Neuropathies Conditions
ulnar claw |
ulnar nerve (hyperextension of 4/5th digits) |
hand of benediction |
high median nerve - only occurs when attempt to make a fist |
ape hand |
median nerve - injured hand at rest - thumb adducted, cannot abduct/oppose thumb |
wrist drop |
ulnar nerve issue |
carpal tunnel |
median nerve compression at wrist |
cubital tunnel |
ulnar nerve compression at elbow |
ulnar tunnel - handle palsy |
ulnar nerve compression at guyons canal |
radial tunnel |
radial tunnel compression |
Neuropathies testing
carpal tunnel testing |
tinel and phalens - prayer/reverse prayer sign |
cubital tunnel testing |
tinels |
de quarvans |
positive finkelstein "hook grip" |
semmes wienstein - sensory |
occlude pts eye; touch different areas of hand |
guyons canal syndrome testing |
testing over guyons canal |
ulnar nerve testing motor innervation of thumb |
positive froments test - flexion of IP joint of thumb |
Finger issues
trigger finger |
A1 pulley |
swan neck deformity |
proximal interphalangeal (PIP) joint hyperextension and the distal interphalangeal (DIP) joint flexion |
boutonniere deformity |
flexed at the proximal interphalangeal joint (PIP) and hyperextended at the distal interphalangeal joint (DIP) |
ulnar drift |
fingers shift towards ulnar side - RA |
tendon repairs
kleinert |
passive flexion using rubber band traction and active extension to the hood of the splint |
- 0-4 weeks early phase |
dorsal block splint |
- 4-7 weeks intermediate phase |
continue dorsal block splint, but adjust wrist to neutral |
- 6-8 weeks AROM |
no splint, AROM, light OT activities |
- 8-12 weeks |
strengthening, work, leisure |
duran |
passive flexion and extension of digit |
- 0-4.5 weeks |
dorsal blocking splint, exercises in splint include flexion of PIP joint, DIP joint |
- 4.5-6 weeks |
active flexion and extension within limits of splint |
- 6-8 weeks |
tendon glides, differential tendon gliding, scar management |
- 8-12 weeks |
strengthening/work activities |
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Splints
brachial plexus injury |
flail arm splint - for positioning |
radial nerve injury |
colditz or radial nerve splint -for function |
medial nerve injury |
opponens splint (for functional activities), Cbar, thumb post |
ulnar nerve injury |
anticlaw splint, lumbrical bar splint - prevent clawing |
spinal cord - C6-C7 |
tenodesis splint - facilitate grasp and release |
carpal tunnel syndrome |
wrist splint positioned in neutral - decrease carpal canal pressure |
cubital tunnel syndrome |
elbow splint position at 30 degrees of flexion - prevent elbow flexion at night |
de quervains |
thumb splint, includes wrist, IP joints free |
skiers thumb |
UCL hand based thumb splint - protect the ulnar collateral ligament of MCP |
CMC arthritis |
hand based thumb splint - for hand to be at rest to decrease inflammation |
ulnar drift |
ulnar wrist/deviation splint - decrease pain, provide stability, realign MCP |
flexor tendon injury |
dorsal protection splint - for protection of site |
swan neck |
silver rings, buttonhole/hyperextension block splint - prevent further deformity |
boutonniere deformity |
silver ring or PIP extension |
arthritis |
functional splint or safe splint - decrease inflammation |
flaccidity |
resting/functional hand splint - prevent joint contracture, common wearing and at night then on off during the day |
spasticity |
spasticity splint or cone splint - prevent joint contracture |
muscle weakness - ALS, SCI, guillain barre |
balanced forearm orthosis (BFO), deltoid sling/suspension sling - supports |
hand burns |
wrist 15-30 degrees extension, MCP 50-70 degrees flexion, IPs in full extension |
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Range of motion
goniometer |
measurement tool |
functional ROM |
rom needed to perform functional movements - reaching to top of head, small of back |
active ROM - AROM |
contractile structures - movement produced by ones own muscle |
passive ROM - PROM |
noncontractile structures - movement produced by an external force |
active assisted range of motion - AAROM |
movement produced by ones own muscles and assisted by an external force |
muscle strength testing and interventions
MMT |
break test is most common |
5 normal |
