Featured Article by Nancy Falkenstein OTR/L, CHT

Nancy Falkenstein OTR, CHT

Susan Weiss OTR, CHT

continued on page 3

The PURPLE BOOK is almost ready for release!!•New illustrations•New questions•New chapters•NEW 3rd edition is

coming.Hand & Upper Extremity Rehabilitation: A Quick Reference Guide and Review”. Weareinfinaleditingstagesofthe

3rd edition. We anticipate release April2013.Seeinsidefordetails.

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Thisnewsletterisforinformationalpurposes only and is not intended tobeasubstituteforprofessionaladvise, diagnosis, or treatment. OpinionsarethatoftheauthorsandnotnecessarilyofEHT/Tx2go.

SeeyouinPhillyfortheannual meeting. Stop by our booth and see the 3rd editionofthePurpleBook!!

In This Issue

1

Exploring Hand Therapy

Treatment2gowww.handtherapy.com

Featured Article ......................................1

Test Your Knowledge. .............................6

Philly Hand Meeting.................................7

PurpleBook ................................8, 11, 12

New Releases .........................................8

Learn & Earn ...........................................8

QuickReferenceTidBits ........................9

Answers to Test Your Knowledge ..........10

Basics&BeyondCHTstudy ................12

Physical Agent Modalities ......................12

Volume 14, Issue 1 January - March 2013

The Elbow:

The most common complication ofelbowinjury,surgeryorarthritisisstiffness.Theelbowisuniqueinits3bone,four-jointarticulationresultinginahighdegreeofcongruence.Thecapsular reaction to trauma is oneofthemostcommonreasonsassociatedwithstiffnessafterinjuryorsurgery.

Ulnohumeral joint: Thisjointaccommodatestheolecranon in extension which makes the elbow vulnerable to a mechanical block in the olecranon fossa.

Radiohumeral joint:Thisjointisinvolvedinflexion-extensionandforearmrotation.Any lateral compartment mechanicaldeformationwillresultinmotiondeficits.

Proximal and Distal radioulnar joints:Thesejointsprovidesupinationand pronation motions. Either the proximal or distal segment can adverselyaffectforearmrotation.

Ligaments and Capsule:The anterior capsule is thin in nature and any alteration in its anatomy will compromise normal elbowflexionandextension.Themedial ligamentous structures canalsocontributetolossofelbowflexionandextensionas they are related to rupture, contracture,andcalcification.Thelateral ligaments are susceptible topostinjurythickeningleadingto compromised elbow motion. Iftheradialheadisinvolvedthe annual ligaments can cause pain and restrict elbow motion.Deficiencyoftheelbowligamentous structures can cause subluxation instability.

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Muscles:Musclefactorsatmusculotendinous units can also have adverse results on elbowmotion.Themusclesofthecommonflexororigin(flexorcarpiradialis,flexorcarpiulnarisand palmaris longus) traverse both the elbow and the wrist. Thereforeanymishapofanyofthesestructurescanaffecttheelbowandcanalsoaffectwristdysfunctiononthelateralsideoftheelbowtheextensorcarpi

radialis brevis and longus and the brachioradialiscanaffectelbowexcursion and strength. During elbowflexionandextensiontheextensor carpi radialis brevis origin glides over the lateral capsuleandbonyareasofthecondyle;thereforeanyalterationsinshapeofthelateralcondyleorscartissuecanadverselyaffectnormal elbow extension.

Neurovascular:Neurovascular considerations about the elbow can slow or cause a “glitch” in the rehabilitation process. For example, when rehabilitating a chronicelbowflexioncontractureandattemptingtoachievefullelbow extension, the brachial artery, median nerve or both may become compressed. The ulnar nerve is vulnerable about

the elbow and through the cubital tunnel and is vulnerable to compression during the rehabilitation process.

Rehabilitation:Rehabilitationoftheelbowisimportant and knowing rehab. timing and implementation is critical.Rehabilitationfocusistocontrolinflammationandpain,restorefunction,andallowhealing.Timingiscriticalforgood results. Obviously every aspectofrehabilitationcannotbe a consideration here and thisarticlewillfocusonelbow

orthosis.immobilizationorthosisforprotection is primarily used forshortperiodstoprotectcertainstructurespostinjuryorsurgery. There are times when an immobilization orthosis is neededandoftenanadjustableimmobilization orthosis is chosen such as the turnbuckle. Flexion contractures are best treated with turnbuckle style orthosis as the turnbuckle is used to gain extension.Thelimitingfactorsforthesesplintstendtobeatendranges in either extension and/or flexion.Mobilizationorthosisisbyfarfavoredfortheelbowtopreventelbowstiffnessforpostinjuryor post surgery. This theory relatestoconstantforce(load)&

willresultincreeporsofttissuedeformation.Onemustbeawarethat a mobilization orthosis can causeinflammationandmustbeawareofthesignstointervene.

