This week focuses on: Musculoskeletal Conditions & Interventions, Physical agent modalities (PAM’S), Chronic Obstructive Pulmonary Disease (COPD), Chronic Heart Failure (CHF)/Met Levels, and Functional Independence Measure (FIM)
This week focuses on: Musculoskeletal Conditions & Interventions, Physical agent modalities (PAM’S), Chronic Obstructive Pulmonary Disease (COPD), Chronic Heart Failure (CHF)/Met Levels, and Functional Independence Measure (FIM)
Study Materials:To streamline studying, we have highlighted our most recommended material. If you are limited on time, please review this material first.
Online TutoringHands and Upper Extremities Powerpoint with Cory
– Hands and Upper Extremities Powerpoint with Cory, with answers
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Thoracic Outlet Syndrome:view
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An OTR® in a hand therapy clinic receives a referral to evaluate and treat a woman with a diagnosis of right hand carpal tunnel syndrome. The hand surgeon wants to try a conservative approach to managing the woman’s symptoms, as the woman has a history of adverse reactions to anesthesia. During the initial evaluation with the woman, the OTR® finds out that the woman does data entry for a bank. She is married, has two very young children, and lives in a rented townhouse. The woman reports that her symptoms began about one month prior to the evaluation.
Section A: Based on the diagnosis and initial evaluation, what clinical tests should the OTR® complete? Select the best 3 choices.
As the patient has been already been diagnosed with Carpal Tunnel Syndrome by the physician, tests to diagnose the condition, such as the Tinel sign and Phalen’s test are not indicated in this scenario. Numbness, tingling, burning, pain, weakness, a tendency to drop things and poor fine motor co-ordination are common symptoms in cases of carpal tunnel syndrome, so the tests that address these areas should be administered. In particular, the Semmes-Weinstein monofilaments test will be useful as it will help to determine the extent of the woman’s loss of sensation resulting from the nerve compression. Limitations in ROM do not always occur unless the symptoms have been present for a long time, so a functional ROM screening would be more appropriate than detailed goniometer measurements. The woman’s ADLs and IADLs may be compromised, but the woman should be able to accurately report her own ADL status, so a KELS is not necessary.. There is no indication that the woman has cognitive limitations, so an Allen Cognitive Levels test would not be necessary.
As the patient has been already been diagnosed with Carpal Tunnel Syndrome by the physician, tests to diagnose the condition, such as the Tinel sign and Phalen’s test are not indicated in this scenario. Numbness, tingling, burning, pain, weakness, a tendency to drop things and poor fine motor co-ordination are common symptoms in cases of carpal tunnel syndrome, so the tests that address these areas should be administered. In particular, the Semmes-Weinstein monofilaments test will be useful as it will help to determine the extent of the woman’s loss of sensation resulting from the nerve compression. Limitations in ROM do not always occur unless the symptoms have been present for a long time, so a functional ROM screening would be more appropriate than detailed goniometer measurements. The woman’s ADLs and IADLs may be compromised, but the woman should be able to accurately report her own ADL status, so a KELS is not necessary.. There is no indication that the woman has cognitive limitations, so an Allen Cognitive Levels test would not be necessary.
Clinical Simulation, setting 1: An OTR® in a hand therapy clinic receives a referral to evaluate and treat a woman with a diagnosis of right hand carpal tunnel syndrome. The hand surgeon wants to try a conservative approach to managing the woman’s symptoms, as the woman has a history of adverse reactions to anesthesia. During the initial interview with the woman, the OTR® finds out that the woman does data entry for a bank. She is married, has two very young children, and lives in a rented townhouse. The woman reports that her symptoms began about one month prior to the evaluation.
Section B: The woman reports significant pain in her right wrist and hand. What modalities should the OTR® consider when deciding what to use to help reduce pain? Select the best 3 choices.
Iontophoresis and TENS can reduce pain and inflammation in the carpal tunnel area. Iontophoresis will also safely inject medication into the affected area and may be more effective than TENS. Fluidotherapy is a safe heat modality that can be used to improve circulation and address loss of tactile sensation. Contrast baths may provide temporary relief of symptoms but are not as effective as the modalities mentioned previously.. Paraffin bath is not a safe modality to use with carpal tunnel as the patient may not feel when the paraffin is too hot and may be at risk for burns. Even though therapeutic ultrasound is used to relieve the symptoms of carpal tunnel syndrome, there is minimal evidence in the research to support its effectiveness.
Iontophoresis and TENS can reduce pain and inflammation in the carpal tunnel area. Iontophoresis will also safely inject medication into the affected area and may be more effective than TENS. Fluidotherapy is a safe heat modality that can be used to improve circulation and address loss of tactile sensation. Contrast baths may provide temporary relief of symptoms but are not as effective as the modalities mentioned previously.. Paraffin bath is not a safe modality to use with carpal tunnel as the patient may not feel when the paraffin is too hot and may be at risk for burns. Even though therapeutic ultrasound is used to relieve the symptoms of carpal tunnel syndrome, there is minimal evidence in the research to support its effectiveness.
Clinical Simulation, setting 1: An OTR® in a hand therapy clinic receives a referral to evaluate and treat a woman with a diagnosis of right hand carpal tunnel syndrome. The hand surgeon wants to try a conservative approach to managing the woman’s symptoms, as the woman has a history of adverse reactions to anesthesia. During the initial interview with the woman, the OTR® finds out that the woman does data entry for a bank. She is married, has two very young children, and lives in a rented townhouse. The woman reports that her symptoms began about one month prior to the evaluation.
Section C:The physician’s order includes splinting the patient’s right wrist, with no specifications. How should the OTR® proceed with the splinting? Select the best 3 choices.
Rationale: Splints for carpal tunnel syndrome should position the wrist in neutral or slight extension. Splinting is especially important at night as many carpal tunnel patients report increased pain at night. If the woman purchases a wrist support herself, that support may not position her wrist correctly. Issuing a prefabricated wrist brace for daytime use will give the woman a bit of flexibility while working, but will hold the wrist in place. A thermoplastic splint for night use will hold the wrist firmly in position while the woman sleeps. The prescription should be clarified with the physician, especially if third party insurance will be billed for the service, but the OTR® should make the recommendation regarding the type of splints to be prescribed, rather than asking the physician what he wants. Because the physician did not specify the type of splint on the initial order, he is relying on the OTR® to provide the correct type of splint.
