OTA 103 mod 5

Characteristics of Peripheral Nerve Injuries

Characteristics of Peripheral Nerve Injuries

Muscle atrophy, Sensory loss along the cutaneous distribution of the nerve, muscle weakness, Trophic changes of soft tissue, & Inability to sweat

Sensory Loss

Along the cutaneous distribution of the nerve

Trophic changes

Changes in soft tissue resulting from interruption of nerve supply (Dry skin, hair loss, cynaosis, brittle fingernails, and slow would healing in the involved area.

Inability to sweat

Above denervated skin surface

Paresthesia

Tingling, numbness, burning, pain, or prickling sensation that is usually felt in hands, arms, legs, or feet.

Causalgia (Complex Regional Pain Syndrome Type II)

Chronic Pain Condition

Neuroma

Benign growth of nerve tissue frequently found at the end of a severed nerve

Clincal Signs Seen With Nerve Regeneration

Improved skin appearance, return of sensation, paresthesia distal to the lesion site, ability to swear returns, muscle tone increases.

Carpal Tunnel Syndrome or Median Nerve Injury

Innervates flexors of forearm & hand, Injury from lacerations & compression syndromes of the wrist. Sensory loss has more impact on fine motor function

Median Nerve Injury Treatment

Icing techniques, Isotoner gloves, Contrast baths reduce edema, Ultrasound, Splinting

Splinting for Median Nerve Injury Treatment

Wrist no more than 20 degrees of extension, thumb in palmar abduction and slight opposition to increase functional use of hand.

Ulnar Nerve Injury

Innervates the flexor carpi ulnaris, median half of the flexor digitorum profundus, Intrinsic muscles of the ring and little fingers. Hyperextension of MCP of ring and small fingers & flexion of the IP joints. Sensory loss results in burns to ulnar side.

Ulnar Nerve Injury Treatment

Allow PIP extension, Block hyperextension of the MCP

Radial Nerve Injury

Innervates extensor-supinator group of muscles. Extensor paralysis & wrist drop. Sensory loss not related to loss of function

Radial Nerve Injury Treatment

Splinting of Dorsal splint that provides wrist extension, MCP extension, and thumb extension. Protects from over stretching. Positions hand for functional use.

Combination of Median & Ulnar Nerve Lesions

Clawing of fingers

OT treatments with peripheral nerve injuries for Assisting with Pain Management

TENS (transcutaneous electrical nerve stimulation) unit, Provide graded sensory input, Instruction in protection of the painful area, divert the client’s attention, educating of relaxation techniques.

Sensory Re-education

Localization, Texture & Shape Discrimination

More OT Treatments with Peripheral Nerve Injuries Continued

Splinting, Faclitates movement & increased strength, Techniques to reduce edema.

Closed reduction

displaced bone manipulated under closed skin

Open reduction

Fracture site is exposed, fragments are aligned

Open reduction internal fixation (ORIF)

Fracture site is open; fragments aligned then held together with an internal fixation such as screws, pins, plate, rod

Extension fixation

Rods screwed into bone and exit body to stablizing structure on outside of the body

During immoblization

ADL compensatory techniques, Maintaining ROM above & below cast, Reducing edema by active motion & elevation as permitted

After Immoblization

Increasing ROM, Reducing edema, increasing endurance & strength, ADL retraining as needed

Adhesive Capsulitis or Frozen Shoulder

Primary adhesive capsulitis spontaneously with no trauma. Seconday adhesive capsulitis occurs due to trauma followed by immobilization. Progressive shoulder pain, Severe restriction of both passive & actve movement

Osteoarthritis (OA) Degenerative Joint DIsease (DJD)

Pain & stiffness in the joints caused by the destruction of projective joint cartilage on ends of bones.

OA risk factors

Older Age, Gender, Obesity, Joint Injuries, Certain Occupations, Genetics, Bone Deformities

Characteristics of OA

Progressive course. Non-inflammatory, non-systemic. Can affect any joint and can be limited to individual joints.

Clincial Features of OA:

Smooth Cartilage becomes soft & loses elasticity. Cartilage wears away and bones rub together. Joint loses normal shape. Hypertropy of bones. Bony growth (spurs), osteophytes. PIP joint: Bauchard’s nodes, DIP joint: Herberden’s nodes. Cysts may form in the bone. Crepitus joint sound grinding on irregular joint surface. Joint becomes stiff & unstable.

Treatment for OA

Aerobic exercises, healthy weight, OT/PT, Medications Surgery.

Medications for OA

Target localized inflammation. Target receptors in joints to reduce or prevent development of OA. Pain management: Acetaminophen, Non-sterodial anti-inflammatory drugs (NSAIDs)

OA Surgical & Other Procedures

Cortisone Injections, Lubrication Injections, Realigning bones, Joint replacement.

