Chapter 11: Biomechanical Approaches: Evaluation and Intervention

Biomechanical Frame of Reference

Focuses on ROM, strength, and endurance required to perform an occupation.

Precautions and contraindications to performing joint measurements (ROM)

• Bone metastasis

• unhealed fracture/recent dislocation

• infection

• post surgery

• myositis osssificans

• subluxed or unstable joints

• skin grafts

Types of MMT: resistance test

• resistance applied throughout the range

• individual can compensate easily

• requires experienced therapist

Types of MMT: break test

• position in gravity eliminated or against gravity

• stabilize proximal to joint the muscles cross

• resistance applied in opposite direction of movement

• muscle grades

Grip strength

Dynamometer

• position UE shoulder abducted to side, elbow flexed to 90, and forearm in neutral

• Types of grip strength tests

  • Handle placed on position #2. Mean of 3 trials is compared to norms

  • One trial in all five positions for each hand. A bell curve is observed if individual is applying max effort

  • sphygmomanometer cuff or vigorimeter/bulb dynamometer: used to evaluate the grip strength of a person with arthritis

Pinch strength

Pinchmeter

• position of upper extremity: shoulder addicted to side, elbow flexed to 90, forearm in neutral

• types of pinch strength tests:

  • key or lateral pinch: thumb pulp to the lateral aspect of the index middle phalanx

  • three jaw chuck (palmar pinch): pulp of thumb to pumps of index and middle fingers

  • tip to tip: thumb pulp to pulp of index finger

three trials on each hand; compare the mean to the norms

Endurance/activity tolerance

• Count number of repetitions per unit of time

• determine percent of max heart rate

• measure time until fatigue

• use MET levels

Edema

Bodies initial response to injury

• Pitting- acute

• Brawny- chronic

Edema (measuring circumference)

• tape measure, recorded in CM

• compare extremities and document landmarks

• figure 8 method (whole hand)

Edema (measuring hand/arm mass)

Volumeter

• significant change is more than 10 ML***

Sensation Testing

Demonstrate with vision then occlude vision for actual testing

test uninvolved side first (apply stimulus to volar and dorsal surfaces

Spinal cord injury sensation testing

Proximal to distal following dermatome pattern

Neurologic disorders sensation testing

Tested for dermatome pattern

Peripheral nerve injury sensation testing

Distal to proximal following peripheral nerves

Order of sensation return for peripheral nerve injuries

Pain —> moving touch —> static light touch —> touch localization

Types of sensory testing

Light touch, localization, pain, temperature, stereognosis, moving two point discrimination, static two point discrimination, proprioceptive position sense, kinesthetic movement sense

Proprioceptive

position of the body In space

Kinesthesia

awareness of positioning of body parts and body movement

Light touch

Using a cotton ball or cotton swab, patient responds 'yes' or 'touched' when touched.

Localization

Using a cotton swab, person responds 'yes' when touched and then with vision points to area that they are touched

Pain (protective sensation)

Using a sterile safety pin or paper clip, the person will respond to 'sharp' or 'dull'.

correct response indicates intact pain sensation incorrect response indicates absent pain sensation

Pain (protective sensation) - response of “sharp” to the “dull” stimulus =

hypersensitivity

Temperature sensation

'Hot' or 'cold' use test tubes or a thermal kit

Stereognosis

Recognition by touch of common objects (scoring is based on the number of correct objects)

a second set of identical common objects should be used for individuals with expressive aphasia

Moving two point discrimination

Using a disk-criminator, Boley gauge, or paper clip

1. Testing begins with points 5-8 mm apart

2. Applied proximal to distal on fingertips in a longitudinal orientation following the digital nerve

3. Person responses to the number of points he/she feels (one, two)

4. Seven out of 10 responses must be correct before decreasing teh stance of the two points

scoring: normal = 2 mm

Static two point discrimination

Using a disk-criminal or, Boley gauge, or paper clip

1. Test begins at 5 mm

2. Applied to fingertips in a longitudinal orientation

3. Person responds one or two depending on the number they feel

4. Distance between points is increased until seven out of 10 responses are correct

5. Test is stopped at 15 mm

scoring

-normal = 5 mm -fair= 6-10 mm -poor= 11-15 mm -protective = one point perceived -anesthetic= no points percieved

Proprioception position sense

Therapist positions involved extremity person duplicates position with contralateral extremity

Kinesthesia movement sense

Therapist moves segment person responds up or down

Purdue pegboard

• Evaluation for coordination/dexterity

• Test of fingertip dexterity and assembly job simulation

• Subtests include:

  • a. Thirty second test: right hand, left hand, both hands, R+, L+, and both.

