 40 degrees or excessive shoulder EXT x 6 weeks
• No supporting of body weight
Suggested Therapeutic Exercises
• PROM of shoulder:
– Flexion to 90 degrees
– ER to 30 degrees
– IR to tolerance (no behind back)
• Scapular clocks:
– Elevation, depression, retraction, protraction
• Pendulums (Codman’s)
• Cervical, hand, wrist, elbow AROM – thumb to shoulder, make fist
Progression Criteria
• Per X-ray evidence of healing
• PROM flexion to 90 degrees, ER to 30 degrees

PHASE II (WEEKS 3-6) DATES:
Rehabilitation Goals
• Regain PROM
• Gentle functional use
• No resistance
Precautions
• Sling and ROM limitations per MD
• No IR/ER
• No driving
• No pushing, pulling, lifting
• No cuff strengthening
Suggested Therapeutic Exercises
• PROM in scapular plane (no hand behind back IR)
• AAROM:
– flexion to 90 degrees
– ER to 40 degrees
• Pulleys
• AROM of elbow, wrist and hand
• Continue scapular isometrics and clocks
• UBE no resistance
Progression Criteria
• Per X-ray evidence of healing
• AAROM flexion to 90 degrees, ER to 40 degrees

PHASE III (WEEKS 6-12)
Rehabilitation Goals
• Regain full PROM
Precautions
• Sling use per MD based on x-ray evidence of healing
• May begin driving
• 20 # weight limit
• No pushing or pulling
• No overhead activity
Suggested Therapeutic Exercises
• Continue PROM/AAROM/AROM cervical, shoulder, elbow, wrist and hand
• General UE strengthening at 10 weeks
Progression Criteria
• Advance to work/sport specific conditioning once AROM is = bilateral and strength is 4+/5 in all directions

PHASE IV (WEEKS 12 +)
Rehabilitation Goals
• Full ROM in all planes
• Transition to HEP
Precautions
• Per MD but generally no lifting, pushing or pulling precautions at this point
• No overhead lifting until 4-6 months post op
Suggested Therapeutic Exercises
• AROM of cervical shoulder, elbow, wrist and hand emphasizing end ROM
• GH and scapular joint mobilizations as needed
• General UE strengthening

https://www.mammothortho.com/pdf/proximal-humerus-fracture-orif-crall.pdf

A. Collecting glass bottles, pulling the caps off, rinsing them with water, and then placing them in a carton.
With these activities, the patient is using the functional use of wrist extension, wrist ulnar deviation, thumb CMC opposition, and flexion of the MCP, PIP, and DIP joints. All these hand wrist and finger movements are required to grasp a steering wheel.

B. Works on lateral pinch and wrist extension with no emphasis on cylindrical grasp.
C. Works on isolated finger movements but does not address grasping.
D. Works on lateral pinch, DIP and PIP flexion as well as thumb opposition but does not rely on cylindrical grasp.

Keogh, J., Sain, S.; and Roller, C. (2012). Kinesiology for the Occupational Therapy Assistant: Essential Components of Function and Movement. Thorofare, NJ: SLACK Incorporated, p 258.

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 therapist can positively influence the patient’s compliance and motivation and determine the readiness of family members for 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.

D. Enhances muscle relaxation and flexibility.
The various PAMs can help decrease muscle tone and spasticity and improve circulation prior to active movement in patients with multiple sclerosis. Whirlpool therapy consists of three main healing properties: heat, buoyancy, and massage. Overall, hydrotherapy studies have shown that the health benefits of immersion in warm water with massage jet action include the relaxation of muscles and loosening of joints. The muscle relaxing and joint loosening benefits of whirlpools help patients with MS who suffer from spasticity from muscle spasms and chronic achiness in their joints.
 

A. Cone splint. A cone splint is best for inhibiting tone. Rood first promoted the inhibition of flexor spasticity by using a firm cone to provide constant pressure over the palmar surface. The device should provide skin contact over the entire palmar surface for maximal effect but should not apply stretch to the wrist and finger flexor muscles. The hard cone has an inhibitory effect on flexor muscles because this device places deep tendon pressure on the wrist and finger-flexor insertions at the base of the palm. The total contact from the hard cone provides maintained pressure over the flexor surface of the palm, thus assisting in the desensitization of hypersensitive skin.

https://musculoskeletalkey.com/antispasticity-splinting/

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. Safe position.
The overall safe position of immobilization for the hand is called the intrinsic plus or clam digger position. In the intrinsic plus position, the MCP joints are positioned in flexion and the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints of the fingers are positioned in extension.

D. Active extension of digit with passive flexion using rubber band traction.
Kleinert protocol: Active extension of digit with passive flexion using rubber band traction.

A. To facilitate tissue extensibility for increasing elbow extension.
Heat increases muscle extensibility, especially helpful when a patient is experiencing restriction in range of movement. This type of physical agent modality also serves as an adjunctive method in preparation for purposeful, functional activity.
https://www.webmd.com/fitness-exercise/understanding-sprains-strains#1, http://www.fixhands.com/how-to-refer/splintorthotics/, https://livehealthy.chron.com/kinds-long-arm-splints-1112.html

B. Passive flexion and extension of the digits.
Duran protocol: Passive flexion and extension of digit

D. Medial epicondylitis brace.
Golfer’s elbow is medial epicondylitis which refers to the chronic tendinosis of the wrist flexors and pronators that attach to the medial epicondyle. Medial epicondylitis occurs most commonly through repetitive pronation of the forearm or flexion of the wrist. The patient usually complains about pain of the elbow distal to the medial epicondyle of the humerus with radiation up and down the arm, most common on the ulnar side of the forearm, the wrist and occasionally in the fingers. Local tenderness over the medial epicondyle and the conjoined tendon of the flexor group, without evidence of swelling or erythema, are also characteristics that can occur. Other symptoms are stiffness of the elbow, weakness in the hand and the wrist and a numb or tingling feeling in the fingers (mostly ring and little finger). The pain is evoked by resisted flexion of the wrist and by pronation. The pain is usually accompanied by a weakness of hand grip. Pain can begin suddenly or can develop gradually over time. The main goal of the conservative treatment is to relieve pain, reduce inflammation and promote healing. The counterforce brace consists of a tight strap which is placed approximately 4 cm distal to the elbow flexion crease and then tightened for comfort. Counterforce braces help reduce tension on the painful tendons.