Rationale: Splints for carpal tunnel syndrome should position the wrist in neutral or slight extension. Splinting is especially important at night as many carpal tunnel patients report increased pain at night. If the woman purchases a wrist support herself, that support may not position her wrist correctly. Issuing a prefabricated wrist brace for daytime use will give the woman a bit of flexibility while working, but will hold the wrist in place. A thermoplastic splint for night use will hold the wrist firmly in position while the woman sleeps. The prescription should be clarified with the physician, especially if third party insurance will be billed for the service, but the OTR® should make the recommendation regarding the type of splints to be prescribed, rather than asking the physician what he wants. Because the physician did not specify the type of splint on the initial order, he is relying on the OTR® to provide the correct type of splint.
Clinical Simulation, setting 1: An OTR® in a hand therapy clinic receives a referral to evaluate and treat a woman with a diagnosis of right hand carpal tunnel syndrome. The hand surgeon wants to try a conservative approach to managing the woman’s symptoms, as the woman has a history of adverse reactions to anesthesia. During the initial interview with the woman, the OTR® finds out that the woman does data entry for a bank. She is married, has two very young children, and lives in a rented townhouse. The woman reports that her symptoms began about one month prior to the evaluation.
Section D: The woman’s employer contacts the OTR® and expresses concerns over the woman’s request for adaptations at work. How should the OTR® respond? Select the best 3 choices.
Most employers think that adaptations to compensate for a medical condition or disability will cost a lot of money. Adaptations for carpal tunnel syndrome, however, can often be accomplished by adjusting the height of the work station in relation to the chair the employee uses. Other adaptations, such as a wrist rest or an ergonomic keyboard, are low cost. Since employees of a bank have jobs that place them at risk for developing carpal tunnel syndrome, the woman’s co-workers would benefit from training in how to prevent the condition and the OTR® could offer this to the employer. The OTR® should not make the employer think that she must change every work station or provide expensive adaptations to comply with the Americans with Disabilities Act.
Most employers think that adaptations to compensate for a medical condition or disability will cost a lot of money. Adaptations for carpal tunnel syndrome, however, can often be accomplished by adjusting the height of the work station in relation to the chair the employee uses. Other adaptations, such as a wrist rest or an ergonomic keyboard, are low cost. Since employees of a bank have jobs that place them at risk for developing carpal tunnel syndrome, the woman’s co-workers would benefit from training in how to prevent the condition and the OTR® could offer this to the employer. The OTR® should not make the employer think that she must change every work station or provide expensive adaptations to comply with the Americans with Disabilities Act.
Clinical Simulation, setting 2: An OTR® in an outpatient rehabilitation clinic receives an order to evaluate and treat a woman with right shoulder girdle muscle denervation. Through medical records review, the OTR® learns that the woman has lost nerve function to a portion of her rotator cuff due to a surgeon accidentally severing a nerve during surgery for another condition. The woman is in her 50s and lives alone. Her adult children live nearby. She works as a waitress at a local diner and enjoys babysitting her grandchildren.
Section A: Since the woman’s injury affects specific muscles, how should the OTR® proceed with the initial evaluation? Select the best 3 choices.
Since the woman’s injury is specific to a certain nerve, it is important to complete goniometer measurements and manual muscle testing to identify the upper extremity functions affected by the loss of innervation to specific muscles. Screening is not adequate. Testing sensation in the full upper extremity is not necessary, although screening sensation in the areas innervated by the severed nerve may be helpful. The woman’s ADLs and IADLs should also be assessed. The woman was previously independent in all tasks, so this can be completed through interview.
Since the woman’s injury is specific to a certain nerve, it is important to complete goniometer measurements and manual muscle testing to identify the upper extremity functions affected by the loss of innervation to specific muscles. Screening is not adequate. Testing sensation in the full upper extremity is not necessary, although screening sensation in the areas innervated by the severed nerve may be helpful. The woman’s ADLs and IADLs should also be assessed. The woman was previously independent in all tasks, so this can be completed through interview.
Clinical Simulation, setting 2: An OTR® in an outpatient rehabilitation clinic receives an order to evaluate and treat a woman with right shoulder girdle muscle denervation. Through medical records review, the OTR® learns that the woman has lost nerve function to a portion of her rotator cuff due to a surgeon accidentally severing a nerve during surgery for another condition. The woman is in her 50s and lives alone. Her adult children live nearby. She works as a waitress at a local diner and enjoys babysitting her grandchildren..
During treatment, the OTR® notices that the woman is having difficulty compensating for the loss of function in her rotator cuff muscles. How can the OTR® help the woman re-learn shoulder movements using different muscles?
While strengthening the shoulder girdle will help the woman overcome the deconditioning that her injury caused, it will not help her learn to compensate for the muscles that no longer function by using other muscles. To do this, she must consciously feel the way each muscle moves when it contracts. Using tactile feedback, such as brushing or vibration, or visual feedback, such as watching movement in a mirror, will help accomplish this. Biofeedback training using a biofeedback machine will help the woman to learn to use alternate muscles through both visual and auditory feedback.
While strengthening the shoulder girdle will help the woman overcome the deconditioning that her injury caused, it will not help her learn to compensate for the muscles that no longer function by using other muscles. To do this, she must consciously feel the way each muscle moves when it contracts. Using tactile feedback, such as brushing or vibration, or visual feedback, such as watching movement in a mirror, will help accomplish this. Biofeedback training using a biofeedback machine will help the woman to learn to use alternate muscles through both visual and auditory feedback.
Clinical Simulation, setting 2: An OTR® in an outpatient rehabilitation clinic receives an order to evaluate and treat a woman with right shoulder girdle muscle denervation. Through medical records review, the OTR® learns that the woman has lost nerve function to a portion of her rotator cuff due to a surgeon accidentally severing a nerve during surgery for another condition. The woman is in her 50s and lives alone. Her adult children live nearby. She works as a waitress at a local diner and enjoys babysitting her grandchildren.
Section C: The woman’s progress in therapy is plateauing and the woman still complains that she cannot complete certain activities, including combing one side of her hair, lifting the coffee pot at work, and picking up her two-year-old grandson. How should the OTR® address these activities? Select the best 3 choices.
Because the woman is plateauing in therapy, she may not relearn how to complete these specific activities using different muscles. That does not mean she should give them up, but the activities should be adapted instead to allow her to continue to perform them. Since only the right arm was affected by the injury, the woman can adapt some activities by using her other arm. This would be appropriate for lifting her grandson and a special harness would not be necessary. A long-handled comb should help the woman reach the parts of her head that she cannot reach due to her right shoulder limitation. The woman’s ability to lift coffee pots at work could be helped by moving the coffee pots to a lower position, but that might not be possible depending on the coffee station set-up. It would be appropriate to ask the woman if recommendations could be given to her employer regarding the coffee station. The woman should work with her employer to adapt her coffee station, rather than adapting it herself by using smaller coffee pots.
