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Treatment2GoExploring Hand Therapy

Manual

Hand Therapy Boot Camp

Exploring Hand Therapy, Corporation d/b/a Treatment2Gowww.handtherapy.comwww.treatment2go.com

727-341-1674Fax: 888-2704079

Treatment2Go is a trademark and d/b/a of Exploring Hand Therapy.

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Tallmadge, OH 44278 Phone: (888) 823-0310 - (330) 630-5090

Fax: (330) 630-5091

http://www.pwrwebintl.com/

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Hand Therapy Boot Camp Introduction Section I: Welcome to Boot Camp Chapter 1: Drop and Give Me UE Anatomy Surface Anatomy Bones & Soft Tissue of the Elbow / Forearm / Wrist / Hand Muscles of the Elbow / Forearm / Wrist / Hand Intrinsic Muscles of the Hand Extensor Mechanism Fibroosseous & Synovial Tissue Structures Vascular Supply Nerves Chapter 2: The Obstacle Course: Stages of Tissue Healing Section II: Learning the Art of War: Assessment Tools Chapter 3: Identifying the Enemy: Assessment History Pain Observation/Palpation Wound Scar Edema/Girth Range of Motion Strength Tendon Function Sensation Function Special Testing Section III: Locked and Loaded: Treatment Strategies Used in the Field Chapter 4: Basic Survival Skills: Physical Agent Modalities Thermal Agents Electrical Agents Mechanical Agents Chapter 5: Passing the Physical Test of Therapeutic Exercise Chapter 6: Wound Management Wound Cleansing Wound Debridement Dressing Selection

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Chapter 7: Lean and Mean: Edema Management Acute Subacute Chronic Chapter 8: Keeping the Pressure On: Scar Management Mechanical Compression Silicone Gel Sheets Soft Tissue Mobilization Ultrasound Iontophoresis Chapter 9: Protective Armor: Splinting the UE Purpose of Splinting Chapter 10: Hand to Hand Combat: Manual Therapy Techniques Joint Mobilization Soft Tissue Mobilization Manual Lymphatic Drainage Neurodynamics Chapter 11: Support the Unit: Taping Techniques Leukotape/Hypafix Kinesiotape SpiderTape



Hand Therapy Boot Camp FAQ 1. Is volumetric testing still useful for measuring edema/girth in the hand? Although many therapists do not like to use the volumeter in their practice due to the setup, it is still and excellent choice for measuring edema/girth in the hand. Volumetric testing is accurate to a point that a 10 ml difference is significant from one measurement to the next. 2. Should measurements of wrist flexion and extension only be taken from the

volar or dorsal surfaces of the wrist? Many therapists do not prefer to measure from the volar or dorsal surface of the wrist. The alternate method preferred is measurement from the radial side of the wrist due to the ulnar 2 metacarpals having some degree of mobility; however, the ulnar side can be used. The most important aspect of goniometry is consistency within your practice or clinic setting. If multiple therapists are employed, it may be beneficial to document the location of the measurement (radial/ulnar) to promote consistency. 3. Does is matter if Semmes-Weinstein monofilament testing is done to the

fingertips or the entire hand? For quick testing or screening, Semmes-Weinstein can be performed to the fingertips to assess sensibility. True monofilament testing is performed to map the sensation of the hand and should be performed if time allows. 4. Are 3 trials always necessary when performing grip strength testing with a

dynamometer? Ideally, the 3 trials are used as they provide an average of the patient’s current strength. It also allows the therapist to monitor for inconsistency in patient effort from one trial to the next. In early stages of strength testing following and injury or surgery, strength may be limited which results in poor endurance with strength testing. In these circumstances, a single trial may be used if the patient is exhibiting their best or maximum effort. 5. How can I obtain information regarding a patient’s current functional level? Functional assessment is performed through patient history and interview initially to understand the patient’s role and physical job requirements. Functional assessment can also be performed through questionnaires such as the DASH and provide a measurable score assigned to the current functional level. In addition, therapists can also assess function through simulation of ADL or Work tasks as well as formal



methods of testing such as Jebsen Taylor; Purdue Pegboard; Valpar Work samples; BTE; and other forms of testing. Any functional task can be recreated in the clinic with a little piece of imagination. 6. How can modalities be integrated into the therapy program? Modalities have a vital role in the treatment of hand therapy patients. The problem is understanding the science behind their use in order to properly select a modality as part of a patient’s treatment program. Modalities should be considered an adjunct to the treatment program providing therapists with another means for increasing tissue elasticity for range of motion, decreasing edema, desensitizing scar tissue, or simply to decrease pain and inflammation. The point to remember is that modalities are only one step in the process to achieve a desired goal with the goal usually being restoration of normal function. Modalities should be selected to improve the chances for a positive outcome. They should never be selected as the sole treatment. 7. What order should modalities be performed in a therapy session? There is no cookie-cutter recipe for modalities or the order for a treatment session. Often, therapists perform an assessment and then develop a treatment plan to achieve a desired goal. The problem is that once the treatment plan is established, the therapist does not want to deviate from the original plan of care. Modalities are adjuncts to treatment and patient status will change with each visit. Due to this, be prepared to be flexible with treatment sessions and adjust the session according to the specific needs of the patient on that particular day. For example, if the focus for the therapy session on a flexor tendon repair is on scar mobilization, a heating modality such as paraffin, fluidotherapy, or even ultrasound may be performed before the scar mobilization. To be effective, be prepared to perform the mobilization immediately after the modality. 8. Are exercises considered to be occupation-based activities? There has always been debate regarding therapeutic exercise versus activity. An exercise is what the term means, and exercise. The purpose of an exercise can be to increase range of motion, increase strength, provide for stress loading, decrease edema, increase proprioception, increase fine motor manipulation, etc. All of these items are essential for restoring function following and injury or surgery. The key to making an exercise occupation-based is that it must be meaningful to the patient and it must transition to the functional needs of a patient in terms of ADLs, leisure activities, and work demands. For example, having a patient who works as an electrician perform theraputty exercises may not be as meaningful as would be performing a Valpar work sample overhead. Select exercises that restore a patient’s function, but make sure it relates to their daily life demands. 9. What is the best method for treatment of edema?



The best method for the treatment of edema is simply elevation. Most often, if a patient is compliant with elevating the affected extremity acute edema can be controlled. As edema progresses through the subacute and chronic phases then there are more appropriate methods of treatment. 10. If high volt pulsed current (HVPC) is used to treat edema, what polarity

should it be set on? When using HVPC for the treatment of edema, a negative polarity is most often used. Recent studies have suggested that the polarity be set to positive for the initial 2 weeks following an injury or surgery and then changed to negative thereafter. 11. How important is manual therapy in hand therapy? Manual therapy can be a valuable asset to therapists in hand therapy. Manual therapy affords therapists with additional treatment techniques to mobilize a joint, mobilize tissue, mobilize neural tissue, and to mobilize edematous fluid. There are a variety of techniques available under the term “manual therapy”. To be successful in hand therapy, therapists must be hands-on and exercises and modalities alone will not provide enough opportunities for success. Due to this, consider incorporating manual therapy techniques into your practice. 12. In terms of splinting, can prefabricated splints be used? Prefabricated splints can be used in therapy practice for certain conditions. When using a prefabricated splint, be sure to make sure the splint has a proper fit and that it maintains the injured structure in the optimal position for healing. Often, prefabricated splints have incorrect joint positioning and need to corrected before issuing to the patient. 13. For custom splinting, what is the best thermoplastic material? Each therapist has to find their own material for splinting. Each material has specific characteristics such as memory, drape, handling time, etc. Most medical suppliers offer a description of each and even provide a description of its common use (i.e. hand splints, dynamic splint bases, etc). The thing to remember is that drape refers to how soft or moldable a material is. This describes how well it conforms to the surface it is being applied to. Memory refers to the ability of a material to return to its original shape when reheated. In my practice, I prefer to use Orthoplast II for hand splints due to its drapability and I prefer Synergy for more rigid splints. 14. How do I know what protocol is best to use? For most therapists practicing in hand therapy, a protocol is a sore subject. The reason is that most therapists use protocols simply as a guide to treatment but rely on assessment and clinical skills to adapt the treatment plan to the specific needs of a



patient. It is definitely not bad to use a protocol in treatment but as therapists gain more clinical expertise they should rely less on the protocol and more on their clinical skills and experience in practice. 15. How can I make sure that a patient’s therapy program is occupation-

based? For a therapy program to be occupation-based it needs to consider a patient’s specific functional needs and be designed to restore a patient to as high a functioning level as possible. It is not essential that every treatment aspect be functional in nature but it does rely on the premise that each treatment intervention does affect a patient’s functional status and the ultimate goal of therapeutic intervention is to affect the specific functional needs of the patient.



Exploring Hand Therapy dba Tx2go 1

Hand Therapy Boot Camp

George LaCour, LOTR, CHT

COURSE OBJECTIVES

• Demonstrate a working knowledge of UE anatomy

• Demonstrate understanding and proficiency in assessment of the UE

• Understand the use of physical agent modalities in hand therapy

• Become familiar with treatment options for management of edema, wounds, and scar

• Become familiar with therapeutic exercises used in hand therapy

• Understand the role of splinting

• Discuss manual therapy and taping techniques used rehab of the hand

Section I

Welcome to Boot Camp




Chapter 1 slides 4 - 114

Drop and Give Me Some Anatomy

• Superficial Anatomy

• Bones & Ligaments of the UE

• Muscles of the UE

• Fibroosseous & Synovial Structures

• Vascular Supply

• Nerve Supply

• It may be helpful to have an anatomy atlas handy!

Overview of Chapter 1

Superficial Anatomy




Skin & Subcutaneous Tissue

• Skin on dorsum of the hand is loose and elastic.

• Dorsum of hand more prone to edema due to the interstitial space.

• Dorsum of hand more prone to developing adhesions of skin to tendon and bone following injury, trauma, or surgery.

• Skin on the volar hand is fixed.