https://www.physio-pedia.com/Medial_Epicondyle_Tendinopathy

B. Movements that place the MCP joints in radial deviation.
A characteristic sign of rheumatoid arthritis is ulnar drift which affects the MCP joints of the hands. The ligaments supporting the joints are either destroyed or weakened. Therefore, when turning knobs, the joints should be moving in the direction away from the ulnar side of the hands as the gripping forces will pull the joints toward the 5th digit.
,em>Joint protection
• Respect the pain – Use it as a sign to change the activity
• Distribute the load on more than one joint
• Reduce the strength and the effort required to perform some activity, changing the way to perform it, using assistive devices or reducing the weight of utensils
• Use each joint in its most stable and functional anatomical plane
• Avoid positions or forces in directions that favor deformities
• Always use the stronger and larger joint to work
• Avoid staying in the same position for a prolonged time
• Avoid holding objects with excessive force
• Avoid awkward postures and inappropriate ways to pick up and handle objects
• Maintain muscle strength and range of motion

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 splint will reduce the manual effort required to access the patient’s palm and therefore maintaining adequate hand hygiene will be achievable. By maintaining what passive ROM the patient does have, the splint provides comfort with gentle, soft-tissue stretch, thus reducing contractures. The nursing staff will therefore require less effort to manage the patient’s hand during bathing and hygiene if the ROM is maintained. The soft material of rolled-up washcloths increases finger flexion, and it does not provide sufficient resistance, making it more difficult to manage hygiene.
A. Although increased sensory feedback is beneficial, the value and purpose of the prescribed splint will increase the likelihood of staff buy-in.
B. It is unlikely that the staff will need to provide any support for self-feeding as the patient has use of her dominant hand.
C. Demonstrated outcomes will support the staff’s active engagement in splint management but their understanding of how the splint will assist them in managing the patient’s hand during bathing and hygiene is the MOST IMPORTANT aspect to discuss.

Coppard, Brenda M.Lohman, Helene. (2008) Introduction to Splinting: A clinical reasoning and problem-solving approach (2nd Edition). St. Louis : Mosby, pp 327-329.
French-Bravo, M., Crow, G., (March 19, 2015) “Shared Governance: The Role of Buy-In In Bringing About Change” OJIN: The Online Journal of Issues in Nursing Vol. 20 No. 2.

D. “I still get so tired when I walk up the stairs, wash myself and cook for my family.”
S: Subjective. What is the patient reporting?
The MOST appropriate statement as reported by the patient will be the statement that relates to her diagnosis and levels of fatigue & energy conservation. Waking up in the morning and attempting to do all those activities will cause the patient to become short of breath and tired. Keeping a stool next to her to sit down when she fatigues is a strategy related to her COPD.

B. Attach wide-based stretchy Velcro straps with D-rings. This strapping method ensures a secure fit, reduces constriction for one with poor circulation, and is compatible for a patient with decreased hand function..

A. Would be appropriate for a patient who has short-term memory deficits for sequencing donning and doffing the splint.
C. This patient needs a wider strap to compensate for his poor hand function. The additional bandage would promote constriction and is contraindicated for a patient with poor circulation.
D. Pulling straps with a D-ring component allows for less fine-motor manipulation than a neoprene splint, and a customized splint may be necessary for supporting unstable joints secondary to rheumatoid arthritis.

Early, Mary Beth. (2013) Physical dysfunction practice skills for the occupational therapy assistant (3rd Edition). St. Louis, Mo.: Elsevier/Mosby, pp 399-400.

C. Immediately have the patient discontinue use of the orthotic as he may be having an allergic reaction to the neoprene adhesive compounds.
There is a possibility that the patient may have be having allergic reaction to the compounds that make up the neoprene material. The initial hypersensitivity stage is displayed as a localized response which may not manifest itself immediately and is indicated by no apparent reaction. When the patient removed it and wore it again the day after, the body’s immune system recognized the allergen and triggered allergic symptoms. Re-exposure intensifies the reaction. At this time, it would be best to remove the splint and seek medical treatment, before returning to the Hand Therapist for an alternative splint.
Callinan, Nancy, et al. “Neoprene Splinting: Dermalogical Issues”. American Journal of Occupational Therapy, July/August 1998, Vol. 62, 573-575.

C. Verify correct placement of the goniometer.
A goniometer is an instrument that either measures an angle or allows an object to be rotated to a precise angular position. If the OT is getting 3 different measurements, then they need to check where they are placing the goniometer.

A. Changes in skin temperature, skin color, or swelling of the affected limb. The injured arm or leg may feel warmer or cooler than the opposite limb. Skin on the affected limb may change color, becoming blotchy, blue, purple, gray, pale, or red. These skin symptoms typically fluctuate as they indicate abnormal blood flow in the area. Opening and closing the small blood vessels under the skin is controlled by the C-nerve fibers that are injured in CRPS.
Complex regional pain syndrome (CRPS) is a broad term describing excess and prolonged pain and inflammation that follows an injury to an arm or leg. CRPS has acute (recent, short-term) and chronic (lasting greater than six months) forms. CRPS used to be known as reflex sympathetic dystrophy (RSD) and causalgia. Patients with CRPS have changing combinations of spontaneous pain or excess pain that is much greater than normal following something as mild as a touch. Other symptoms include changes in skin color, temperature, and/or swelling on the arm or leg below the site of injury. Although CRPS improves over time, eventually going away in most people, the rare severe or prolonged cases are profoundly disabling.
Other symptoms may include:
A. Stiffness in affected joints. This common problem is that reduced movement leads to reduced flexibility of tendons and ligaments. Tight ligaments or tendons sometimes rub or pinch nerves to provide an internal cause of CRPS in people who do not have external injuries.
B. Excess or prolonged pain after use or contact. There is often increased sensitivity in the affected area, known as allodynia, in which light touch, normal physical contact, and use is felt by the person to be very painful. Some notice severe or prolonged pain after a mildly painful stimulus such as a pin prick, known as hyperalgesia.
C. Impaired muscle strength and movement. Most people with CRPS do not have direct injury to the nerve fibers that control the muscles coordinating muscle movement. However, most report reduced ability to move the affected body part. This is usually due to pain and abnormalities in the sensory input that helps coordinate movements.