Complete ROM against gravity and maximal resistance. Resistive exercise is used to increase strength. Example: Tossing a medicine ball while standing. |
4 good |
Complete ROM against gravity and moderate resistance. Resistive exercise is used to increase strength. Example: Tossing a beach ball with weighted cuffs strapped to the patient’s wrists. Tossing a therapy ball. |
3+ fair plus |
Complete ROM against gravity and slight resistance. Resistive exercise is used to increase strength. Example: Tossing a beach ball. |
3 fair |
Complete ROM against gravity. When a grade of 3 is reached, the activity can be structured to move against gravity. Example: Balloon volleyball / throwing a balloon at a target, which requires the patient to lift their arm up against gravity. Adapted volleyball type game. |
3- / fair minus |
More than 50% ROM against gravity. Example: Structure an activity to encourage the patient to lift his arm up in a vertical plane, against gravity. As the patient will not be able to achieve a complete ROM, place the goal at the highest level which the patient is able to reach. |
2+ poor plus |
Less than 50% ROM against gravity / complete ROM gravity eliminated slight resistance. Example: Place the patient’s arm on top of a table. Structure a table top activity which requires the patient to slide their arm along the surface of the table, through a complete ROM (in a gravity eliminated plane). Using a regular surface and introducing weighted game pieces, will add resistance to the movement. |
2 poor |
Complete ROM with gravity eliminated. For exercises/activities performed in a gravity-reduced plane, use a powdered surface or skateboard to reduce the resistance produced by friction on a supporting surface. Example: Place the patient’s arm on top of a table which has been covered with powder. Structure a table top activity which requires the patient to slide their arm along the surface of the table, through a complete ROM (in a gravity eliminated plane). Play a board game with light game pieces, or table cricket. |
2- / poor minus |
Incomplete ROM with gravity eliminated. Patient moves the joint through partial ROM and the therapist or mechanical device completes the ROM. Example: Support the patient’s arm and allow the patient to actively move through as much range as is possible, in a gravity eliminated plane. As soon as the therapist feels/observes that the patient has stopped actively moving, the therapist continues to support and move the patient’s arm through the complete ROM. Incorporate a goal into the exercise e.g. incorporate using a suspension mobile arm support with a meaningful activity. |
1 trace |
No movement but can contract muscle. Facilitate muscle contraction – Tap, rub, vibrate muscle to facilitate a stronger contraction. Active-Assisted Exercise. The patient contracts their muscle, and the therapist or a mechanical device completes the entire ROM. Slings, pulleys, weights, springs, or elastic bands may be used to provide mechanical assistance. This exercise is graded by decreasing the amount of assistance until the patient can perform active exercises. Example: Supporting and moving the patient’s arm through a full ROM in a gravity eliminated plane. Incorporate a goal into the exercise e.g. support the patient’s arm on a large ball and assist the patient in rolling the ball through a full ROM, to play a variation of traditional ten-pin bowling. |
0 zero |
No muscle contraction. Paralysis. Maintain PROM. The purpose of passive exercise is to prevent contractures, adhesions, and deformity by maintaining ROM. |
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simple interventions
increasing strength |
high resistance, low reps |
increasing endurance |
increase reps, low weight/resistance |
edema reduction |
elevation, retrograde massage, compression, contrast baths |
scar mgt |
ROM, massage, compression, scar pad with compression, splinting, edema control |
sensory training - desensitization for hypersensitivity |
massage, textures, vibration, fluidotherapy |
sensory training - re-education |
massage, textures, vibration, fluidotherapy *high risk for injury since they are not feeling |
joint protection |
use hips/knees, push large items with full body, carry bags on forearm |
body mechanics |
