55thth January 2011 January 2011

Question 4Question 4

Joyce sustained a fall where she fell on Joyce sustained a fall where she fell on her outstretched hand 2 days ago. her outstretched hand 2 days ago.

Her X-ray results were normal.Her X-ray results were normal. The Doctor referred her for The Doctor referred her for

physiotherapy.physiotherapy. On examination, her MCP and PIP joints On examination, her MCP and PIP joints

of the hand are swollen and restricted of the hand are swollen and restricted in movement.in movement.

The Patient is unable to close the hand The Patient is unable to close the hand fully and the grip is weak.fully and the grip is weak.

Subjective & Objective AssessmentSubjective & Objective AssessmentQuestions to ask JoyceQuestions to ask Joyce

Were you able to flex your fingers into a fist Were you able to flex your fingers into a fist beforebefore

the fall?the fall?

Were you able to lift/hold objects Were you able to lift/hold objects

(e.g. hook grip/princer grip etc) before the fall?(e.g. hook grip/princer grip etc) before the fall?

If yes to both questions, have you ever had If yes to both questions, have you ever had

difficulty in performing the above? difficulty in performing the above?

Possible Objective AssessmentPossible Objective Assessment

AROM & PROM MCP Flexion / ExtensionAROM & PROM MCP Flexion / Extension AROM & PROM PIP Flexion / ExtensionAROM & PROM PIP Flexion / Extension

MMT For MCP and PIP JointsMMT For MCP and PIP Joints

Main ProblemsMain Problems

Fell on her outstretched hand 2 days ago Fell on her outstretched hand 2 days ago ACUTEACUTE

MCP and PIP joints of the hand are swollen MCP and PIP joints of the hand are swollen and restricted in movement and restricted in movement Decreased Decreased in ROMin ROM

Unable to close the hand fully and the grip is Unable to close the hand fully and the grip is weak weak Decreased in Strength. Decreased in Strength.

SwellingSwelling of MCP and PIP Joints of MCP and PIP Joints

Subjective & Objective AssessmentSubjective & Objective AssessmentGoalsGoals

Short Term Goals – reduce pain and edema, Short Term Goals – reduce pain and edema, increases ROM (usually to accomplish within increases ROM (usually to accomplish within

2-3 sessions of Physiotherapy )2-3 sessions of Physiotherapy )

Long Term Goals – To be able to perform Long Term Goals – To be able to perform higher intensity functional tasks – e.g. higher intensity functional tasks – e.g. cleaning the house, lifting heavier objects, cleaning the house, lifting heavier objects, playing sports that require grip strength e.g. playing sports that require grip strength e.g. tennis, badminton, squash, golf etctennis, badminton, squash, golf etc

(Usually within 1 to 2 months of Physiotherapy)(Usually within 1 to 2 months of Physiotherapy)

Subjective & Objective AssessmentSubjective & Objective AssessmentPrecautions and contraindications of CryotherapyPrecautions and contraindications of Cryotherapy

Hypersensitivity to ColdHypersensitivity to Cold

Cardiac DiseaseCardiac Disease

Coronary ThrombosisCoronary Thrombosis

Vasoconstriction of coronary arteryVasoconstriction of coronary artery

Arterial Blood PressureArterial Blood Pressure

Cooling larger areas, e.g. limb segment may lead to transient Cooling larger areas, e.g. limb segment may lead to transient rise in B.P. rise in B.P.

Elderly or young children with no ability to give f/b or Elderly or young children with no ability to give f/b or reliable answers/ may not understand the potential reliable answers/ may not understand the potential dangers.dangers.

Patients lacking local thermal & painful sensationPatients lacking local thermal & painful sensation

RationaleRationalePhysiological Effects Why did I choose Cryotherapy?Physiological Effects Why did I choose Cryotherapy?

Vasoconstriction of cutaneous blood vessels Vasoconstriction of cutaneous blood vessels

reduce heat loss to body surface)reduce heat loss to body surface) Increasing blood viscosity, increasing resistance Increasing blood viscosity, increasing resistance

to blood flow to blood flow reduced bleeding reduced bleeding Intense cold reduces conduction velocity of Intense cold reduces conduction velocity of

peripheral nerves , delay synaptic transmission peripheral nerves , delay synaptic transmission

Reduce Pain Reduce Pain

alleviated by reducing the release of pain-alleviated by reducing the release of pain-inducing irritantsinducing irritants

Decrease rate of swellingDecrease rate of swelling Lowers metabolism rate Lowers metabolism rate

REST, ICE, COMPRESSION, ELEVATION

Treatment Treatment Possible electrotherapeutic modalitiesPossible electrotherapeutic modalities

Acute Stage Acute Stage

(up to 72hours)(up to 72hours)

Swelling Swelling hence do not use Heat hence do not use Heat

Paraffin WaxParaffin Wax

Before Treatment……….Before Treatment………. Hot/Cold Test (Test-tube) Hot/Cold Test (Test-tube) Sharp/Blunt Test – due to burning sensation Sharp/Blunt Test – due to burning sensation Ice-cube test – 3 minutesIce-cube test – 3 minutesContraindicated if a round, red/pink patch appearsContraindicated if a round, red/pink patch appears(skin hypersensitivity to ice)(skin hypersensitivity to ice) Position the patient's hand above the heart Position the patient's hand above the heart

Warning Prior to TreatmentWarning Prior to Treatment

While receiving ice treatment, you are expected to feel cold, While receiving ice treatment, you are expected to feel cold, burning, achy and numbness at the area of application. burning, achy and numbness at the area of application.

Should you feel any discomfort, press the bell and call your Should you feel any discomfort, press the bell and call your Physiotherapist immediately.Physiotherapist immediately.

Throughout the treatment, please do not touch any equipment or Throughout the treatment, please do not touch any equipment or move around. move around.

Should you have any doubts, please call your Physiotherapist for Should you have any doubts, please call your Physiotherapist for assistance.assistance.

Do you understand?Do you understand?

TreatmentTreatment

TreatmentTreatmentMethod of ApplicationMethod of Application

Home Programme/ExercisesHome Programme/Exercises

Exercises to increase ROM & Muscle Strength

Ice bath for 20minutes at home

Progression of treatmentProgression of treatment(Assuming improved condition)(Assuming improved condition)

Heat TherapyHeat Therapy

Only if localised temperature riseOnly if localised temperature rise subsides subsides

Timeline between Timeline between

Subacute and Chronic StageSubacute and Chronic Stage

Paraffin Wax

NOT TO BE USED DURING ACUTE STAGE!

Progression of treatmentProgression of treatmentHeat Therapy – Physiological EffectsHeat Therapy – Physiological Effects

Vasodilate local cutaneous blood vesselVasodilate local cutaneous blood vessel Increasing blood flowIncreasing blood flow Increasing metabolic rate (oxygen uptake)Increasing metabolic rate (oxygen uptake) Promotes HealingPromotes Healing Increasing ROM Increasing ROM Heat allows greater tolerance of stretchingHeat allows greater tolerance of stretching Viscosity of tissues reducedViscosity of tissues reduced Increased collagen extensibility at high Increased collagen extensibility at high

temperaturestemperatures