Rheumatoid Arthritis (RA)

Chronic inflammatory disorder that can affect multiple body systems, Autoimmune disorders, Affects lining of joints, causing a painful swelling that can eventually result in bone erosion & joint deformity.

Symptoms of RA

Tender, warm, swollen joints (fusiform swelling), Joint stiffness, Fatigue, fever, & weight loss. Early RA affect smaller joints first. Progresses to larger joints. Flare ups & Remissions.

Systemic Symptoms of RA?

Fatigue, Weight loss, Fever, Diffuse achiness, Prolonged morning stiffness

RA joint pathology

Synovitis occurs, joint swelling, joint space & surrounding tissues stretch out, inflamed joints, and continued inflammation.

(RA) Swan-Neck Deformity

PIP hyperextension DIP flexion

Boutonniere Deformity

PIP flexion DIP hyperextension

RA treatment

Remission more likely when treatment begins early with strong meds. DMARDs or Disease-modifying anti-rheumatic drugs.

Surgery: Restore use of the joint, reduce pain & correct deformities.

Synovectomy, Tendon surgery, Joint fusion (arthrodesis), Total joint replacement. Risk of Bleeding, Infection, & pain.

Gout

Metabolic disease. Heat, extreme pain, redness, swelling, joint stiffness, and deformity.

Risk factors for Gout

Male, obese, genetics, alcohol abuse, intake of foods rich in purines, enzyme defect. Treatment: Medications, lifestyle changes, and client education.

Acute ROM exercise for Arthritis

Gentle P/AROM to the point of pain (without stretch)

Subacute ROM Exercise for Arthritis

P/AROM with gentle passive stretch.

Chronic/inactive ROM exercise for Arthritis

Stretch at the end of range

Subacute Strength Exercise for Arthritis

Gentle exercise, which does not stress the joint

Chronic/Inactive Strength Exercise for Arthritis

May do resistive exercise, but use care to not over-stress the joint.

Heat PAMS

Increase blood flow and may provide, some pain relief, improve flexibility

Cold PAMS

Reduces Inflamation and Pain

Tetraplegia (Quadriplegia)

Paralysis to the four limbs & trunk. Injury to cervical spine.

When a person has an injury to the spinal cord,

there is loss of sensation & motor function below level of the injury

SCI level designates last

fully functional neurological segment of the cord.

Complete Injury

Complete lesion with a total lack of either sensory or motor function below the level of injury

Incomplete Injury

Some function of the spinal cord may be partially or completely intact below the level of the lesion.

American Spinal Injury Association (ASIA)

ASIA Impairment Scale (AIS), Classifies Injuries into 1-5 levels. Tests muscle strength and somatosensation.

SCI Evaluation of Motor Function

Tests muscle strength, Myotome: Group of muscles innervated by a single spinal nerve; 10 key muscles.

SCI Evaluation of Sensory Function

Tests light touch & pinprick.

Dermatome

Area of skin that is innervated by the sensory axons within each segmental nerve root; 28 key sensory dermatomes are each tested separately.

A= Complete

No sensory or motor function is preserved in sacral segments S4- S5

B= Incomplete (Sensory Incomplete)

Sensory, but not motor, function is preserved below the neurologic level and extends through sacral segments S4-S5

C= Incomplete (Motor Incomplete)

Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have a muscle grade of less than 3

D= Incomplete (Motor Incomplete)

Motor function is preserved below the neurologic level, most key muscles below neurologic level has a muscle grade is greater tan or equal to 3

E= Normal

Sensory & Motor Functions are normal

Sacral Sparing

Presence of sensory or motor function at the analmucocutaneous junction (S4-S5)

Zone of Partial Preservation

Used with complete injuries (ASIA) where the sensory and motor levels below the level of injury are partially innervated

Central Cord Syndrome

Damage to the middle of the spinal cord. Greater impairment of motor function in the upper extremities. Bladder dysfunction & sensory loss below the level of injury.

Brown-Sequard Syndrome

Damage to one side of the spinal cord.

Ipsilateral

Upper motor neuron paralysis & loss of proprioception

Contralateral

Loss of touch, pain, and temperature sensation.

Anterior Cord Syndrome

Damage to anterior 2/3 of spinal cord. Loss of motor control and loss of pain & temperature below the lesion. Intact proprioception, touch, and vibration.

Cauda Equina Syndrome

Damage to cauda equina. Low back pain, numbness and/or tingling in the buttocks and LE, LE weakness, incontinence of bladder and/or bowels.

Conus Medullaris Syndrome

Damage to conus medullaris. Severe back pain, bowel & bladder dysfunction, spastic or flaccid weakness depending on level of the lesion, bilateral sensory loss.

Early SCI Medical Treatment

Restoring normal alignment of the spine. Decompressing the spinal cord. Maintaining stabilization of the injured area. Portable immobilization devices used during healing process.