do not move items that are too heavy, keep objects close to the body during lifting, hold object centered at waist level |
PAMS
pam |
indication |
precautions/contraindication |
cold pack |
pain management, anti inflammation, edema control, decrease of muscle guarding, spasm. |
Hypersensitivity or poor tolerance to cold • Raynaud’s disease and phenomenon • Circulatory impairment – e.g. hemorrhaging tissue or untreated hemorrhagic disorders • Peripheral vascular disease • Active DVT • Impaired sensation (neuropathy) • Open wounds, near chronic wounds • Cryoglobulinemia* • Over regenerating nerves • Impaired cognition and/or ability to communicate |
hot pack |
subacute and chronic conditions. Relieves pain, increases soft tissue extensibility, reduces muscle spasm, relaxes skeletal muscles, decreases joint stiffness, and promotes wound healing. |
Peripheral vascular disease • Impaired circulation, bleeding disorder, DVT or thrombophlebitis • Local malignancy and recently radiated areas • Acute inflammation or trauma, edema, infection • Open wounds • Over large scars • Impaired sensation (neuropathy) • Large areas, or at sufficient intensity to raise core temperature- pregnancy, severe cardiac disease/in cardiac failure • Impaired ability to communicate- cognition or communication impairments sufficient to prevent patient from giving accurate and timely feedback • Areas affected by heat-sensitive skin diseases (e.g., eczema) • Areas of skin breakdown or damage producing uneven heat conduction across the skin • Reproductive organs (testes) |
fluidotherapy - heat |
help patients with their hands and wrists. Arthritis, chronic tendonitis, postoperative conditions, post fracture management, and Raynaud’s syndrome. |
open wounds |
neuromuscular electrical stimulation NMES - muscle stimulation |
stimulate paralyzed, paretic muscle, muscle weakness, peripheral neuropathy, and muscle spasm. |
Pregnancy • Cancer • Presence of a cardiac pacemaker, or any other electrical simulators. Precautions include obesity, impaired sensation, and over relatively superficial metal implants. |
paraffin |
useful for contractures due to rheumatoid arthritis, burns, and progressive systemic sclerosis (scleroderma). Used to treat chronic arthritis of the hand, various distal extremity conditions to increase ROM, manages pain, and assists in wound healing. |
if patient has open wounds, abrasions or skin infections. |
transcutaneous electrical nerve stimulation - TENS - used for PAIN |
Stimulates nerve fibers and provides symptomatic relief of pain. Used to treat chronic pain syndrome, spinal radiculopathy, low back pain, reflex sympathetic dystrophy, etc. |
Pregnancy • Pacemakers • Prone to seizures- Tens “pulses” have the ppotential to trigger a seizure. |
ultrasound |
Penetrates deep into the musculature and joint tissues. • Increase the extensibility of collagen fibers in tendons and joint capsules • Reduce muscle spasms • Aids tissue healing – speeds up the rate of healing & enhance the quality of the repair • Modulate pain, goes to the deepest layer for pain |
Pacemaker • Areas of decreased circulation • Impaired sensation • Pregnancy • Along the cervical sympathetic ganglion (or over the anterolateral neck) • Directly over the spinal column after laminectomy • Severe arterial disease or DVT • Bleeding disorders • Over a bony prominence • Over epiphyseal plates • Any surgically implanted artificial product (e.g., Gortex or mesh) may build up heat in an area. |
whirlpool |
Pain management • Wound management, particularly in the management of burn patients • To facilitate debridement in infected wounds, non-draining wounds, wounds with thick eschar, and on wounds with loosely adherent necrotic tissue • Helps dressings to be removed slowly and gently, reducing the pain of dressing changes. • ROM exercises • Promoting muscular relaxation |
Fever • Recent skin grafts • Circulatory impairment • Active bleeding/ hemorrhaging • Open wounds • Sensory or vascular impairment |
contrast baths |
Hot/cold immersion therapy is a method of treating: • Muscle soreness • Swelling • Inflammation. • Joint injuries, mild sprains, • Symptoms of chronic pain and repetitive strain injuries • Edema |
Same as Superficial Heat and Cold |
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