Rehab Lecture Notes Review

Pain Pathways

• C-fibers:
  • Unmyelinated and slow.
  • Transmit chronic pain, which is long-lasting, dull, throbbing, aching, burning, or tingling.
  • Can cause increased sweating, heart rate (HR), blood pressure (BP), and nausea.
  • Blocked by opioids.
• A delta fibers:
  • Myelinated and fast.
  • Transmit acute pain, which is sharp, stabbing, or pricking, and sensations of hot or cold.
  • Not blocked by opioids.
• Interneurons:
  • A beta fibers:
    • Signal interneurons to gate off pain, preventing the brain from receiving pain stimuli.

Types of Pain

• Acute:
  • Lasts less than 30 days.
  • A direct result of potential tissue injury.
• Subacute:
  • Lasts between 30 days and 3 months.
  • Typically occurs during the proliferation phase of healing.
• Chronic:
  • Lasts 3-6 months or longer.
  • Associated with chronic diseases, Complex Regional Pain Syndrome (CRPS), fibromyalgia, or neuropathy.

OT Goals for Pain

1. Resolve the underlying issue if possible.
2. Modify discomfort.
3. Maximize function within the patient's limitations.

Physical Agents

• Energy and materials applied to a patient (e.g., hot, cold, water, pressure, sound, electric, radiation).
• Modalities describe the type of energy used.
• More commonly used in initial rehab sessions.
• Used in combination when they have similar effects or address different aspects of symptoms (e.g., RICE - Rest, Ice, Compression, Elevation).

Types of Physical Agents

• Thermal:
  • Hot packs
  • Ice packs
  • Ultrasound
  • Diathermy
  • Whirlpool
• Mechanical:
  • Water
  • Traction
  • Compression
  • Ultrasound (applies force to increase or decrease pressure on the body)
• Electromagnetic:
  • Infrared
  • Laser
  • Diathermy
  • E-stim (applies energy from electromagnetic radiation or electrical stimulation)

Why Use Physical Agents?

• Reduce inflammation
• Accelerate tissue healing
• Relieve pain
• Alter collagen extensibility
• Modify muscle tone

General Contraindications

• Pregnancy
• Malignancy
• Pacemaker (implanted electrical device)
• Impaired sensation

Definitions of Heat Transfer

• Conduction: Direct collision between molecules of two materials at different temperatures (e.g., hot packs).
• Convection: Contact between a circulating medium and another material of a different temperature (e.g., whirlpool). Transfers more heat than conduction.
• Conversion: Converts a non-thermal form of energy into heat (e.g., ultrasound).
• Radiation: Direct transfer of energy without an intervening medium or contact (e.g., infrared lamp).
• Evaporation: Material absorbs energy to evaporate/change from a liquid to a gas (e.g., vapocoolant sprays).

Ultrasound

• Sound waves are created by crystals inside the head (travel with a frequency > 20,000 Hz) and travel through the molecules of the body.
• Effective Radiating Area (ERA): The size of the head. Determines treatment time. If you can fit 2 sound heads in the treatment area, time should be between 5-10 minutes. Time increased if area is larger than 2x the treatment head size.
• Beam Nonuniformity Ratio (BNR): How uniform the intensity is across the ERA. Ratio of peak intensity (near the middle of ERA) and average intensity across the ERA (typically 5:1). A higher BNR means less uniform intensity, so the head should always be moved to prevent burns.

Ultrasound Application

• Pulsed:
  • Non-thermal effect (mechanical).
  • Promotes cell function, tissue healing, and wound care.
  • Used with phonophoresis.
    • 20% duty cycle for acute conditions.
    • 50-80% duty cycle for subacute conditions.
• Continuous:
  • Used to increase tissue temperature and extensibility.
  • For chronic conditions.
  • Higher temperatures are achieved in tissues with higher collagen content and with higher frequencies.

