UE Conditions & Interventions

Ulnar Nerve Deformity

Claw Hand

Radial Nerve Deformity

Wrist drop and impaired wrist extension.

Median Nerve Deformity

Ape hand

Where are extrinsic muscles located?

extrinsic muscles are in the forearm with tendons leading into the hand

Where are intrinsic muscles located?

Intrinsic muscles are completely within the hand

What is the keyline for orthotics?

“Immobilize early to protect, mobilize later to correct”

What are the stages of healing?

• Inflammation: avoiding infection (few days), stabilizing

  • Reduce edema

  • Cryotherapy instead of heat

• Proliferation: forming scar tissues (few weeks), stabilizing & cautiously grading movement/activity

  • Begin ROM

  • Continue to protect

• Maturation: remodeling (few months to years), getting back to more typical function

  • Push for full function

  • Contracture management

What is the purpose of a static splint?

to immobilize, protect, and position (preventative and functional)

What is the purpose of a serial static splint?

to mobilize and improve ROM. splint that you keep remolding over time.

What is the purpose of a static progressive splint?

to mobilize, improve ROM, effective on stiff joints, follow wear with active use, adjustable

What is the purpose of a dynamic splint?

to mobilize, improve ROM, resistance exercise, and assist with movement (radial nerve palsy)

Orthoses Immobilization Purpose

pain relief

protection

positioning (functional, preventative)

prevent/manage contractures

manage muscle force

Orthoses Mobilization Purpose

remodel scar tissue

address contractures

increase ROM

facilitate movement

resistance exercise

joint fracture reduction

Orthoses General Guidelines (Wear)

tend to increase TERT (total end range time) before increasing force

watch for red spots, blanching, sensation changes etc. especially if they persist for longer than 10-20 minutes after removing the splint

Resting Hand Splint Use

general comfort

Antideformity Splint Use

positioning after trauma/edema

Short Thumb Spica Splint (Short Opponens) Use

Arthritis of CMC and MP of thumb

Long Thumb Spica Splint (Long Opponens) Usage

De Quervain’s Syndrome

Dorsal Blocking Splint Use

Post flexor tendon repair to limit tension on flexor tendons of digits to minimize risk of rupture

Wrist Cock-up Splint Use

radial nerve injury (holds wrist in extension)

radial tunnel syndrome

carpal tunnel syndrome (positions wrist in neutral)

Posterior Elbow Splint Use

positions the elbow into more flexion

Anterior Elbow Splint Use

postions the elbow into more extension

burns on the dorsal aspect of the arm

Purpose of PAMS

address pain, inflammation, muscle tone and encourage healing and muscle function

Heat (PAMS)

Very common

Relaxes tissues - vasodilation, tendons, muscles

Results in improved healing, stretch, pain relief

Superficial heat penetrates 1-2cm, Deep heat penetrates 2-5cm

What comes first after heat, PROM or AROM?

AROM is preferred, but be gentle when using PROM

Fluidotherapy usage

Allows for motor tasks during heating, sensory component for re-ed

Ultrasound

Deep heat

Continuous: provides benefits of heat to deep tissues (2-5cm)

Pulsed: provides mechanical benefits with minimal heating (on & off)

Cold purpose

AKA: cryotherapy

decreases circulation, inflammation and pain following initial discomfort

extra caution with vascular conditions, Raynaud's Syndrome

Remove cold as soon as numbness sets in to avoid tissue damage

E-stim purpose

Stimulates muscle contractions and sensations

Manual Edema Mobilization

trained technique (not entry level)

light manual mobilization for skin over lymph nodes to promote lymph flow

best for persistent edema from surgery or trauma

Compression

encourages fluid reabsorption

Contraindicated by DVT, severe cardiovascular concerns, peripheral neuropathy, and active TB

Edema gloves, elastic stockinette, short-stretch bandages, KT tape, Intermittent Pneumatic Compression

Cold

Reduces edema, especially early in the inflammatory phase

decreases blood flow

Isometric movement

holding resistance

Eccentric movement

lengthening of muscles

Concentric movement

shortening of muscles

SPORC

S- Strength

P- Pain

O- Occupations/tasks

R- ROM

C- Coordination

Which level of Spinal Cord Injury would benefit from using a wrist-driven flexor hinge orthosis?

C6

Rheumatoid Arthritis: which type of splint or orthoses is most appropriate for the purpose of resting the joints, decreasing pain, and preventing contractures?

Resting hand orthosis

What is the Shoulder Principle?

Proximal stability leads to distal mobility

What is Scapulohumeral Rhythm?

The humerus comes up 90 degrees; above that, the scapula moves to allow for full ROM

Erb’s Palsy

upper brachial plexus injury, affects the upper arm: shoulder on down

Klumpke’s Palsy

lower brachial plexus injury, affects lower arm: hand on up

Frozen Shoulder Protocols

do not overstretch during the freezing phase

encourage regular movement through comfortable range

primary treatment is compensatory strategy training and environmental modification

encourage pain-free AROM and to work around it until it thaws on its own

GH Instability treatment

start with isometrics in neutral position

anterior instability: focus on internal rotators and adductors

global instability: all muscles of the shoulder and scapula

Osteoarthritis

wearing down of cartilage elements of joints

Rheumatoid Arthritis

autoimmune condition that attacks the joints

What is the goal for dealing with arthritis?

to manage and prevent worsening symptoms and maximize function

Common deformities in OA

Boutonniere and mallet finger

Common deformities in RA

Boutonniere, swan neck

Ulnar drift

CMC

Wrist-radial subluxation

Arthritis Treatment - AROM

Pain free AROM of wrist and digits

Strengthening might be a part of treatment but very gentle, pain free

Arthritis Treatment - PAMS

OA: heat (paraffin is common, other heat modalities are effective)

RA: responds to a wider variety including heat, cold, and TENS

What is the standard mobility progression for a wrist fracture?