• Fascia present on volar hand.

Bones & Ligaments of the UE

Medial Elbow

• A: Olecranon Process:

• B: Ulnar Collateral Ligament:Has 3 portions which provide stability to valgus stress, especially between 20-120°flexion

• C: Medial Epicondyle

• D: Annular Ligament:Stabilizes proximal radioulnar joint and provides stability to varus stress

A

B

C

D




Lateral Elbow

• A: Lateral Epicondyle

• B: Radial Collateral Ligament:Part of the LCL complex. Taut throughout flexion

A

B

Landmarks of Forearm

• A: Radial Head: Articulates with capitellum. Covered in articular cartilage which allows it to rotate

• B: Radial Styloid

• C: Ulnar Styloid:Attachment of the TFCC

A

E

D

C

B

Landmarks of Forearm

• D: Lister’s Tubercle

• E: Distal Radio-ulnar Joint:DRUJ is stabilized by the TFCC. Triangular Fibrocartilage Complex is the articular disc, dorsal/volar ligaments, and the sheath of the ECU tendon

A

E

D

C

B




The Wrist

• In the normal forearm, 80% of the forces are transmitted through the distal radius.

• Of the 80%, 50% are transmitted through the scaphoid fossa and 30% through the lunate fossa.

• 20% of forces are transmitted through the ulna.

The Wrist

• Joints of the proximal row of the carpals are primarily a gliding joint.

• The distal carpal row is anchored by attachments to the metacarpals.

Bones of the Wrist & Hand




• Ligaments of the wrist are divided into 3 groups.

1. Volar radiocarpal ligaments

2. Interosseous ligaments

3. Dorsal intercapsular ligaments

Ligaments of the Wrist

Volar Radiocarpal Ligaments of the Wrist

• Volar wrist ligaments provide the majority of stability of the radiocarpal joint and maintain the position of the individual carpal bones.

• Scapholunate (SL) interosseous and Lunotriquetral (LT) interosseous ligaments are the 2 most important.

• SL interosseous ligament is implicated in the formation of dorsal intercalated segment instability (DISI)

• LT interosseous ligament is implicated with volar intercalated segment instability (VISI)

• These ligaments are arranged in a double chevron pattern which allows them to adjust the carpal rotation and the ulnar and radial heights of the carpus during radial and ulnar deviation.

Ligaments of the Volar Wrist




Ligaments of the Wrist

• The dorsal intercarpal (DIC) and the dorsal radiocarpal (DRC) ligaments are important thickenings in the dorsal joint capsule.

• These structures provide important stabilization of the carpal bones.

Ligaments of the Dorsal Wrist

Ligaments of the Hand




Sagittal Band

• Stabilizes the extensor tendons at midline.

• Without the sagittal bands, the extensor tendon will snap at the MCP joint during flexion.

Triangular Ligament

• Prevents excessive volar shift of the lateral bands.

• Taut with PIP flexion and relaxed with PIP extension.

Oblique Retinacular Ligament

• Extends DIP when the PIP is extended

• Taut when PIP is extended and relaxed when PIP is flexed




Collateral Ligaments

Ligaments of the Hand

Ligament Function Clinical Importance

Oblique RetinacularExtends DIP when PIP

extendedTaut when PIP is extended,

relaxed with PIP flexed

TriangularPrevents excessive volar

shift of lateral bandsTaut when PIP is flexed,

relaxed with PIP extended

Sagittal BandsStabilizes extensor tendons

at midline

MCP / IP Collateral Joint stabilityIP Collateral taut at 25

degrees flexion

Volar Plate Prevents IP hyperextension Stronger in PIP than DIP

Bones & Ligaments of the UE



Ligament Function Clinical Importance

Oblique Retinacular Extends DIP when PIP extended Taut when PIP is extended, relaxed with PIP flexed

Triangular Prevents excessive volar shift of lateral

bands

Taut when PIP is flexed, relaxed with PIP extended

Sagittal Bands Stabilizes extensor tendons at midline

MCP / IP Collateral Joint stability IP Collateral taut at 25 degrees flexion

Volar Plate Prevents IP hyperextension Stronger in PIP than DIP

Ligaments of the hand




Key Muscles of the Upper Extremity

Muscles Discussed

• Elbow Flexors / Extensors

• Forearm Supinators / Pronators

• Wrist Extensors / Flexors

• Extrinsic Finger Flexors / Extensors / Thumb Extensors

• Intrinsic Muscles of the Hand

• Extensor Mechanism

• Thenar / Hypothenar Muscles

Muscles Acting on the Elbow




Biceps BrachiiInsertion - Radial Tuberosity and Biceps AponeurosisInnervation - Musculocutaneous (C5-6)Action - Elbow Flexion and Supination of Forearm

Biceps Aponeurosis

BrachialisInsertion - Coronoid Process and Tuberosity of UlnaInnervation - Musculocutaneous (C5-6)Action - Strongest flexor or Elbow; Does not affect Supination/Pronation




BrachioradialisInsertion - Distal Radius at the Radial Styloid ProcessInnervation - Radial nerveAction - Flexor or Elbow with forearm at neutral; Stabilizes elbow during quick motions

Triceps BrachiiInsertion - Olecranon Process of UlnaInnervation - Radial nerveAction - Elbow Extension and assists with Shoulder Adduction

AnconeusInsertion - Lateral surface of olecranon and Posterior ulnaInnervation - Radial nerveAction - Assists with Elbow Extension; Stabilizes elbow during rotation




Muscles Acting on the Forearm

SupinatorInsertion - Lateral radial shaftInnervation - Deep branch of Radial nerveAction - Supinates forearm

Pronator TeresInsertion - Lateral surface of radiusInnervation - Median nerveAction - Pronates the forearm




Muscles Acting on the Wrist

Wrist Extensors

• ECRB

• ECRL

• ECU

ECRBInsertion - Base of 3rd MetacarpalInnervation - Deep branch of Radial NerveAction - Extension and Radial Deviation of wrist




ECRLInsertion - 2nd MetacarpalInnervation - Radial NerveAction - Extension and Radial Deviation of Wrist

ECUInsertion - 5th MetacarpalInnervation - Posterior Interosseous Nerve (Radial)Action - Extension and Ulnar Deviation of Wrist

• Flexor Carpi Radialis (FCR)

• Flexor Carpi Ulnaris (FCU)

Wrist Flexors




FCRInsertion - Base of 2nd/3rd MetacarpalInnervation - Median NerveAction - Flexion and Radial Deviation of Wrist

FCUInsertion - Pisiform and TFCCInnervation - Ulnar NerveAction - Flexion and Ulnar Deviation of Wrist

The Finger Extrinsics




• FDS

• FDP

• FPL

Extrinsic Finger Flexors

FDS

• Insertion - Base of middle phalanx

• Innervation - Median Nerve

• Action - Flexion of PIP

• Tendons of FDS are independent of one another

• Camper’s chiasma is where the tendon of FDS splits before its insertion

FDS




FDP

• Insertion - Distal phalanx

• Innervation - Anterior Interosseous (Median); Ulnar Nerve

• Action - Flexion of DIP and PIP joints

• Ulnar 3 digits share common muscle belly

FDP

• At Camper’s Chiasma, the FDP emerges on its course from underneath the FDS tendon to its attachment on the distal phalanx

• The area of Camper’s Chiasma is very prone to develop tendon adhesions following a flexor tendon repair.

FPLInsertion - Base of thumb distal phalanxInnervation - Anterior Interosseous Nerve (Median)Action - Flexion of the thumb




Extrinsic Finger Extensors

• Extensor Digitorum Communis (EDC)

• Extensor Indicis Proprius

• Extensor Digiti Minimi (EDM)

EDCInsertion - Extensor Expansion of Middle/Distal PhalangesInnervation - Posterior Interosseous Nerve (Radial)Action - Primarily extends MCP; Assists with IP and Wrist Extension

EIPInsertion - Extensor hood of Index fingerInnervation - Posterior Interosseous NerveAction - Extension of Index; Assists with Wrist Extension




EDMInsertion - Extensor expansion of small fingerInnervation - Posterior Interosseous NerveAction - Extension of the small finger

• A: APL

• B: EPB

• C: EPL

Thumb ExtensorsA

B

C

The Intrinsics




Intrinsic Muscles of the Hand

• Dorsal Interossei

• Palmar Interossei

• Lumbricals

Dorsal Interossei

• 4 Dorsal Interossei

• Insertion: Proximal phalanx

• Innervation: Deep branch of ulnar nerve

• Action: Abduct the finger

Palmar Interossei

• 3 Palmar Interossei

• Insertion: Proximal phalanx

• Innervation: Deep branch ulnar nerve

• Action: Adduct the finger




Lumbricals

• 4 Lumbricals

• Insertion: Extensor expansion

• Innervation: 1st/2nd - Median nerve; 3rd/4th - Ulnar nerve

• Action: Flexion of MCP joint and Extension of IP joints

The Extensor Mechanism

Extensor Mechanism

• Extrinsic and intrinsic tendons merge to perform MCP/PIP/DIP motion

• The extensor mechanism has attachments from the interosseous muscles and a lumbrical muscle.

• These intrinsics make up the lateral bands which allow DIP extension.

• The triangular ligament prevents their subluxation.




Extensor Mechanism

• The central slip inserts on the base of the middle phalanx allowing PIP extension.

Extensor Mechanism

• The sagittal band is the most proximal portion and centralizes the extensor mechanism over the metacarpal head.

• It allows extension of the proximal phalanx on the metacarpal head. Primary extension of the MCP is accomplished when the extensor tendon pulls on the sagittal bands lifting the proximal phalanx.




