Upper Extremity Evaluation - ASHT 2016_HTRC... · Upper Extremity Evaluation ... limitations?)...
Transcript of Upper Extremity Evaluation - ASHT 2016_HTRC... · Upper Extremity Evaluation ... limitations?)...
Hand Therapy Review CourseCurtis National Hand Center
Baltimore, MD
October 7-9, 2016
Upper Extremity Evaluation
Paige E. Kurtz, MS, OTR/L, CHT
Establish baselines Determine components to be addressed in treatment
Determine limitations Set treatment goals Determine treatment results and outcomes
Accurate Standard methods Reliable Reproducible Valid
Movement Carrying angle, protective positioning or posturing
Is the patient unable to look at their hand? Use or avoidance of use Nail condition Affect and attitude ‐ toward the injury, employer, “why me?” vs. “what do I need to do to get better?”
will have a significant effect on the outcome
Personal Information: Age, hand dominance, occupation, hobbies, medications
History:
Date of injury, surgery, onset of symptoms
Diagnostics performed
Previous treatment
Full medical history:
Other conditions – Diabetes, blood pressure, etc.
health conditions
▪ smoker, allergies
cardiac (contraindication for many electrical modalities)
vascular
arthritis (pre‐existing limitations?)
diabetes (reduces peripheral circulation, slows healing)
previous injuries and treatments (pre‐existing limitations?) prior level of function
Physical Findings with pathology outside the hand: edema from cardiac, renal dz, lymphatic insufficiency.
Tremors, atrophy, ischemic contractures: neurological disorders –dystonia, CHI, ALS, MS, Parkinson’s, proximal nerve compression
Symptoms: pain, numbness ,tingling, weakness, deformity, poor coordination, functional deficits.
Patient Goal of treatment (JCAHO) “what are your biggest issues?”
Pain Reports: Intensity• 0‐10 scale• Least / worst rating• Duration, Frequency, Consistency• Location• Exacerbating / alleviating factors
Pain chartsVisual analog scale (VAS)Wong Baker Faces scaleObservational pain rating
DASH: Disabilities of the Arm, Shoulder and Hand 30 items
Quick DASH has 11 items covering ADL performance and symptoms
NOT specific to injured extremity
Established reliability and validity of both
www.dash.iwh.on.ca/
Patient rated wrist/hand evaluation (PRWHE): Specific to injured extremity
5 items covering pain
10 items on function
2 optional items on appearance
Poor‐moderate correlation to impairment ratings (MacDermid et al 2002)
MCID – 12/24 points (Schmitt and Di Fabio 2004)
Established reliability and validity http://www.srsmcmaster.ca/ResearchResourcesnbsp/Musculoskeletal/Up
perLimbNeck/tabid/2723/Default.aspx
Wrinkles Calluses Atrophy
Deformity Arthritic Nodes:–Heberdens’ (DIP)–Bouchard’s (PIP)
Resting joint postures
mallet
boutonniereswan neck
Sudomotor: sweating Vasomotor: skin color and temp. Pilomotor: gooseflesh response Trophic: skin texture, soft tissue atrophy (‘penciling’ of finger tips),nail changes, hair growth, rate of healingHunter, Mackin, Callahan; Rehabilitation of the Hand, 5th edition, Mosby
Location Size: length, width, depth
Color: red, yellow, black Odor: pungent, musty, sweet
Temperature Integrity: tunneling, undermining, sinus tracts
Describe Drainage (where applicable)
Bloody/Sanguinous/Red (healthy, bloody drainage)
Serous (thin yellowish/clear fluid) Serosanguinous (combination of above)
Purulent (often thick, greenish or yellowish, signs of infection, often malodorous)
Tissue: slough, eschar, granulation, macerated, dessicated, necrotic
Wound edges: defined, attached Signs of infection: pain, redness, streaking, warmth, pus, fever
Macerated fingers after replant Healing wounds
Healed and scarred fingers
Weekly photos of healing wound (note the progression from mixed red/yellow/black to all red to closed) secondary closure
Scar: red, raised, mature, immature, keloid, hypertrophic, supple, adherent
Vancouver Scar Scale: BurnsPigmentationVascularityPliabilityHeight
See Cowan and Stegink‐Jansen: A Review of Assessments to Address Hand Function After Burn Injury. Clinical Assessment Recommendations. ASHT online Publication.
Affected by general health: Smoker
Diabetes
Alcohol use
Cardiac Affected by occupational factors: Cold exposure, vibratory tools, repetition of tasks, and time
at current job
PALE, dusky, gray, white: may indicate arterial insufficiency
RED: may indicate infection/irritability
CYANOTIC, purplish: may indicate venous insufficiency
due to decreased circulation
Assess pulses Subclavian – sternal end of clavicle in scalene (mm.)