Ultrasound Adverse Effects

• Burns
• Standing waves (blood boils)
• Cross-contamination/infection

Ultrasound Indications

• Soft tissue shortening
• Pain control
• Dermal ulcers
• Surgical incisions
• Tendon/ligament injuries
• Fractures
• Carpal tunnel syndrome
• Phonophoresis (transdermal medication delivery)

Ultrasound Contraindications

• Malignancy
• Pregnancy
• CNS tissue
• Joint cement
• Plastic
• Pacemaker
• Eyes/reproductive organs
• Thrombophlebitis

Ultrasound Precautions

• Acute inflammation
• Epiphyseal plates
• Fractures
• Breast implants

Ultrasound Parameters

• Intensity (W/cm^2)
• Frequency (MHz)
  • 1.0 MHz: deep
  • 3.3 MHz: superficial
• Duty cycle (%)
  • Continuous
  • Pulsed
    • 0.5-1.0 W/cm^2
    • 1.0-1.5 W/cm^2
    • 1.5-2.0 W/cm^2

Underwater Ultrasound

• Add 0.5 to the intensity.
• Hover the US head over the treatment area.
• Good for skin sensitivities or if the patient cannot get into positions to receive US (contractures).

Ultrasound Documentation

• Area treated and skin appearance before treatment
• Frequency
• Intensity
• Duty cycle
• Duration
• If underwater
• Response to treatment and skin after treatment
• Example: Ultrasound applied to right lateral elbow for pain management. Skin intact pre-treatment. Used 3.0 MHz frequency, 1.0 W/cm² intensity, 20% duty cycle for 5 minutes with gel contact (not underwater). Client reported mild warmth; skin slightly pink post-treatment with no adverse reactions.

Cryotherapy

• CBAN: Cooling, burning, aching, numbness (what you feel with cryotherapy).

Neuromuscular Effects

• Decreased nerve conduction velocity
• Increased pain threshold
• Decreased spasticity
• Facilitation of muscle contraction

Metabolic Effects

• Decreased metabolic rate

Hemodynamic Effects

• Initial decrease in blood flow

Why Use Cryotherapy?

• Inflammation control
• Edema
• Pain
• Spasticity
• MS symptom management
• Facilitation
• Cryokinetics
• Cryostretch

Cryotherapy Contraindications

• Cold hypersensitivity
• Cold intolerance
• Cryoglobulinemia
• Paroxysmal cold hemoglobinuria
• Raynaud’s disease
• Area of regenerating nerves
• Area of circulatory compromise

Cryotherapy Precautions

• Superficial main branch of nerve
• Open wound
• Hypertension
• Poor sensation
• Poor mentation
• Very young/old patients

Cryotherapy Documentation

• Area treated
• Skin before application
• Agent used (cooling or heating)
• Duration
• Patient positioning
• Response to intervention
• Skin after application
• Example: Cold pack applied to left shoulder for pain and inflammation. Skin inspected pre-treatment, intact with no redness or open areas. Cooling agent used with towel barrier for 15 minutes. Client positioned in semi-reclined chair with arm supported. Tolerated intervention well, reporting reduced soreness. Skin was cool to touch and mildly red post-application, with no signs of irritation.

Diathermy

• Electromagnetic energy, has thermal and non-thermal effects.
• Deep heat, deeper than US.
• Frequency:
  • Shortwave (1.8-30 MHz).
  • 13.56, 27.12, and 40.68 MHz (27.12 is the most common).
  • Can be pulsed or continuous.
• Amount of temperature increase based on:
  • Field intensity
  • Tissue type
  • Duty cycle
  • Distance from patient

Types of Applicators

• Inductive coils: Cause oscillation of tissue particles causing friction and creating heat.
• Capacitive plates: Patient is sandwiched between plates to be part of the electrical circuit to heat the tissue.

Heat Effects of Diathermy:

• Neuromuscular:
  • Changes in nerve conduction and firing rate.
  • Increased pain threshold.
  • Changes in muscle strength.
• Metabolic effects:
  • Increased metabolic rate and tissue extensibility.
• Hemodynamic:
  • Vasodilation.

Why Use Heat (Diathermy)?

• Pain control
• Increased range of motion
• Decreased joint stiffness
• Accelerated healing

Diathermy Contraindications

• Hemorrhage
• Thrombosis
• Impaired sensation
• Impaired mentation
• Malignancy
• Eyes

Diathermy Precautions

• Acute injury/inflammation
• Pregnancy
• Impaired circulation
• Edema
• Cardiac insufficiency
• Metal
• Open wounds
• Topical counterirritant
• Demyelinated nerves (MS)

Diathermy Thermal Effects

• Heats large deep areas of tissue.
• Increases circulation.
• Increases extensibility.