Thenar & Hypothenar Muscles of the Hand

• Opponens Pollicis

• Flexor Pollicis Brevis

• Abductor Pollicis Brevis

Thenar Muscles

Opponens PollicisInnervation - Median NerveAction - Flexion of the thumb at the CMC joint




Flexor Pollicis BrevisInnervation - Median / Ulnar NervesAction - Flexion of the thumb at the MCP joint

Abductor Pollicis BrevisInnervation - Recurrent branch of Median Nerve Action - Abduction of the thumb

Hypothenar Muscles

• Opponens Digiti Minimi

• Flexor Digiti Minimi Brevis

• Abductor Digiti Minimi




Opponens Digiti Minimi Innervation - Ulnar NerveAction - Draws small finger anteriorly, rotating it for opposition

Flexor Digiti Minimi BrevisInnervation - Ulnar NerveAction - Flexion of the small finger

Abductor Digiti MinimiInnervation - Ulnar NerveAction - Abduction of the small finger




Insert Video: Muscles of the UE

Take a Moment to Review

Fibroosseous & Synovial Tissue Structures

Fibroosseous Tunnels of the Wrist

• Carpal tunnel is formed by the bony ridges of the trapezium and the scaphoid on the radial side and the hook of the hamate and the pisiform on the ulnar side. The roof is formed by the transverse carpal ligament.

• Guyon’s canal is ulnar to the carpal tunnel. The boundaries are formed by the pisiform and hook of hamate. The roof is formed by the volar carpal ligament.

Carpal Tunnel

Guyon’s canal




Flexor Retinaculum

• Fibrous connective tissue on the volar side of the wrist crease.

• Provides mechanical advantage for the flexor tendons at the wrist level by preventing bowstringing.

Flexor Tendon Sheath

• Radial bursa (FPL) and the Ulna bursa

• The index, middle, and ring synovial sheath begins at the DPC

• The small finger is continuous with the ulna bursa

• In the digit, the sheath contains the FDS/FDP tendons.

Flexor Tendon Sheath

• At the level of the MCP, the flexor tendons enter a fibroosseous tunnel referred to as the flexor tendon sheath.

• The flexor tendon sheath keeps the tendons close to the bone improving the biomechanics of flexion by preventing bowstringing.

• The flexor tendon sheath also aid in providing tendon nutrition.




Flexor Tendon Pulley System

• 5 Annular Pulleys and 3 Cruciate Pulleys

• 3 Cruciate pulleys are collapsible and allow finger flexion without impingement of the adjacent pulleys.

Flexor Tendon Pulley System

• A2 & A4 most important for mechanical advantage

• A1 is usually implicated in trigger finger

Extensor Tendon Sheaths

• Localized at the wrist, extending 1cm distal to the extensor retinaculum and to the base of the metacarpals

• The 6 extensor compartments have separate synovial sheaths




Extensor Retinaculum

• Strong fibrous band of connective tissue on the dorsum of the wrist.

• Medially, the extensor retinaculum is attached to the ulnar styloid, triquetrum, and pisiform and laterally to the lateral margin of the radius.

• Loss of the retinaculum will result in bowstringing of the extensor tendons at the wrist level.

Extrinsic Extensor Tendons Compartments at the Wrist• 1st Dorsal Compartment: APL & EPB

• 2nd Dorsal Compartment: ECRL & ECRB

• 3rd Dorsal Compartment: EPL

• 4th Dorsal Compartment: EDC & EIP

• 5th Dorsal Compartment: EDM

• 6th Dorsal Compartment: ECU

Extensor Compartments at the Wrist




Take 10 to Review

Extensor Tendon Zones

Flexor Tendon Zones




Quiz Time!

Vascular Supply of the Hand

Vascular Supply

• The main arterial supply to the hand is from the radial and ulnar arteries, both terminal branches of the brachial artery.

• The radial artery is the smaller of the terminal branches. Can be palpated proximal to the radial styloid anteriomedial to the APL and EPB tendons. Its deep branch is palpated in the floor of the anatomical snuffbox.

• The ulnar artery is the primary arterial contribution to the hand. It can be palpated lateral to the pisiform.




The Arterial Arches of the Hand

• Provides collateral blood supply to the hand.

• Composed of the superficial and deep palmar arch

• The superficial palmar arch is formed primarily from the ulnar artery. It branches into 3 common digital arteries. These common digital arteries branch into proper palmar digital arteries which course along the sides of the index, middle, ring, and small fingers.

• The deep palmar arch is formed mainly by the radial artery and is proximal and deeper than the superficial palmar arch. This arch gives off 3 palmar metacarpal arteries, which join the common digital arteries from the superficial palmar arch.




Arches of the Hand

Veins on the Dorsum of the Hand

Nerve Supply of the Hand




The Brachial Plexus

Median Nerve (C5-T1)

• Pronator teres

• Palmaris longus & brevis

• FDS

• FDP to index and middle

• FPL / FPB

• Pronator quadratus

• APB

• Opponens Pollicis / Lumbrical (1,2)

Ulnar Nerve (C8-T1)

• FCU

• FDP to ring and small fingers

• Palmaris brevis

• Abductor digiti minimi

• Opponens digiti minimi

• Flexor digiti minimi

• 3rd & 4th Lumbrical

• Palmar & Dorsal Interossei




Radial Nerve (C5-T1)• Triceps

• Brachioradialis

• ECRL

• ECRB

• Supinator

• Anconeus

Radial Nerve (C5-T1)• Extensor Digitorum Communis

• Extensor Digiti Minimi

• Extensor Carpi Ulnaris

• Abductor Pollicis Longus

• Extensor Pollicis Brevis

• Extensor Pollicis Longus

• Extensor Indicis Proprius

Nerves of the Volar Hand

Median & Ulnar Nerves




UE Dermatomal Patterns

Sensation -Dorsal Hand

Sensation –Volar Hand




Course of Arteries & Nerves in UE

Chapter 1 Quiz

Chapter 1 Quiz - Answers




Chapter 2 slides

The Obstacle Course: Stages of Tissue Healing

Phases of Healing

• Hemostasis

• Inflammatory

• Proliferative

• Maturation

The Healing Process

• Immediately following injury or trauma to tissue, a chemical process is set into motion.

• Most models for tissue repair discuss 3 phases, but it is important to consider the effect of hemostasis as part of this process because it occurs within minutes of the initial trauma.

• The phases of tissue repair overlap one another in terms of timeframes, but each is essential in order to achieve the definitive outcome of complete tissue repair.

• Assessment and treatment varies according to the phase of tissue repair so a thorough understanding is essential.




Outline of Healing Timeline

Stage 1: Hemostasis• When tissue is injured, the blood comes into contact with collagen which triggers

blood platelets to release inflammatory factors.

• Platelets within the blood express glycoproteins on their cell membranes which allow them to “stick” to one another and to aggregate forming a mass.

• Fibrin and fibronectin cross-link to form a plug which traps proteins and other particles preventing further blood loss. This plug is the main structural support for the wound until collagen is deposited.

• Platelets are the cells which are present highest in number shortly after a wound occurs.

The picture of Platelet Aggregation




Hemostasis

• Platelets release cytokines and growth factors which stimulate cells to increase their rate of division.

• Platelets also release other inflammatory factors such as: serotonin, bradykinin, prostaglandins, and histamine which serve many purposes such as increasing cell proliferation and migration to the area as well as causing blood vessels to dilate and become more porous.

Inflammation• Within an hour of the initial trauma, neutrophils arrive at the wound site and become

the predominant cells in the wound for the first 2 days after the injury occurs, with higher numbers on the 2nd day.

• Neutrophils phagocytise debris and bacteria in the wound and kill bacteria by releasing free radicals.

• Neutrophils also cleanse the wound by secreting proteases that break down damaged tissue. Once they have completed their tasks, neutrophils are engulfed and degraded by macrophages.

• T cells divide more and increase inflammation from secreted cytokines. T cells also increase the activity of macrophages.

Inflammation• Macrophages are the predominant cells in the wound by the end of the 2nd day after

injury. They are essential to wound healing.

• The macrophage’s main role is to phagocytize bacteria and damaged tissue. They also debride damaged tissue by releasing proteases.

• Macrophages secrete growth factors and cytokines during the 3rd and 4th days post-injury. These factors attract cells involved in the proliferation stage of healing.

• Macrophages release factors which stimulate cells to re-epithelialize the wound, create granulation tissue, and lay down a new extracellular matrix.




Stage 3: Proliferation• Angiogenesis, also called neovascularization, occurs with fibroblast proliferation

when endothelial cells migrate to the area of the wound. Because the activity of fibroblasts and epithelial cells require oxygen and nutrients, angiogenesis is imperative for other stages in wound healing, like epidermal and fibroblast migration.

• The tissue in which angiogenesis occurs is typically red due to the increased presence of capillaries.

• Simultaneous with angiogenesis, fibroblast accumulate within the wound site. They enter the wound site at 2-5 days post-injury as the inflammatory phase is ending and their numbers peak at 1-2 weeks post-injury. By the end of the 1st week, fibroblasts are predominant in the wound.

• Fibroplasia ends 2-4 weeks after the initial injury.

Proliferation• Fibroblasts initially utilize the fibrin

cross-linking fibers to migrate across the wound where they adhere to fibronectin. Fibronectin then deposit ground substance into the wound bed, and later collagen, which they can adhere to for migration.

• Granulation tissue appears in the wound during the inflammatory phase (2-5 days post-injurymatrix.

Proliferation• One of fibroblasts’ most important duties is the production of collagen.

• Collagen deposition is important because it increases the strength of the wound.

• Type III collagen and fibronectin are generally produced between 10 hours and 3 days post-injury. This deposition peaks at 1-3 weeks.

• In the later phases of maturation, they are replaced by the stronger Type I collagen




Stage 4: Maturation / Remodeling• When the levels of collagen production and degradation equalize, the maturation

phase of tissue repair has begun.

• During maturation, type III collagen is degraded and the stronger type I collagen is laid down in its place.