Axillary – center of armpit.
Brachial‐ superior to antecubital fossa, medial to biceps tendon.
Radial‐ just proximal to wrist crease, volar‐radial wrist.
Ulnar – just proximal to wrist crease, volar‐ulnar wrist.
Capillary refill test: apply pressure to pulp of nail,.N= 3 sec.
Palpate radial and ulnar arteries at the wrist, and apply pressure to occlude both.
Exsanguinate the hand by having the patient open and close fist several times, then open the hand to a relaxed open position.
Release one of the arteries Note quality and time for the hand to re‐perfuse. Normal is 3‐5 seconds.
American Society for Surgery of the Hand.The hand: examination and diagnosis, 1978Allen EV. 1929Asif M, Sarkar PK. 2007Jarvis MA, et al 2000Husum B, BerthelsenP. 1981
Observation: creases, wrinkles, ROM, resting joint position
Define: Brawny, pitting, location
•Evaluates hand mass via water displacement.•Preferred method for edema measurement •Mild difference from right to left hand (~3%), test both hands, but compare injured extremity to itself.•Standard test
Use flexible tape to measure in mm. Due to the variables of placement of tape and
tension applied, this testing is not standardized or reliable.
Common sites to measure: P1, P2, and P3 PIP and DIP Across MPs Distal palmar crease (DPC) Wrist level (DWC) Elbow
Figure of Eight Method (Reliable and valid for ankle) Fully described in Lavelle and Breger Stanton: Measurement of Edema in the Hand Clinic. Clinical Assessment Recommendations. ASHT online Publication.
Subject is seated with the arm Abd and ER 90°, the elbow flexed 90°, the wrist neutral, the fingers add and extended, and the thumb abd in the plane of the hand.
Begin on the radial/palmar side of the wrist, aligning the distal edge of the measuring tape with the distal wrist crease.
Wrap the tape measure in an ulnar direction across the wrist, staying proximal to the distal wrist crease until passing over the tendon of the FCU.
The tape is then wrapped across the dorsum of the hand distally and obliquely, passing over the midpoint of the second MC head with the distal edge of the tape aligned with the radial aspect of the palmar digital crease of the 2nd digit.
At the palmar digital crease of the 2nd digit, the tape is drawn in an ulnar direction across the palmar surface with the distal edge aligned with the palmar digital crease of the fifth digit.
Continuing over the palmar crease of the fifth digit the tape is drawn back across the dorsum of the hand in a proximal oblique direction, passing over the tendon of the APL
At the dorsum near the tendon of the APL, the distal edge of the tape is realigned with the distal crease and directed back to the starting point.
ASHT recommendations for ROM: “0” is neutral. “+” is hyperextension “‐” is an extension deficit Measurements should be written as
extension/flexion (e.g. ‐10/85). Hamilton and Lachenbruch ‘equal
reliability between lateral and dorsal goniometer placement’
Muscle’s ability to move a joint Variations from person to person in what is
considered “normal”
Limitations can be due to: Denervation Lack of tendon continuity (rupture, laceration) or
tendon attenuation Joint restrictions (articular or capsule, e.g. RA and OA) Pain
Adhesions between tendon and surrounding structures
Inflammation of tendon
Subluxation, dislocation, or bowstringing of the tendon
Weakness
If there are tendon adhesions, PROM will be higher than AROM
You will be able to passively flex the joint but the patient will be unable to maintain same position actively
this may also occur with triggering and muscles which cannot pull through full excursion due to weakness
The thumb has a highly mobile CMC joint with the saddle‐shaped trapezium as its base.
Occurs in the frontal plane, parallel to the plane of the palm.
Frontal plane, parallel to plane of palm
–Hunter, Mackin, Callahan; Rehabilitation of the Hand, 4th edition, Mosby, p105
Sagittal plane, perpendicular to palmAdduction returns the thumb to palm
–Hunter, Mackin, Callahan; Rehabilitation of the Hand, 5th edition, Mosby
Opposition: nail beds in line, parallel to each other
With median nerve loss attempts at opposition result in nail beds perpendicular to each other
American Society for Surgery of the Hand. The hand: examination and diagnosis,1978. Hunter, Mackin, Callahan; Rehabilitation of the Hand, 5th edition, Mosby
Fingertip to palmMeasure in cm
Fingertip to distal palmar crease (DPC)
Hunter, Mackin, Callahan; Rehabilitation of the Hand, 5th edition, Mosby
Ability of a joint to be moved through its normal arc of motion by means outside the body.
