Therapy Ed Chapter 11- Biomechanical Approaches

Front 1

What is the biomechanical approach?

Back 1

-focuses on ROM, strength, and endurance required to perform and occupation
-most commonly used to treat patients with lower motor neuron deficits and orthopedic problems
-approach should not be used in isolation: most effective when used in combination with other approaches that focus on engagement in meaningful and purposeful activity

Front 2

Settings that most commonly use the biomechanical approach

Back 2

-hand clinics
-work programs
-physical medicine and rehab departments
-ergonomic programs

Front 3

Finger ROM p.248

Back 3

Total AROM and total PROM
(TAM) + (TPM)
-measures tendon excursion
-add extension deficits and subtract from flexion measurement, ex:
Digit #2
MCP 10-50
PIP 15-75
DIP 0-10
TAM=110

Front 4

Recording measurements for ROM

Back 4

-starting position/ending position (eg 0-150)
-do not use negatives

- Within Functional Limits (WFL) = ROM is fxn

-Within Normal Limits (WNL) = ROM achieves normal ranges

Front 5

Average ROM for cervical spine (table p. 248)

Back 5

flexion: 0-45
ext: 0-45
lateral flexion: 0-45
rotation: 0-60

Front 6

Avg ROM for thoracic and lumbar spine

Back 6

flexion: 0-80
ext: 0-30
lateral flexion: 0-40
rotation: 0-45

Front 7

ROM for shoulder

Back 7

flexion: 0-170
extension: 0-60
abduction: 0-170
adduction: 0
horizontal abduction: 0-40
horizontal adduction: 0-130
internal rotation: 0-60
external rotation: 0-80

Front 8

Associated girdle movements for shoulder ROM

Back 8

-flexion: abduction, lateral tilt, elevation, slight upward rotation
-extension: depression, adduction, upward tilt
-abduction: upward rotation, elevation
-adduction: depression, downward rotation
-horizontal abduction and internal rotation: abduction with lateral tilt
-horizontal adduction and external rotation: adduction w/ reduction of lateral tilt

Front 9

Elbow ROM

Back 9

flexion: 0- 135-150
extension: 0

Front 10

Forearm ROM

Back 10

pronation: 0- 80-90
supination: 0- 80-90

Front 11

Wrist ROM

Back 11

Flexion: 0-80
Extension: 0-70
ulnar deviation: 0-30
radial deviation: 0-20

Front 12

Thumb ROM

Back 12

DIP flex: 0-90
MP flex: 0-50
Adduction: 0
Palmar abd: 0-50
Radial abd: 0-50

Front 13

Finger ROM

Back 13

MP flex: 0-90
MP hyperext: 0- 15-45
PIP flex: 0-110
DIP flex: 0-80
abd: 0-25

Front 14

Hip ROM

Back 14

flex: 0-120 (bent knee)
ext: 0-30
ABd: 0-40
Add: 0-35
Int rot: 0-45
Ext rot: 0-45

Front 15

Knee ROM

Back 15

flex: 0-145

Front 16

Ankle and foot ROM

Back 16

plantar flex: 0-50
dorsiflex: 0-15
inversion: 0-35
eversion: 0-20

Front 17

Types of MMT

Back 17

Break test = most common MMT

Test position: gravity eliminated (lessened) or against gravity.

Stabilization: usually proximal to the joint the muscle crosses over. DO not hold over the muscle being tested.

Resistance: applied in opposite direction of movement; should be gradual.

Front 18

Types of MMT

Back 18

Resistance Test

Resistance is applied throughout the range.

Individual can compensate easily

Requires experienced therapist

Front 19

mm grade 5

Back 19

normal
-part moves through full ROM against gravity, max resistance

Front 20

mm grade 4

Back 20

Good
-full ROM against gravity, mod resistance

Front 21

mm grade 4-

Back 21

good minus
-full ROM against gravity, less than mod resistance

Front 22

mm grade 3+

Back 22

fair plus
-full ROM against gravity, min resistance

Front 23

mm grade 3

Back 23

fair
-full ROM against gravity, no resistance

Front 24

mm grade 3-

Back 24

fair minus
-less than full ROM against gravity

Front 25

mm grade 2+

Back 25

poor
-full ROM in gravity eliminated w/ no resistance

Front 26

mm grade 2-

Back 26

poor minus
-less than full ROM in gravity eliminated

Front 27

mm grade 1

Back 27

trace
tension palpated but no movement

Front 28

mm grade 0

Back 28

zero
no tension

Front 29

Types of grip strength tests

Back 29

1. Position of UE: shoulder adducted, elbow 90, forearm neutral- mean of 3 trials w/ dynamometer
2. one trial in all 5 positions for each hand, bell curve to see if person applying max effort
3. vigorometer or BP cuff to evaluate grip strength for people with arthritis

Front 30

Pinch Strength entails...