B. The proximal interphalangeal joint of his ring finger.
Dupuytren’s contracture is an abnormal thickening of the tissue just beneath the skin. This thickening occurs in the palm and can extend into the fingers. Firm pits, bumps and cords (thick lines) can develop and cause the fingers to bend into the palm. Dupuytren’s contracture is a flexion contracture of the proximal interphalangeal joint. The 4th and 5th digits are usually affected. The thumb and index finger are always spared. The lumps can be uncomfortable in some people, but Dupuytren’s contracture is not typically painful. The contracture makes it difficult to position the finger and release the finger in a timely manner during chord progression on the neck of the guitar because of the snapping effect the finger produces when moved in extension.

A. The proximal interphalangeal joint is affected, not the distal.
C and D. The thumb and web space are not affected.

Walthall J, Rehman UH. Dupuytren’s Contracture. [Updated 2019 Feb 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526074/
https://orthoinfo.aaos.org/en/diseases–conditions/dupuytrens-disease/
http://www.assh.org/handcare/hand-arm-conditions/dupuytrens-contracture

A. Thumb spica splinting, edema control, isometric abduction of the thenar eminence, grasp of small tools, and manipulation of nuts and bolts.
The best client-centered intervention is guided by the patient’s perspective and values, meets their needs, and recognizes their experience and knowledge.

B. This protocol prevents or reduces clawing and focuses on finger extension but does not relate to engagement in work-related activities.
C. Works on mobilizing the wrist which is not the focus of this protocol and the activities do not relate to carpentry work.
D. Does not work on thumb opposition, stretching of the web space, nor do the activities relate to carpentry-related work

B. CMC short opponens orthosis.
The CMC joint of the thumb is also known as the first CMC joint.
The CMC short opponens orthosis maintains approximation of the CMC joint. Unlike other orthoses, this splint does not need to cross the joint to be effective. With simple radial support to the proximal metacarpal head the joint is approximated as the ulnar strap helps maintain contact and stability. The splint also maintains the web space in a functional position with abduction and slight opposition.

A. Shoulder abduction.
Testing Myotomes: SCI vs Brachial Plexus Injury
• With a SCI, the loss of motor and/or sensory function is due to damage to neural elements within the spinal canal.
• With a brachial plexus lesion/injury it is the peripheral nerves outside the spinal cord that are being affected.
When testing for a brachial plexus lesion, you want to test movement(s) which have the strongest association with each myotome.
Most muscles in the limbs receive innervation from more than one spinal nerve root and are hence comprised of multiple myotomes.
The primary muscles involved in the action of arm abduction include the supraspinatus, deltoid, trapezius, and serratus anterior:
• Serratus Anterior, Deltoid- innervated by C5.
• Cranial nerve XI innervates the motor function of the trapezius.
• The supraspinatus muscle is supplied by the suprascapular nerve (C5 and C6)
Technique for assessing C5 myotome with BPL.
C5- Shoulder abduction. Ask the patient to raise both their arms to the side of them simultaneously as strongly as then can while the examiner provides resistance to this movement. Compare the strength of each arm.

The brachial plexus is formed by the anterior primary rami of C5 through T1 and provides sensory and motor innervation of the upper extremity. The brachial plexus is divided, proximally to distally into rami/roots, trunks, divisions, cords, and terminal branches. Most muscles in the upper and lower limbs receive innervation from more than one spinal nerve root. Muscular innervation of the C5 spinal nerve includes arm abduction and external rotation. These 2 arm movements are very important for upper extremity function and are classically lost with upper brachial plexus injuries, including neonatal palsy (i.e., Erb’s palsy). The terminal branches mediating these movements include the axillary nerve to the deltoid muscle, and the suprascapular nerve to the supra- and infraspinatus muscles. A composite movement involving all 3 of these muscles, and therefore predominantly mediated by the C5 nerve root, is abduction of the arm. When assessing a myotome’s functioning, using a single movement, it is important to know which movement is MOST strongly associated with that myotome.
Movements most strongly associated with each myotome for BPI:
C5 – Shoulder abduction
C6 – Elbow flexion Wrist extension
C7 – Elbow extension
C8 – Finger flexion
T1 – Finger abduction
L2 – Hip flexion
L3 – Knee extension
L4 – Ankle dorsiflexion
L5 – Great toe extension
S1 – Ankle plantarflexion

https://www.kenhub.com/en/library/anatomy/myotomes

C. Index finger length, the height and position of the hump of the mouse, and hand size.
The index finger length determines optimal reach of the mouse clicker. The length of the index finger is typically considered to be the prime anthropometric measurement related to computer task performance when wearing a splint. A mouse that promotes less pronation posture while holding it lowers the risk of repetitive motion injuries. Therefore, a rear-hump mouse would be the best design. A rear-hump mouse also preserves cutaneous feedback.
A. Thumb opposition is not relevant when considering preservation of cutaneous feedback.
B.The length of the index finger and not the middle finger is typically considered to be the key measurement related to using a mouse when wearing a splint.
D. This is a compensatory strategy. As the entire lab uses desktop computers, the environmental modification would not be reasonable or practical for the school to pursue.

Chien-Hsiou, Liu; Shih-Chen Fan. “Ergonomic Design of a Computer Mouse for Clients with Wrist Splints”. American Journal of Occupational Therapy, May/June 2014, Vol. 68, 317-324. doi:10.5014/ajot.2014.009928

C. After washing the dishes, suggest he uses a dish rack to allow the dishes to drip dry.
Letting dishes drip dry and soaking them before washing them to eliminate the need to scrub them are examples of energy conservation techniques.

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/

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. 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. Brushing the fur of a large therapy dog (Greyhound) in the rehabilitation gym while seated.
Grade 3+ (Fair plus) – complete ROM against gravity and slight resistance.The goal of a task-oriented approach is to improve motor function by performing a task in an environment that utilizes common everyday objects and tools, provides opportunities to practice functional tasks, and uses the principles of training or retraining skills. Brushing the hair of the Greyhound requires full active elbow and shoulder ROM against gravity, as the patient is sitting and the dog is a large breed. Brushing the fur offers slight resistance as this breed has short hair. The task incorporates retraining motor performance with repetitive action.

