Ahmad A. Fannoon, Hand Therapist
Part 1
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, no physician treatment, previous rehabilitation). Dates. Occupation. Gender.
Date of birth. Family role. Caregiver. Pertinent medical history (e.g. diabetes and peripheral vascular disease, blood pressure, heart problems, etc) healing process, effort for exercise, etc.
Obtaining history is essential because: Understand what physician and previous
therapist were attempting to determine by several tests accurate diagnosis. Understand the injury or the condition effective treatment. Understand what was the treatment provided by physician and previous therapist effective treatment. Build client confidence and trust in you cooperation in treatment.
In
the initial process of evaluation while interviewing your client, use your observation skills!
Nonverbal communication (facial expressions and body language) mood, emotions, and motivation. Use of the involved UE and trunk: some clients may exaggerate their impairment (guarding or less AROM) during the formal assessment to make sure that you appreciate the extent of their deficit. Thus, observing them during spontaneous actions (gestures during conversation or movement during taking off the jacket) will give you an indication.
With such clients: 1. Use different approaches
2. 3.
to elicit best
responses. Keep reminding the client that your ultimate goal is to help him get better. If the client still exaggerating; use a gentle nonjudgmental approach where you point out the discrepancy between formal testing and observation.
Part 2
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 management centers.
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 (referred pain: palpation of one area results in pain in another area). Type of pain: throbbing ()نابض, aching, sharp, stabbing, shooting, burning, or hypersensitivity to light touch. Frequency of pain: constant or intermittent! What seem to cause the pain? What is pain associated with (e.g. AROM).
Chronic pain (more than 6 months in one area) is usually associated with some psychological involvements (e.g. depression and anxiety); get help 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 pain indicated in left volar wrist.
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.
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, ligament injury, cartilage injury, or inflammation). Pain with joint distraction, pain relief with compression problem with capsule or ligament being 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).
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.
Part 3
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 was sterile. 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, apparent revascularization, myofibroblasts (the shrinkers), epithelial cells present.
2.
3.
Yellow: Pseudomonas bacteria can be present, wound may have odor, draining and purulent, semi-liquid slough, dominant cellular activity is the macrophage (Pac Man), epithelialization will be delayed due to infection. Black: Presence of Escher (necrotic tissue) will increase the work required by the macrophage and delay healing.
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 … indicates presence of microorganisms (infection) will need dressing changes and infection control medication. 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 to the referring physician.
Oder: means infection, if present refer client back to the referring physician. Temperature: use thermometers or temperature tapes to measure the temperature of an area near the wound and compare it with an intact area. Always observe the wound for the cardinal signs of infection: redness, swelling, increased temperature and pain.
Part 4
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 or moderate. 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 hand or on the wrist: describe it by location, size, and height. Adhesions: adhesions of superficial scar to underlying fascia and tendons. Can be seen during active movements. Observe and palpate and describe by mild, moderate, or sever.
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 the treatment or assessment of scar over a tendon in the early stages of healing.
Part 6
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.
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 of healing or infection.
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.
Capillary 1. 2. 3.
Refill Test: firmly press on the distal portion of the volar finger or finger nail. Until it turns white. Release and count seconds. Normal refill time is less than 2 seconds.
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 BAD position.
1. 2.
3. 4.
5. 6. 7.
8.
Modified Allen’s test (blood flow within the hand through radial and ulnar arteries): Firmly press the redial and ulnar arteries just proximal to the wrist crisis. Ask patient to perform tight fist then extend fingers and repeat until palm is WHITE (no blood flow to the hand)! Ask the patient to relax. Release from one side. Count seconds for the hand color to return normal. Do steps 1 - 3 again. Do step 4 but this time release the other side of the wrist. Do step 5 again. Normal response time is 5 seconds, you can also compare to the intact hand.
1. 2.
3. 4. 5.
If forearm temperature is at least 4 degrees warmer than the fingertips temperature then vascular problems are expected. In testing for Raynaud’s phenomenon: Test baseline temperature. Test after being in a warm room for 30 minutes. Record time of temperature returning to baseline. Test after being immersed in ice for 20 seconds. Record time of temperature returning to baseline. Normal time is 10 minutes, Raynaud’s phenomenon patients may take 20 – 45 minutes.
Part 7
Inflammatory
swelling is a normal body response to injury, surgery or trauma, bringing good cells for healing. Normal reduction of edema begins within 2 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!! it becomes more like gel interferes with joint and tendon motion UE function. Inflammatory edema spongy fibrotic!!.