Because the woman is plateauing in therapy, she may not relearn how to complete these specific activities using different muscles. That does not mean she should give them up, but the activities should be adapted instead to allow her to continue to perform them. Since only the right arm was affected by the injury, the woman can adapt some activities by using her other arm. This would be appropriate for lifting her grandson and a special harness would not be necessary. A long-handled comb should help the woman reach the parts of her head that she cannot reach due to her right shoulder limitation. The woman’s ability to lift coffee pots at work could be helped by moving the coffee pots to a lower position, but that might not be possible depending on the coffee station set-up. It would be appropriate to ask the woman if recommendations could be given to her employer regarding the coffee station. The woman should work with her employer to adapt her coffee station, rather than adapting it herself by using smaller coffee pots.
Clinical Simulation, setting 2: An OTR® in an outpatient rehabilitation clinic receives an order to evaluate and treat a woman with right shoulder girdle muscle denervation. Through medical records review, the OTR® learns that the woman has lost nerve function to a portion of her rotator cuff due to a surgeon accidentally severing a nerve during surgery for another condition. The woman is in her 50s and lives alone. Her adult children live nearby. She works as a waitress at a local diner and enjoys babysitting her grandchildren.
Section D: During therapy, the woman has repeatedly stated that she may sue the surgeon who severed her nerve. Realizing that a lawsuit may be involved with this injury, what should the OTR® do? Select the best 3 choices.
Rationale: If an upper extremity injury is the result of an action that could result in a lawsuit, the OTR® should be very careful to remain neutral to the cause of the injury during evaluation and treatment. The OTR® should not document opinion or express opinion to the patient, but should carefully document all evaluation and treatment sessions and the outcomes of those sessions. Regular, detailed reports should also be provided to the woman’s physician. Treatment should continue until treatment goals are reached or until progress plateaus, just as it would with any other patient. If the OTR® is subpoenaed as a witness in a lawsuit, she will be required to testify based on the written documentation, so it is important that the documentation be accurate and thorough.
Rationale: If an upper extremity injury is the result of an action that could result in a lawsuit, the OTR® should be very careful to remain neutral to the cause of the injury during evaluation and treatment. The OTR® should not document opinion or express opinion to the patient, but should carefully document all evaluation and treatment sessions and the outcomes of those sessions. Regular, detailed reports should also be provided to the woman’s physician. Treatment should continue until treatment goals are reached or until progress plateaus, just as it would with any other patient. If the OTR® is subpoenaed as a witness in a lawsuit, she will be required to testify based on the written documentation, so it is important that the documentation be accurate and thorough.
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Richard, a 30-year-old college soccer coach, fractured his left wrist after landing on an outstretched arm when he fell off his bike. After 6 weeks of wearing a cast, he has been given a wrist brace to wear for support. Richard reports that his left wrist remains painful, stiff, and the swelling in his hand is limiting his ability to drive to soccer training and matches. Pain and edema are being addressed with the use of PAMs. The main focus of OT is now on improving his wrist and hand strength for grasping. What is the BEST activity that can be used to improve Richard’s grasp on the steering wheel?
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.
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.
An OTR® is fabricating a splint for a 36-year-old truck driver who sustained an injury to his right wrist when he fell off a ladder at home. The patient presents with wrist pain and edema, and his AROM is limited in all planes of movement. The patient is extremely concerned about lost time from work, and as he is the only breadwinner his wife is upset, making it difficult to engage in conversation with her. To initiate the discussion about the need for a splint, for the patient, what approach should the OTR® use, taking into consideration the couple’s emotional state at this time?
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.
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 64-year-old patient who fractured his left femur when he fell onto a barricade, is currently 4 weeks post-op, and is attending outpatient rehab services. The patient has recently consulted with his orthopedic surgeon for a routine follow-up. At his next OT session, the patient presents the clinician with new orders from the surgeon, stating that the patient can progress from non-weight-bearing (NWB) to toe-touch weight bearing (TTWB) of the affected extremity. With this new change in his weight-bearing status, how would you BEST adapt a dish washing task, to incorporate the patient’s new weight-bearing precautions?
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.
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.
What is the benefit of using a physical agent modality such as whirlpool therapy with patients who have multiple sclerosis?
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.
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.
What type of splint is used to inhibit flexor spasticity in the hand and should not apply stretch to the wrist and finger flexor muscles?
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.
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.
An OT is working with a patient who sustained a proximal humerus fracture requiring ORIF. Post op, when can the patient begin AROM?
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.
Proximal Humerus Fracture Post-Operative ORIF
0-8 WEEKS
• Sling worn for sleep and at all times except hygiene and exercise first 2 wks, then as needed for comfort
• No active shoulder ROM for the first 4 wks
• Use cold pack after exercises
• Posture Education
• No active IR or cross body adduction first 6 wks
• No lifting/pushing/pulling >5 lbs first 6 wks
• Modalities prn
Exercises (3-5 days post op):
• Pendulum exercises
• Move uninvolved joints
• PROM in supine forward flexion to 90 degrees and ER to 40 degrees
• Passive IR as tolerated (not behind back)
o Exercises (4-8 Weeks):
• AAROM ER to 40 degrees, forward flexion to 90 degrees, progress 20
degrees per week
• Pulleys
• Scapular retraction and depression
• May discontinue sling if comfortable
8-12 WEEKS:
o Exercises (8-12 weeks):
• Continue PROM/AAROM
• Begin posterior capsule stretching
• Begin IR behind back
• Begin anterior chest wall stretches (pec minor)
• Scapular strengthening including shoulder shrugs and scapular retraction
exercises
• Theraband pull downs
• Progress to AROM in supine once PROM restored or nearly restored and tolerating AAROM standing; Progress AROM to standing as tolerated
• Once AROM in standing is well tolerated, add progressive isotonics, low resistance, high reps
o Exercises (12 weeks)
• Theraband exercises or free weights as appropriate- standing
• Self stretching with home exercise program, emphasize posterior capsule
• Recreation/vocation specific conditioning program if needed
http://www.tcomn.com/wp-content/uploads/2016/07/Proximal-Humerus-Fracture-Post-Operative-ORIF.pdf
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.