A. Demands working memory with little challenge for motor performance for the upper extremity in this case. Moving the mouse is a gravity eliminated task.
C. It requires the person to lift, hold and carry a load which is more than slight resistance. Transferring a hot liquid is dangerous.
D. Does not offer any resistance to movement as the seeds are very light

Katharine Preissner; Use of the Occupational Therapy Task-Oriented Approach to Optimize the Motor Performance of a Client With Cognitive Limitations. Am J Occup Ther 2010;64(5):727-734. doi: 10.5014/ajot.2010.08026.
Israely, S., Leisman, G., & Carmeli, E. (2017). Improvement in arm and hand function after a stroke with task-oriented training. BMJ case reports, 2017, bcr2017219250. doi:10.1136/bcr-2017-219250

D. Coach on compensatory methods.In this scenario, the patient has developed restricted joint movement due to the normal aging process and the goal should therefore, be to teach the patient compensatory methods.
No matter how healthy an individual is, as they age their joints will show some changes in mobility, due in part to changes in the connective tissues. As joint range of movement has a direct effect on movement, this can result in marked alteration of function. With ageing, joint movements becomes stiffer and less flexible because the amount of synovial fluid inside the synovial joints decreases and the cartilage becomes thinner. Ligaments also tend to shorten and lose some flexibility, making joints feel stiff.

C. Hanging his clothes in the closet.
In order to hang clothes in the closet, Jeff would be required to flex and abduct his shoulder beyond 120º.

A, B and D. These actions require movements that are within the patient’s functional capabilities.

Early, Mary Beth. (2013) Physical dysfunction practice skills for the occupational therapy assistant (3rd Edition). St. Louis, Mo.: Elsevier/Mosby, pp 562-564.

A. Positive Finkelstein.
Chronic overuse of the wrist is commonly associated with de Quervain’s tenosynovitis. Although the exact cause of de Quervain’s tenosynovitis isn’t known, any activity that relies on repetitive hand or wrist movement, such as working in the garden, playing golf or racket sports, or lifting your baby, can make it worse.
Finkelstein’s test is the classic provocative test for diagnosis of De Quervain’s syndrome and is used in the diagnosis of De Quervain’s syndrome. The patient actively (or active assistive) flexes their thumb maximally and wraps their fingers over the thumb, making a fist. The patient then ulnarly deviates his/her wrist to stretch the muscles of the 1st extensor compartment. The test is positive if the patient complains of pain over the 1st extensor compartment of the wrist.
Positive result: Ask the patient if he or she feels pain radiating up the inside of his or her arm from the thumb. If the patient reports noticeable pain then, the Finkelstein’s test is positive, what indicates De Quervain’s syndrome.

Symptoms of de Quervain’s tenosynovitis include:
– Pain near the base of your thumb
– Swelling near the base of your thumb
– Difficulty moving your thumb and wrist when you’re doing something that involves grasping or pinching
– A “sticking” or “stop-and-go” sensation in your thumb when moving it
– If the condition goes too long without treatment, the pain may spread further into your thumb, back into your forearm or both. – Pinching, grasping and other movements of your thumb and wrist aggravate the pain.

C. Install levered handles and a water temperature control device to prevent scalding in order to maintain constant water temperature.

Levered handles are easier to use, especially for individuals with RA, and a water temperature control device is essential to prevent and further injuries from hot water.
Rheumatoid arthritis is an autoimmune disorder that is characterized by inflammation, pain, and loss of function in the joints. It most often affects the wrist and hand, but it sometimes affects the elbows, shoulders, neck, knees, hips or ankles. Rheumatoid vasculitis is a condition which is associated with rheumatoid arthritis in which blood vessels become inflamed. Vasculitis is a serious complication of rheumatoid arthritis. Vasculitis that injures the nerves can cause loss of sensation, numbness and tingling, or potentially weakness or loss of function of the hands and/or feet.

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.

C. Volumeter.
A volumeter uses water displacement to measure edema in an extremity. To measure, the volumeter is filled up to a predetermined level and the patient immerses the affected extremity to the level directed by the OT practitioner. The amount of water displaced is recorded. The process is repeated as the patient’s edema decreases to record progress. Volumeter measurement is more objective than measuring edema with a tape measure because the procedures for volumeter measurement are more standardized and there is less chance for error than tape measurements.

B. A volar wrist immobilization splint with forearm trough and an MP and hypothenar bar with the wrist positioned in neutral. A wrist sprain is caused by a tear in a ligament which requires the wrist to remain in a static position for healing. It is important to avoid extreme wrist extension or flexion as it will interfere with the normal functional position of the hand. This splint will enhance digital function and minimize tension on involved structures while the hand rests and heals.

A. This is more appropriate for a peripheral radial nerve lesion to facilitate mobilization of wrist extension in 30 degrees and MCPs in dynamic extension.
C. Although a wrist cock-up splint provides the greatest functional wrist position, it is more appropriate to maximize passive extension which the patient can tolerate in conditions such as wrist fractures, radial nerve palsy, tendinitis, median nerve compression and CRPS. However, in acute stage where pain and inflammation is present, a neutral position is advised.
D. This is more appropriate for a median peripheral nerve lesion.

Coppard, Brenda M.Lohman, Helene. (2008) Introduction to Splinting: A clinical reasoning and problem-solving approach (2nd Edition). St. Louis : Mosby, pp 145-188.

A. Make the splint as lightweight as possible.
There are some special considerations for splinting in patients with RA. A splint should be as lightweight as possible because the added weight of a splint puts additional stress on the upper extremity and may exacerbate pain and fatigue.

B. Thermoplastic splinting material comes in varying levels of perforation (holes). Highly perforated materials allow for greater ventilation and are more lightweight.
C. Thicker materials are more rigid and firm, and therefore heavier.
D. Thermoplastic splinting material is lighter than traditional plaster casting.

Pedretti’s Occupational Therapy – E-Book (Occupational Therapy Skills for Physical Dysfunction (Pedretti)) (p. 1023). Elsevier Health Sciences. Kindle Edition.

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).