Illustration of Phases of Healing in a Hand Wound

1 2 3

Tissue Early Healing Consolidated Healing

Skin 1 week 3 weeks

Tendon to Tendon 3 weeks 6-12 weeks

Tendon to Bone 3 weeks 6-12 weeks

Ligament as for tendon as for tendon

Nerve 3 weeks 6 weeks

Bone to Bone 3 weeks 6-12 weeks

Specific Tissue Healing Times



Tissue Early Healing Consolidated Healing

Skin 1 week 3 weeks

Tendon to Tendon 3 weeks 6-12 weeks

Tendon to Bone 3 weeks 6-12 weeks

Ligament as for tendon as for tendon

Nerve 3 weeks 6 weeks

Bone to Bone 3 weeks 6-12 weeks

Specific Tissue Healing Times




Section II

Learning the Art of War: Assessment Tools

Chapter 3

Identifying the Enemy: Assessment

Assessment of the Wrist & Hand

• History & Medical Record Review

• Pain Assessment

• Physical Examination

• Wound

• Scar

• Edema / Girth

• Temperature

• Range of Motion

• Strength

• Sensation

• Tendon Function

• Special Testing




History

• Mechanism of Injury

• Date of Onset

• Date of Injury

• Date of Surgery

• Time between injury and treatment

• Diagnostics

• Hand Dominance

• Occupation

• Current Treatment

• Current Complaints

Pain Assessment

• Location

• Score (Usually 0-10)

• Description: Sharp, Dull, Burning, Throbbing, etc)

• Frequency: Constant, Intermittent, Sporadic, At night, In A.M., with use, etc

• Aggravating Factors

• Pain Relief Measures

• Assessment Tools: Visual Analog Scale; Numeric Analog Scale; Pain Questionnaire; Graphic representation

Observation




Deformities

• Thumb Adduction Contracture

• Dupuytrens contracture

• Boutonniere

• Swan Neck

• Intrinsic Minus

• Claw hand

• Ape Hand

• Benediction Hand

• Ulnar Drift

• Mallet finger

• Jersey finger

Ulnar Drift; Thumb Adduction Contracture; Hyperextension of the thumb IP joint

Boutonniere Deformity




Dupuytren’s Contracture

Atrophy

• Inspect UE for signs of atrophy.

• If atrophy found, check sensation, muscle function, and palpable defects

• Median nerve: Atrophy of thenar eminence and thumb web space

• Ulnar nerve: Atrophy of hypothenar eminence and hand intrinsics

• Circumferential used to assess forearm and upper arm.

• Volumetric used to assess hand

Palpation

• Structures are palpated to determine variations in skin temperature; presence of sweating or dryness.

• Tendons, ligaments, joints, and scars are assessed for hypersensitivity.

• Muscles are assessed for trigger point tenderness, muscle spasms, and soft tissue restrictions.

• Tendons are palpated for tenderness, nodules, or adhesions.




Wound Assessment

• Location

• Size: Length; Width; Depth

• Color: Wound bed is described as red, yellow, or black

• Drainage (Exudate): Note amount, color, and presence of any odor

• Periwound Condition

• Periwound temperature

• Sutures / Staples

• Percutaneous pins / External fixators

Scar Assessment

• Color: Scars begin as deep red and become lighter as time progresses

• Size: A ruler can be used to measure the length and width

• Height: A scar is assessed if it is flat or raised.

• Pliability

• Sensitivity




Edema / Girth Assessment

• Location

• Type of Edema: Soft, Pitting, Brawny

• Edema refill test can be used by therapist to test the fluidity of the edema.

• General assessment of edema describes it as mild, moderate, severe.

• Can be measured objectively with circumferential or volumetric

Circumferential• Technique uses a tape measure with

circumference measured at a specific landmark. Measure contralateral side.

• Usually used if only a digit or isolated joints are involved.

• Also used to measure area proximal to the wrist.

• Consistency is key.

• Can also be used to measure girth for atrophy or hypertrophy.

Volumetric• Proper setup is key. Water should be

room temperature.

• Hand is lowered into volumeter with dowel between the middle and ring fingers.

• Water displacement is measured in a graduated cylinder.

• This test is accurate to 5 mL or 1% of the volume of the hand. Due to this a 10 mL difference is considered significant from one measurement to the next.




Insert Video

Edema Assessment

Temperature Assessment

• Compare temperature to contralateral side

• Note color of extremity: Erythema (Red); Cyanosis (Blue); Pallor (White)

• Note moisture / dryness

• Can measure with skin temp tapes or infrared

Range of Motion Assessment




• Elbow ROM is measured as extension/flexion as a 0-180 degree arc of motion.

• Example: -20/120 degrees

Elbow Extension/Flexion

Forearm Supination/Pronation• Forearm ROM is measured as

supination/pronation from the neutral position.

• The elbow must be flexed to 90 degrees with the arm held by the side.

• Hand-held goniometers for measuring supination/pronation are commercially available.

Wrist Extension/Flexion• ASHT recommends dorsal

placement of goniometer for flexion and volar placement for extension.

• Measurements can be taken from radial or ulnar side but they must be documented and consistency maintained.




Wrist Radial / Ulnar Deviation (Maintain position on the metacarpal)

Finger Range of Motion Assessment• In the hand, joint ROM is measured as extension/flexion.

• Flexion is recorded as a positive number.

• Lack of extension is recorded as a negative number while hyperextension is recorded as a positive number.

• Example: Index MCP: -8/65 degrees; Thumb IP: +10/45 degrees

• Other ROM techniques used are Flexion to the DPC, TAM, and TPM.

MCP Extension / Flexion




PIP Extension / Flexion

DIP Extension / Flexion

Thumb Radial Abduction




Thumb Palmar Abduction

Composite Finger Flexion to DPC• Measure finger flexion to the distal

palmar crease (DPC)

• Allows for quick measurement of composite finger flexion.

• Measure from the tip of the finger to the DPC crease.

• Measurement is documented as -0.0cm

• Example: Index Finger -2.5cm

Assessment of Range of Motion Limitations

• Extensor Lag

• Extrinsic Tightness

• Intrinsic Tightness




Extensor Lag• Can occur as result of weakness,

tendon lengthening, gap formation, and tendon adhesion.

• Extensor lag is the absence or lack of full extension.

• At the MCP joint, the EDC is involved.

• At the PIP/DIP joints, the extensor mechanism is involved.

• Example: MCP -15/70 degrees

• Adherence or tightness of the extrinsic flexors is detected by passively maintaining the fingers in full extension while passively extending the wrist.

• If flexor tightness is present, the increasing flexor tension that develops as the wrist is pulled into extension will pull the fingers into flexion.

• At the point where tension is first detected, the therapist should measure the position of the wrist to document the degree of restriction.

• Flexor restrictions may also occur distal to the wrist. In these cases, the position of the wrist will not affect the tendon tension.

• To test for tightness distal to the wrist, the MP joint is passively extended while the PIP/DIP are maintained passively in extension.

• The angle at the MP joint when tension is detected is documented.

Extrinsic Flexor Tightness

Extrinsic Extensor Tightness

• Extrinsic extensor tightness is measured in a reverse process.

• The digits are passively held in flexion while the wrist is flexed by the therapist.

• As tension develops the fingers will be pulled into extension.

• The position of the wrist at the point of tension is noted.

• Extensor restrictions distal to the wrist are tested with the PIP/DIP joints passively held in flexion as the MP joint is passively flexed.

• The position of the MP joint is noted when there is tension detected.




Bunnell’s IntrinsicTightness Test

• MCP joint is held in extension and the PIP joint is flexed.

• If the PIP can flex with the MCP in flexion but not extension, intrinsic tightness should be suspected.

• If the PIP is unable to flex regardless of the MCP position, then there can be intrinsic tightness or capsular contracture

Assessment of Grip and Pinch Strength

Grip Strength• To test grip strength, position the patient

with the elbow flexed to 90 degrees, the forearm in neutral, and the wrist in a slightly flexed position.

• For grip testing, the handle position is usually set on #2 for women and #3 for men, unless their hand size is smaller.

• Grip should be performed with 3 trials in order to get an average.




Grip Strength Testing

• 5-Position grip can be used to test validity of results. Results should be a bell-shaped curve.

• Rapid Exchange grip testing is excellent for testing patient maximum effort or malingering. The examiner rapidly moves the dynamometer from the left to right hands for 8-10 trials on each hand. The coefficient of variance is used to identify grip strength results which are not consistent with the average.

Intrinsic Strength

• To test intrinsic strength in the hand, use a Jamar dynamometer.

• Set the handle position on #1.

• Follow the same testing protocol as for grip strength testing.

Pinch Strength Testing




Lateral Pinch

Tripod Pinch

Tip Pinch




Alternate Grip Strength Method• Use BP cuff or bulb dynamometer.

• To use BP cuff, make sure baseline is same for left and right.

• Measurement is in mm Hg

• Bulb dynamometers are available but the range of testing should be identified.

Manual Muscle Testing

• MMT can be performed to test specific muscle or muscle groups. Results are subjective and vary greatly.

• For more objective measurement of muscle strength, manual muscle testers are available but very expensive.

• Alternate is to use BP cuff. Establish baseline and be consistent with each measurement.

Assessment of Tendon Function




Extensor DigitorumCommunis (EDC)• To test EDC function, have the patient flex

the PIP/DIP joints and perform active extension of the MCP joint. This isolates the EDC.

• Patient may need to use an object (i.e. dowel, highlighter, etc) to perform correctly.

Flexor Digitorum Superficialis (FDS)

• Hold the adjacent fingers into a fully extended position.

• Ask the patient to flex the digit being tested.

• As the patient flexes the digit, PIP flexion will occur.

• Remember tendons of FDS are independent of one another.

Flexor DigitorumProfundus (FDP)• The DIP is held in a blocked position and the

PIP is held into extension while the patient actively flexes the DIP joint.

• Remember the ulnar 3 digits have FDP that share a common muscle belly.




Extensor Pollicis Longus (EPL)• To test the EPL, have the

patient place the palm down on a flat surface.

• Have the patient actively extend or try to lift the thumb off of the surface to test for normal EPL function.

Sensation

Classification of Sensory Tests

• Innervation density tests

• Threshold tests

• Stress tests

• Sensory nerve conduction studies.