Back 30

1. Use of Pinchmeter

2. Position of UE: Shoulder adducted to side, elbow flexed 90 and forearm in neutral

3. Type of pinch strength test

- Key or later pinch: thumb pulp to lateral aspect of index middle phalanx.

- three jaw chuck (palmar pinch): pulp of thumb -pulp of index and middle fingers

- tip to tip thumb pulp to pulp of index fingers.

4. trials on each hand are obtained for all pinch strengths

Front 31

Types of edema

Back 31

pitting-acute
brawny- chronic

Front 32

How to measure edema in hand with tape measure

Back 32

figure 8 method

Front 33

What is significant edema change in volumeter?

Back 33

10 ml; only true objective tool

Front 34

What are the steps to measuring sensation?

Back 34

1. Demonstrate sensory test w/ vision; then occlude vision for actual test.

2. Test uninvolved side first. Apply stimular to volar and dorsal surfaces

Front 35

Sensory testing in SCI and peripheral nerve injuries

Back 35

SCI tested proximal to distal.

Peripheral injuries tested distal to proximal using dermatomes.

Front 36

What is the order of return for peripheral nerve injuries?

Back 36

pain, moving touch, static light touch, then touch localization

Front 37

Types of sensory testing

Back 37

1. light touch: cotton swab; +(intact), -(impaired), or 0(absent)
2. localization: cotton swab; +, -, or 0
3. pain: paperclip; sharp or dull; S+, D+, S, D, S-, or D-
4. temp: test tubes or thermal kit; score +, -, or 0
5. stereognosis: # of correct objects identified

Front 38

Type of sensory testing

Moving 2 pt discrimination

Back 38

-begin with points 5-8 mm apart
-applied prox to distal on fingertips in horizontal orientation
-responds 1 or 2; # of points felt.
-7 out of 10 correct before decreasing distance between 2 points
-normal score= 2mm

Front 39

Type of sensory testing

Static 2 pt discrimination

Back 39

-test begins at 5mm
-apply to fingertips in longitudinal orientation
-responds 1 or 2
-inc distance until 7 out of 10 correct
-test stopped at 15mm
-scoring:
normal=5mm, fair=6-10mm, poor 11-15mm, protective-1 point perceived, anesthetic-no points felt

Front 40

Testing proprioception

Back 40

*position sense
-therapist positions involved extremity
-person duplicates position with uninvolved extremity

Front 41

testing kinesthesia

Back 41

*movement sense
-therapist moves segment
-person responds up or down

Front 42

dermatome anterior facial region (p.250)

Back 42

1. spinal segment: CN V
2. mm facilitated: mm of masication
3. function- ingestion