B. Acknowledge her concerns and redirect her 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 which is related to her anxiety is occurring at this time and should be addressed straight away.
C. The focus of action should be on gradual redirection, not encouraging discussion regarding physical symptoms.

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

D. Instruct the patient to inhale deeply through their nose and to slowly exhale through pursed lips.
Pursed-lip breathing (PLB) is thought to prevent tightness in the airway by providing resistance to expiration. This technique has been shown to increase use of the diaphragm and decrease accessory muscle recruitment.
1. Purse the lips as if to whistle.
2. Slowly exhale through pursed lips. Some resistance should be felt.
3. Inhale deeply through the nose.
4. It should take twice as long to exhale as it does to inhale.

A. Patients in respiratory distress typically need to sit up or lean over by resting their arms on their legs to enhance lung expansion. Patients who have dyspnea will not tolerate lying flat in bed.
B. An order to use oxygen therapy or to increase the oxygen dose during exertion should only be requested by the physician.

C. Types of activities used to reduce stress. Controllable risk factors include lifestyle influences such as foods, exercise, stress level and methods used to control stress. Medications and prior medical history are non-controllable risk factors. Since this patient’s primary problem appears to be stress, it would be most important to find out what the patient already does to control stress, if anything. Although types of exercises could be relevant in reducing stress, it is not immediately assumed in this case and thus is not the best answer.

D. To prevent the trolley from rolling forward, push it against a wall. Remain standing, lean forward from your hips and rest your forearms on the supermarket trolley.
Dyspnea Control Postures:
Adopting certain postures can reduce breathlessness. In a seated position, the patient bends forward slightly at the waist while supporting the upper part of the body by leaning the forearms on a table or the thighs. In a standing position, relief may be obtained by leaning forward and propping oneself on a counter or shopping cart.

Pedretti’s Occupational Therapy – E-Book (Occupational Therapy Skills for Physical Dysfunction (Pedretti)) (p. 1207).

A, B and D are the best techniques.

A. Pursed lip breathing decreases hyperinflation of the lungs which enables the patient to breathe in more oxygen and reduces dyspnea on exertion.

B. Positioning techniques such as leaning slightly forwards, elevating the head of the bed, and sleeping propped up on pillows reduces dyspnea with rest.

D. Diaphragmatic breathing incorporates inhaling with pushing or contracting the abdomen while keeping the shoulders relaxed.

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

C. Start with the fingers straight, keep the PIP joints straight while flexing the MCP joints, then flex the PIP joints. This exercise is an example of a tendon gliding exercise. It is designed to keep the tendons from adhering to the scar tissue that forms around the laceration site, ensuring that the tendons glide smoothly during motion and maintaining Andy’s ability to move his fingers.

A. No active range of motion.
Trace contraction can be observed or felt, but there is no motion. Trace is defined as a visible or palpable contraction. This contraction is not strong enough to move a limb, therefore no AROM is present.

C. When the patient is able to tolerate an activity level of 3.5 MET.
Phase 2 for cardiac patients is in outpatient rehab and begins 12 weeks post cardiac event. This phase begins when a patient is able to tolerate an activity level at 3.5 MET. It is completed through outpatient rehabilitation and can last up to 12 to 18 weeks after the patient’s initial cardiac event.

A. Assess the individual’s lifestyle and dietary habits
Controllable risk factors of heart disease include smoking, high lipids, high cholesterol, hypertension, obesity, diabetes, mental stress, and lack of exercise.

D. Normal range is 70-90 degrees, and his ROM is slightly below the limits but expected for his age and remains a functional movement.
This question is specifically asking about interpreting the results of the goniometer measurement. As the reading is within the functional range for the patient’s age, further investigation needs to be done as to why the patient is having difficulty retrieving his wallet from the back pocket of his jeans. Further assessments could include: Assessing muscle strength, looking at the quality of the movement to see if the patient is using any compensatory movements, knowing if the patient experiences pain when performing this movement, knowing if there are any underlying arthritic factors.
Internal rotation of shoulder:
Normal ROM: 70-90 degrees
Testing position: Patient supine with the shoulder abducted to 90 degrees and the forearm is in neutral position
Axis: Olecranon process of the ulna
Fixed Arm: Perpendicular to the floor (vertical)
Movable Arm: Along shaft of ulna

No matter how healthy an individual is, as they age their joints will show some changes in mobility, due in part to changes in the connective tissues. As joint range of movement has a direct effect on posture and movement, this can result in marked alteration of function. Joint range of movement (ROM) decreases with increasing age; passive and active ROM both decrease, but often within a single joint the active ROM reduces more than the passive ROM.

https://www.healthline.com/health/shoulder-range-of-motion#3
https://www.physio-pedia.com/Effects_of_Aging_on_Joints

A. PIP joint appears flexed and the DIP joint appears hyperextended.
A Boutonniere deformity describes a medical condition in which the finger is flexed at the proximal interphalangeal joint (PIP) and hyperextended at the distal interphalangeal joint (DIP). This is usually a result of trauma and is caused by a rupture of the PIP central slip. This results in damage to the extensor function of the affected digit.

A. Complex regional pain syndrome.
Complex regional pain syndrome (CRPS) is a form of chronic pain that usually affects an arm or a leg. CRPS typically develops after an injury, fracture or surgery. The most common and prominent symptom of CRPS is the pain that affected individuals will feel. The pain is often deep inside the limbs with a burning, stinging, or tearing sensation. Sensory changes are also common, and may include increased sensitivity to painful stimuli, feeling pain from stimuli that are usually non-painful, and in some instances, sensory loss (e.g., numbness). In addition to pain, patients commonly experience an affected extremity that is warm, red, and swollen, at least initially. In many patients, as CRPS continues, the affected extremity may more often feel cool with dark or bluish skin. Swelling, resulting from fluid build-up in the limb (edema), can be present regardless of the color and temperature of the skin, but is typically more prominent with the early clinical picture (red and warm skin). Skin color and temperature may sometimes change even over short periods of time inconsistently. In addition to the changes above, CRPS patients may experience skin that becomes thin and shiny, and may experience either increased or decreased hair and nail growth in the affected extremity. Most patients will experience motor impairment, which is the decrease in the ability to use the limbs for movement, with weakness or limited range of motion being the most common impairments. Some patients may develop spasms or even uncontrollable muscle contractions (dystonia).