You should consider: Amount of swelling:
Volumetric displacement. Circumferential measurement.
Characteristics
observation. Palpation.
of edema:
Equipments: Tank. Collection beaker. Graduated cylinder. Methods: See picture
next slide.
Notes: After measuring
the affected hand, compare it to the intact hand, a difference of 10-ml is significant and shows a systematic increase in volume.
Precautions:
This method must not be used with: open wounds, unstable vascular status, casts, external fixators, 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.
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, standardize tension, and have the same therapist do the test all times. Compare to intact hand.
Look
for and document using a checklist including:
Shininess. Dryness. Loss of joint creases. Skin color (erythematic, cyanosis, or pallor).
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 is eliminated. Brawny edema: clogged interstitial fluid which is more spongy and gel-like. Does not move away easily with pressure.
Best
test to date is the Artsberger edema rebound test, use it.
Artsberger
edema rebound test:
Observe original shape of tissue. Place thumb on tissue (only thumb weight no additional force). Leave their for 10 seconds. Remove thumb. Count seconds for the skin to return to original shape. E.g. if first test gave you 60 seconds, retest gave you 45 seconds edema became more fluid! This is good!
Tonometer!
clinics.
A device used in lymphedema
Part 8
Measures
innervation density (number of nerve endings). Flexor zones I and II are to be tested. Two-point discrimination relates to the clients’ ability to feel something and to know what they are feeling. Equipments:
Disk-Criminator. Boley gauge.
Methods:
Ask patient to respond by “two” or “one”. Support client’s hand. Occlude the client vision. Start with 5 mm. Force must be applied to the point of blanching, in a longitudinal direction, and perpendicular to the skin. If patient recognizes 5 mm increase distance, vice versa. Begin distally and progress proximally.
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
Always
returns earlier than static two-point discrimination. Measures progress in return of sensation following nerve injury. Equipments:
Disk-Criminator. Boley gauge.
Methods:
Ask patient to respond by “two” or “one”. Support client’s hand. Occlude the client vision. Start with 5 mm. Moving force must be applied to the point of blanching, in a longitudinal direction, and perpendicular to the skin, along the finger tip only. Begin proximally and progress distally. Begin with 5 – 8 mm and increase or decrease as needed.
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.
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 is also available).
Equipments:
The Semmes-Weinstein Pressure Aesthesiometer kit of 20 monofilaments (5-monofilaments kit is also 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
3.84-4.31
Red
Loss of protective sensation
4.56-6.65
Untestable
Unable to feel largest MF
---
Methods: Explain the test to client. Support the hand in a putty. Occlude client’s vision. Ask the patient to respond with
“touch” when
he/she feels a touch. Begin with the largest green MF. If responded continue to smaller, if no response continue to larger MF. For green and blue MFs, apply the filament must be applied 3 times, 1 correct response is good enough. All other large MFs must be applied once for each trial. Distal to proximal.
Filament must be applied perpendicular to the skin until it bends. Apply in 1-1.5 seconds hold for 1.5 seconds lift in 1-1.5 seconds. Record on a hand chart (MF size and color).
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.
Methods:
Explain the test to client. Support the hand in a putty. Occlude client’s 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 you’ve 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 dot you’ve drawn toward the place he/she pointed out.
Ninhydrin
test: to evaluate sympathetic nervous 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. O’Riain 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.
Moberg’s
pick-up test: used to determine tactile 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.
Use
the Semmes-Weinstein Pressure Aesthesiometer 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.
Part 9
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 Pegboard Test
Part 10
As
simple as this: is the testing going to damage 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.
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 client’s hand. Provide gentle support at the base of the dynamometer. Instruct client squeeze smoothly not jerkily. Allow wrist extension during grip.
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 shows up/down/up/down waves lack of maximal efforts. Rapid change grip test: therapist alternate the dynamometer between hands for 10 trials for each hand. Thought to prevent client from selflimiting his grip strength!!!!!!!!!
There
are normative data, BUT compare to the intact hand if possible.
Use
the pinchmeter. Testing setting:
Client seated. Shoulder adducted. Elbow flexed to 90 degrees. Forearm neutral. Place pinchmeter in the client’s hand. Instruct client to squeeze smoothly not jerkily.
Methods
and procedures, proceed as following:
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 and the pulps of the index and middle fingers. Two-point pinch (tip to tip pinch): between the tip of the index and the tip of the thumb. Ask the patient to pinch as hard as possible.
Please find the “Evaluation” form titled: UE Evaluation