SCI Decreased Vital Capacity

Caused by weakness/ paralysis of diaphragm, intercostal muscles, and latissimus dorsi muscles leading to atelectasis (collapse or closure of a lung). Decreased productive cough and a tendency to develop respiratory infections. OTA may manually assist with coughing & deep breathing exercises.

Osteoporois due to SCI

Can develop due to disuse of the long bones, especially the legs. Can cause fractures. OTA may use standing frames to slow onset.

Orthostatic Hypotension

Decrease in blood pressure when person is moved from supine to upright position. Dizziness, nauseous, and may lose consciousness. Recline until symptoms go away. Abdominal binders and compression garments

Autonomic Dysreflexia (AD)

Sudde onset of excessively high BP. Caused by reflex action of autonomic nervous system in response to some stimulation: Distneded bladder, Fecal Mass, Urinary Tract Infection, Skin Breakdown, Tight Clothing, Painful Stimulus, DVT.

Autonomic Dysreflexia Symptoms

Pounding headaches. Flushed face and/or red blotches on the skin above the level of spinal injury. Nasal Stiffness. Nausea. A slow heart rate (bradycardia). Pilomotor reflex (goose bumps) below level of spinal injury.

What to do with Autonomic Dysreflexia client?

Sit up straight, loosen or take off any tight clothing or accessories. Empty the bladder and bowel. Check skin for red spots. Check blood pressure. Call doctor. If symptoms return, repeat the above steps and go to the emergency room or call emergency services. OTA should stay with client while getting medical help.

Spasticity

Maintains muscle mass, facilitates blood circulation, and can assist in ROM and bed mobility. Severe spasticity can be a problem and it is frequently treated with medications.

Heterotopic Ossification

Bone that develops in abnormal places usually around the hip, knee, shoulder or elbow. Can cause pain and limit joint ROM. Treatedwith medications. OTA, Maintenance of ROM, gentle stretching, and adaptive ways to approach ADLs.

SCI OT Treatment Evaluation

ROM, MMT, Sensation, Postural control, hand function, and ADLs. Goals established to utilize the motor skills that the client had to maxmize independence in functional activity.

Expected Functional Outcomes (C1-4)

Possible movement: Neck flexion, extension, and rotation. C4, scapular eleveation & rotation. Requires a ventilator for breathing at C1-3 but may be able to breath without a ventilator for C4. Suction needed to clear secretions. Totally dependent for all care. Independent in power chair with chin or breath control. Participation in functional activity is with mouth stick, high tech equipment and environmental control units (ECU).

Expected Functional Outcomes C5

Shoulder and Elbow ROM (No active elbow extension). No ventilator, but decreased vital capacity & may need help to clear secretions. Able to do pressure relief with equipment. Some ADL participation set up with splints or universal cuff. Mobility, can use a power wheelchair with hand control or push manual w/c short distances. May not require 24 hour attendant.

Expected Functional Outcomes C6

Scapular protraction, supination, radial wrist extension. Use of tendosis grasp with use of a splint. Continued decreased vital capacity. Independent for some level transfers. ADL Independent with self-feeding & upper body dressing with adaptive equipment. Mobility: Independent with manual. Independent with modified van with a lift.

Expected Functional Outcomes C7-8

Continued decreased vital capacity. Weak trunk control. Able to assist with bowel & bladder management. ADLs: Independent self feeding, grooming, upper body dressing & bathing. Independent for level transfers & some uneven transfers. IADLs able to do light meal preparation & homemaking.

Expected Functional Outcomes T1-9

Intact upper extremities & limited upper trunk stability. Independent with bowel & bladder management. Independent transfers. Driving a car with hand controls. Assisted with heavy housecleaning.

Expected Functional Outcomes T10- L1

Respiratory Function is now intact. Fair to good trunk stability. May ambulate with forearm crutches or walker and KAFO.

Expected Functional Outcomes L2-S5

Good trunk control & partial control of lower extremities. Able to ambulate with forearm crutches or cane and KAFO or AFO. Independent with all daily living.

Mobile Arm Support

Mounts on arm of w/c and allows client to produce elbow & shoulder motion with slight motion of the trunk or shoulder. Used with patients who moderate to severe UE muscle weakness.

Benefits of a standing frame

Preventing contractures, Maintaining bone mass, Psychological well being.

Sexuality & SCI COTAs Roles

Understand sexual function for SCI population. Be able to discuss issues.

Sexuality & SCI Intimate relationship includes

Affection, Tenderness, Sharing feelings, Intimate conversation

Sexuality & SCI Concerns

Inability to fully participate to please partner. Ability to have an orgasm. Becoming a parent. Bowel & Bladder Control. Autonomic dysreflexia.

Sexuality & SCI concerns for AMAB

Ability to achieve an erection

Sexuality & SCI concerns for women

ability to conceive is not usually imparied. Easier time returning to sexual activity. Use of lubricant to maintain skin integrity & prevent friction.