https://rarediseases.org/rare-diseases/reflex-sympathetic-dystrophy-syndrome/

C. Active stretching.
Rheumatoid arthritis is a chronic disease characterized by periods of disease flares and remissions.
Rest and energy conservation can be helpful for locally inflamed joints but should be avoided long-term due to the potential side effects. A structured exercise program can be greatly beneficial to the overall well-being and functioning of the individual with rheumatoid arthritis. Such a program should focus on stretching, strengthening and aerobic conditioning while conserving energy. Acutely, inflamed joints should be rested to prevent exacerbation of symptoms. 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 most activities of daily living.

https://www.hopkinsarthritis.org/patient-corner/disease-management/rehabilitation-management-rheumatoid-arthritis-patients/

C. Pain.
Complex regional pain syndrome (CRPS) is a chronic (lasting greater than six months) pain condition that most often affects one limb (arm, leg, hand, or foot) usually after an injury. CRPS is believed to be caused by damage to, or malfunction of, the peripheral and central nervous systems. The central nervous system is composed of the brain and spinal cord; the peripheral nervous system involves nerve signaling from the brain and spinal cord to the rest of the body. CRPS is characterized by prolonged or excessive pain and changes in skin color, temperature, and/or swelling in the affected area. As the key symptom is prolonged severe pain that may be constant, it is important to address pain and pain management first with the patient.
https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Complex-Regional-Pain-Syndrome-Fact-Sheet

C. Using a Volumeter
Cancer and its treatment are risk factors for lymphedema.
Lymphedema can occur after any cancer or treatment that affects the flow of lymph through the lymph nodes, such as removal of lymph nodes. It may develop within days or many years after treatment. Most lymphedema develops within three years of surgery.
The accurate evaluation of upper limb volume is crucial for an early diagnosis of lymphedema and also for monitoring treatment. Water displacement methods are commonly used to measure upper limb swelling and is considered the gold standard for evaluating limb lymphedema.

https://www.liebertpub.com/doi/full/10.1089/lrb.2018.0040

B. Isometric.
During isometric exercises, the muscle doesn’t noticeably change length and the affected joint doesn’t move.
Isometric contractions are contractions that generate force without altering the length of the muscle. These muscles are common in body parts that are responsible for grips, such as your hands and forearms. These muscles are also prominent in maintaining posture. You experience isometric contractions when you are trying to lift items that are too heavy for you, leading to the object not being lifted. In this case, the maximum force a muscle can generate has been reached. In contrast, isotonic contractions do involve shortening. Force is generated by isotonic contractions by the change of length of muscles. These isotonic contractions can either be eccentric (the muscle lengthens) or concentric (the muscle shortens). With isotonic contractions, you are able to lift the object that you are attempting to lift, unlike isometric contractions.

1. Isometric: A muscular contraction in which the length of the muscle does not change.
2. Isotonic: A muscular contraction in which the length of the muscle changes.
• Eccentric: An isotonic contraction where the muscle lengthens.
• Concentric: An isotonic contraction where the muscle shortens.

D. Active exercise to all extremities in supine.
Stage. Exercise 1-1.4 MET
Supine: Active exercise to all extremities (10-15 x/extremity)
Sitting: AROM to only neck and LE

A. Active exercise to all extremities in sitting position.
This is relevant for stage 2 (1.4 – 2.0 MET)
In sitting – May exercise all extremities but NO ISOMETRICS or strengthening exercises are allowed. AROM to all extremities, progressively increasing number of repetitions.
B. Active exercise to all extremities in standing position.
At stage 3 ( 2.0 – 3.0 MET) – Standing: AROM exercises to all extremities, progressively increasing number of reps.
C. Balance and mat activities with mild resistance.
At stage 3 ( 2.0 – 3.0 MET) – May include: balance exercises, light mat work with no resistance

B. Knitting.
Stage 2 (1.4 – 2.0 MET)
For Recreational activities, patient permitted to:
In sitting: crafts (painting, knitting, sewing, mosaics, embroidery)
NO ISOMETRICS

A. Golf – Leisure activity appropriate at stage 4 (3.0 – 3.5 MET)
C. Driving – Leisure activity appropriate at stage 4 (3.0 – 3.5 MET)
D. Dancing – Slow dancing appropriate at stage 6 (4.0 and above MET)

A. Recommend a shower chair and a terry bath robe.
Showering expends less energy, especially if seated. Bathing is strenuous because the hot, humid air makes breaking difficult.
B. This would be recommended for a patient who is at risk for falling.
C. A reacher is usually recommended for a patient who has limited reach.
D. Proper body mechanics is typically recommended for back injuries.

C. Ulnar nerve palsy.
Positive Froment’s sign: Froment’s sign tests for the action of adductor pollicis, which is weak with ulnar nerve palsy. With ulnar nerve palsy, the patient will experience difficulty maintaining a hold and will compensate by flexing the FPL (flexor pollicis longus) of the thumb to maintain grip pressure, causing a pinching effect.

A. Adduction and internal rotation.
The patient should be able to reach the lower border of the scapula (~ T 7 level). This combination of movement is important for independence in ADL. It allows one to tuck in the back of their shirt, wash their mid-back and fasten/undo a bra strap etc.

B. AROM of uninvolved joints.
Immobilization such as wearing a cast can result in tissue shortening. Stretching the tissue around the immobilized joint helps to maintain ROM which will help the patient regain function. 

C. The restorative approach forms part of the biomechanical frame of reference which places emphasis on restoring previous function via participation in activity. The restorative approach can only be initiated once the cast has been removed.

C. Median.
There are three entrapment syndromes involving the median nerve or its branches:
1. Carpal Tunnel Syndrome
2. Anterior Interosseous Syndrome
3. Pronator Teres Syndrome
Anterior Interosseous Syndrome (AINS) is a pure motor neuropathy, as the anterior interosseous nerve contains no sensory fibers; dull forearm pain is however sometimes mentioned by patients. Typically, patients fail to make an “O.K.”-sign, as flexion of the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger, is impaired. Another sensitive test is the pinch test: a patient with AINS will also not be able to pinch a sheet of paper between his thumb and index finger, instead of clamping the sheet between his extended thumb and index fingers.