Assesses the capacity of a joint, may be affected by:
• soft tissues (skin, scar, tendon)
• joint incongruency (bone)
• capsular structures surrounding the joint (ligaments)
• Other (edema)•If PROM>AROM then the joint is being limited by adhesions, weaknesses or tendon integrity. Document measurement of A/PROM.
Hunter JM, Schneider LH, Mackin E, Callahan AD. Rehabilitation of the hand: surgery and therapy. Mosby, 2002
The flexor tendons glide:
–proximally with active contraction
–and distally with passive stretch
TAM = AROM of the MP, PIP, and DIP minus any extension deficits.
Example: MP 0/90PIP ‐10/85DIP ‐5/55TAM = (90 + 85 + 55) – (10 + 5) = 215
*not accurate if the patient has hyper extensible joints.
Total passive motion (TPM) – same formula
American Society for Surgery of the Hand.The hand: examination and diagnosis, 1978
Test for ligament integrity
Perform radial and ulnar stress test with:
MP joint in flexion and PIP and DIP joints in extension (closed packed position)
–Use caution with an acute injury prior to x‐ray
Intrinsic Tightness Test
•Hold MP in full extension and passively flex the PIP, note ROM.•Then place MP into flexion, and passively flex the PIP, note ROM.
•Test is positive if PIP ROM is greater with the MP flexed.
When might you encounter intrinsic tightness? What condition? What injury?
Extrinsic Tightness Test
Same test, reverse findings
•Text Mackin E et al 2002Finochetto 1920 referred to by Zancolli E. 1968.Bunnell S. 1953.Smith R 1971
What could cause extrinsic tightness?Could you have both intrinsic and extrinsic tightness?
PROXIMAL ATTATCHMENT: volar proximal phalanx
DISTAL ATTATCHMENT: terminal extensor tendon
SLACK IN PIP FLEXION AND DIP EXTENSION
TAUT IN PIP EXTENSION AND DIP FLEXION
Helps coordinate extension of IP joints
Grant’s Atlas of Anatomy/ 8th Edition/ 6‐107
What dx often presents with ORL tightness?
Shortened Position: PIP flexed and DIP extended
Lengthened Position: PIP extended and DIP flexed
Test Position: max PIP extensionthen flex DIP. If motion is less than with PIP flexed, ORL is tight.
Mackin EJ, et al. eds. 2002.Landsmeer JMF. Anat Rec 1949.Shrewsbury M, Johnson R. 1977.
If there is joint contracture, finger joint ROM will not change passively regardless of position of the wrist or MPJ
Assess PROM with different positions of wrist and MPJ to assess where tightness is occurring
if there is little or no change in A/PROM in any position, there is a stiff/contracted joint
When might you see this?
Flexors
If there is extrinsic flexor tightness, the IP’s can be passively extended with wrist and MP flexion but not with MP and wrist extension
Extensors
If there is extrinsic extensor tightness, the IP’s can be flexed with the wrist and MP in extension, but not in flexion
• Hold MP in extension and passively flex IPs.(elbow extended and forearm pronated)
• Repeat IP flexion with the MP in flexion.
• Test is “+” if the IP ROM is greater with the MP in extension (vs. flexion).
• Varying wrist position will affect results.
• Must rule‐out IP limitations prior to completing this test.
Mackin E et al 2002
• Place wrist in neutral and passively extend the digits; then slowly increase wrist extension(elbow extended and forearm supinated)
• Positive test if patient is unable to passively maintain IPs in extension as the wrist extension is increased
• Rule out PIP or DIP joint tightness by evaluating the individual joint status with wrist in neutral or slight flexion.
MMT: can measure groups of muscles or can be specific to each muscle.
Scale is 0‐5
▪ (0=no movement, 5=full AROM and strength).
Note any pain with excursion of muscle‐tendon unit
▪ (ie. 1st dorsal compartment with DeQuervain’stendonitis).
Florence Kendell, Manual
Dynamometer
Standard Method
Pinch Meter
Lateral
Tripod
Tip
American Society of Hand Therapists, Clinical Assessment Recommendations, 2nd Edition
no good norms, compare to contralateral hand
Average Grip Range
Male: 80‐140 lb.
Female: 40‐80 lb.