Proximal Humerus Fracture Post-Operative ORIF
0-8 WEEKS
• Sling worn for sleep and at all times except hygiene and exercise first 2 wks, then as needed for comfort
• No active shoulder ROM for the first 4 wks
• Use cold pack after exercises
• Posture Education
• No active IR or cross body adduction first 6 wks
• No lifting/pushing/pulling >5 lbs first 6 wks
• Modalities prn
Exercises (3-5 days post op):
• Pendulum exercises
• Move uninvolved joints
• PROM in supine forward flexion to 90 degrees and ER to 40 degrees
• Passive IR as tolerated (not behind back)
o Exercises (4-8 Weeks):
• AAROM ER to 40 degrees, forward flexion to 90 degrees, progress 20
degrees per week
• Pulleys
• Scapular retraction and depression
• May discontinue sling if comfortable
8-12 WEEKS:
o Exercises (8-12 weeks):
• Continue PROM/AAROM
• Begin posterior capsule stretching
• Begin IR behind back
• Begin anterior chest wall stretches (pec minor)
• Scapular strengthening including shoulder shrugs and scapular retraction
exercises
• Theraband pull downs
• Progress to AROM in supine once PROM restored or nearly restored and tolerating AAROM standing; Progress AROM to standing as tolerated
• Once AROM in standing is well tolerated, add progressive isotonics, low resistance, high reps
o Exercises (12 weeks)
• Theraband exercises or free weights as appropriate- standing
• Self stretching with home exercise program, emphasize posterior capsule
• Recreation/vocation specific conditioning program if needed
http://www.tcomn.com/wp-content/uploads/2016/07/Proximal-Humerus-Fracture-Post-Operative-ORIF.pdf
What is the purpose of a compression garment?
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.
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.
What position is the hand in when the MCP joints are positioned in flexion and the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints of the fingers are positioned in extension.
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.
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.
What is the Kleinert protocol for a flexor tendon injury repair?
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.
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 23-year old student has been receiving OT intervention in an outpatient hand therapy clinic for the past 6 weeks. The patient sustained an injury to her left forearm when she fell during a college basketball tournament. Her left arm has been immobilized in a long-arm cast for that time period and as a result, she has now developed a flexion contracture of her elbow. The OTR® applies a warm pack over the patient’s bicep tendon prior to the patient participating in an activity involving shoulder flexion and elbow extension. What is the PRIMARY purpose for using this modality over the elbow?
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
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
What is the Duran protocol for a flexor tendon injury repair?
B. Passive flexion and extension of the digits.
Duran protocol: Passive flexion and extension of digit
B. Passive flexion and extension of the digits.
Duran protocol: Passive flexion and extension of digit
A 22-year-old male professional golfer has been diagnosed with medial epicondylitis. What is the most appropriate splint for this patient, when being treated conservatively?
D. Medial epicondylitis brace.
Medial epicondylitis 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. Also called Golfer’s elbow. 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.
D. Medial epicondylitis brace.
Medial epicondylitis 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. Also called Golfer’s elbow. 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.
An OTR® is working with a patient who has rheumatoid arthritis. The patient works in the kitchen of a local restaurant and he has identified that turning the knobs of the stove and the taps of the sinks, exacerbates his pain. Which type of movements should the patient focus on using while working in the kitchen in order to protect his joints?
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. 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
A new patient who has been diagnosed with radial tunnel syndrome, is being fitted for a splint. The patient is being treated conservatively and has therefore had no surgical intervention. What is the BEST splint to fabricate for this patient?
B. Long arm splint.
If a patient had an operation, then the patient would use a wrist cock up splint (extension) while the elbow is flexed, forearm supinated, and wrist neutral for 2 weeks.
If a patient did not have an operation, then the patient would use a long arm splint while the elbow is flexed, forearm supinated, and wrist in neutral.
B. Long arm splint.
If a patient had an operation, then the patient would use a wrist cock up splint (extension) while the elbow is flexed, forearm supinated, and wrist neutral for 2 weeks.
If a patient did not have an operation, then the patient would use a long arm splint while the elbow is flexed, forearm supinated, and wrist in neutral.
A 78-year-old resident in a skilled nursing facility has been referred for OT intervention following a CVA. As a result of her CVA, she has developed hypertonicity in her left non-dominant upper extremity. The patient has been fitted with an ulnar platform anti-spasticity hard cone splint to reduce the tone in her hand and to prevent palmar skin maceration. Several days later, when you arrive to review the splint, you notice that instead of wearing her cone splint, the nursing staff have taken rolled-up washcloths and placed them in the patient’s palm to keep her hand open. The nursing staff report that they are not confident that the splint is effective, and they therefore decided to use the washcloths as an alternative. What is the MOST IMPORTANT objective of the prescribed splint you should discuss with the nursing staff, to assure them that the splint is a necessary part of the patient’s treatment so that they are aware of the benefits of the splint and are empowered to help the patient with her splint management?
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. 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.
A patient who has COPD complains of shortness of breath while walking upstairs, performing her grooming routine, and cooking. The OT has already educated the patient about her disease and energy conservation. Which subjective statement would the OT most likely write down in her SOAP note?
D. “I keep a stool nearby so I can sit down when I get tired”.
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.
D. “I keep a stool nearby so I can sit down when I get tired”.
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.
An OTR® is fabricating a customized resting hand splint for an 80-year-old patient with rheumatoid arthritis. The patient has also been diagnosed with hyperthyroidism and poor circulation. One of the symptoms of hyperthyroidism is the development of a tremor , which usually presents as a fine trembling in the hands and fingers. The patient lives alone in an apartment and his daughter regularly checks up on him and helps him with his meals and light house cleaning. The daughter is concerned that her father will have difficulty removing and re-applying his splint as his tremors interfere with his hand function. How can the OTR® ensure that the patient can independently manage his splint?
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.
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.
2 days ago, a 60-year-old farmer was seen at the local hand therapy clinic where he was issued a neoprene hand-based splint. On the first day he only wore the splint for 2 hours and as advised, he did not wear the splint that evening. On waking in the morning of the second day, he noticed small red welts on the area where the splint had been in contact with his skin. Despite the red marks, he re-applied the splint and after wearing it for 4 hours, he started to complain of swelling and pain from his fingertips to his forearm. The patient’s wife calls the hand clinic to explain his situation to the OTR® and asks the OTR® what she should do. What is the MOST appropriate recommendation the OTR® can give the patient’s wife at this point?
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. 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.
An entry-level OT is assessing a patient who has ALS. The OT is measuring the patient’s active range of elbow flexion using a standard goniometer. In an attempt to get an accurate measurement, the OT asks the patient to flex his elbow 4 times in succession, and still finds that the measurements vary 2-10 degrees. In this scenario, what should the OT do NEXT?
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.
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.
When evaluating an individual with suspected complex regional pain syndrome, what are the key symptoms you would expect to see?
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.
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.