A. Ulnar nerve use the “peace sign”.
B. Radial nerve use “thumbs up”/”hitchhiker”.
D. The peroneal nerve is a branch of the sciatic nerve, which supplies movement and sensation to the lower leg, foot and toes.

Module 3. NEUROPATHIES. https://passtheot.com/neuropathies/

A. NMES. NMES is used to contract muscles and also help with pain relief.Neuromuscular Electrical Stimulation or NMES uses a device that sends electrical impulses to nerves. This input causes muscles to contract. The electrical stimulation can increase strength and range of motion and offset the effects of disuse. It is often used to “re-train” or “re-educate” a muscle to function and to build strength.

C. Tap along the medial epicondyle of the humerus.
Cubital tunnel syndrome (CBTS) is a peripheral nerve compression syndrome. It is a progressive entrapment neuropathy of the ulnar nerve at the medial aspect of the elbow (irritation or injury of the ulnar nerve in the cubital tunnel at the elbow). It is also known as ulnar nerve entrapment and is the second most common compression neuropathy in the upper extremity after carpal tunnel syndrome.
Tinel’s Sign is the general term for a test in which the therapist identifies an irritated nerve trough a percussive or tapping technique. At the elbow, Tinel’s sign indicates an irritated Ulnar nerve. The therapist should locate the Ulnar nerve that is seated in the groove between the olecranon process and the medial epicondyle, the Ulnar nerve is then tapped on repeatedly by the index finger of the therapist. A positive sign is indicated by a tingling sensation in the ulnar distribution of the forearm and hand distal to the tapping point.

D. Incorporate gentle range of motion exercises.
The biomechanical approach using range of motion will help loosen the patient’s joints. In the first session the OT can use gentle range of motion exercises to mobilize the patient’s joints.

B. Wipe off the kitchen table with a dishcloth.

If Janet’s right upper extremity strength rates a grade 2 to 2+, she will have difficulty completing any activities against gravity. She will be able to complete tasks with her right UE that have gravity eliminated. Wiping off the kitchen table meets this requirement because Janet can slide her hand and forearm along the table rather than actively lifting it.

A myotome is the group of muscles that a single spinal nerve innervates

C4-shoulder elevation

C5-shoulder abduction

C6-wrist extension/elbow flexion

C7-wrist flexion/elbow extension

C8-thumb extension/finger flexion

T1-finger adduction/abduction

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. Trigger finger. Trigger finger is a condition that causes pain, stiffness, and a sensation of locking or catching when you bend and straighten your finger. The condition is also known as “stenosing tenosynovitis.” The ring finger and thumb are most often affected by trigger finger, but it can occur in the other fingers, as well.

A. Results in ulnar claw deformity and numbness of the ulnar side of the hand and the fifth and half of the fourth digits, with generalized weakness of the ulnar side of the hand and pain.

C. Swan-Neck Deformity is a deformity of the finger, in which the DIP and MCP is in flexion, and PIP is in hyperextension.

D. A Smith’s fracture, also known as a reverse Colles’ fracture or Goyrand-Smith’s, is a fracture of the distal radius. It is caused by a direct blow to the dorsal forearm or falling onto flexed wrists, as opposed to a Colles’ fracture which occurs as a result of falling onto an extended wrist.

D. Bend slightly forward and hook the bra in the front. Bending slightly forward and hooking a bra from the front will conserve the most amount of energy. Hooking a bra from behind requires fine motor coordination and putting on a sports bra requires the patient to put the bra overhead, which requires a large amount of energy.

B. Spherical grasp.
A spherical grasp is one in which the hand curves to hold a round or sphere-shaped object. The intrinsic muscles of the hands play a big part in this grasp. In order for the hand to curve, the metacarpophalangeal joints need to abduct. Involved in this action are the interossei muscles and the hypothenar eminence. The interossei include the palmar interossei and the dorsal interossei. These allow the fingers to abduct and adduct in order to grasp smaller and larger sphere shaped objects. The hypothenar eminence includes three intrinsic muscles that allows the ulnar side of the hand to flex, rotate to oppose the thumb, and create the bulk of the ulnar side of the palm when curving around shapes like spheres.

https://www.theottoolbox.com/cylindrical-and-spherical-grasp-development-korxx-blocks/.

B. MCP Blocking Splint. The picture shows claw hand deformity. A claw hand deformity develops due to injury of the ulnar nerve. The claw hand deformity is more common with a lower ulnar nerve lesion (below the elbow) and typically causes flexion and clawing of the fourth and fifth fingers due to the unopposed action of the medial part (ulnar part) of the flexor digitorum profundus muscle. Clawing is determined when the patient is asked to extend the fingers. A hand in the ulnar claw position will have the fourth and fifth fingers extended at the metacarpophalangeal (MCP) joints and flexed at the interphalangeal (IP) joints. When you ask the patient to extend the fingers, the patient will not be able to extend the interphalangeal (IP) joints at the fourth and fifth fingers. Treatment includes PROM, joint mobilization to reduce contracture, splinting, therapeutic activity, adaptations for grip. The appropriate splint for this condition is a lumbrical blocking splint, also called a MCP blocking splint.

The picture in this question may be confused with the Hand of Benediction sign:
Ulnar claw: 4th and 5th fingers hyperextended at the MCP joints and hyperflexed at the IP joints. Permanent fixed position of the hand at rest
Hand of Benediction: Seen when the patient is asked to make a fist and digits 4 and 5 (ring and little finger) flex but digits 2 and 3 (index and middle fingers) cannot flex at the MCP or IP joints. Active sign- only occurs when attempt made to make a fist (flex the digits). When hand relaxed, the clawed appearance goes away.

B. PIP hyperextension and DIP flexion.
Swan neck deformity: Injury to the MCP, PIP, or DIP joints characterized by PIP hyperextension and DIP flexion.

B. Brachial Plexus Injury.
The brachial plexus is a network of nerves that conducts signals from the spinal cord to the shoulder, arm and hand. These nerves originate in the fifth, sixth, seventh and eighth cervical (C5-C8), and first thoracic (T1) spinal nerves, and innervate the muscles and skin of the chest, shoulder, arm and hand. Brachial plexus injuries, or lesions, are caused by damage to those nerves. Injury can occur as a result of shoulder trauma, tumors, or inflammation. Any motion beyond 90° abduction may induce added stress to the brachial plexus and its roots.