Innervation Density Tests

Threshold Sensory Tests

Stress Tests




Selecting the Appropriate Sensory Assessment

Nerve CompressionNerve Laceration &

RegenerationSensory Screening

Semmes-Weinstein

Vibration (30 / 256 MHz)

Stress Tests

Tinel’s

Semmes-Weinstein

Static 2-Point Discrimination

Moving 2-Point Discrimination

Semmes-Weinstein



• Not a standardized test for procedure but a scoring scale was developed

• Hand is supported and vision occluded.

• Begin at 2mm, apply one or 2 points to fingertip pulp just before the point of blanching.

Static 2-Point Discrimination• Stimulus is applied parallel to the

longitudinal axis of the finger with the prongs perpendicular.

• Ask the patient is they feel 1 or 2 points. I

• f they are unable to detect 2 points 2mm apart, the width is increased and repeated until the correct number of responses are obtained (7/10).

• Testing is concluded at 20 mm.




2-Point Discrimination Scoring

Result Grade

1-5 mm Normal

6-10 mm Fair

11-15 mm Poor

1 Point PerceivedProtective Sensation

Only

0 Points Perceived Anesthetic

Semmes-WeinsteinMonofilament

Semmes-Weinstein• The hand is supported and vision occluded.

Patients are instructed to give response of “Touch” is stimuli is perceived.

• Monofilament is applied perpendicular to the skin until it bows. Pressure is applied for only 1-11/2 seconds.

• Filaments 1.65-4.08 are applied 3x to achieve the desired threshold. 1 correct response is all that is needed. The other filaments are only applied 1x.




Color Definition Monofilament

Green Normal 1.65-2.83

BlueDiminished Light

Touch3.22-3.61

PurpleDiminished Protective

3.84-4.31

Red Loss of Protective 4.56-6.65

UT Unable to Test ---

Assessment of Nerve Function

Radial Nerve Injury -Elbow Level• Muscles Affected: ECU; ECRL; ECRB;

EDC; EDM; APL; EPL; EPB; EIP; Supinator

• Functional Loss: Loss of radial and ulnar wrist extension; weakened supination; loss of MCP joint extension; loss of thumb extension and radial abduction.

• Sensory loss involves: Dorsal aspect of the thumb and the dorsum of the index, middle, and half of the ring fingers to the level of the PIP joint. If the PIN is solely involved, no cutaneous sensory deficit will occur.




Radial Nerve Injury -Forearm Level• Muscles Affected: ECU; EDC; EDM;

APL; EPL; EPB; and EIP.

• Functional deficits include: Loss of MCP joint extension of all digits; loss of thumb radial abduction and extension, and loss of ulnar wrist extension.


Radial Nerve Injury -Just Proximal to Elbow

• Muscles Affected: ECU; ECRL; ECRB; EDC; EDM; APL; EPL; EPB; EIP; Supinator; and Brachioradialis

• Functional Loss: Loss of radial and ulnar wrist extension; weakened supination; weakened elbow flexion; loss of MCP joint extension; loss of thumb extension and radial abduction.

• Sensory loss involves: Dorsal aspect of the thumb and the dorsum of the index, middle, and half of the ring fingers to the level of the PIP joint.

Radial Nerve Injury -Upper Arm

• Muscles Affected: ECU; ECRL; ECRB; EDC; EDM; APL; EPL; EPB; EIP; Supinator; Brachioradialis; and Triceps

• Functional Loss: Loss of radial and ulnar wrist extension; weakened supination; weakened elbow flexion; loss of elbow extension; loss of MCP joint extension; loss of thumb extension and radial abduction.





Median Nerve Injuries -High Level (At or Above Elbow)

• Muscles Involved: Opponens pollicis, APB, FPB, 1st and 2nd lumbricals; Pronator teres; FCR; FDS; Palmaris longus; FPL; FDP to the index and middle finger; Pronator quadratus

• Functional Deficits: Loss of thumb opposition; Limited fine motor prehension; weakened pronation and wrist flexion; loss of thumb and index IP joint flexion

• Sensory Loss: Involves the volar aspect of the thumb, index, middle, and half of the ring finger, and the dorsal surface of the distal phalanges of the thumb, index, middle, and radial half of the ring fingers.

Median Nerve Injuries-Low or Wrist-Level• Muscles Involved: Opponens pollicis,

APB, FPB, 1st and 2nd lumbricals

• Functional Deficits: Loss of thumb opposition; Limited fine motor prehension

• Sensory Loss: Involves the volar aspect of the thumb, index, middle, and half of the ring finger, and the dorsal surface of the distal phalanges of the thumb, index, middle, and radial half of the ring fingers.

Ulnar Nerve Injuries -High Level (At or Above the Elbow)• Muscles Involved: Abductor Digiti Minimi; Flexor Digiti

Minimi; Opponens Digiti Minimi; Lumbricals to the 4th and 5th digits; Dorsal Interossei; Palmar Interossei; Flexor Pollicis Brevis; Adductor Pollicis; FCU; FDP to the ring and small fingers

• Functional Deficits: Significant decrease in power grip. Finger prehension is affected. With lateral pinch, there is flexion of the thumb IP joint to compensate for loss of the adductor. Finger adduction/abduction is lost. Loss of the ability to actively flex the MCP of the ring and small fingers during simultaneous IP extension.

• Sensory Deficits: Volar surface of the ulnar aspect of the palm and the small and ulnar half of ring fingers; and the dorsal surface of small and ulnar half of the ring fingers.




Ulnar Nerve Injuries -Low or Wrist-Level• Muscles Involved: Abductor Digiti Minimi; Flexor

Digiti Minimi; Opponens Digiti Minimi; Lumbricals to the 4th and 5th digits; Dorsal Interossei; Palmar Interossei; Flexor Pollicis Brevis; Adductor Pollicis

• Functional Deficits: Functional grip and pinch are affected. With lateral pinch, there is flexion of the thumb IP joint to compensate for loss of the adductor. Finger adduction/abduction is lost. Loss of the ability to actively flex the MCP of the ring and small fingers during simultaneous IP extension. Decrease in power grip.

• Sensory Deficits: Volar surface of the ulnar aspect of the palm distally, and the volar surface of the small and ulnar half of the ring fingers.

Assessment of Nerve Function Quiz

• How is wrist extension affected by a radial nerve injury at the elbow vs. forearm level?

• Finger adduction/abduction is affected by injury to which nerve?

• Forearm supination is weakened with a high median nerve injury. True or False?

Assessment of Nerve Function Quiz - Answers

• How is wrist extension affected by a radial nerve injury at the elbow vs. forearm level? With injuries at the elbow wrist flexion is weakened.

• Finger adduction/abduction is affected by injury to which nerve? Ulnar

• Forearm supination is weakened with a high median nerve injury. True or False? False. Forearm pronation is weakened.




Assessment of Function

Methods of Functional Assessment

• Questionnaires

• Interview

• Observation

• Staged Observation

• Functional Tests

Questionnaires

• Canadian Occupational Performance Measure (COPM)

• Health Assessment Questionnaire: Uses HAQ Disability Index to assess disability and HAQ VAS Pain Scale

• Disability of the Arm, Shoulder, and Hand Index (DASH)

• Michigan Hand Outcome Questionnaire

• Arthritis Impact Measurement

• Boston Questionnaire




Functional Tests

• Moberg Pickup Test

• Bennett Hand Tool test

• Crawford Small Parts Dexterity Tests

• Jebsen-Taylor Hand Function (Composed of 7 subtests)

• Minnesota Rate of Manipulation

• 9-Hole Peg Test

• Purdue Pegboard

• Valpar Work Samples

• BTE Work Simulator

Moberg

Bennett Hand Tool Test




Minnesota Rate of Manipulation

O’Connor Tweezer Dexterity

Purdue Pegboard




Grooved Pegboard

Special Testing for Assessment of Common Conditions

Cervical Myotome Screen

• C5: Shoulder Abduction

• C6: Elbow Flexion / Wrist Extension

• C7: Elbow Extension / Wrist Flexion

• C8: Finger Flexion

• T1: Finger Abduction




Median Nerve Testing

Phalen’s Test

• Detects Carpal Tunnel Syndrome (Sensitivity 59%-79%)

• Method 1: Patient places elbows on table with wrists flexed for 1 minute.

• Method 2: Patient places dorsal surfaces of hand together, fully flexing the wrists and holding this position for 1 minute.

• Method 3: Reverse Phalen’s. Palms of both hands are placed together fully extending the wrists and this position is held for 1 minute.

• Positive Sign: Tingling in the thumb, index, middle, and radial side of the ring finger. Note the time of onset of symptoms.

Phalen’s Test: Method 2




Phalen’s Test: Method 1

• Detects: Carpal Tunnel Syndrome (Sensitivity 61%)

• Method: Patients elbows are extended, forearm supinated, and wrist flexed to 60 degrees. Examiner compresses with thumb or finger over the median nerve at the carpal tunnel and this position is held for 20 seconds.

• Postive Sign: Pain and paresthesia in the thumb, index, and middle fingers.

Wrist Flexion & Median Nerve Compression

Pronator Syndrome Testing (Median N.)




Anterior Interosseous Syndrome Testing

Radial Nerve Testing

Radial Tunnel Syndrome Testing




Superficial Radial Nerve Lesion Testing

Ulnar Nerve Testing

Elbow Flexion Test

• Detects: Ulnar nerve compression at the elbow

• Method: Elbow is fully flexed and the wrist is held in neutral for up to 5 minutes.

• Positive Sign: Reproduction of symptoms in the ulnar nerve distribution




Froment’s Sign

Wartenberg’s Sign

Wrinkle Test

• Detects: Denervation of fingers (Sensitivity 97%)

• Method: Patient’s fingers are placed in warm water for 30 minutes.

• Result: Normal nerve innervation is exhibited by finger wrinkling (shriveling) while denervation is exhibited by a lack of wrinkling.