Diathermy Non-Thermal Effects

• Increased microvascular perfusion
• Altered cell membrane function and cellular activity

Diathermy Adverse Effects

• Burns, fainting, bleeding, skin/eye damage from infrared/radiation.
• All Diathermy: implanted or transcutaneous stimulators (pacemakers) and pregnant women should not be in the room.

Diathermy Documentation

• Area treated
• Frequency range
• Average power/power setting
• Pulse rate
• Duration
• Type of applicator
• Patient position and stance from applicator
• Response to intervention
• Example: Pulsed shortwave diathermy applied to right lumbar region for muscle relaxation and pain reduction. Frequency range set at 27.12 MHz with average power of 48 W. Pulse rate was 800 pulses/sec. Drum applicator used for 20-minute session. Client positioned in prone with a towel layer between skin and applicator, maintaining appropriate distance per manufacturer guidelines. Client reported gentle warmth without discomfort. Skin appeared normal post-treatment with no adverse effects noted.

Application Specifics

Cold Packs

• Remove jewelry and clothing from the area.
  • Damp towel = cools faster (dampen with warm water to help client acclimate to the cold)
  • Dry towel = cools more slowly
• Elevate if edema is present.
• Apply for 10-20 minutes (30 if spastic).

Ice Massage

• Remove clothing and jewelry and inspect the area.
  • Place towels around the treatment area to absorb falling water.
• Massage using small overlapping circles.
• More appropriate for small localized injury, tendon, or deeper pressure is needed.

Moist Hot Packs

• Stored in hydrocollators @ 158-167°F (70-75°C).
• Remove clothing and jewelry and inspect the treatment area.
• Wrap hot pack with cover and 2-3 layers (or w/o cover - 6-8 towels).
• Provide client with a way to call for assistance.
• Check after 5 minutes for signs of overheating.
• 20 minutes.
  • Proteins denature at 113°F.
  • Or 109°F for 60 minutes.
  • CELL DEATH can occur if agent is too hot or is applied for too long.
• Reduce treatment time and add layers if pt has decreased circulation.

Paraffin

• 113-122°F
• Wash and dry hands.
• Remove jewelry.
• Don’t touch sides of the bath.
• Keep fingers spread apart.
• Wait for wax to appear opaque and dip again.
• Wrap in plastic bag and then a towel.
  • Methods:
    • Dip and wrap - 10-15 minutes
    • Dip-immersion (keep wax temp at lower end of the range and keep hand in paraffin for 20 min)
    • Paint - with a brush 6-10 layers and cover - 20 minutes

Contrast Baths

• Remove jewelry.
• Fill 2 containers with water (warm - 100° - 111°F / cold - (50° - 64°F).
  • Pain/edema: temperature difference should be LARGE.
  • Desensitization: temperature difference should start small and gradually increase.
• Warm water - 3-10 min.
• Cold water - 1-3 minutes.
• Repeat 5-6 times for up to 30 min.
• Dry area quickly and thoroughly after treatment.

Thermal and Non Thermal Contraindications and Precautions

Thermal Contraindications

*Metal
*Malignancy
*Eyes
*Testes
*Growing epiphyses

Non-Thermal Contraindications

*Deep tissue/internal organs
*Substitute for conventional therapy for edema/pain
*Pacemakers, electronic devices, or metal implants

All Precautions

*Near electronic or magnetic equipment
*Obesity
*Copper IUD

Non-Thermal Precautions

*Skeletal immaturity

Precautions for Therapists

*Stay 2m (6 ft) from continuous diathermy applications
*Stay 1.5m (4.5 ft) away from SWT applicators when on

Tendon Transfers

*Why would someone have a tendon transfer? To re-innervate a muscle that may not be working how it should be.

