evaluation of the hand!

7/30/2019 Evaluation of the Hand!

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Ahmad A. Fannoon, Hand Therapist


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Part 1


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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.


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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.


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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.


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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.


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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.


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Part 2


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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.


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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).


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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.


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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.


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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).


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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.


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Part 3


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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.


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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.


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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.


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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.


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Part 4


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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.


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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.


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Part 6


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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.


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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.


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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.


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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.


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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.


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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.


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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.


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Part 7


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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!!.


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You should consider:

Amount of swelling: Volumetric displacement.

Circumferential measurement.

Characteristics of edema: observation.

Palpation.


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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.


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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.


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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.


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Look for and document using a checklist

including: Shininess.

Dryness.

Loss of joint creases.

Skin color (erythematic, cyanosis, or pallor).


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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.


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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!


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Part 8


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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.


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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.


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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


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Always returns earlier than static two-point

discrimination.

Measures progress in return of sensation

following nerve injury.

Equipments: Disk-Criminator.

Boley gauge.


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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.


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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.


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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).


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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 ---


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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.


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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).


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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.


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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.


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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.


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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.


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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.


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Part 9


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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


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Part 10


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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.


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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.


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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.


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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.


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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.


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Please find the Evaluationform titled:

UE Evaluation

evaluation of the hand!

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