Upload
ahmad-a-fannoon
View
216
Download
0
Embed Size (px)
Citation preview
7/30/2019 Evaluation of the Hand!
1/84
Ahmad A. Fannoon, Hand Therapist
7/30/2019 Evaluation of the Hand!
2/84
Part 1
7/30/2019 Evaluation of the Hand!
3/84
You should obtain the history of symptoms or
injury that brought the client to your clinic: Onset of symptoms (gradual vs. essential). Prior medical interventions (surgery, injections,
x-ray, MRI, CT scan, NCS, cast, splinting,medications, manual tests by physician, nophysician treatment, previous rehabilitation).
Dates. Occupation.
Gender.
7/30/2019 Evaluation of the Hand!
4/84
Date of birth. Family role. Caregiver. Pertinent medical history (e.g. diabetes and
peripheral vascular disease, blood pressure,heart problems, etc) healing process, effortfor exercise, etc.
7/30/2019 Evaluation of the Hand!
5/84
Obtaining history is essential because: Understand what physician and previous
therapist were attempting to determine byseveral tests accurate diagnosis.
Understand the injury or the condition effective treatment. Understand what was the treatment provided by
physician and previous therapist effectivetreatment.
Build client confidence and trust in you
cooperation in treatment.
7/30/2019 Evaluation of the Hand!
6/84
In the initial process of evaluation while
interviewing your client, use your
observation skills! Nonverbal communication (facial expressions and
body language) mood, emotions, andmotivation.
Use of the involved UE and trunk: some clientsmay exaggerate their impairment (guarding orless AROM) during the formal assessment to make
sure that you appreciate the extent of theirdeficit. Thus, observing them during spontaneousactions (gestures during conversation ormovement during taking off the jacket) will giveyou an indication.
7/30/2019 Evaluation of the Hand!
7/84
With such clients:1. Use different approaches to elicit best
responses.2. Keep reminding the client that your ultimate
goal is to help him get better.3. If the client still exaggerating; use a gentle
nonjudgmental approach where you point outthe discrepancy between formal testing andobservation.
7/30/2019 Evaluation of the Hand!
8/84
Part 2
7/30/2019 Evaluation of the Hand!
9/84
No equipment is necessary.
During initial evaluation; use a pain scale. Numeric analogue scale (1, 2, 3, 10). Visual analogue scale (10 cm vertical line). Verbal rating scale (no pain, mild, moderate). Graphic representation (point out pain on a body
chart). Pain questionnaires (e.g. McGill pain
questionnaire) usually used by pain managementcenters.
7/30/2019 Evaluation of the Hand!
10/84
7/30/2019 Evaluation of the Hand!
11/84
7/30/2019 Evaluation of the Hand!
12/84
7/30/2019 Evaluation of the Hand!
13/84
Obtain a written description of the pain
including the following factors:
Level of pain: see previous slide. Location of pain: have the client point out his or
her pain on a body chart and rate them (referredpain: palpation of one area results in pain inanother area).
Type of pain: throbbing ( ), aching, sharp,stabbing, shooting, burning, or hypersensitivityto light touch.
Frequency of pain: constant or intermittent!What seem to cause the pain? What is painassociated with (e.g. AROM).
7/30/2019 Evaluation of the Hand!
14/84
7/30/2019 Evaluation of the Hand!
15/84
Chronic pain (more than 6 months in one area) isusually associated with some psychologicalinvolvements (e.g. depression and anxiety); gethelp from pain management specialists.
Indicate pain associated with evaluation
procedures: e.g. pain with active elbow flexion,right grip strength 100, left 60 with mild painindicated in left volar wrist.
7/30/2019 Evaluation of the Hand!
16/84
Many clients are anxious about attending
therapy, they may be afraid of; provocative
tests, touching a tender area, or moving the
hand beyond comfort levels, etc.
Always start your evaluation with pain.
Talk to your clients about their pain.
Reassure your clients that you are aware of
their pain.
7/30/2019 Evaluation of the Hand!
17/84
To confirm diagnosis and understand symptoms,
therapist may have to use pain provocative
testing: Pain with AROM and no pain with PROM
problem with muscle or tendon. Pain with both PROM & AROM joint problem
(e.g. tightness of joint structures, ligamentinjury, cartilage injury, or inflammation).