Cardinalsignsofinflammationwhen using orthosis include increased:

•soreness•discomfort•swelling

Progressivelossofmotionisnoted when one would expect improvements daily.Treatinginflammationinvolves

PhotoCourtesyofLaurieRogers,OT,CHT

UsedwithpermissionfromMichelleReinerOTR/L,CHTwww.illustratedseries.com

continued page 4

UsedwithpermissionfromMichelleReinerOTR/L,CHTwww.illustratedseries.com

UsedwithpermissionfromMichelleReinerOTR/L,CHTwww.illustratedseries.com

Exploring Hand Therapy dba Treatment2go

4

constantassessmentoftheorthosis, exceptional written and verbal patient education to include; avoiding causative factors,orthosisadjustments,heat and ice interventions, and antinflammatorymedicationifprescribed.

Orthoticon/offschedulewilldepend on the motion being addressed. Many times with the elbowbothflexionandextensionare lacking. Typically I have always addressed the motion needing most attention to wear the orthosis at night while the less severe motion is being addressed during the day.

At night donn the device in the direction most needed. Apply about30to60minutesbeforesleeping as the orthosis should becomfortablefortheentirenight.Ifthepatientisawakeningdue to pain it is too aggressive.

Upon awaking remove the orthosis and gently move the elbowinflexionandextension.Itisoftenagoodideatomoveduring the morning warm shower. Ifthepatientistotakemedicationforinflammationmorningisagood time to take it.

During the day apply the orthosis intheoppositedirectionfromthe evening wear. It is typically recommended to remove the splint 3 to 5 times during the dayfor1hourintervals.Whentheelbowisfreeoforthosisencouragemovingtheelbow.Iftheelbowissoreorinflamedfromtheorthosisroutineapplyiceasneededfor15to20minutes.Iftheelbowisnotinflamedbutstiffapplyheatfor15 to 20 mintues and try to work the elbow during the treatment.

Early motion is critical in regards to the elbow post injuryorpostsurgery.Ithasbeenshownimmobilizationformore than 4 weeks results in unfavorableoutcomes.Despitetherecognitionofearlymotionabout the elbow there are limiting factors.WelltrainedOTs/PTsrehabilitatingthestiffelbowmustappreciate the elbow anatomy, pathologyofelbowcontracture,cardinalsignsofinflammation,ways to avoid or decrease inflammation,andtheuseofthe orthosis. A well trained therapist understands timing and implementation and has a better chanceofreversingoravoidingastiffelbow.

GEM: Exploring Hand Therapy has an excellent course on the elbow.

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Supination/pronation mobilization orthosis. Used with permission fromEHT’s“Hand&UERehabilitation: A Quick ReferenceGuideandReview” 3rd edition.

PhotoCourtesyofLaurie Rogers, OT, CHT

Activeassistiverangeofmotionexercises.UsedwithpermissionfromEHT’s“Hand&UERehabilitation:AQuickReferenceGuideandReview”3rdedition.

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Distinguish between upper brachial plexus and lower brachial plexus pathologies

Recognize venous TOS symptoms

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AOTA Approved Provider Course for .35 CEUs or NBCOT 4.0 Contact HoursInstructors: Nancy Falkenstein OTR/L CHT; Susan Weiss OTR/L CHT; Charles Eaton MD, P.A. Description: AOTAapprovedprovidermovie.35CEU(3.5contacthour)andNBCOT(4.3PUDs).Viewingoptionsareweb-basedstreaminginteractiveorDVDinteractiveviewing.Thisisanintermediatecourse.ThiscoursefeaturesanintervieweducationalsessionwithDr.Eaton.Varioussurgicalinterventionsarediscussed in detail. Instructional methods include lecture, PowePoint, video, instructor demonstration, and 47 page manual. Learn new surgical and therapeutic techniques,orthoticapproachesandpearlsfromexperts.UponSuccessfulcompletionoftheexamination(80%)yourcertificatewillbesentviaemail.

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Recognizepost-operativecomplicationsandoptionsforinterventionDupuytrens release post op Photo usedwithpermissionfromEugeniaPapadopoulos

Exploring Hand Therapy dba Treatment2go

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Answers on page 10

Test Your EHT Newsletter Knowledge

S I N G L E PAT I E N T U S ER O M T H E R A P Y

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1. What nerve is vulnerable to compression during elbow rehabilitation?

2.Whatjointisprimarilyinvolvedinelbowflexion/extensionandforearmrotation/extension?

3.Whatelbowjointthatshowslateralcompartmentmechanicaldeformationwillresultinmotiondeficits?

4. What ligament is involved when theradialheadisinjured?

5. Turnbuckle orthosis are typically used to treatflexioncontractions.TrueorFalse

6.WhenwouldyoutypicallybegingentleAROMoftheelbowoutoftheorthosisinastableelbowdislocation?

7.Inreferencetoanunstableelbowdislocation,whencouldyou consider allowing light sports such as swimming?

8.Inreferencetounstableelbowdislocationwhatshouldermotion(s)aretobeavoideduntil6weekspostinjury?