  • b. One minute test: assembly

• Scoring: thirty second test is the number of pins placed in the board in 30 seconds.

• Assembly is the number of parts assembled during 1 minute

Minnesota Manual Dexterity Test

Test of gross hand and arm movements

Subtests:

a. Placing test: measures rate of hand movement (one hand only)

b. Turning test: measures rate of bilateral finger manipulation

Scoring: time to complete board. One practice trial and 4 scored trials

O'Connor Tweezer Test

Test of Eye hand coordination using tweezers

• the number of seconds to place all pins in board using tweezers is the score

Crawford Small Parts Dexterity Test

Test of fine motor dexterity using small tools (tweezers and screwdriver) -the score is the time it takes to complete the assembly

9 Hole Peg Test

Measures finger dexterity (unilateral)

the time for each hand to place 9 pegs in a square board and remove them is the score

Jebson-Taylor Hand Function Test

Tests hand function

7 subtests:

• writing

• simulated page turning

• picking up common objects

• simulated feeding

• stacking

• picking up large light objects

• picking up large heavy objects

the time that it takes to complete each subject is the score

Michigan Hand Outcome Questionnaire

Looks at client perceptions of unilateral and bilateral functional activities.

also addresses perceptions of pain level, ability to participate in household and school activities, and appearance

Isometrics are contraindicated for persons with hypertension and cardiovascular problems because

They can increase blood pressure and heart rate

**- they should be avoided

Isometric exercise

Contraction without movement

Isotonic exercise

Contraction with movement

Two types of isotonic exercise

eccentric

concentric

isotonic exercise (eccentric)

lengthening

isotonic exercise (concentric)

shortening

Increase ROM

• PROM, passive stretching,

• heat or other thermal agents

• joint mobilization is performed before passive ROM but is a speciality area*,

• pendulum exercises,

• manual stretching,

• HEP,

• splinting,

• equipment,

• tendon gliding,

• blocking exercises,

• functional use,

• Preperatory methods, purposeful and occupation based activities

Increase strength

High resistance low repititions

Increase endurance

• Work at 50% of maximal resistance or less

• Increased repetitions, and duration, NOT resistance

• use energy conservation methods

Edema reduction

• elevate extremity above heart

• manual edema mobilization

• retrograde massage

• compression garments

• cold packs

• contrast bath

• elastic bandage, wraps and intermittent compression pumps

edema (elevation) precaution

Avoid extreme positions for individuals with right-sided heart weakness; this can cause the fluid to empty into the heart too fast

edema (MEM/retrograde massage) precaution

cardiac edema is present

Manual edema mobilization

hands-on-technique for stimulating the lymphatic system to remove the edema

• requires specialized training

Retrograde massage

Assists with return of blood and lymphatic fluid to the venous system

1. Gentle stroking is applied to centripetal direction

2. Massage should be performed with the extremity elevated

Common types of compression garments

Isotonic glove tubigrip ace wraps custom made coban wrap (wrapped distal to proximal)

Contrast bath

alternating immersion in hot and cold water

edema reduction techniques contraindications

DO NOT USE WITH PEOPLE WITH

• INFECTION,

• GRAFTS, OR WOUNDS;

• VASCULAR/CIRCULATION DAMAGE;

• BLOOD CLOTS;

• UNSTABLE FRACTURES;

• CONGESTIVE HEART FAILURE

• CARDIAC EDEMA

Scar management

1. Early mobilization

2. massage in circles with friction

3. compression

   1. Coban for the digits

   2. isotonic glove for the hand

   3. tube grip for the UE

4. scar pad with compression

5. Splinting to prevent contracture

6. Edema control

Desensitization for hypersensitivity

work over scar

1. massage

2. texture

3. vibration

4. three phase desensitization kit

5. fluidotherapy

*should be performed several times daily

Sensory re-education

• Massage,

• textures,

• vibration,

• desensitization

• review safety precautions

Sensory re-education (loss of protective sensation)

high risk for injury- must avoid use of hands where vision is occluded

Sensory re-education (impaired discriminative sensation)

has protective sensation, but cannot distinguish between objects when vision is occluded