Pain with joint distraction, pain relief with
compression
problem with capsule or ligamentbeing stretched. Pain with joint compression, pain relief with
distraction problem with joint surfaces (e.g.thinning of cartilage, inflammation within joint,or bone abnormalities like bone spur).
7/30/2019 Evaluation of the Hand!
18/84
Be careful! Do not use aggressive problem
solving methods when it is not safe. E.g.
after tendon repair or transfer, new stitches,
nerve repair, or against internal or external
fixations. Check with the referring physician
if AROM, PROM, joint distraction or
compression, etc are yet allowed.
7/30/2019 Evaluation of the Hand!
19/84
Part 3
7/30/2019 Evaluation of the Hand!
20/84
If the wound is closed; skip to scar
assessment, if the wound is open, assess the
following: Size: length and width using a ruler, do not
touch the wound by the ruler except wassterile. What about future measurements?
Depth: use sterile cotton swap. Color: wound are red, yellow, black, or any
of them together. We love the red wound!1. Red: uninfected, definite borders,granulation tissue present, apparentrevascularization, myofibroblasts (theshrinkers), epithelial cells present.
7/30/2019 Evaluation of the Hand!
21/84
2. Yellow: Pseudomonas bacteria can be present,wound may have odor, draining and purulent,semi-liquid slough, dominant cellular activity isthe macrophage (Pac Man), epithelializationwill be delayed due to infection.
3. Black: Presence of Escher (necrotic tissue) willincrease the work required by the macrophageand delay healing.
7/30/2019 Evaluation of the Hand!
22/84
7/30/2019 Evaluation of the Hand!
23/84
7/30/2019 Evaluation of the Hand!
24/84
7/30/2019 Evaluation of the Hand!
25/84
Drainage: mild, moderate, or heavy?
1. Serous: clear, white or slightly yellow,indicator of healthy open wound.
2. Purulent: is thick, yellowish and may have
odor or can be green blue or gray indicatespresence of microorganisms (infection) willneed dressing changes and infection controlmedication.
3. Sanguinous: bloody drainage, indicates new
bleeding.4. Serosanguinous: thin watery and pink or red
seen in initial post op period.
If infection is suspected, refer client back tothe referring physician.
7/30/2019 Evaluation of the Hand!
26/84
Oder: means infection, if present refer clientback to the referring physician.
Temperature: use thermometers or temperaturetapes to measure the temperature of an area
near the wound and compare it with an intactarea. Always observe the wound for the cardinal signs of
infection: redness, swelling, increased temperature andpain.
7/30/2019 Evaluation of the Hand!
27/84
Part 4
7/30/2019 Evaluation of the Hand!
28/84
7/30/2019 Evaluation of the Hand!
29/84
In assessing scar, consider the following: Color: deep red lighter with time. Size: length x width. Flat/raised: the scar itself maybe flat or raised,
if raised describe it in terms of mild ormoderate.Sometimes their will be a lump under the skin
which is a combination between scar and fluid,commonly it appears on the dorsum of the handor on the wrist: describe it by location, size, and
height. Adhesions: adhesions of superficial scar to
underlying fascia and tendons. Can be seenduring active movements. Observe and palpateand describe by mild, moderate, or sever.
7/30/2019 Evaluation of the Hand!
30/84
Precautions: Respect the healing of a new scar the tissue to
which it may adhere.
Do not move the scar if when a portion of the
wound is still open. Do not aggressively attempt to move the scar
within the first week after suture removal.
Do not manipulate a scar strongly in thetreatment or assessment of scar over a tendon inthe early stages of healing.
7/30/2019 Evaluation of the Hand!
31/84
Part 6
7/30/2019 Evaluation of the Hand!
32/84
7/30/2019 Evaluation of the Hand!
33/84
Blood flow to the hand may be affected by
proximal injuries or diagnoses, e.g.: Thoracic outlet syndrome.
Injury to the hand itself.
Conditions such as Raynaud's phenomenon.
7/30/2019 Evaluation of the Hand!
34/84
Consider the following:
Color: White grayish (pallor): arterial interruption.
Congested purple blue: venous blockage. Dusky blue: chronic venous insufficiency.
Red: venous problem or inflammatory phase ofhealing or infection.
7/30/2019 Evaluation of the Hand!