Tendon Transfers Median Nerve Palsy:

*Low median nerve injury: Opponensplasty
*High median nerve injury: brachioradialis to flexor policies longus

Treatment Goals (Pre-Op)

*Achieve and maintain full PROM and AROM
*Maximize strength of donor and antagonist muscles
*Minimize scar and edema to maximize tissue mobility
*Pt and family education

Treatment Goals (Post-Op)

*Protect with a cast followed by static forearm based orthotics
*Maintain ROM of uninvolved joints
*Control pain
*Manage edema and scar tissue
*Increase soft tissue mobility to prevent adhesions
*Progress to hand ROM exercises, functional use and strengthening

Precautions

*Acceptance of less than full PROM before transfer
*Overestimating donor muscle strength
*“Drag” along the transfer route due to scar tissue
*Technical failures
*Stretching the transfer too early

Opponensplasty:

*Flexor digitorum superficialis of ring finger is connected to the abductor pollicis brevis
*A. For thumb opposition
B. forearm based thumb spica orthoses (wrist in neutral of 20-30flexion)
*Palmaris longus is connected to the abductor pollicis brevis
*A. For thumb opposition
B. forearm based thumb spica orthoses (wrist in neutral of 20-30 flexion)
*Extensor indices proprius routed around the pinky to the abductor pollicis brevis
*For thumb opposition
Static forearm-based thumb spica (wrist in 30 flexion)
*Abductor digiti minimi is taken across the palm and attached to the abductor pollicis brevis
*A. For thumb opposition
*B. Static hand based or forearm based thumb spica (wrist in neutral)

Post-Op Therapy:

10-14 days:

*Splinting, wound care, edema reduction, scar management

Week 3

*Mobilization
*AAROM, PROM, AROM thumb exercises wearing orthotics. (6-8 times a day)

Week 4:

*Begin AROM thumb exercises out of the orthotics. (Light grasp)

Week 6:

*Discontinue use of orthotics and begin unrestricted AROM/PROM
*Avoid simultaneous wrist extension and supination

Week 8:

*Progressive resistance exercises

Week 12:

*Resume unrestricted activities

High Median Nerve Injury:

*Brachioradialis to flexor pollicis longus

10-14 days: splint

*Dorsal blocking forearm based thumb spica orthotics
    *Wrist in 20-30* flexion and elbow at 90* flexion
    *CMC in full palmar abduction
    *Thumb MCP in 20* flexion IP in 20-30* flexion

Week 3:

*AROM exercise of MCP/IP in the orthotics

Week 4:

*AROM exercises out of the orthotics for transfer activation and light prehension
*Duchenne’s sign: hypertension of MCP joints
*Jeanne’s sign: Hyperextension of the thumb MCP joint
*Wartenberg’s sign: excessive abduction of the pinky

Ulnar Nerve Palsy

Pre-op treatment goals:

*Assess ROM and perform Bouliver’s test (IP extension with MCPs held)
*Optimize joint mobility and position
*Strengthening and soft tissue prep
*Address muscle tightness
*Eval and education
*Communication

Post-op treatment goals:

*Protect transfer
*Preserve joint mobility
*Manage symptoms
*Initiate transfer activation
*Restore function

Low unlar nerve injury:

*Intrinsic rebalancing procedures

Static transfer: Zancolli lasso procedure

*Flexor digitorum superficialis is looped around the base of the the affected finger and attached back to itself
    *Prevent excessive extension (claw deformity)

Dynamic transfer: brand transfer

*ECRB or ECRL to lumbricles (intrinsic)
    *Help with flexion (tenodesis)

Stiles Bunnel

*Flexor digitorum superficialis is split and stitched to the pinky and ring finger
    *Help with flexion (tenodesis)

smith-Hastings procedure:

*ECRB is transferred to the adductor pollicis
    *Restore power pinch (key pinch)

Littler procedure:

*Flexor digitorum superficialis is attached to the adductor pollicis
    *Restore power pinch (key pinch)

High Ulnar Nerve Injury:

*ECRL is attached to the flexor digitorum profundus
*Improve DIP flexion

Radial Nerve Palsy

*HIGH: Affects more muscles (including triceps). Leads to hand and wrist drop
*LOW: Involves posterior interosseous nerve. Causes wrist drop. ECRL remains intact

Pronator teres to ECRB

*improve wrist extension

Flexor carpi ulnaris to extensor digitorum

*improve MCP extension

Palmaris longus to extensor pollicis longus

*improve thumb extension

Flexor Tendon Repair

*Minimum 6 month healing process

Intrinsic healing

*Occurs within the tendon, fewer adhesion = better tendon glide, slower rehab to avoid rupture