A. This affects the wrist. Limitations would therefore be to wrist movement.
C. This is a form of chronic pain. Active exercise that emphasizes normal use of the affected limb is essential to permanent relief of this condition.
https://orthoinfo.aaos.org/en/diseases–conditions/complex-regional-pain-syndrome-reflex-sympathetic-dystrophy/
D. This may also be correct as an important part of the treatment of this condition would be to try and eliminate the source of the cumulative microtrauma. If the patient’s work involves reaching up to stack shelves , for example, then this movement would be contraindicated while the patient is recovering from his injury. It is unlikely that a repetitive movement which would cause a CTD would only involve one joint / one isolated movement . Therefore a brachial plexus injury is more likely.

A. Dorsal blocking splint. With a flexor tendon injury it is best to provide a patient with a Kleinert or Duran dorsal protection splint. The dorsal blocking splint protects the surgery and guards against flexor tendon rupture.

D. Ulnar Nerve Injury. This results in an ulnar claw deformity and numbness of the ulnar side of the hand and the fifth and half of the fourth digits, with generalized weakness of the ulnar side of the hand and pain. Trouble cutting with small knife. Trouble with power grip and lateral pinch.

A. Skier’s thumb is an acute, partial or complete rupture of the ulnar collateral ligament (UCL) of the thumb’s metacarpophalangeal joint due to a hyperabduction trauma of the thumb. Whilst both terms are often used interchangeably, skier’s thumb refers to the cause being an acute injury. Gamekeeper’s thumb specifically refers to the cause being a chronic injury to the UCL in which it became attenuated through repetitive stress.
B. Swan-Neck Deformity (SND) is a deformity of the finger, in which the distal interphalangeal joint (DIP) and the metacarpal phalangeal (MCP) is in flexion. While the proximal interphalangeal (PIP) is in hyperextension; it is caused by abnormal stress on the volar plate, the ligament around the middle joint of the finger (PIP joint), plus some damage to the attachment of the extensor tendon. The resulting shape looks similar to a swan’s neck, which is how the condition got its name.
C. Radial nerve palsy is characterized by paralysis of all extensors of the wrist and digits, as well as the forearm supinators.

D. Mobility due to needing supplemental oxygen.
Requiring supplemental oxygen is typically associated with lung cancer and not breast cancer.

A. Radical mastectomy involves having the entire breast removed including the axillary lymph nodes, and the pectoral muscles.
The pectoral muscles are primarily responsible for movement of the shoulder joint. i.e. Shoulder adduction, medial rotation, and flexion. Shoulder movements are affected due to movement restrictions imposed by the surgeon post-op and tightness of the muscles due to the surgery. Most ADLs and IADLs require shoulder movement.
B. Edema may result from a number of causes associated with cancer and is often seen in individuals who have breast cancer. When a tumor invades the tissues near a limb or when lymph nodes adjacent to a body part are resected or irradiated, lymphedema may develop. Edema is uncomfortable, and patients who suffer from this condition may complain of soreness or a chronic aching pain in their limbs. The presence of edema may also limit the person’s ability to engage in various occupations or participate in preferred activities. In addition, persons with edema may find it difficult to wear their normal clothing and accessories if use of these items causes circulatory restriction.
C. Having a body part amputated has a significant affect on a person both from a physical and psychological perspective. Losing a breast often makes a woman feel less attractive. Fear of returning to sexual activity is a significant issue post mastectomy because in our culture breasts belong to the attributes of femininity and motherhood. Therefore, negative self-perception of one’s changed body and the fear of rejection by the partner may ultimately result in sexual dysfunction.

D. The patient is able to donn a shirt and pants without becoming fatigued.
When working with a patient who has a goal of energy conservation, the best expected outcome would be completion of the activity without fatigue. In OT, an outcome typically refers to a functional outcome.A.

A. Pursed lipped breathing is a technique typically used for patients with COPD. It is a technique used in energy conservation and not an outcome
B. Diaphragmatic breathing can be used as a technique to help patients in cardiac failure and patients with COPD. It is a technique used in energy conservation and not an outcome
C. Pacing is considered a technique/strategy which can be used to help with fatigue and energy conservation. It is therefore not an outcome.

C. Rolling TheraPutty into a large ball. This will provide the patient with sensation around her entire palm.

D. Mallet finger due to an avulsion of the terminal extensor tendon.
The term mallet finger is used to describe the deformity produced by the disruption of the terminal extensor mechanism at the distal interphalangeal (DIP) joint. It is the most common closed tendon injury seen in athletes, though it is also common in nonathletes after “innocent” trauma. Mallet finger has also been referred to as drop, hammer, or baseball finger.
Splint the patient’s DIP joint in full extension continuously for 6 weeks. The DIP terminal tendon is delicate and requires continuous splinting to prevent extensor lag of the tendon. Old injuries may be splinted continuously for up to 6 months. DIP extension splint.

https://www.medscape.com/answers/1242305-99708/what-is-mallet-finger

C. 4 (Good/G).

A. Sweep the floor for ten minutes at a time. In order to increase endurance, it is best to increase the number of minutes in an activity. Sweeping the floor is an activity that the patient is able to perform without an exacerbation of her symptoms (cubital tunnel syndrome). By increasing the amount of repetitions in the activity, the patient is able to work on her endurance/work tolerance. Other strategies for improving endurance is contraindicated in this scenario, e.g. Introducing resistance.

C. Yoga in a warm to hot room.
Gentle movement and stretching in 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. 

B. Median.
The median nerve innervates the flexors of the forearm and hand and is often called the “eyes” of the hands because of its importance in sensory innervation of the volar surface of the thumb, index, and middle fingers. Median nerve loss may result from lacerations, as well as from compression syndromes of the wrist, such as carpal tunnel syndrome.

A. Document and contact the physician.
It is important to document the situation and notify the physician about the patient’s behavior.

A. Activities of daily living.
To achieve the goals of cardiac rehabilitation a multidisciplinary team approach is required. The main goal of cardiac rehabilitation is to promote secondary prevention and to enhance quality of life among cardiac patients. To promote independence in ADLs for those who are compromised is core to OT intervention.