Frederick, a professional guitarist has been diagnosed with Dupuytren’s contracture affecting his left hand. As he is right hand dominant, he uses his left hand to transition between chords on the neck of the guitar and his right hand for strumming/picking. This has impacted on his ability to play the guitar and subsequently he has been unable to perform in any concerts with his band, over the past 6 months. Frederick has recently had a fasciotomy to release the pull of the tissue cords, in his palmar fascia. What part of Frederick’s hand is MOST LIKELY causing him to experience difficulty playing the guitar?
B. The proximal interphalangeal joint of the 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
B. The proximal interphalangeal joint of the 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 58-year-old male who is a carpenter by trade, was diagnosed with subluxation of the CMC joint of his right, dominant hand. After conservative treatment failed, surgery was performed. Since the surgery however, contractures of the stabilizers of the CMC joint including the thumb flexors and adductors, have developed resulting in a diminished web space. The patient’s goal is to return to his full-time employment within 2 months, once his course of therapy has been completed. To help this patient achieve his goal, what hand therapy protocol (splint, exercises, hand-function activities) should the OT select as part of the patient’s OT intervention?
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
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
Irene is a 62-year-old woman with two teenage children. She loves to travel, however, she has pain in her hands due to arthritis. What splint in this photo is she wearing to help her with comfort?
B. Thumb CMC Brace.
A thumb CMC brace will help this patient with pain relief due to her CMC (basal joint) osteoarthritis. This splint will allow for unrestricted movement of the hand and wrist. The splint is not intended to cover the CMC joint and some movement of the thumb CMC joint is possible when wearing the orthosis.
For more information: http://www.arthritissupplies.com/push-thumb-cmc-brace.html?gclid=CKyA-qfjldQCFVe2wAodL2ABAQ
B. Thumb CMC Brace.
A thumb CMC brace will help this patient with pain relief due to her CMC (basal joint) osteoarthritis. This splint will allow for unrestricted movement of the hand and wrist. The splint is not intended to cover the CMC joint and some movement of the thumb CMC joint is possible when wearing the orthosis.
For more information: http://www.arthritissupplies.com/push-thumb-cmc-brace.html?gclid=CKyA-qfjldQCFVe2wAodL2ABAQ
A patient recently experienced shoulder trauma and as a result sustained a brachial plexus injury. What single upper limb movement would be the MOST appropriate to ask the patient to perform in order to assess the functioning of their C5 myotome?
A. Shoulder abduction.
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:
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
In more detail: Like spinal nerves, myotomes are organized into segments because they share a common origin. However, myotome testing can be difficult since individual muscles can be innervated by more than one nerve and by nerves that originate from different spinal cord levels. It is generally done by checking a patient’s ability to perform specific actions and checking for muscle weakness. Like dermatomes, myotomes can overlap. So even though myotomes have been mapped to certain areas of the body, the mapping is not precise because of natural variation in where muscles receive their innervation. For example, the musculocutaneous nerve (C5-C7) innervates the muscles in the anterior compartment of the arm – coracobrachialis, biceps brachii, and brachialis muscles. If it is absent, these muscles can instead be innervated by branches from the median nerve (C5-T1).
A. Shoulder abduction.
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:
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
In more detail: Like spinal nerves, myotomes are organized into segments because they share a common origin. However, myotome testing can be difficult since individual muscles can be innervated by more than one nerve and by nerves that originate from different spinal cord levels. It is generally done by checking a patient’s ability to perform specific actions and checking for muscle weakness. Like dermatomes, myotomes can overlap. So even though myotomes have been mapped to certain areas of the body, the mapping is not precise because of natural variation in where muscles receive their innervation. For example, the musculocutaneous nerve (C5-C7) innervates the muscles in the anterior compartment of the arm – coracobrachialis, biceps brachii, and brachialis muscles. If it is absent, these muscles can instead be innervated by branches from the median nerve (C5-T1).
A 28-year-old student who is studying computer science is being treated at an outpatient hand clinic for carpal tunnel syndrome. The nature of her studies requires her to spend many hours working on the desktop computers at the computer lab which is based on the college campus. The student has been assessed by the OT, and a dorsal wrist splint was provided. During a follow-up appointment, the student reports that she is finding it difficult to hold the mouse while wearing the splint as the splint covers the proximal portion of her palm and the palmar transverse bar tends to get in the way. In order to recommend a suitable ergonomic mouse which would preserve the student’s cutaneous feedback and thereby increase her task efficiency, what characteristics should the OT consider in terms of the features of the mouse and the anthropometric measurements of the hand (width of hand and length of hand, palm, and index finger)?
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. 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
An OT is working on energy conservation with a 73-year-old male patient who has COPD. Which strategy would be the most effective in helping him conserve the most amount of energy while he completes a dishwashing task at the sink?
C. Suggest he use a long-handled sponge with a soap attachment.
Using a long-handled sponge with a soap attachment is the only option where he’s actually washing the dishes.
C. Suggest he use a long-handled sponge with a soap attachment.
Using a long-handled sponge with a soap attachment is the only option where he’s actually washing the dishes.
Elliot is a 36-year-old man who sustained a Proximal Humeral Fracture in a MVA. He begins occupational therapy treatment one week after open reduction internal fixation surgery. Which treatment technique is contraindicated at this stage of recovery?
C. Resistive exercises for strengthening. Resistance to the surgical area is contraindicated at this point in recovery. Beginning resistive exercises too early could cause damage to the fracture site and could loosen the internal pins holding the fracture together. Patients should also avoid weight bearing on the affected arm.
Proximal Humeral Fracture Post-Surgical Rehabilitation Protocol (Open Reduction / Internal Fixation)
General Principles:
1. Bony healing occurs usually within 6 to 8 weeks in adults
2. Return to normal function and motion may require 3 to 4 months
Overall Goals:
1. Increase ROM while protecting the fracture site (you can be slightly more aggressive with this vs. a closed fracture due to the hardware fixation)
2. Control pain and swelling (with exercise and modalities)
3. Perform frequent gentle exercise to prevent adhesion formation
Phase I – Early Motion Phase (0 – 5 weeks)
A. Week 1 Early Passive Motion
1. Wear the sling at all times except to exercise
2. Hand, wrist, elbow, and cervical AROM
3. Grip and wrist strengthening without resistance
4. PROM: ER to 30° and flexion to 130º
5. Modalities as needed for pain relief or inflammation reduction
6. Edema control.
https://www.orthoillinois.com/wp-content/uploads/2015/03/PROXIMAL-HUMERAL-FRACTURE-ORIF.pdf
C. Resistive exercises for strengthening. Resistance to the surgical area is contraindicated at this point in recovery. Beginning resistive exercises too early could cause damage to the fracture site and could loosen the internal pins holding the fracture together. Patients should also avoid weight bearing on the affected arm.