35/84
Trophic changes (texture of the skin and
nails) which can be the result of sympathetic
nerve or vascular changes: Dry/moist.
Shiny/dull.
Pain: in 2/3 of clients with UE vascular problems.Aching, cramping, tightness, or cold intolerance.May be associated with vibration, cold, or
repetition.
7/30/2019 Evaluation of the Hand!
36/84
Capillary Refill Test:
1. firmly press on the distal portion of the
volar finger or finger nail.
2. Until it turns white.3. Release and count seconds.
Normal refill time is less than 2 seconds.
7/30/2019 Evaluation of the Hand!
37/84
7/30/2019 Evaluation of the Hand!
38/84
Peripheral Pulse palpation (usually used with
proximal vascular problems e.g. TOS):
1. Gently press on the radial or ulnar arteries
just proximal to the wrist crisis.2. Record pulse strength and quality.
3. Compare with intact hand.
4. check before and after each exercise with
certain movements to determine the BADposition.
7/30/2019 Evaluation of the Hand!
39/84
Modified Allens test (blood flow within the handthrough radial and ulnar arteries):
1. Firmly press the redial and ulnar arteries justproximal to the wrist crisis.
2. Ask patient to perform tight fist then extendfingers and repeat until palm is WHITE (no bloodflow to the hand)!
3. Ask the patient to relax.
4. Release from one side.
5. Count seconds for the hand color to return normal.
6.
Do steps 1 - 3 again.7. Do step 4 but this time release the other side of thewrist.
8. Do step 5 again.
Normal response time is 5 seconds, you can alsocompare to the intact hand.
7/30/2019 Evaluation of the Hand!
40/84
7/30/2019 Evaluation of the Hand!
41/84
If forearm temperature is at least 4 degrees warmer
than the fingertips temperature then vascular
problems are expected.
In testing for Raynauds phenomenon:
1. Test baseline temperature.
2. Test after being in a warm room for 30 minutes.
3. Record time of temperature returning to baseline.
4. Test after being immersed in ice for 20 seconds.
5. Record time of temperature returning to baseline.
Normal time is 10 minutes, Raynauds
phenomenon patients may take 20 45 minutes.
7/30/2019 Evaluation of the Hand!
42/84
Part 7
7/30/2019 Evaluation of the Hand!
43/84
Inflammatory swelling is a normal body
response to injury, surgery or trauma,
bringing good cells for healing.
Normal reduction of edema
begins within2 weeks post surgery/trauma/injury but may
take months to complete.
Edema that does not decrease gradually and
stays longer than 2 weeks is a problem!! itbecomes more like gel interferes with
joint and tendon motion UE function.
Inflammatory edema spongy fibrotic!!.
7/30/2019 Evaluation of the Hand!
44/84
You should consider:
Amount of swelling: Volumetric displacement.
Circumferential measurement.
Characteristics of edema: observation.
Palpation.
7/30/2019 Evaluation of the Hand!
45/84
Equipments: Tank. Collection beaker. Graduated cylinder.
Methods: See picture next slide.
Notes: After measuring the affected hand, compare it tothe intact hand, a difference of 10-ml issignificant and shows a systematic increase involume.
7/30/2019 Evaluation of the Hand!
46/84
7/30/2019 Evaluation of the Hand!
47/84
Precautions: This method must not be used with: open
wounds, unstable vascular status, casts, externalfixators, etc.
Discussion: To increase test reliability, repeat the test 3
times and average.
To increase test reliability, mark the forearm at
the edge of water! Web-space between fingers.
7/30/2019 Evaluation of the Hand!
48/84
Equipments: Tape measure with finger loop (standardize
location in relation to anatomic landmarks,standardize tension!).
Methods: Apply tape measure. Tighten. Record reading.
Discussion: To increase reliability: standardize location in
relation to anatomic landmarks, standardizetension, and have the same therapist do the testall times.
Compare to intact hand.
7/30/2019 Evaluation of the Hand!
49/84
7/30/2019 Evaluation of the Hand!
50/84
Look for and document using a checklist
including: Shininess.
Dryness.
Loss of joint creases.
Skin color (erythematic, cyanosis, or pallor).
7/30/2019 Evaluation of the Hand!
51/84
Edema begins as a pitting edema and may
develop to brawny edema. Pitting edema: large amount of free fluid in the
tissue that can be moved away by pressure and
leaves a pit that slowly refill when pressure iseliminated.