1- AROM

2- PROM

3- Resistive exercise

What is the standard mobility progression for a hand fracture?

1- AROM

2- PROM (external force)

3- Resistive exercise (external force)

What is the standard ROM progression for the elbow?

AROM to PROM to resistance

What is protective sensation?

sensitivity to touch as well as temperature

What does the monofilament and two-point discrimination test measure?

light touch

Which type of splint is most commonly used for wrist drop?

wrist cock-up splint

What are the functional common issues of the ulnar nerve?

grip strength

key pinch

being able to hold objects in hand

What is a positive froment’s sign

if the thumb slips or bends (compensates), during a key pinch test

What type of splint can be used for an ulnar nerve injury?

Nighttime elbow extension splint to limit elbow flexion

What type of splint is used for a median nerve injury?

Wrist cock-up splint with wrist in neutral, MP, thumb or elbow support might also be necessary

OT Role with peripheral nerve injuries

• Manage/prevent complications including pain and further injury

• Maintain function - ROM and nerve gliding

• Facilitate regaining function

OT interventions with peripheral nerve injuries?

Sensory Re-education

Pain Management

Desensitization

Modalities (depends on what is effective and safe for the client)

What test is most effective for testing for carpal tunnel syndrome?

Phalen’s sign

What is Wartenburg’s sign?

involuntary finger abduction of the fifth digit

What is the O’Rian wrinkle test and what population benefits from this test?

Keeps the hand submerged and observe lack of wrinkles

Toddlers and infants benefit from this test since they cannot verbally express pain

What is CRPS?

Chronic pain and edema that is marked by hypersensitivity to touch, texture, and temperature

OT Treatment for CRPS

Goal: repair the broken the relationship between the pain centers of the brain and affected.

decrease the perceived threat, and desensitize the area as much as possible

CRPS: Calm, Reflection, Progressive Stimulation

Calm (CRPS)

CBT

Relaxation/Mindfulness

Reflection

Mirror Therapy: touching or moving the unaffected side while looking at its reflection, it is critical that the client attempts to perceive the reflection as their actual body part

Progressive Stimulation

Desensitization: textures, vibration. Start near the painful area and work into it

SHOULD NOT BE PAINFUL

Build tolerance, not enduring pain

What is the primary modality used for CRPS?

Fluidotherapy reduces pain and swelling.

Useful for desensitization

Tendinopathy

Pain in the tendons with movement or tension

collagen breakdown from overuse, not inflammation

What is Lateral Epicondylosis?

• Tennis Elbow/Lateral Epicondylitis

• Painful extrinsic extensor tendons near the elbow

• Painful to the touch

• Decreased grip strength

What is Medial Epicondylosis?

• Golfer’s Elbow/Medial Epicondylitis

• Painful flexor tendons near elbow (involved with pronation)

• Painful to touch

• Painful to grip/pronation

What is De Quervain’s Tenosynovitis?

• tendinopathy of abductor pollicis longus and extensor pollicis brevis of the first dorsal compartment

• painful for thumb abduction/extension

• Test

  • Finklesteins test

Tendinopathy Mnemonic

O- Orthotic

A- Activity Modification

S- Stretch

I- Ice

S- Strengthening

What splint can be used for lateral epicondylosis?

Wrist cock-up splint (35 degrees of extension)

What type of splint can be used for lateral epicondylosis?

Wrist cock-up splint (neutral)

How would you splint Trigger Finger?

In MP extension for 6-10 weeks

Extensor tendon tension limiting mobility progression

Standard: Immobilization, gentle AROM, gentle PROM

Tension-limiting: Immobilization, PROM, AROM

Extensor tendon splint for zones 5,6,7 (immobilization)

Pan splint (full hand extension -including MCPs, slight wrist extension) to minimize tension on the extensors

Extensor tendon splint for zones 5,6,7 (early PROM)

Passive extension, active flexion (up to 30 degrees)

Dynamic splint, dorsal outrigger with volar block

Flexor tendon tension limiting mobility progression

Standard: Immobilization, gentle AROM, gentle PROM

Tension-limiting: Immobilization, PROM, AROM

Flexor Tendon (Immobilization) Splint

Dorsal blocking splint (antideformity position)

Flexor Tendon (Early PROM) Splint

Passive flexion, active extension within dorsal block splint

Flexor Tendon (Early AROM) Splint

Use dorsal block for most of the time, and then a separate orthosis with wrist extension for gentle active flexion (place and hold)

Dupuytren’s Contracture

• Progressive contracture into MP and sometimes PIP flexion, typically of the 4th and 5th digits

• Results from thickening of the palmar fascia

Dupuytren’s Contracture Treatment

• Immediate A/PROM, light ADLs

• MP Extension splint at night and during the day if necessary

• Avoid strenuous activity/sports for 6 weeks 

Non-surgical treatment for Dupuytren’s

Soft tissue mobilization

ultrasound

progressive stretching with heat

extension splint at night