10% rule: “normal” difference between dominant and non‐dominant hands
tends to be less than 10% in left handed people (often right hand is stronger)
may be more than 20% in people who extensively use one‐handed tools requiring tight grip (e.g. wrench, pliers)
calibration essential previously thought that coefficient of variance should be < 15% on average of 3 trials ‐ if patient is exhibiting maximal effort –research has shown this to be untrue
(Schectman, J Hand Ther, 2000)
Pinch meter Lateral Pinch = key pinch Three jaw chuck = tripod or three‐point standard positioning/instructions
instructions should be standardized, similar to grip instructions
forearm neutral
make sure no other fingers assist
Three Point Pinch
Patient is asked to place two fingers (index and middle) on the top of pinch meter, and the thumb opposing on the bottom
they then are asked to pinch as hard as able
alternate hands, average three trials
Lateral Pinch
patient is asked to curl fingers into a loose fist
the pinch meter is placed along the middle phalanx with the thumb on top
again, three trials are taken and averaged for each hand
Static 2 point discrimination Moving 2 point discrimination Semmes Weinstein monofilaments Temperature Stereognosis
Sample recording form for sensibility eval
May indicate scars, amputations, and results on picture of hand
Detection: Touch/Pressure Threshold
Semmes‐Weinstein Monofilaments
Correlates with the ability to discriminate
textures
Instrument reliability established with standardized equipment and testing procedure
position patient, seated, hand supinated, resting on towel or putty
vision occluded, quiet atmosphere clearly explain the test to the patient show them the monofilaments on your own hand ‐
“thinnest is like a hair” and “ thickest is like a toothpick” “some are easy to feel and some are hard to feel” “I will move around and touch different fingers, let me
know when you feel a touch”
monofilament applied to skin per protocol
apply perpendicular to skin for 1.5 seconds, to bending, lift for 1.5 seconds
repeat x3 for filaments 1.65 ‐ 4.08
1x only for filaments 4.17 ‐6.65
volar surface first follow digital nerve innervation progress testing distal to proximal progress to filaments of increasing pressure randomize sequencing and timing to minimize anticipation of responses
Normal: 1.65 ‐ 2.83
Diminished light touch: 3.22 ‐ 3.61
Dim. protective sensation: 3.84 ‐ 4.31
Loss of protective sens: 4.56 ‐ 6.65
Untestable: greater than 6.65
Discrimination: perceive a difference between two stimuli
requires finer reception acuity and more judgement
Two‐point discrimination, disk‐criminator Innervation density test
explain that you will touch with either one or two tips, request verbal response of “one” or “two”
show the disk‐criminator to the pt: demonstrate the difference between one and two points on their hand using widely spaced points
Position patient, same as Semmes‐Weinstein Measure fingertips only Begin with 5mm, increase or decrease one or two points are applied just to blanching in longitudinal orientation perpendicular to the skin
randomized order
2 point discriminationnote: prongs applied perpendicular to fingerin line with finger (not across finger)to blanching
Patient replies with “one” or “two”
7/10 accurate responses needed for scoring
keep increasing distances until accurate
response level achieved
comparison with contralateral hand as
needed
testing discontinued at 15mm if still
inaccurate
Normal: 0mm ‐ 5mm
Fair: 6mm ‐ 10mm
Poor: 11mm ‐ 15mm
Protective: one point perceived
Anesthetic: no points perceived
Pain/temperature 30cps vibration Moving touch Static touch 256 vibration 2‐point discrimination Localization to touch Stereognosis
Nine hole peg test Minnesota Rate of Manipulation
Jebson Taylor Hand Function Test MRMT Purdue Pegboard Crawford Small Parts Dexterity Box and Block Test Bennett Hand Tool Dexterity Test Etc.
Test of: tactile gnosis, functional level of sensibility, touch discrimination
Equipment: any combination of small objects may be used (no true standardized test)
Considerations: motor function required, ability to pinch and hold an object required.
correlates with 2‐PD test
Summarize data to get full picture Set goals for components to achieve long term functional goals
Re examine at intervals to determine progress and outcome from treatment
Shechtman and Sindhu: Grip Strength. Clinical Assessment Recommendations. ASHT online Publication
Lavelle and Breger Stanton: Measurement of Edema in the Hand Clinic. Clinical Assessment Recommendations. ASHT online Publication.
Cowan and Stegink‐Jansen: A Review of Assessments to Address Hand Function After Burn Injury. Clinical Assessment Recommendations. ASHT online Publication.
Clinical Assessment Recommendations, 2nd Ed. ASHT. 1992. Magee DJ. Orthopedic Physical Assessment. 3rd Edition, WB Saunders Co.
Philadelphia, 1997. Beaton, Dorcas): Shared Property of:Institute for Work and Health (IWH) and the
American Academy of Orthopaedic Surgeons (AAOS) Hunter, Mackin, Callahan; Rehabilitation of the Hand, 5th edition,
MosbyAmerican Society for Surgery of the Hand. The hand: examination and diagnosis,
1978. Dutton Mark: orthopedic Examination, Evaluation & Intervention. McGraw Hill 2004