Brawny edema: clogged interstitial fluid which ismore spongy and gel-like. Does not move awayeasily with pressure.
Best test to date is the Artsberger edema
rebound test, use it.
7/30/2019 Evaluation of the Hand!
52/84
Artsberger edema rebound test: Observe original shape of tissue.
Place thumb on tissue (only thumb weight noadditional force).
Leave their for 10 seconds. Remove thumb.
Count seconds for the skin to return to originalshape.
E.g. if first test gave you 60 seconds, retest gaveyou 45 seconds edema became more fluid!This is good!
7/30/2019 Evaluation of the Hand!
53/84
7/30/2019 Evaluation of the Hand!
54/84
Part 8
7/30/2019 Evaluation of the Hand!
55/84
Measures innervation density (number of
nerve endings).
Flexor zones I and II are to be tested.
Two-point discrimination relates to theclients ability to feel something and to know
what they are feeling.
Equipments: Disk-Criminator.
Boley gauge.
7/30/2019 Evaluation of the Hand!
56/84
Methods: Ask patient to respond by two or one.
Support clients hand.
Occlude the client vision.
Start with 5 mm. Force must be applied to the point of blanching,
in a longitudinal direction, and perpendicular tothe skin.
If patient recognizes 5 mm
increase distance,vice versa.
Begin distally and progress proximally.
7/30/2019 Evaluation of the Hand!
57/84
Scoring: 7 out of 10 correct response in one area are
required for a correct responses.
Distance Score
1 5 mm Normal
6 10 mm Fair
11 -15 mm Poor
One point perceived Protective sensation only
No points perceived Anesthetic
7/30/2019 Evaluation of the Hand!
58/84
Always returns earlier than static two-point
discrimination.
Measures progress in return of sensation
following nerve injury.
Equipments: Disk-Criminator.
Boley gauge.
7/30/2019 Evaluation of the Hand!
59/84
Methods: Ask patient to respond by two or one.
Support clients hand.
Occlude the client vision.
Start with 5 mm. Moving force must be applied to the point of
blanching, in a longitudinal direction, andperpendicular to the skin, along the finger tiponly.
Begin proximally and progress distally.
Begin with 5 8 mm and increase or decrease asneeded.
7/30/2019 Evaluation of the Hand!
60/84
Scoring: 7 out of 10 correct response in one area are
required for a correct responses.
2 mm is considered normal moving two-point
discrimination.
7/30/2019 Evaluation of the Hand!
61/84
Recovers earlier than two-point
discrimination sensation.
Effective in identifying sensory impairments
due to nerve compressions.
Equipments: The Semmes-Weinstein Pressure Aesthesiometer
kit of 20 monofilaments (5-monofilaments kit isalso available).
7/30/2019 Evaluation of the Hand!
62/84
Equipments: The Semmes-Weinstein Pressure Aesthesiometer
kit of 20 monofilaments (5-monofilaments kit isalso available).
Color Definition Monofilament
size range
Green Normal light touch threshold 1.56-2.83
Blue Diminished light touch 3.22-3.61
Purple Diminished protective sensation 3.84-4.31Red Loss of protective sensation 4.56-6.65
Untestable Unable to feel largest MF ---
7/30/2019 Evaluation of the Hand!
63/84
7/30/2019 Evaluation of the Hand!
64/84
7/30/2019 Evaluation of the Hand!
65/84
Methods: Explain the test to client. Support the hand in a putty. Occlude clients vision.
Ask the patient to respond with touch whenhe/she feels a touch. Begin with the largest green MF. If responded
continue to smaller, if no response continue tolarger MF.
For green and blue MFs, apply the filament mustbe applied 3 times, 1 correct response is goodenough. All other large MFs must be applied oncefor each trial.
Distal to proximal.
7/30/2019 Evaluation of the Hand!
66/84
Filament must be applied perpendicular to theskin until it bends. Apply in 1-1.5 seconds holdfor 1.5 seconds lift in 1-1.5 seconds.
Record on a hand chart (MF size and color).
7/30/2019 Evaluation of the Hand!
67/84
The last sensory stimulus to return.
Has a significant importance after nerve
repair.
Equipments: Smallest MF recognized earlier. Determined by
the previous test.
Cotton ball.