9. With a stable elbow dislocation when is the orthosis or sling typically discharged?

10. How many degrees per week is recommendforgradualAROMtotheelbowwith an unstable elbow dislocation?

Exploring Hand Therapy dba Treatment2go

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Exploring Hand Therapy dba Treatment2go

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Exploring Hand Therapy dba Treatment2goQuick Reference Elbow Tid Bits

o

9

General Elbow Rehabilitation:Loss of elbow extension is the most common complication following elbow dislocation:

Typicallyalongstandingelbowcontracturedoesnotimprovewithtime.Rehabilitationisalwaysfocusedonregainingmotion.Ofcoursestabilityafterreductionofanelbowdislocationmustbeconsideredtogainthemostrangeofmotion.Todothisgentlypassivelyrangetheelbowthroughflexionandextension.IftheelbowdislocateswithgentlePROMtheninstabilitywithruptureofthemedialcollateralligamentsandforearmflexorsishighlylikely.Ifthedislocationisstablebeginactiverangeofmotion(AROM)inaprotectedmotionby14dayspostinjury.Ofcoursethetherapistmusthavetheclinicalsensetoknowwhento continue and when to hold. As we all know when therapy is too aggressive it can result in recurrent subluxationandtherapythatistooconservativecanleadtoflexioncontractures.Alsotherapistsmustrealizethatthegeneralpopulationisdifferentfromtheathlete.Obviouslytheathletemustachievefullextensionbutinthegeneralpopulationendrangeelbowextensioncanbesacrificedtodecreaserecurrentsubluxationordislocation.Again,thereisnoperfectprotocolandeachpersonandsituationisunique.Thefollowingaremerelyguidelinesandaresomeofthemanywaystotreatelbowdislocations.

Stable Elbow Dislocation

1 to 4 days•Elboworthosisforrestandprotection•Handrangeofmotionexercises•Light gripping exercises with a light sponge•Light shoulder isometric exercises

5 to 10 days•Ifusingorthosisremoveforgentleexercises•Beginactiverangeofmotionexercisesoutof

the splint or sling•NOPASSIVEMOTION-ACTIVEONLY•Elbowflexion/extensionAROM•Elbow supination/pronation AROM•Introducelightandslowupperbodybike(UBE)•Isometricsoftheelbowinflexionandextension

can begin•Wrist isotonic exercises•Shoulder strengthening and progress with stabilizationofelbow

10 to 14 days•Orthosis typically discharged by 2 weeks•AROM as stated above•GentlePROMmaybeinitiated•Isotonic exercises but caution with ER to avoid valgusstressofelbow

•IfhingedsplintisusedROMistypically15degreesto90degreesfor2moreweeks

Unstable Elbow Dislocation

0 to 21 days•Orthotics & begin ROM at 10 degrees less than

active ROM elbow extension limit•Elbowflexionisperformedtotolerance•Hand gripping exercises start light•Wrist ROM•ShoulderROMbutavoidinternalrotation(IR),externalrotation(ER),gentlebicepsmotion

•Supination/pronation exercises

4 to 8 weeks•GradualelbowextensionROMabout10

degrees per week is recommended•Beginmusclestrengthingsuchaswristextension/flexionof1to2pounds

•Pronation/supination•Elbowflexion/extension•ShoulderstrengtheningbutcontinuetoAVOIDIR/ERuntilweek6postinjury

•GentlePROMforelbowflexion/extension

9 to 14 weeks•FullelbowROMthrougheccentricelbowflexion/

extension; continue isotonic exercises•Manual resistance •Plyometric exercises•Light sports around 12 weeks is a possibility (swimming,golf)

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Answers to Quiz (from page 6)

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5 Amazing New Chapters •SpinalCord/CNS/Brachial

Plexus•Ergonomics/Return to Work•PsychosocialAspectsof

Impairment•Ligamentous and Muscular Injury

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4 Fantastic Appendixes:•Anatomy Labeling•VendorListing•Drugs in Hand Therapy•Practice Exams

Chapters:•Clinical Anatomy •Evaluation •Neuroanatomy/NerveInjury/

Sensory Reeducation •Physical Agent Modalities •Assorted Treatment

Techniques •Orthotics: Design/

Fabrication/Training •Edema/Lymphedema/VascularDisorders

•Wounds/Infection/Grafts/

Burns•Fractures/Dislocations/

Subluxations •Ligamentous and Muscular Injuries

•Arthritis and Related Disorders

•CRPS/Fibromyaligia •TendonInjuriesand

Conditions •Complex Traumatic Hand/TendonTransfers

•Cumulative Trauma Disorders

•Tumors/Cysts/Dupuytrens •Congenital Anomalies/

Amputations/Prosthetics •SportsInjuries•Wrist •Elbow •Shoulder •SpinalCord/CNS/Brachial

Plexus •Ergonomics/Return to Work •PsychosocialAspectsof

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Management

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