Tinel’s Sign

Tendinitis Testing

Finkelstein’s

• Detects: DeQuervain’s




Intersection Syndrome Testing• Complaint: Pain and tenderness 4-6cm

proximal to Lister’s tubercle where the APL and EPB muscle bellies intersect with the ECRB and ECRL.

EPL Tendinitis

• Complaint: Pain at Lister’s tubercle

FCR Tendinitis

• Complaint: Pain over the volar proximal wrist crease and at the scaphoid tubercle.

• Method 1: Resisted wrist flexion and radial deviation

• Method 2: Pain with passive wrist extension

• Positive Sign: Reproduction of symptoms




ECU Tendinitis

• Complaint: Pain along the ulnar side of the wrist in the area of the ECU tendon. Swelling may be palpable.

• Method: Forearm supination with wrist ulnar deviation

• Positive Sign: Reproduction of symptoms

Epicondylitis Testing

Cozen’s Test

• Detects: Lateral Epicondylitis




Mill’s Test

• Detects: Lateral Epicondylitis

Varus / Valgus Stress Test

• Detects: Instability of the digital collateral ligaments

Piano Key Test

• Detects: DRUJ instability

• Method: Examiner grasps the patient’s radius and ulna. They are then moved in opposite directions (volar vs dorsal) while the forearm is in varying degrees of supination/pronation.

• Positive Sign: DRUJ instability when compared to the contralateral side




Watson Test

• Detects: Scapholunate instability

TFCC Press Test

• Detects: TFCC Tears

TFCC Load Test

• Detects: Ulnocarpal impingement; TFCC tears

• Method: Examiner ulnarly deviates the patient’s wrist while simultaneously manipulating the proximal carpal bones repetitively from a volar to a dorsal position or relatively pronating and supinating the forearm.

• Positive Sign: Crepitus, clicking, catching, and reproduction of patient’s symptoms.




Section III

Locked and Loaded: Treatment Strategies Used in the Field

Chapter 4

Basic Survival Skills: Physical Agent Modalities

Physical Agent Modalities

• Moist Heat Packs

• Cold Packs

• Fluidotherapy

• Paraffin

• Contrast Bath

• Hydrotherapy

• Electrical Stimulation

• Ultrasound

• LASER

• Biofeedback

• Vasopneumatic Compression




What is the role of Physical Agent Modalities?

Physiological Effects of Cold

• Vasoconstriction

• Decrease edema and inflammation

• Decreases collagen extensibility

• Increases pain threshold by acting as a counter-irritant

• Slows nerve conduction velocity

• Temporarily decreases spasticity

Cold Pack

• Silicone gel packs

• Stored at -5 degrees C

• Must be covered with a towel or pillowcase to protect the skin

• Treatment time is 5-20 minutes




Ice Massage

• Can use probes

• Water frozen in a plastic or styrofoam cup.

• Small, circular motion is performed over the area prior to deep massage

• Treatment time is 1-7 minutes

Cool Water Soak

• Hand is immersed in a whirlpool, sink, or basin.

• Allows for exercise or movement during.

• Temperature is 55-80 degrees F

• Easy for patient to perform at home

Physiological Effects of Heat

• Elevates temperature 1-3cm of skin surface (5-8 minutes for skin and 20 minutes for muscle). Increase blood flow thereby increasing nutrients and removing by-products

• Increases connective tissue elasticity

• Increases metabolic rate

• Increases arteriole dilation and capillary pressure which can increase edema

• Increases endorphin release

• Decreases tonic contractions with muscle spasms




Precautions/Contraindications of Heat

• Tissue destruction occurs at 113 degrees

• Edema

• Areas of decreased sensation or circulation

• Areas of malignancy

• Replantation

• Infection

• Patients prone to bleeding (hemophiliac; long-term steroid use)

Hot Packs

• Heats by conduction

• Canvas hot packs which contain a silicone-based gel. Packs are heated in hydrocollator at 160 degrees F.

• Different hot packs for different areas of use. Use 4-6 layers of towels.

• Heat penetration is only to 1cm and this temperature increase will remain elevated for 45-60 minutes.

• Treatment time is 10-20 minutes.

• Most effective when stretch or mobilization immediately follows

Hot Packs -Precautions/Contraindications

• Never have patient lie on the hot pack

• Avoid if edema is present

• Avoid if sensation is impaired

• Do not use if there is active inflammation

• Do not use in the presence of infection




Paraffin• Paraffin wax and mineral oil with melting point at 125 degrees. Treatment

temperature is usually 115-120 degrees.

Paraffin - Precautions/Contraindications

• No open wounds or infection.

• Combustible

• Remove jewelry and watch clothing

• Do not use with decreased areas of sensibility

• Maximum heating time if patient keeps the wax seal intact.

Fluidotherapy

• Dry heat modality which uses a finely ground medium (natural cellulose or corn husks) and simultaneously applies heat, massage, and sensory stimulation.




Fluidotherapy - Precautions/Contraindications

• Open wounds

• Presence of infection

• Severe edema

• Skin hypersensitivity (Allergies)

• Use caution with asthma

• Circulatory problems

Whirlpool

• Used now mostly for the debridement or cleansing of wounds.

• Additive are used for sterilization and debridement.

• Treatment temperature can range 98-105 degrees for 15-20 minutes. 91-96 degrees are used for acute injuries.

Whirlpool - Precautions/Contraindications

• Edema

• Cellulitis Infection

• Monitor temperature when inflammation is present

• Venous insufficiency

• Arterial compromise

• Monitor agitation level when using for burn or when skin grafts present

• Do not use with external fixator, percutaneous pins, or k-wires which are exposed




Contrast Bath

• Uses 2 containers. One is filled with warm water (105 degrees) and the other with cold water (60 degrees).

Contrast Bath - Precautions/Contraindications

• Raynaud’s

• Hypertension

• Following crush injury or replantation use caution due to vascular status

• Do not use when the extremity has poor circulation

• Do not use with open wounds

Ultrasound

• Energy-->Crystal-->Sound Energy-->Vibration-->Heat/Mechanical

• Has thermal and non-thermal properties

• 1Mhz US is absorbed 3-5cm (50% penetrates to 5cm)

• 3MHz is absorbed 2-3cm




Ultrasound: Continuous (Thermal Effects)

• Increase blood flow and oxygen uptake

• Increases cellular metabolism

• Increases collagen tissue elasticity

• Decreases pain

• Increases peripheral nerve conduction

Ultrasound: Pulsed

• Increases cellular metabolism

• Decreases pain

Ultrasound - Contraindications

• Pacemaker

• Pregnant uterus

• Area of malignancy

• Eyes

• Carotids

• Brain / Sinus

• Growth plate (<21)

• Spinal cord following laminectomy

• Active infection

• Heart

• Areas of impaired sensation




Electrical Agents

• NMES / Russian

• Interferential (IFC) / Premodulated

• High Volt Pulsed Current (HVPC)

• TENS

• Biofeedback

• Iontophoresis

Iontophoresis

• Direct electrical current used to deliver ions

• Coulomb’s Law: Opposite charges attract and like charges repel

• Medications used must be dissolved in water

• Time required to drive medication depends on the amount of current. (40 mA/min is usual dose)

Iontophoresis: Common Medications

Dexamethasone - Anti-inflammatory Pain

Lidocaine + Analgesic Pain

NaCl - Sclerolytic Scar Adhesions

Acetic Acid - Sclerolytic Calcium Deposits




Iontophoresis - Precautions/Contraindications

• Pacemakers

• Drug allergies

• Pregnancy

• Diabetics

• Seizures

• Impaired sensation / vascularization

• Areas with compromised skin integrity

LASER

• Works by photobiomodulation

• Effects the body at a cellular level

• Can promote healing, decrease pain, decrease muscle spasm, etc

Vasopneumatic Compression• Applies compression either

intermittently or sequentially.

• Amount of pressure for UE is usually no more than 40 mm Hg

• GameReady uses intermittent compression and cryotherapy




Modality Tips

• Never base treatment solely on modalities.

• It may take 2-3 treatments to know effectiveness of modality.

• Watch reimbursement. Fluidotherapy is often denied. Iontophoresis often not reimbursed, especially with Medicare. Documentation is key.

• Know the purpose of the modality within the treatment plan.

Passing the Physical Test of Therapeutic Exercise

• Passive Range of Motion (PROM)

• Active-Assisted Range of Motion (AAROM)

• Active Range of Motion (AROM)

• Isometric Strengthening

• Isotonic Strengthening

Progression of Therapeutic Exercise




Passive Exercise

• Exercise is produced entirely by an outside force such as therapist, patient, machine, gravity.

• Passive exercise is used to maintain joint and soft tissue mobility as well as the mechanical elasticity of a muscle.

• Passive Exercise decreases edema, assists with circulation, enhances synovial diffusion, and decrease pain.

• Indicated when pain, paralysis, spasticity, and weakness prevent a patient from actively maintaining full joint range of motion.

Active Exercise

• Used to maintain mobility, enhance synovial diffusion, and decrease pain.

• AROM provides several advantages over PROM. Because AROM can apply stress to joints, soft tissue, and tendons, active exercises are the preferred mode of exercise when the integrity of repaired structures is not a consideration.

• Active exercise also provides for mechanical elasticity and contractibility of muscles and helps to stimulate bone integrity to prevent demineralization.

Resistive Exercise




Selecting Exercises

• Exercises to Restore Joint Mobility and Increase Range of Motion

• Exercises to Maintain and Restore Tendon Glide

• Exercises to Increase Elasticity / Extensibility of Muscle Unit

• Exercises to Increase Muscle Strength and Endurance

• Exercises to Improve Fine Motor Manipulation and Dexterity

• Exercises and Activities for Stress Loading and Desensitization

Exercises to Restore Joint Mobility and Increase Range of Motion

Passive Stretching Exercises

• Passive stretching can be done through the available ROM to maintain joint and soft tissue mobility or it can be done at end-range to lengthen shortened soft tissue structures.