7/30/2019 Evaluation of the Hand!
68/84
Methods: Explain the test to client.
Support the hand in a putty.
Occlude clients vision.
Touch the hand somewhere and dot it on a chart. Ask the patient to respond by opening his/her
eyes and point out where youve touch him/her.
If the response was correct do not draw any
thing on the chart. If the client pointed out the stimulus in another
place than given, draw an arrow from the dotyouve drawn toward the place he/she pointedout.
7/30/2019 Evaluation of the Hand!
69/84
7/30/2019 Evaluation of the Hand!
70/84
Ninhydrin test: to evaluate sympatheticnervous system function. Is a spray of a clear
agent that turns purple when reacting with
small amounts of sweat. After a complete
nerve laceration no sweat.
ORiain wrinkle test: to evaluate sympathetic
nervous system function or recovery
complete nerve laceration. Normal palmar
skin wrinkles when soaked in 420 C water for
20-30 minutes.
7/30/2019 Evaluation of the Hand!
71/84
7/30/2019 Evaluation of the Hand!
72/84
Mobergs pick-up test: used to determinetactile gnosis, or functional discrimination.
Using small specific small objects, the client
picks the objects up with each hand and is
timed, with vision and without vision.
7/30/2019 Evaluation of the Hand!
73/84
Use the Semmes-Weinstein PressureAesthesiometer with nerve compressions
such as Carpal and cubital tunnel syndromes.
Use The Semmes-Weinstein Pressure
Aesthesiometer and the 2-point
discrimination testing with nerve injury or
laceration.
7/30/2019 Evaluation of the Hand!
74/84
Part 9
7/30/2019 Evaluation of the Hand!
75/84
The Crawford small parts dexterity test.
The 9 Hole Hold Peg Test
The Bennett Hand Tool Test
The Box and Block Test
The Finger Tapping Test
The Grooved Pegboard Test
The Jebsen Hand Function Test
The Minnesota Manual Dexterity Test The Moberg Pick Up Test
The O'Conner Finger Dexterity Test
The O'Conner Tweezer Dexterity Test
The Perdue Pe board Test
7/30/2019 Evaluation of the Hand!
76/84
Part 10
7/30/2019 Evaluation of the Hand!
77/84
As simple as this: is the testing going todamage a healing process (fracture, ligament
repair, tendon laceration, tendon transfer,
etc)?
So do not perform strength testing except
when resistance is approved by referring
physician.
7/30/2019 Evaluation of the Hand!
78/84
Always use the Jamar grip dynamometer.
Do not ignore calibration!
Testing setting:
Client seated. Shoulder adducted.
Elbow flexed to 90 degrees.
Forearm neutral.
Place dynamometer in the clients hand.
Provide gentle support at the base of thedynamometer.
Instruct client squeeze smoothly not jerkily.
Allow wrist extension during grip.
7/30/2019 Evaluation of the Hand!
79/84
7/30/2019 Evaluation of the Hand!
80/84
Methods and procedures: Standard grip test: 3 trials on the 2nd handle
setting.
Five-level grip test: 1 trial on each handle
setting, when curve is a flat line or showsup/down/up/down waves lack of maximalefforts.
Rapid change grip test: therapist alternate thedynamometer between hands for 10 trials for
each hand. Thought to prevent client from self-limiting his grip strength!!!!!!!!!
There are normative data, BUT compare to
the intact hand if possible.
7/30/2019 Evaluation of the Hand!
81/84
Use the pinchmeter.
Testing setting: Client seated.
Shoulder adducted.
Elbow flexed to 90 degrees.
Forearm neutral.
Place pinchmeter in the clients hand.
Instruct client to squeeze smoothly not jerkily.
7/30/2019 Evaluation of the Hand!
82/84
7/30/2019 Evaluation of the Hand!
83/84
Methods and procedures, proceed asfollowing: Lateral pinch (key pinch): pinchmeter between
radial side of the index and the thumb.
Three-point pinch (three jaw chuck pinch):pinchmeter between the pulp of the thumb andthe pulps of the index and middle fingers.
Two-point pinch (tip to tip pinch): between thetip of the index and the tip of the thumb.
Ask the patient to pinch as hard as possible.
7/30/2019 Evaluation of the Hand!
84/84
Please find the Evaluationform titled:
UE Evaluation