Improving coordination

• begin with gross motor, grade up to fine motor

• ROM within reach yet challenging

• focus on accuracy and speed

Energy conservation and work simplification principles and methods

1. Plan rest periods

2. Schedule tasks with balance between light/heavy

3. Organize tasks

4. Avoid multi trips

5. Eliminate non essential tasks

6. Delegate

7. Combine

8. Sit to work

9. Organize cabinets so frequently used items are near

10. Use AE as needed

11. Use appliances

12. Slide rather than lift

13. Use lightweight items

14. Rest before fatigue sets in

Joint protection principles and methods

1. Maintain joint ROM by using max ROM during daily activities

2. Maintain muscle strength by using max strength during daily activities

3. Use the strongest and largest joint possible for task completion

4. Use joint in most stable and functional position

5. Avoid holding joints in one position / sustaining contraction for extended periods

6. Avoid positions of deformity

7. Do not start activity that can not be immediately stopped

Body mechanics principles and methods

• Do not move items that are too heavy; ask for assistance

• Slide or push an object along the surface rather than lift it, if possible

• Directly face the object about to be lifted. Do not face the direction in which the item is going to move

• Keep object close to the body during lifting and carrying

• Hold object centered at waist level

• Feet should be kept flat on the floor; balancing on toes should be avoided

• Maintain a firm and broad base of support. Maintain the body balanced over a wide stance

• Bend at the knees and hips, not at the waist

• Keep the back straight as possible

• Breathe while lifting

• Lift by straightening legs; do not pull upward with arms and back

• Do not rotate the trunk. Pick up the object completely and then pivot the entire body

• Lower the body to the level of the work

Static splint

No moving parts and immobilizes a joint or part

Dynamic splint

-includes a resilient component (elastic rubber band, or spring) which the individual moves

• designed to increase PROM or to augment AROM

Serial static splint

Static splint or use of casting material that is remolded to address changes in joint motion

Static progressive splint

Includes static adjustment part (turnbuckle or strap) that allows the patient or therapist to make changes to the tension or angle to increase motion

Purpose of splinting

• Rest

• Prevent deformities and contractures

• Increase joint ROM

• Protect bone, joint, and soft tissue

• Increase functional use

• decrease pain

• restrict ROM

Hand splinting design standards

-Maintain arches of the hand (proximal transverse arch; distal transverse arch; longitudinal arch)

-Do not impinge upon creases of the hand (distal and proximal palmar creases; distal and proximal wrist creases; thenar crease

Mechanical principles of splinting

-Decrease pressure: wide, long splint base is the most desirable. Round edges are needed

-Using sling applied with a 90 angle of pull

-Use low load to increase duration

-Maintain three-point pressure versus circumference

-Avoid the position of deformity (wrist flexion; MCP hyperextension; IP joints flexed; thumb adducted)

-Select the appropriate splinting position

Mechanical principles of splinting (functional position)

• wrist 20-30 extension

• MCPs 45 flexion

• IPs 20-30 flexion

• thumb abducted

Mechanical principles of splinting (Safe position (intrinsic + OR antideformity)

• wrist 0-20 extension

• MCPs 70-90 flexion

• IPs in extension

• thumb abducted and extended

Education on splinting

1. Maintenance and routine skin care and inspection

2. Ensure individual accepts and understands purpose/function/limitations

3. Teach proper donning/doffing

4. Provide FX use training

5. Re evaluate

OT/OTA role for splinting

1. OT/OTA team must carefully assess for most appropriate splint

2. OT must set splinting goals

3. Experienced OTAs can fabricate STATIC SPLINTS and can assist with dynamic splints

What type of splint is used for positioning with a person who has a brachial plexus injury?

Flail arm splint

What type of splint is used to assist with partial motion and finger extension for someone who has a radial nerve injury?

Colditz Splint or radial nerve splint

*this is a functional splint. It assists the digits with extension to release an object

*some therapists Rx resting hand splint for PM use to prevent flexion contracture

What type of splint is used to hold the thumb in opposition to use during functional activity for someone with a median nerve injury?