• The potential abuses of passive stretching are mobilization of unprotected joints, stretching of the wrong joint or structure, and the infliction of additional tissue trauma.

• The corrective force should be applied in a gentle, slow, and sustained manner. When more than 1 structure is responsible for limitations in joint motion, separate exercises should be incorporated. (i.e. PIP flexion limited by joint tightness as well as intrinsic tightness)





• Stretching exercise should be used with caution when osteoporosis is suspected.

• After prolonged immobilization, vigorous or overly aggressive stretching is discouraged because immobilization can result in the decrease of the tensile strength of connective tissue.

• Precaution should be used when stretching edematous tissue because it is more susceptible to injury than normal tissue. Use the unaffected side as a guide to determine normal range.

• Limitations in joint motion may result from changes in the contractile and non-contractile components of muscle.

• While passive stretching procedures are capable of elongating both components, active inhibition techniques facilitate stretching of the contractile element of the muscle. Active inhibition techniques reflexively relax the muscle fibers to be elongated prior to the stretching maneuver. The contract-relax exercise is an example of active inhibition techniques.

• When stretching muscle-tendon systems that cross multiple joints, the muscle must be stretched over one joint at a time, and then all joints simultaneously, until optimum length of soft tissues is achieved.

• To minimize compressive forces in the small joints, stretching should start with the small, distal joints, and proceed proximally.


Passive Stretching of the Elbow for Extension / Flexion




Passive Stretching of the Forearm for Supination

Passive Stretching of the Forearm for Pronation

Passive Stretching of the Wrist for Extension




Passive Stretching of the Wrist for Flexion

Passive Stretching of MCP/PIP/DIP Joints

Passive Stretching of Thumb CMC/MCP Joints




Passive Stretching of Intrinsics (Interossei and Lumbricals)

Extrinsic Extensors (EDC)

Oblique Retinacular Ligament

Passive Stretching: Ligaments




Active Exercise

• When used to maintain joint mobility, active exercise should be performed through the full available ROM.

• Composite motions, such as fisting and thumb opposition to each digit, should be encouraged, as they reproduce normal functional activities.

• When active exercise is used to restore mobility in the presence of increasing tissue resistance, fast, ballistic movements are discouraged by instructing the patient to maintain the end range position so that a gentle stretch can be applied.

• When active exercise is used to restore motion in stiff joints, care must be taken to ensure that the corrective force is directed toward the stiff joint and not dissipated in the adjacent normal joints

Elbow Extension / Flexion

Forearm Supination / Pronation




Wrist Extension / Flexion

AROM Exercises - Wrist Radial/Ulnar Deviation

Low-Load Stretch Exercises - Elbow Extension/Flexion




Low-Load Stretch Exercises - Wrist Extension/Flexion

FlexionExtension

Isolated MP Joint Flexion - Isolates the Intrinsics

Blocking Exercises - Isolate AROM to the PIP joint




Blocking Exercises - Isolate AROM to the DIP joint

Exercises to Maintain and Restore Tendon Glide

Passive vs Active Exercise




• An important consideration when starting early active exercise to restore motion is the amount of force the exercise exerts on the tissue in the hand.

• Place-hold is the form of active exercise that applies the least amount of force on the tendon while producing the same tendon excursion as would occur with active motion.

Place-Hold Exercise

• With the hook position, maximum gliding is achieved between the FDS/FDP tendons.With the full fist position, the FDP achieves maximum gliding with respect to sheath and bone as well as a substantial amount of gliding over the FDS tendon.Withthe straight fist position, there is maximum glide of the FDS with respect to the flexor sheath and bone.

• Maximum FPL gliding is obtained by flexing the IP and MP joints of the thumb fully.

• Adhesions need to be stretched distally and proximally, therefore each position should be preceded by full finger extension.

Flexor Tendon Glides

Flexor Tendon Glides - Straight Fist / Full Fist / Hook Fist




• The muscle bellies of the FDS tendons are independent, allowing independent PIP flexion of each digit.

• Isolated FDS exercises are done by flexing one finger at a time at the PIP joint, with the uninvolved hand keeping the other fingers in extension.

Isolated FDS Exercise

Blocking Exercises

• Blocking exercises can also produce gliding of the flexor tendons with respect to surrounding structures, and gliding of the profundus tendon with respect to the superficialis.

• DIP joint flexion, with the PIP maintained in extension, inactivates the FDS tendon and produces glide of the FDP with respect to the FDS and the surrounding tissue.

DIP Blocking - Promotes Gliding of the FDP




Blocking Exercises

• PIP joint flexion, with the MP maintained in extension, encourages gliding of the FDS with respect to the surrounding tissue.

• PIP joint flexion, with the MP and DIP maintained in extension, encourages gliding of the FDS with respect to the FDP and surrounding tissue. During PIP joint flexion, with the MP joint in extension, if the patient can passively extend the DIP joint then the motion is performed exclusively by the FDS

PIP Blocking - Promotes Gliding of the FDS

Extrinsic Flexor Stretch




Extensor Tendon Exercises

• At the finger level, the EDC, interossei, and lumbrical tendons form a complex extensor mechanism. Adhesions can form at any point along the system, limiting active and passive finger flexion as well as active finger extension.

• extensor lag.

• Overcoming an extensor lag is not an easy task, considering the fact the extrinsic extensors are substantially weaker than the extrinsic flexors, making the proximal stretching of adhesions more difficult to achieve.

• The extrinsic extensors can generate only 38% of the tension of all the extrinsic finger flexors.

Extensor Tendon Exercises

• Extensor tendon adhesions can prove to be more disabling by limiting finger flexion more than finger extension.

• Lack of full active extension at the MP joint indicates an adhesion of the EDC, An extensor lag present at the PIP and DIP joints indicates adhesion of the extensor expansion,

Isolated EDC Exercise




• Active PIP and DIP extension should be performed with the MCP joint held in flexion. This position encourages intrinsic extension but also directs the force of the extrinsic extensor tendon more distally.

• As extension improves, the difficulty of the exercise can be increased. With the palm flat on the table, the patient is asked to lift the middle and distal phalanx off the table while the proximal phalanx remains on the table.

• .

PIP and DIP Joint Extensor Lags

PIP and DIP Joint Extensor Lags - Isolated Extensor Mechanism

• Adhesions between the EDC tendons are frequently a problem with injuries over the dorsum of the wrist.

• Differential gliding can be restored by alternately moving each digit into graded flexion, while the adjacent digits are held in extension.

• Combinations of dynamic flexion and extension splinting can be used to create a shear between these tendons, thus improving differential excursion.

Differential Extensor Tendon Glide




Extrinsic Extensor Stretch

• The manner in which extensor tendon adhesions are stretched distally depends on the location of the adhesion.

• Adhesions distal to the MCP joint are not affected by the wrist.

• Adhesions

Resistive Exercise for Tendons

• Maximizing muscle strength is important component of any program to manage tendon adhesions because active contraction of the muscle is the only way (except for NMES) an increased proximal pull can be exerted on tendon adhesions.

• Whenever possible, resistance exercises should promote a sustained contraction of the muscle, which will not only increase strength but also provide the most favorable force for scar remodeling.

• Sustained contractions provide the low-load, long duration force at the end range of motion that encourages lengthening changes of the scar collagen.

• Activities such as raking and sanding require sustained contraction of the FDS and FDP. These activities are effective only if each fingertip comes in direct contact with the tool handle. Due to this, the tool handle may need to be built up.

Resistive Exercise

• To strengthen the FDS, isolated FDS exercises can be performed into putty, PIP flexion against a clothespin in the palm.

• The FDP can be strengthened by having patients grasp a dowel with their hand and either push the dowel into putty or prevent the dowel from being pulled out of their hand.

• With an extensor lag, a velcro board is an effective means to apply graded resistance to finger extension. To strengthen the intrinsic finger extensors, the patient is asked to roll the can along the velcro board extending the PIP and DIP joints while maintaining the MCP joints in extension. To strengthen the EDC, the MCP is extended against the can while the PIP and DIP joints are maintained in flexion.




FDS Strengthening

FDP Strengthening

EDC / Intrinsic Extensor Strengthening




Exercises to Increase Elasticity / Extensibility of Muscle Unit

Extrinsic Extensor / Flexor Stretches

Exercises to Increase Muscle Strength and Endurance




• Immobilization produces muscle atrophy, with complete inactivity resulting in decreased strength at a rate of 5% per day. Resistance exercises not only increase muscle strength and endurance, but also improve the ability of the patient to actively mobilize stiff joints.

• Resistance exercise can be classified as either static (isometric) or dynamic (isotonic).

• Isometric exercise allows for strengthening without the stress to joints and soft tissue produced by dynamic exercise. Strength gains made with isometric exercise occur only at the joint angle at which the exercise is performed.

• Isotonic exercise occurs when a muscle is subjected to a constant or variable resistance throughout the available range of motion.

Resistance Exercise

Resistive Exercises - Forearm

Resistive Exercises - Wrist




Resistive Exercises - Grip

Resistive Exercises - Intrinsics

Resistive Exercises: Tendon




Exercises to Improve Fine Motor Manipulation and Dexterity

Fine Motor Activities

Exercises and Activities for Stress Loading and Desensitization




Desensitization / Stress Loading

Therapeutic Exercise Tips & Tricks

• Exercises are only limited by the imagination.

• Believe it or not Activity Analysis can be useful in formulating a therapeutic exercise program specific to each patient’s needs.

• Patients should feel tension on stretching, not pain.

• Patients should feel fatigued with AROM and strengthening exercises, otherwise patients are not being challenged.

• Change and adapt exercises each visit to target areas of limitation.