Extrinsic healing

*Involves surrounding tissues, can cause more adhesions, leads to stiffness, faster rehab to restore more motion

*Pyramid of Force Safe zone examples
*1- picking up an apple
*5- opening a drawer
*10- yellow resistance band
*20- pulling on a stuck drawer
*40- max pressure

Zones of Injury

*1- distal to FDS insertion
*2- A1 pulley to FDS insertion
*3- Distal Carpal tunnel to A1 pulley
*4- Within the carpal tunnel
*5- proximal to carpal tunnel
*T1- Distal IP Joint
*T2- A1 pulley to IP joint
*T3- Thenar Eminence

Flexor tendon reconstruction

*Has become less prevalent due to improvements in tendon repairs: Repair allows for early mobilization and faster functional recovery

Why do a reconstruction?

*Failed tendon repair
*Complex injuries
*Sever tissue and pulley damage
*Wounds
*Poor patient health

Treatment Goals:

Week 1-3:

*use orthotics
*Prevent edema
*Wound care
*Address pain
*PROM
*Encourage full IP extension with orthotics
*Place and hold, or active flexion within safe range

Week 3-6:

*Adjust orthotics to neutral or slight extension
*Begin graded force protocol
*Deep soft tissue mobilization
*Night time extension orthotics to address flexion contractures

Week 6-12:

*Wean from orthotics
*Promote functional use
*Focus on speed, coordination, accuracy
*Begin strengthening based on AROM

Types of reconstruction:

Primary grafting

*Remove injured tendon and replace if pulley system is intact

Two stage reconstruction:

Stage 1:

*Silicone rod inserted to create fake sheath

Stage 2:

*Tendon graft inserted after 3+ months

Pre-op therapy:

*Scar management
*Exercise
*PROM
*Active flexion of PIP if FDS is uninvolved
*Buddy tap in (PROM)
*Orthotics

Extensor Tendon

*Mallet Finger: Loss of DIP extension due to tendon rupture Normally crush injuries
*Swan-Neck Deformity: PIP in hyperextension DIP is flexed
*Boutonnière Deformity: PIP in flexion DIP in extension
*Extensor Tendon Imbalance

*Treatment
6-8 weeks
*immobilization

Phase 1 (1-8 weeks)
*immobilize DIP joint in full extension
Phase 2
*wean from splint and being active motion
*Monitor for extension lag
*Functional use

Treatment
Week 0-6
PIP in orthotics at 30 flexion and DIP at 0*
3-14 days- active motion that allows full flexion and limits extension of PIP joint to 30
*Orthotics to improve PIP flexion
Treatment (orthosis)
Week 0-6
*orthosis with PIP at 0, DIP flexion exercises only
Week 6-8:
*day and night orthosis
*Gentle PIP flexion 30-40*
*Watch for extension lag
Week 8-10:
*stop day orthosis
*If continued lag, balance ex and orthosis use
Week 10-12:
*begin light strengthening if safe
Week 12:
*Full use
*Resume orthosis if lag returns

Week 6-10

*Orthosis adjusted to allow increased extension
*Strengthening for flexion may being at 6-8 weeks
Treatment Cont.
Week 0-4
*scar management
Week 4-6
*Scar management
Week 6-8
*advance AROM
Week 8-12
*static/dynamic flexion assist
*AROM
*Gentle strengthening
Week 12+:
*begin progressive strengthening

Extensor Tendon Tenolysis

*What is it? surgical excision of scar tissue binding the tendon to surrounding tissues
Post-op therapy:
*edema control
*Pain
*Wound care
*AROM (within 24-48 hours)
*Full tendon glide
*Reverse blocking
*PROM
*Gentle extension (cautious flexion)
*Scar management
*Orthotics
*Grip strengths (after 6 weeks)
AROM:

Full tendon excursion

*emphasize full gliding, joint blocking and tendon motion
*10 reps every 1.5-2 hrs, hold end range for 5-10 sec.