Front 43

dermatome neck region

Back 43

1. C3
2. sternocleidomastoid, upper trap
3. head control

Front 44

dermatome upper shoulder region

Back 44

1. C4
2. trapezius (diaphragm)
3. head control

Front 45

dermatome lateral aspects of shoulder

Back 45

1. C5
2. deltoid, biceps, rhomboid major and minor
3. elbow flexion

Front 46

dermatome thumb and radial forearm

Back 46

1. C6
2. extensor carpi radialis, biceps
3. shoulder abduction, wrist extension

Front 47

dermatome middle finger

Back 47

1. C7
2. triceps, wrist and finger extensors
3. wrist flexion, finger extension

Front 48

dermatome little finger, ulnar forearm

Back 48

1. C8
2. flexors of wrist and fingers
3. wrist flexion, finger extension

Front 49

dermatome axilla and proximal medial arm

Back 49

1. T1
2. hand intrinsics
3. abd, add of fingers

Front 50

dermatome thorax

Back 50

1. T2-T12
2. intercostals
3. respiration

Front 51

dermatome nipple line

Back 51

1. T4-T6
2. intercostals
3. respiration

Front 52

dermatome midchest and lower rib

Back 52

1. T11
2. abdominal wall, abd muscles
3. T5-T7 superficial abdominal reflex

Front 53

dermatome umbilicus

Back 53

1. T10
2. psoas, iliacus
3. leg flexion

Front 54

dermatome inside of thigh

Back 54

1. L1-L2
2. cremasteric reflex, accessory mm
3. elevation of scrotum

Front 55

dermatome proximal anterior thigh

Back 55

1. L2
2. iliopsoas, adductors of thigh
3. reflex voiding

Front 56

dermatome anterior knee

Back 56

1. L3-L4
2. quads, tibialis anterior, detrusor urinae
3. hip flexion, knee ext, thigh abduction

Front 57

dermatome big toe

Back 57

1. L5
2. lateral hamstrings
3. knee flexion, toe extension

Front 58

dermatome foot region

Back 58

1. L5-S1
2. gastroc, soleus, ext digitorum longus
3. flexor withdrawal, urinary retention

Front 59

dermatome small band of post thigh

Back 59

1. S2
2. small mm of foot
3. bladder retention

Front 60

Purdue pegboard

Back 60

-test of fingertip dexterity and assembly job simulation
-subtests:
a. 30 sec : right hand, left hand, both hands, R+, L+, both
b. one minute test: assembly
-scoring:
30 sec test is the number of pins placed in the board in 30 sec. Assembly is # of parts assembled in 1 minute

Front 61

minnesota manual dexterity test

Back 61

-test of gross hand and arm movements
-Subtests:
1. placing test-measures rate of hand movement(one hand only)
2. turning test- measures bilateral rate of finger manipulation
-scoring:
time to complete board. one practice and 4 scored trials

Front 62

O'Connor tweezer test

Back 62

-test of eye-hand coordination using tweezers
-scoring: # of seconds to place all pins in board using tweezers

Front 63

Crawford Small Parts Dexterity Test

Back 63

-test of fine motor dexterity using small tools
-scoring: time to complete assembly

Front 64

Nine hole Peg Test

Back 64

-measures finger dexterity
-scoring: time for each hand to place nine pegs in the board and remove them
-Purdue pegboard is preferred over 9 hole b/c it is unilateral and bilateral, and is more reliable

Front 65

Jebsen hand function test

Back 65

-test of hand function
-7 subsets:
writing, simulated page turning, picking up common objects, simulated feeding, stacking, picking up large heavy objects, picking up large light objects
-scoring: time to complete each subject

Front 66

Informal assessment of coordination should include

Back 66

1. fine motor: observation of routine task performance
2. gross motor: observe activities that involve (tossing ball, reaching in cabinet, etc)

Front 67

Passive ROM and Passive stretching to increase ROM

Back 67

PROM = moving joint to desired range using an external force. Therapy gently moving extremity to desired range or when resistance is felt.

Passive stretching is PROM w/ overpressure.

* heat prior to stretching increases extensibility

Front 68

Codman's exercise

Back 68

common form of PROM use for post-surgical shoulder patients (letting arm dangle and circular motion) p.252

Front 69

Active ROM

Back 69

-should be performed when PROM is greater than AROM
-tendon gliding
-emphasize functional use
-preparatory interventions: wall walking, AROM, cane exercise, etc
-purposeful activities

Front 70

ROM precautions

Back 70

myositis ossificans may result from overstretching (especially noted in elbow flexors)

Front 71

Isometrics used to increase strength entail...

Back 71

Isometric = contraction w/o movement

-Sometimes can produce more forceful contraction

Front 72

who are isometric exercises contraindicated for?

Back 72

people with hypertension and cardiovascular problems.

Front 73

isotonic strengthening

Back 73

contraction with movement
1. eccentric- lengthening
2. concentric- shortening

Front 74

Increasing endurance

Back 74

-work at 50% of max resistance or less
-increase repetitions and duration, not resistance
-energy conservation methods

Front 75

Edema Reduction techniques

Back 75

1. elevation: above the heart, unless circulation problems
2. retrograde massage: performed w/ extremity elevated
3. compression garments to prevent re-accumulation of fuids after massage
4. cold packs: most effective when combined w/ elevation
5. contrast bath
6. other: wraps and compression pumps, not common
7. manual edema mobilization: special training
8. heat rarely
9. Precautions/Contraindications:
infection, wounds or grafts, vascular damage, unstable fractures, congestive heart failure (CHF)

Front 76

Scar management

Back 76

1. ROM
2. massage (circles and friction)
3. compression: coban for fingers, isotoner glove, tubigrip for UE
4. scar pad with compression
5. splinting to prevent contracture
6. edema control

Front 77

In sensory training: Desensitization for hypersensitivity involve...?

Back 77

If post surgery, being in periphery of the scar and as tolerated work over the scar.

Massage

textures

vibrations

three phase desensitization kit

fluidotherapy

Front 78

Sensory re-education involve?