Wound Management

Chapter 6




Steps Involved in Wound Care

• Dressing Removal

• Wound Assessment

• Wound Irrigation / Cleansing

• Dressing Selection

• Special Considerations

Classifying the Wound

• Clean wound

• Dirty Wound

• Infected Wound




Wound Characteristics

• Wound Bed: Red; Yellow; White; Black; Bluish-green; Green

• Periwound: Macerated; Dry; Contracted

• Exudate: Amount; Color (Clear, Cloudy, Yellow, Bloody, Brown); Odor

• Tracking / Undermining

Wound Irrigation / Cleansing

• Wounds should be irrigated and cleansed with saline (NaCl

• Whirlpoolo

• Granulation and agigation

• Solutions such as Hydrogen Peroxide, Provodone Iodine, Phisohex, Acetic Acid, and/or Hibiclens should be used with caution in wound care.

• External fixators and percutanous pins require wound care.




Dressing Basics

• Dressings should suit their purpose: preventing infection; debridement; absorption of exudate; compression; promoting a healthy wound bed.

• Wet-to-dry dressings are for debridement of necrotic tissue. Make sure the wet gauze is applied only to the area where debridement is desired.

• Periwound

• motion

Common Dressings Used: Xeroform Gauze; Vaseline Gauze; Adaptic

Common Dressings Used: Packing Strip; Telfa; N-terface




Dressings: Tegaderm; Sorbsan

Wound Care Tips

• Promote healing of the wound bed but protect the periwound tissue.

• Wet-to-dry dressings are still good for debridement of wound. They should not be used once granulation tissue is noted in the wound.

• Triple antibiotic and Neosporin are oil-based and can inhibit normal wound healing if not used judiciously.

• Silvadene is often used for burn care but beware of the exudate.

• Be aware of wound odor.

• Bacteria can enter the body when any object breaks the skin barrier. Due to this, pin site care is paramount to prevent secondary infection.

Lean and Mean: Edema Management




Causes of Edema

• Tissue trauma

• Infection

• Immobilization or disuse

• Dependent position

• Constriction

3 Types of Edema

• Acute (Soft)

• Subacute (Pitting)

• Chronic (Brawny)

pitting

Brawny edema




Acute or Soft Edema

• Caused by an inflammatory response (trauma or infection).

• Elevated protein content

• Immediately reducible

• Can be temporarily displaced

• Soft to palpation

• Uniformly distributed

Treatment of Acute Edema

• Bulky Dressing

• Elevation

• Compression

• Limited AROM

• Manual Edema Mobilization (MEM)

• Cold Pack

• Splinting

• Balance of Activity and Rest

• HVPC

Bulky Dressing - Often applied post-op by physician




Elevation & Cold

Active ROM (Fist Pumping)

Compression: Silipos Gel Tube; Coban; Tubigrip




Subacute (Pitting) Edema

• Caused by increased arterial pressure or decreased venous pressure.

• Unaltered protein content

• Pitting to palpation

• Uniformly distributed.

Treatment of Subacute Edema

• MEM (Diaphragmatic breathing)

• Active and Passive exercise / ROM

• Vasopneumatic compression

• HVPC

• Coban wrap

• Loose Tubigrip stockinette or finger sleeves

• Compression gloves (Not too constrictive)

• Chip bags

• Fluidotherapy @ 98 degrees F or less

• Contrast Bath

• Gentle myofascial release

• Kinesiotaping

•HVPC: Polarity (-) @ 80-100 pps for 15-30 minutes




Loose Stockinette

Compression Glove

Contrast Bath




Retrograde Massage / MEM / Myofascial Release

Kinesiotaping

Chronic (Brawny) Edema

• Caused by prolonged inflammatory response.

• Elevated protein content

• Not easily reducible

• Hard or brawny to palpation

• Compartmental in distribution.




Treatment of Chronic Edema

• MEM (Diaphragmatic breathing)

• Active and Passive exercise / ROM

• Vasopneumatic compression

• HVPC

• Low Stretch bandages

• Coban wrap

• Loose Tubigrip stockinette or finger sleeves

• Compression gloves (Not too constrictive)

• Chip bags; Convoluted foam

• Fluidotherapy; Thermal modalities to increase elasticity

• Gentle myofascial release

• Kinesiotaping

Keeping the Pressure On: Scar Management

Scar Management Techniques

• Thermal Agents: Paraffin; Fluidotherapy; Moist Heat; Ultrasound; Iontophoresis

• Scar Tissue Mobilization: Applied perpendicular, parallel (in direction opposite line of pull), or circular motion

• Mechanical Vibration

• Silicone gel sheets; Scar Creams; Otoform Silicone Elastomer Molds

• Splinting

• Compression




Agents used for Massage / Mobilization of Scars:Cocoa Butter / Eucerin / Prossage Heat

Manual Scar Mobilization

Using Clockwise Motion Moving Parallel to Scar

Scar Mobilization Tools




Scar Mobilization with Pencil Eraser

Mepiform Silicone Bandage / Cica Care Silicone Gel Sheets

Compression with Silipos Gel Sleeves/Tubes




Compression with Glove

Protective Armor: Splinting the UE

Purpose of Splints

• To prevent or correct deformity

• To increase muscle strength

• To increase and maintain ROM

• To improve function

• To decrease pain

• To promote healing

• To protect injured / repaired structures

• To control scar formation




Choosing a Splint Type

• Static Splint

• Drop-out Splint

• Articulated Splint

• Dynamic Splint

• Static-progressive Splint

• Serial Static Splint

Static Splint

• Have no movable parts and maintain joints in one position.

• Position: To shorten or lengthen scar; To gain mechanical advantage of a given joint; To support a painful arthritic joint for function




Neoprene splint

Static Splint

• Immobilization to minimize inflammation; to promote vascularization of skin or bone grafts

• Protection for healing bone or newly repaired structures

• Pressure on scar for softening and bulk reduction




Serial Static Splint

• Decrease PROM limitations that have a hard end-feel when the therapist wants to maximize control of forces generated

• Lengthen adhesions

• Requires the therapist to remold the splint to accommodate increases in mobility.

• Serial casting for the fingers and serial wrist splints are examples.

Static-progressive Splint




Drop-out Splint

• Decrease PROM limitation when active motion can assist in improving PROM.

• Block joint motion in one direction but allow motion in another.

• Commonly used on elbow flexion contractures. The splint prevent elbow flexion but allows the triceps to contract to increase ROM in extension.

Articulated Splint

• Allow motion of joint in one plane while protecting: Bone proximally and distally; Joint capsule and ligaments in the perpendicular plane

• Provides specific arc of motion at a joint especially for ligament avulsion fractures

• Contain at least 2 static components and are connected in such a way to allow motion in one plane at a joint.

• Hinged braces




Dynamic Splint

• Substitute for weak or denervated musculature

• Lengthen adhesions proximally and distally

• Create a mobilizing force on a segment




dynamic

Dynamic Splint

• Decrease PROM limitations with soft end-feel

• Provide strengthening of specific muscles while controlling: proximal joints; length of muscle tendon unit during contraction; force magnitude; line of pull

• Create a mobilizing force on a segment

Splinting Tips

• Splints need to be functional in order for patients to be compliant with use.

• Theraputty is excellent to use over bony prominences to prevent pressure areas.

• Coban can be used when modling splints to make for easy removal so the warm splinting material does not adhere to underlying bandages. It also helps to prevent from making circumferential areas too tight.

• D-rings used on straps make it easier for patient application/removal.

• The splinting material makes the therapist!




Hand to Hand Combat: Manual Therapy Techniques

Manual Therapy Techniques

• Joint Mobilization

• Soft Tissue Mobilization

• Manual Lymphatic Drainage (MLD)

• Neurodynamics

Joint Mobilization

• Used to modulate pain

• Used to increase joint ROM

• Used to improve joint mechanics which can be altering ROM

• Applied to joints & related soft tissues at varying speeds & amplitudes using physiologic or accessory motions

• Force is light enough that patient’s can stop the movement




Soft Tissue Mobilization

• Type of manual therapy technique which targets tissue restriction such as myofascial limitations and scar tissue.

• Myofascial Release

• Graston

• ASTYM (Augmented Soft Tissue Mobilization)

Manual Lymphatic Drainage

Neurodynamics

• Developed by David Butler, PT

• Neurdynamics is an innovative, conservative management technique which involves mobilization of neural tissue.

• Neurodynamics offers management strategies for common syndromes such as tennis elbow, nerve root disorders, carpal tunnel syndromes and cubital tunnel syndrome.

• The technique involves assessment of neural glide with specific techniques of mobilization.




Chapter 11

Support the Unit: Taping Techniques

Types of Taping Techniques

• Athletic

• Leukotape/Hypafix

• Kinesiotape

• Spider Tape

Leukotape / Hypafix

• 2-layer taping technique.

• Base layer is Hypafix. Layer of tension or support us provided by Leukotape.

• Can be used for rigid support/fixation or in place of supporting splint/counterforce brace.




Demonstration

Taping of the Wrist and Elbow

Kinesiotape

• The Kinesio Taping Method is designed to facilitate the body’s natural healing process while allowing support and stability to muscles and joints without restricting the body’s range of motion.

• Taping technique that is designed to facilitate the body’s natural healing process while providing support and stability to muscles and joints without restricting the body’s range of motion as well as providing extended soft tissue manipulation to prolong the benefits of manual therapy.

Spider Tape

• Developed by Nitto Denko

• Precut tape for specific treatment areas: Shoulder, Elbow, Wrist, Power Strip, Lymphedema, etc.

• Hypoallergenic. Can be worn up to 5 days.




Closing Thoughts

Good Luck Soldier!

References

• Concepts in Hand Rehabilitation - Barbara Stanley and Susan Tribuzi. F.A. Davis Company, 1992

• Fundamentals in Hand Therapy: Clinical Reasoning and Treatment Guidelines for Common Diagnoses of the Upper Extremity - Cynthia Cooper. Mosby, 2007

• Hand, Elbow, & Shoulder: Core Knowledge in Orthopaedics - Trumble, Budoff, and Cornwall. Mosby, 2006

• Hand and Upper Extremity Splinting, Principles, and Methods (3rd Edition) - Fess, Gettle, Philips, and Junson. Mosby, 2005

• Rehabilitation of the Hand (3rd Edition)

• www.wikipedia.org



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