Proximal Humeral Fracture Post-Surgical Rehabilitation Protocol (Open Reduction / Internal Fixation)
General Principles:
1. Bony healing occurs usually within 6 to 8 weeks in adults
2. Return to normal function and motion may require 3 to 4 months
Overall Goals:
1. Increase ROM while protecting the fracture site (you can be slightly more aggressive with this vs. a closed fracture due to the hardware fixation)
2. Control pain and swelling (with exercise and modalities)
3. Perform frequent gentle exercise to prevent adhesion formation
Phase I – Early Motion Phase (0 – 5 weeks)
A. Week 1 Early Passive Motion
1. Wear the sling at all times except to exercise
2. Hand, wrist, elbow, and cervical AROM
3. Grip and wrist strengthening without resistance
4. PROM: ER to 30° and flexion to 130º
5. Modalities as needed for pain relief or inflammation reduction
6. Edema control.
https://www.orthoillinois.com/wp-content/uploads/2015/03/PROXIMAL-HUMERAL-FRACTURE-ORIF.pdf
Which branch of the radial nerve if entrapped, results in sensory manifestations and no motor deficits?
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.
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.
Daniela is a 76-year old woman who moved to the United States, a year ago from Romania to live with her son and his family. She is currently being treated by a hand therapist for a wrist fracture caused by a fall on the steps at the entrance of her church. The OTR® has fitted Daniela with a volar immobilization wrist splint, and she has been instructed to wear the splint continuously for 3-6 weeks, only removing it for bathing. Which of the following is NOT a factor in establishing whether the patient will be compliant with splint use?
A. The ability to read and follow written instructions in the English language.
Instructions can be written in the patient’s language or translated by the family for the patient. Visual demonstration and written instructions with photos could also be helpful.
B, C and D are critical for determining the compliance to use and follow a wearing
schedule.
Coppard, Brenda M.Lohman, Helene. (2008) Introduction to Splinting: A clinical reasoning and problem-solving approach (2nd Edition). St. Louis : Mosby. Pp 452-453.
A. The ability to read and follow written instructions in the English language.
Instructions can be written in the patient’s language or translated by the family for the patient. Visual demonstration and written instructions with photos could also be helpful.
B, C and D are critical for determining the compliance to use and follow a wearing
schedule.
Coppard, Brenda M.Lohman, Helene. (2008) Introduction to Splinting: A clinical reasoning and problem-solving approach (2nd Edition). St. Louis : Mosby. Pp 452-453.
An 85-year-old man who has been diagnosed with Type 2 Diabetes Mellitus and osteoarthritis is experiencing chronic pain in both his wrists and CMC joints. Symptomatically, his right dominant hand has been more affected by the arthritis and this has resulted in the patient having difficulty maintaining his grasp on objects and tools which in turn has compromised his level of hygiene and ability to participate in his woodworking hobbies. It has been determined that the patient would benefit from wearing a resting hand splint with D-ring straps at night to support his wrist and CMC joint, for pain management. What is the purpose of the D-ring straps in this scenario?
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.
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.
An OT is working with a 70-year-old patient who presents with right-sided weakness secondary to a CVA. The patient has intact procedural memory despite demonstrating minor cognitive deficits. The focus of the session is on encouraging active movement of the patient’s affected upper limb which currently scores at a grade 3+ (Fair plus) on the MMT, for both shoulder and elbow movements. Using a task-oriented approach, which meaningful activity would achieve the patient’s goal of increasing their affected limb’s function?
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
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
Due to structural changes in the arm muscles, an elderly patient has lost joint motion. What should the goal of OT intervention be at this stage?
D. Coach on compensatory methods. In this situation, it appears the patient has developed long-standing contractures; the goal should be to teach the patient compensatory methods since these conditions do not respond to nonsurgical treatment methods.
D. Coach on compensatory methods. In this situation, it appears the patient has developed long-standing contractures; the goal should be to teach the patient compensatory methods since these conditions do not respond to nonsurgical treatment methods.
Jeff, a 23-year-old college athlete, recently sustained an injury to his right dominant upper limb during football practice. He was diagnosed with a brachial plexus injury, which required surgical intervention. 2 weeks post-surgery, Jeff continues to experience weakness in his right upper limb and his shoulder movements are limited, with both flexion and abduction measuring at 120º. One of Jeff’s main goals, at this stage of his recovery is to use his affected upper limb for function and to continue doing his own laundry without enlisting the help of his roommate. Which of the following tasks would be the MOST CHALLENGING for Jeff to perform?
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.
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 mother of twins appears to have developed De Quervain’s tenosynovitis due to repeatedly lifting her children up. Which test is typically used to confirm this diagnosis?
A. Positive Finkelstein.
Lifting your child repeatedly involves using your thumbs as leverage and this is associated with the condition.
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.
Finkelstein’s test produces severe tenderness and usually pain on the radial aspect of the wrist when the thumb is flexed into the palm and the wrist is ulnar deviated.
A. Positive Finkelstein.
Lifting your child repeatedly involves using your thumbs as leverage and this is associated with the condition.
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.
Finkelstein’s test produces severe tenderness and usually pain on the radial aspect of the wrist when the thumb is flexed into the palm and the wrist is ulnar deviated.
An OTR® is educating a patient on proper body mechanics. He has chronic lower back pain. He works as a library technician and as part of his daily tasks, he is required to lift and carry books and place them on the shelves. Which techniques would be beneficial for the OTR® to teach the patient to help him cope with the demands of his job? Choose the best 3 answers.
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 height 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. 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 height 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.
Matilda, a woman in her late 70s who has RA, lives on her own in a ground-floor apartment, and has enlisted the help of a part-time caregiver. Matilda arrives for her weekly water aerobics class, which is run at the local community center, with a visible first degree burn on her non-dominant hand. When questioned about this burn, Matilda reports that she is having difficulty opening and closing her basin taps and she cannot always get the temperature right. What recommendations would be the MOST beneficial for Matilda so that washing her hands can become a safe and efficient task for her?
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.
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.
Karen, a 70-year-old woman who is a retired secretary, recently sprained her left (non-dominant) wrist while lifting a heavy object. As a result, she requires an immobilization splint to support her wrist to promote healing and for pain management. Karen is an avid gardener who has expressed her desire to continue working in her garden. She has agreed to learn 1-handed techniques with her dominant hand, while her wrist heals, and will only use her left hand for light stabilization, for bilateral activities. What type of splint is the MOST appropriate to address Karen’s needs during the acute stage of healing?
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.