EDC gliding

*move from hook fist to MCP hyperextension

Reverse blocking for PIP lag

*MCP in hyperflexion while actively extending PIP

Tightness management

*Extrinsic- gentle composite ROM
*Intrinsic- stretching, exercise, orthotic support

Extensor tendon acceleration

*during full extension with iso contraction

Intro to Splinting

Why splint?

*protection, immobilization, stability, assist in movement

Types of splints

*dynamic- mobilization (pulleys)
*Static- restrictive (prevent contracture)
Thermoplastic considerations:
*Drapability- how much it conforms to what it is being draped over
*Elasticity- resilience to stretching
*Bonding- how easily it sticks to itself
*Memory- how well it returns to its original shape when reheated
*Moisture permeability- ability to keep moisture out
*Durability- amount of time it will last
*Rigidity- degree of stiffness once set Distal digital crease Middle digital crease Proximal digital crease Distal Palmar crease Proximal palmar crease Thenar crease Distal wrist crease Proximal Wrist Crease
*When splinting to immobilize or restrict, the therapist must be certain to include the corresponding joints palmar crease

Splinting Continued

Forearm based splint:

*Should be 2/3 the total length of the forearm
*Should be able to flex elbow without interference from splint
*Width of the trough of the splint should be 1/2 the circumference (thumb or forearm)

Padding and Strapping:

*Adding padding increases the needed width of the splint and can increase pressure
*May be better to heat the thermoplastic rather than add padding
*Strapping: Velcro hook and loop

Staticsplint:

• Immobilization, joint protection, protect healing, prevent contractures, edema management (inflammation), substitute for loss of motor function (most used form of splinting)

Serial Cast:use when a contracture is present

*Change the shape as the contracture lessens
*Slowly work the affected area to the end of the ROM

Dynamic SPLINT; assist in movement:

*More freedom in movement
*Allows for compensation of weak muscle group
*Slowly put tension on something (finger flexion slowly pulled into extension)

Arches of the Hand

Longitudinal arch:

Follows the longitudinal axes of each finger Allows finger to flex Cupping and flattening of the palm

Distal transverse arch

Deepens with finger flexion Mobile Passes through metacarpal bones Splints must allow for movement to maintain or increase hand movement

Proximal transverse arch

Distal row of carpal bones never splint a flat hand (the arches must be preserved)

Prehension Patterns

*Fingertip prehension: contact with pad of the thumb (less movement than grasp)
*Cylindrical- object rests against palm and held in place by fingers
*Spherical- use of palm and finger for round ball object
*Hook- uses fingers only for carrying bags or suitcases

#Muscle Anatomy…:

Cellular Elements:

*Neural stimulation of calcium release Formation of action and myosin cross bridges (Most cross bridges are formed at mid-range of the muscle)
*ATP energy use

Contractile elements:

*Myofilaments Sarcomere- contractile unit (composed of myofilaments) that can be shortened or lengthened

Golgi Tenon Organs- sensory organs that are in the connective tissue at the junction between muscle fibers and tendons at the musculotendinous junction:

*Transmit signals to the alpha motor pools of both agonist and antagonist muscles in the 1a sensory neurons Muscle spindles-

Sensory organ within muscle:

*Receptors sense when muscle is stretched and sends mediates to the brain on the 1a sensory neurons to the brain.
How it happens (nervous system) dendrites receive signals axons conduct signals to other neurons using neurotransmitters (myelin increases speed of transmission)
Depolarization and repolarization initated by Na/K pumps, creating a wave of activity
k proteins are higher in concentration INSIDE the cell Nat and Cl are higher in concentration OUTSIDE of the cell They exchange to try and equal out

Key terms:

*Rigidity- abnormal hypertonic state characterized by stiffness Spasticity- resistance to stretch (increased tone but still stretches)
*Hypotonicity- low tone, decreased resistance to stretch Flaccidity- absence of resistance to stretch
*Contracture- shortening of tissue resulting in loss of ROM How we would splint:

Rigid- Serial Static

Spastic- Static (focus on prevention of rigidity)

Hypotonic- static (help maintain position)

Flaccid- Static (maintain joint position/ prevent contracture)

Contracture- Serial static Tone vs Contraction:

Tone- underlying tension that is present in a muscle low tone leads to muscle weakness Increased tone leads to contracture Contraction- active shortening of a muscle (like doing a curl)
Tone Abnormalities: Hypotonic- low tone

Decreased resistance to stretch

Flaccidity is total absence of tone Can occur in DS, CVA, poliomyelitis Hypertonicity- high tone clonus- rhythmic breaths of involuntary contraction in response to quick stretch Rigidity and Spasticity Can occur after CVA

Splinting Education and Training

*Splint wear schedule (24 hrs a day, at night, etc.)
*Care for the splint (can they shower in it?) Exercises to be performed at home
*Occupational restrictions (no pushing/ pulling/lifting etc.)