Opponens splint, C-Bar, or thumb post splint

-a thenar webspace is used to prevent thumb adduction contracture

Ulnar nerve injury

Anti law or lumbrical bar to position MCPs in flexion of digits 4 & 5;

used to prevent clawing of 4th and 5th digit

Combined median ulnar

figure of eight or dynamic MCP flexion splint to position MCPs in flexion for digits 2-5 to prevent the hand from assuming the intrinsic minus position

Spinal cord (C6-C7)

tenodesis splint

facilitates grasp and release

Carpal tunnel syndrome

Wrist splint positioned in neutral; decrease carpal canal pressure especially at night

Cubital tunnel syndrome

elbow splint positions at 30 degrees of flexion to prevent elbow flexion at night which will decrease ulnar nerve symptoms

De quervain's

Thumb splint including the wrist and leaving the IP joint free to place the first dorsal compartment at rest

Skiers thumb

Hand based thumb splint to protect the ulnar collateral ligament of the MCP joint of the thumb until healed

CMC arthritis

Hand based thumb splint to place the CMC joint of the thumb at rest

Ulnar drift

Ulnar drift splint/deviation splint to decrease pain, provide stability, and realign the MCP joints of digits 2-5 for a person with arthritic changes

Flexor tendon injury

Dorsal protection splint to protect the repair site and allow for early controlled mobilization while wearing the splint

Swan neck

Silver ringers, buttonhole/hyper extension block splint or digital dorsal splint in slight PIP flexion to place the PIP joint in slight flexion to prevent further development

Boutonniere

Silver rings or PIP extension splint to place the PIP joint in extension to allow for the lateral bands to move dorsal to the PIP axis

*often combined with DIP flexion exercises while wearing the splint

Arthritis

functional splint or safe splint, depending on stage.. to place joints at rest until inflammation decreases

Flaccidity

Resting/functional hand splint to prevent joint contracture and hold the hand in a position of function until muscle return occurs

commonly worn at night and periodically through the day

Spasticity

Spasticity splint or cone splint to prevent joint contracture

Muscle weakness (ALS, SCI, GBS)

Balanced forearm orthosis (BFO), deltoid sling/suspension sling to support the proximal UE to allow for use of distal extremity during activity IEP such as eating.

It mounts to a WC and prevents loss of shoulder motions

Hand burns

Wrist at 15-30 degrees extension MCP 50-70 flexion IPs full extension

to maintain soft tissue structures in a safe position

Physical agent modalities (PAMs)

preparatory methods to be used before purposeful and/or occupation based activities

Common types of PAMs used by entry level OT practitioners

1. Superficial thermal (paraffin, hot packs, fluido therapy)

2. Superficial cooling agents (cold packs, ice massage)

3. Mechanotherapy (ultrasound, whirlpool)

4. E stim units such as NMES, TENS, HVGS, and Iontophoresis

Types of heat transfer used with superficial thermal therapy

Conduction (hot packs and paraffin) HEATS UP TO 1 CM

Convection (fluidotherapy)

Radiation (laser)

Conversion (ultrasound) HEATS 4-5 CM

superficial thermal benefits

• RELIEVES PAIN,

• INCREASE TISSUE EXTENSIBILITY THUS INCREASING ROM,

• ASSISTS WITH HEALING,

• DECREASES SPASMS

Hot pack application

-check temperature of hydrocollator 165 is standard

-place hot pack in cover and add four layers of a folded towel between patients skin and hot pack cover

-check skin after 5 minutes to assess for issues

-remove after a total of 20 minutes

Paraffin Application

1. Check temperature of paraffin- 125 to 130 f is standard

2. After washing and thoroughly drying the hand, dip the hand into paraffin and quickly pull out. Repeat this process 8-10 times forming a glove of paraffin ove the hand.

3. Following the dip method, the hand should be wrapped with cellophane and then covered with a towel for 20 minutes

Fluidotherapy application

1. Preheat machine between 102-118 degrees f

2. Adjust blowers according to persons sensitivity

3. Place persons hand in the sleeve for 20 minutes; during this time person can exercise hand

4. Treatment is for 20 minutes and the persons hand is slowly removed from the machine making sure there are no particles coming out

Whirlpool application

used to clean and debride wounds

1. Fill tank with water at 100-108 degrees if treating burns temp should be body temp

2. Maintain sterile technique

3. Adjust turbine and turn it on- check the temp again

4. Slowly lower the extremity into the whirlpool

treat for 20 minutes