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 32-year-old ballet instructor who recently sustained a left proximal humeral fracture which required surgical intervention, has been referred to OT. The surgeon’s orders for treating the patient’s left upper limb include no weight bearing on that arm, maintaining full AROM of the wrist and fingers and extension/flexion of the elbow as tolerated, with supervision from the therapist. The OTR® is currently working with the patient on dressing and is instructing her on how to correctly don her elastic waist pants. The OTR® has already established that the patient has good trunk control and normal upper extremity strength of her unaffected arm. After carefully assisting the patient with doffing her sling, what sequence of dressing would be the MOST effective for the patient to follow, to help her learn to dress independently while adhering to the doctor’s instructions?
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
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
When treating a patient who recently suffered a CVA, which physical agent modality (PAM) would cause the patient’s muscles to contract, thus strengthening the muscles which have become flaccid due to the CVA?
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. 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).
Barbara is a 68-year old retired professional baker who, 5 years ago, was diagnosed with RA. Recently, Barbara has also been diagnosed with severe anxiety associated with her having to deal with her progressive RA symptoms. Barbara is currently participating in a community mobility group, which is focusing on public transportation. Lately, she has been missing her bus because she has been distracted by her thoughts which have been centred around thinking about her symptoms. During the group session, Barbara begins to display signs of anxiety. What should the OTR® ‘s NEXT course of action be at this point?
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.
Early, Mary Beth. (2009) Mental Health Concepts & Techniques for the Occupational Therapy Assistant (4th Edition). Baltimore, MD.: Walters Kluwer, pp 290-291.
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.
Early, Mary Beth. (2009) Mental Health Concepts & Techniques for the Occupational Therapy Assistant (4th Edition). Baltimore, MD.: Walters Kluwer, pp 290-291.
During an assessment a patient with heart disease states that he is under an extreme amount of pressure since he lost his job and the bank is about to take away his home. Which would be the most important aspect to assess in regards to controllable risk factors?
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.
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.
An OTR® is working with Emily, a 65-year-old woman with COPD, in an outpatient setting. The focus of the session is on teaching Emily how to manage her disease, including adopting appropriate coping strategies. Emily identifies that shopping for groceries typically causes her to experience dyspnea. What is the BEST strategy for Emily to use in this type of situation?
D. 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).
D. 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 55-year old housewife and mother of 4 adolescent children has COPD. She reports fatigue and a Borg rating of 3/10 (on the modified Borg Scale) for moderate breathlessness which interferes with her ability to complete morning routines. She has a goal for improving endurance to make breakfast for her children before they leave for school. Which techniques would be beneficial to teach the client to use for supporting this goal? Choose the best 3 answer choices
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
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
Andy is a 34-year-old man who recently sustained a laceration across the palm of his hand, which required surgical intervention. The surgeon has referred Andy to OT to initiate active finger exercises to maintain his ROM. Which is the BEST type of exercise to use at this stage of his recovery to ensure Andy’s AROM is maintained while his hand heals?
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.
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 patient who has muscular dystrophy exhibits trace strength on the manual muscle test (MMT). What type of active range of motion (AROM) does this patient have?
A. No active range of 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.
A. No active range of 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.
When are cardiac patients usually ready to be discharged to phase 2 of their cardiac rehab?
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.
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 67-year-old male was recently admitted to the hospital for coronary artery disease. What are the most important factors to assess when working with this patient?
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.
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.
An 82-year-old male patient who has been diagnosed with CHF, is consulting with an OT as he is having difficulty retrieving his wallet from the back pocket of his jeans, using his right dominant hand. As part of his evaluation, the OT asks the patient to perform the movement, which he does but with great effort. The OT then uses a goniometer to measure the patient’s shoulder movements. She reads a measurement of 68 degrees for internal rotation. How should the OT document this findings?
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
Internal rotation of shoulder:
Normal ROM: 70-90 degrees
Patient Position: Prone, elbow off edge of table
Axis: Olecranon process of the ulna
Fixed Arm:Aligned with midline of body
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
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
Internal rotation of shoulder:
Normal ROM: 70-90 degrees
Patient Position: Prone, elbow off edge of table
Axis: Olecranon process of the ulna
Fixed Arm:Aligned with midline of body
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
What is the typical presentation of a Boutonniere deformity?
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. 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.
Jim, a 57-year-old landscape architect who sustained a wrist fracture 3 weeks ago, is beginning to feel pain, stiffness, and sudomotor changes. Why is he experiencing this?
Complex regional pain syndrome
Distal radius fracture is the primary reason. Pain dispropriate to an injury that is either sympathetically maintained or independent of the sympathetic nervous system. Symptoms often include pain, swelling, stiffness, and sudomotor and trophic changes.
Complex regional pain syndrome
Distal radius fracture is the primary reason. Pain dispropriate to an injury that is either sympathetically maintained or independent of the sympathetic nervous system. Symptoms often include pain, swelling, stiffness, and sudomotor and trophic changes.
When a patient who has been diagnosed with RA, is experiencing a flare-up, what aspect of OT intervention is contraindicated?
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.
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.
When working with a patient who has been diagnosed with complex regional pain syndrome, what aspect of OT intervention should the therapist focus on initially?
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. 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
A 45-year-old patient who has a history of breast cancer has been referred for OT intervention. The OT who is performing the initial evaluation observes that the patient has significant lymphedema in her left upper extremity. The OT would like to accurately measure the patient’s lymphedema in order to form a baseline and monitor progress in response to a newly developed lymphedema program. Which method would be the most objective to attain precise measurements?
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.
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.
Name the type of exercise that uses the force generated by the contraction in which there is no joint movement and minimal change in its muscle length.
B. Isometric.
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.
B. Isometric.
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.
To keep the fingers from digging into the palmar surface due to increased spasticity, what type of splint should be used?
C. Cone splint.
Frequently, a rolled up cloth is put into the clenched hand; however, because this might facilitate increased spasticity, a hard splint is more appropriate.
C. Cone splint.
Frequently, a rolled up cloth is put into the clenched hand; however, because this might facilitate increased spasticity, a hard splint is more appropriate.
A patient recovering from a MI in the cardiac unit is eager to start an exercise program. He is currently only permitted to participate in exercises which expend 1.0 to 1.4 MET. What would you advise this patient in terms of what exercise is safe for him to perform?
D. Active or active-assistive exercises to all extremities in supine position.
Exercise 1-1.4 MET Stage 1
Supine: active or active-assistive 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
D. Active or active-assistive exercises to all extremities in supine position.
Exercise 1-1.4 MET Stage 1
Supine: active or active-assistive 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
A patient has advanced to the second stage (1.4 to 2.0 MET) of her cardiac rehab and she is very keen to participate in a leisure activity. What activity can the OT recommend to this patient while she is at this stage of her recovery?
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)
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)
For a patient with COPD, which energy conservation technique for washing their body would be the MOST useful?