Back 78

Massage

textures

vibrations

three phase desensitization kit

Front 79

Improving coordination

Back 79

1. Begin w/ gross motor activities and grade up to fine motor activities

2. Select appropriate activities which ROM is required w/in the person's reach and yet challenging

3. Focus on accuracy and speed. Being w/ slow gross movements and gradually progress to faster precise movements.

Front 80

Energy Conservation (econs) & work simplification principles and methods

Back 80

1. Planned short rests (5-10min) during daily routine

2. Schedule task to alternate btwn heavy/light work tasks to achieve balance

3. Organize tasks; gather all items/equip before task

4. Avoid multiple trips to obtain items

5. Eliminate tasks that are non-essential

6. Delegate tasks

7. Combine tasks

8. Sit to work

9. Organize cabinets for easy reach/convenient
10. Use adaptive equipment

11. Use electrical appliances

12. Slide rather than lift heavy items

13. Use light weight equipment, tools, utensils

14. Rest before fatigue sets in.

Front 81

Joint protection principles

Back 81

-maintain joint ROM by using maximal ROM during activity
-maintain mm strength by using maximal strength during daily activity
-use strongest and largest joint possible for task completion
-use each joint in stable and functional position
-avoid sustained positions
-avoid positions in deformity
-no activity that can't be immediately stopped if needed

Front 82

Types of splints

Back 82

1. Static splints = has no resilient components and immobilizes a joint or part

2. Dynamic: includes a resilient component (elastic, rubber band, or spring) which the individual moves. Designed to increase PROM or to augment AROM.

Front 83

Purpose of Splinting

Back 83

Rest

Prevent deformities & contractures

Increase joint ROM

Protect bone, joint and soft tissue

Increase functional use

Front 84

Hand splinting design standards

Back 84

1. Maintain arches of the hand
a) proximal transverse arch
b) distal transverse arch
c) longitudinal arch
2. Do not impinge upon creases of the hand
a) distal and proximal palmar creases
b) distal and proximal wrist creases
c) thenar crease

Front 85

Mechanical principles of splinting

Back 85

1. decrease pressure
2. use sling applied with 90 deg angle of pull
3. low load to increase duration
4. maintain 3 pt pressure versus circumference
5. avoid the position of deformity
-wrist flexion
-MCP hyperextension
-IP joints flexed
-thumb adducted
6. Select the appropriate splinting position

Front 86

Resting position for splinting

Back 86

wrist 10-20 ext,
MCPs 30-45 flex,
IPs 0-20 flex,
thumb abducted

Front 87

Safe position for splinting

Back 87

wrist 20-30 ext,
MCPs 50-70 flex,
IPs in extension,
thumb abducted and extended

Front 88

splint for brachial plexus injury

Back 88

flail arm splint

Front 89

splint for radial nerve palsy

Back 89

dynamic wrist, finger and thumb extension splint

Front 90

splint for median nerve injury

Back 90

opponens splint, C-bar, or thumb post splint

Front 91

splint for ulnar nerve injury

Back 91

dynamic/static splint to position MPs in flexion

Front 92

splint for combined median ulnar nerve injury

Back 92

figure of eight or dynamic MCP flexion splint

Front 93

splint for spinal cord injury (c6-c7)

Back 93

tenodesis splint

Front 94

splint for carpal tunnel syndrome

Back 94

wrist splint positioned in neutral

Front 95

splint for cubital tunnel syndrome

Back 95

elbow splint positioned at 30 deg flexion

Front 96

splint for DeQuervain's

Back 96

thumb splint, includes wrist, IP joint free

Front 97

splint for Skier's thumb

Back 97

UCL hand based splint

Front 98

splint for CMC arthritis

Back 98

hand based thumb splint

Front 99

splint for ulnar drift

Back 99

ulnar drift splint

Front 100

splint for flexor tendon injury

Back 100

dorsal protection splint

Front 101

splint for swan neck deformity

Back 101

silver rings or buttonhole splint

Front 102

splint for Boutonniere deformity

Back 102

silver rings or PIP extension splint

Front 103

splint for arthritis

Back 103

functional or safe splint, depending on stage

Front 104

splint for flaccidity

Back 104

resting splint

Front 105

splint for spasticity

Back 105

spasticity splint or cone splint

Front 106

splint for mm weakness (ALS, SCI, Guillan-Barre)

Back 106

balanced forearm orthosis (BFO), deltoid sling/suspension sling
-mounts to wheelchair
-individuals must have shoulder or trunk movement

Front 107

splint for hand burns

Back 107

wrist 15-3o ext,
MCP 50-70 flex,
IPs full ext

Front 108

Important note of physical agent modalities

Back 108

should NEVER be used alone

Front 109

benefits of e-stim

Back 109

relieves pain, dec swelling, stimulate and strenghen, stimulated denervated mm

Front 110

benefits of ultrasound

Back 110

relieves pain, dec inflammation, dec tissue extensability (inc ROM), decrease adhesions

Front 111

general contraindications for PAMs

Back 111

cancer, pacemaker, pregnancy, cognitive impairment, sensory impairment, vascular impairment
**ultrasound never used over a growth plate