Data Measurements

*Standardized assessments- used to reduce problems with reimbursement DASH and Quick DASH most used in UE treatment Easy to track, and easy for insurance companies to see that our work is impactful for the client

Non-standardized data:

*MMT, ROM, observations (swelling, redness, crepitus (creaking) end feel)

Documentation

*Type of splint Purpose (goal of the splint) Location of the splint
*Communication of wear schedule and precautions Any changes made (in follow up visits) Wether problems with compliance are present Wether ROM is increasing or functional independence
*Consequences of LOW tone ⬇ insufficient activation of alpha motor neuron From prolonged use of sling/cast Rehabilitation to increase tone E-stim, hydrotherapy, quick ice, exercise, orthotics, functional training
*Consequences of HIGH tone ⬆ Aggravated by pain, cold, or stress From SCI… Initial flaccidity followed by spacticity Management: ROM exercises, prolonged stretch, positioning orthotics, medications, or surgery From Cerebral Lesion… CVA, Parkinson’s, MS Management: prolonged stretch, icing, inhibitory pressure, casting, passive motion, biofeedback, task Spasticity vs Rigidity:

Spasticity

Develops after time of injury Recover follows predictable course

Rigidity

Consequence of CNS pathology Parkinson’s/TBI Posturing Decorticate Decerabrate Tendonitis-
*Can occur at any joint in the body Pain is the #1 reason patients seek medical attention And #1 reason why they get sent to therapy Can cause clients to withdraw from occupations Can cause improper compensatory movements during movements Rest the tendon Or splint to where they can still use their hands Night splints Ask the client… What are their occupations What is important to them

Example:

*A volar wrist cock-up splint was fabricated for the right upper extremity to support the wrist in neutral and reduce carpal tunnel symptoms. It extends from the mid-forearm to the palm, leaving fingers free. The client was instructed to wear the splint at night (8–10 hours) and remove it during the day for hygiene and tasks. Precautions for skin checks and splint care were reviewed. At follow-up, padding was added near the ulnar styloid to improve comfort. The client has been mostly compliant, with improved wrist ROM (30° to 45° extension) and decreased nighttime numbness. Continued use is recommended, with reassessment in two weeks.

L codes (Hick Pick)-

Normally for DME like orthotics or prosthetics Includes evaluation, fabrication, and fitting Has more weight than a CPT code from a reimbursement perspective Captures time, commitment, and customization better than a CPT code L code first, next encounter CPT code L code for fabrication, CPT code for training Number determines body part L3975-L3978: shoulder, elbow, wrist, hand orthotics L3980-L3999: shoulder, elbow, wrist, hand, and finger orthotics Billing Splinting:
CPT codes 97760 - orthotics management/training 97761- Prosthetics training 97763- orthotics/ prosthetics management/ training:
TENS and NMES Contraindications
Pacemaker Implanted defibrillator Unstable arrhythmia Over carotid sinus Over venous/ arteriothrombosis Pregnancy (over trunk) Over recent tendon repair surgical site, or tendon tear Precaution
Cardiac disease Impaired sensation Impaired mentation Malignancy Skin irritation Open wound Adverse effects burns if applied incorrectly or turned up too high, burns can occur
Skin irritation Pain
DC- direct current DC- direct current Also called monophasic Continuous stream of particles flowing in one direction Used in ionophoresis Used for stimulating denervated muscles AC- alternating current
AC- alternating current Continuous particles flow in two directions Constantly flow back and fourth Used for pain management and muscle contraction PC- pulsed current PC- pulsed current Interrupted flow of particles Has periods of no current flow Used for pain control, tissue healing, or muscle contraction
**Monophasic PC Flows in one direction Tissue healing or edema
**Biphasic