A. 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 (this is for back injuries)
A. 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 (this is for back injuries)
If a patient tests positive for Froment’s sign, what nerve injury might they have?
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.
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.
What type of shoulder range of motion is being demonstrated when an OT asks the patient to place their hand behind their back and instructs them to reach as high up their spine as possible, and observes the extent of their reach in relation to the scapula and/or thoracic spine?
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.
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.
An OT is treating a patient who recently fractured his humerus while playing football. The patient is being treated conservatively and is currently wearing a cast. In this scenario, what is the BEST treatment intervention for this patient?
B. AROM of uninvolved joints.
Immobilization such as wearing a cast can result in tissue shortening. Stretching the tissue helps to maintain ROM which will help the patient regain function.
The two main treatment approaches used in functional rehabilitation are the compensatory and restorative approaches. These approaches belong to corresponding frames of reference which are used to guide occupational therapy practice. The restorative approach forms part of the biomechanical frame of reference which places emphasis on restoring previous function via participation in activity. The compensatory approach forms the basis of the rehabilitative frame of reference in which the aim is to modify the demand a task places on the person. This may be achieved by teaching different techniques and strategies or may include the provision of assistive equipment and aids. The restorative approach can only be initiated once the cast has been removed.
B. AROM of uninvolved joints.
Immobilization such as wearing a cast can result in tissue shortening. Stretching the tissue helps to maintain ROM which will help the patient regain function.
The two main treatment approaches used in functional rehabilitation are the compensatory and restorative approaches. These approaches belong to corresponding frames of reference which are used to guide occupational therapy practice. The restorative approach forms part of the biomechanical frame of reference which places emphasis on restoring previous function via participation in activity. The compensatory approach forms the basis of the rehabilitative frame of reference in which the aim is to modify the demand a task places on the person. This may be achieved by teaching different techniques and strategies or may include the provision of assistive equipment and aids. The restorative approach can only be initiated once the cast has been removed.
A patient is experiencing numbness in his hands due to a sensory disturbance. What dressing task might this patient have difficulty with?
Zipping up his jacket
When a patient has numbness due to sensory issues, this patient will have difficulty with many fine motor tasks such as zipping, buttoning, and tying shoes.
Zipping up his jacket
When a patient has numbness due to sensory issues, this patient will have difficulty with many fine motor tasks such as zipping, buttoning, and tying shoes.
A new patient is being fitted for a splint. The patient has radial tunnel syndrome but was not operated on. What is the best splint to use on this patient?
Long arm splint
If a patient had an operation, then the patient would use a wrist cock up splint (extension) while the elbow is flexed, forearm supinated, and wrist slightly extended for 2 weeks.
If a patient did not have an operation, then the patient would use a long arm splint while the elbow is flexed, forearm supinated, and wrist in neutral.
Long arm splint
If a patient had an operation, then the patient would use a wrist cock up splint (extension) while the elbow is flexed, forearm supinated, and wrist slightly extended for 2 weeks.
If a patient did not have an operation, then the patient would use a long arm splint while the elbow is flexed, forearm supinated, and wrist in neutral.
A patient has flaccidity in the right upper extremity and the OT would like to use a physical agent modality to activate the patient’s muscles. Which physical agent modality would be best to use?
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.
https://www.cincinnatichildrens.org/service/o/ot-pt/electrical-stiumulation.
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.
https://www.cincinnatichildrens.org/service/o/ot-pt/electrical-stiumulation.
A patient comes into a hand clinic for an initial evaluation. The patient complains of tingling in the lateral aspect of her right arm when her hand is pronated. She also complains of having a weak power grip and difficulty cooking dinner for her family. What should the OT do next as a part of the evaluation?
C. Tap the lateral aspect of the right arm at the elbow. The patient is describing symptoms of ulnar nerve impingement at the elbow. Ulnar nerve compression at the elbow is called cubital tunnel syndrome. Numbness and tingling in the hand and fingers are common symptoms of cubital tunnel syndrome. By tapping the lateral aspect of the right arm at the elbow, the OT can determine if impingement is present by the patient’s report of pain, observation of hyper-reflexivity in response to tapping, and palpation of tight forearm muscles.
C. Tap the lateral aspect of the right arm at the elbow. The patient is describing symptoms of ulnar nerve impingement at the elbow. Ulnar nerve compression at the elbow is called cubital tunnel syndrome. Numbness and tingling in the hand and fingers are common symptoms of cubital tunnel syndrome. By tapping the lateral aspect of the right arm at the elbow, the OT can determine if impingement is present by the patient’s report of pain, observation of hyper-reflexivity in response to tapping, and palpation of tight forearm muscles.
A patient who works as a custodian for a local high school reports having difficulty lifting chairs, mopping, and performing other janitorial duties due to tightness in his right wrist and fingers. The physician diagnosed the patient with having a non-displaced distal radius fracture to his right-dominant upper extremity. How should the OT incorporate the biomechanical approach in the first intervention to help the patient with his job tasks?
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.
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.
Janet is a 53-year-old patient recovering from a left CVA. The OT completes a manual muscle test on Janet’s right upper extremity and finds that her shoulder, elbow and forearm musculature consistently rate grade 2 (poor). Her wrist and hand rate grade 2+. What ADL activity will Janet be able to complete with her right upper extremity based on these test results?
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.
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 patient recently experienced shoulder trauma and as a result has a brachial plexus injury. What would be the most appropriate movement to assess when testing the myotome to C4?
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
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
What is the most appropriate muscle grade when a patient can raise and lower his arms to the ceiling without resistance?
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
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
What condition does the patient in this photo present with?
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.
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.
An OT is providing energy conservation techniques to a patient who has very low energy and is deconditioned. What is the best intervention to introduce to this patient on ways to put on her bra?
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.
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.
A patient who is recovering from an ulnar nerve injury is experiencing great difficulty grasping and holding an apple. What type of grasp does grasping an apple entail?
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. 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/.
What would the most appropriate splint be, for the patient in this photo?
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.
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.
An OT has been referred to work with a patient who has swan neck deformity. How should the OT expect the patients hand to be positioned?
Swan neck deformity: Injury to the MCP, PIP, or DIP joints characterized by PIP hyperextension and DIP flexion.
Swan neck deformity: Injury to the MCP, PIP, or DIP joints characterized by PIP hyperextension and DIP flexion.
A patient goes to the bathroom and notices that his mouthwash has been moved to the upper shelf of the bathroom medicine cabinet. In order to reach for the mouthwash, the patient will be required to abduct his shoulder beyond 90 degrees AROM. If this movement is contraindicated, what injury does this patient have?
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