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2/16/2012 1 Introduction to Hand & UE Rehabilitation Hand Evaluation Basics J. Robin Janson, MS, OTR, CHT Indiana University Department of Occupational Therapy Learning Objectives After actively engaging with this presentation, you should be able to: 1. Identify a minimum of four evaluations used to assess to the hand. 2. Appreciate the importance of informally assessing a client’s psycho-emotional health. 3. Identify a pain assessment that is more detailed than the numeric pain rating scale. 4. Describe how to perform zone 7 (fingertip) sensory testing of the fingers for 2-Point Discrimination and Semmes Weinstein Mononfilaments. 5. Interpret sensory tests (Semmes Weinstein and 2-Point Discrimination). Where to Start Prior to sitting down with the client Ask client to complete a functional outcome measure such as the ULFI, DASH, or QuickDASH. To save time, have client complete outcome measure prior to being seen in therapy. Carefully review orders from physician. If available review medical chart, read operative report, review X-rays. Calculate the number of weeks/months post onset of condition/injury and or post surgery (to determine appropriate treatment based on wound healing time lines). Sitting down with the Client Establish rapport Observe –client’s affect, posture, injured extremity Interview Client-Injury/Surgery-MOI, DOI, DOS, Occupational Profile & Medical History Review completed outcome measure with client. Identify affected areas: ADLs, IADLs, Leisure, Work, Play, Social Participation, Sleep Ascertain client goals/priorities (reference functional outcome measure for goal ideas) Get a sense of how client is doing psychologically. Evaluation of the Hand History Observation Physical Exam Psych. Status Pain Wound Edema Range of Motion Sensation Strength Function/Work/Dexterity Interactive Hand-Image reproduced with permission-Primal Pictures Observation Posture Guarding? Displaying other non-verbal signs of pain? Posture of the patient’s hand when relaxed? Note any deformities Compare hands

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2/16/2012

1

Introduction to Hand & UE Rehabilitation

Hand Evaluation Basics

J. Robin Janson, MS, OTR, CHT

Indiana University

Department of Occupational Therapy

Learning ObjectivesAfter actively engaging with this presentation, you should be able to:

1. Identify a minimum of four evaluations used to assess to the

hand.

2. Appreciate the importance of informally assessing a client’s

psycho-emotional health.

3. Identify a pain assessment that is more detailed than the

numeric pain rating scale.

4. Describe how to perform zone 7 (fingertip) sensory testing of

the fingers for 2-Point Discrimination and Semmes Weinstein

Mononfilaments.

5. Interpret sensory tests (Semmes Weinstein and 2-Point

Discrimination).

Where to Start

Prior to sitting down with the client

• Ask client to complete a functional outcome measure

such as the ULFI, DASH, or QuickDASH. To save time,

have client complete outcome measure prior to

being seen in therapy.

• Carefully review orders from physician.

• If available review medical chart, read operative

report, review X-rays.

• Calculate the number of weeks/months post onset of

condition/injury and or post surgery (to determine

appropriate treatment based on wound healing time lines).

Sitting down with the Client

• Establish rapport

• Observe –client’s affect, posture, injured extremity

• Interview Client- Injury/Surgery-MOI, DOI, DOS,

Occupational Profile & Medical History

• Review completed outcome measure with client.

• Identify affected areas: ADLs, IADLs, Leisure, Work,

Play, Social Participation, Sleep

• Ascertain client goals/priorities (reference functional

outcome measure for goal ideas)

• Get a sense of how client is doing psychologically.

Evaluation of the Hand

• History

• Observation

• Physical Exam

• Psych. Status

• Pain

• Wound

• Edema

• Range of Motion

• Sensation

• Strength

• Function/Work/Dexterity

Interactive Hand-Image reproduced with

permission-Primal Pictures

Observation

• Posture

– Guarding?

– Displaying other non-verbal signs of pain?

• Posture of the patient’s hand when relaxed?

– Note any deformities

• Compare hands

2/16/2012

2

Observation

• Skin

– Color -bruising, redness, discoloration,etc.

– Temperature

– Texture

– Scars, wounds, lack of skin creases, callouses

– Overly moist or dry skin

Observation

• Hair & Nails

– Excessive hair growth (hypertrichosis)

– Nails pitted, discolored, and/or deformed

• Edema

– pitting, brawny

• Muscle Atrophy

Physical Exam

• Palpation

• Use contralateral extremity for comparison

• Provocative testing (when indicated)

– Variety of tests for different conditions/diagnoses

• Document findings

Mental Health

• MANY clients experience fear, stress, anxiety, depression, etc. related to their condition/situation. Consider how you might feel in the same situation.

• Initiate conversation with your client addressing how they are coping with their condition. Be supportive.

• Recognize when your client is not adjusting well.

• If there’s an issue –talk with client re: your concerns and encourage client to talk with their physician.

Mental Health Status

• When necessary, make referral to the appropriate mental health care professional (Get approval from client’s physician).

• I cannot over emphasize the importance of one’s mental health and it’s impact on the rehabilitation process.

• YOUR THERAPEUTIC USE OF SELF CAN DO WONDERS IN HELPING YOUR CLIENT THROUGH A DIFFICULT TIME.

Mental Health

The “Challenging” Client• One Example - Client expresses anger

– DO NOT REACT NEGATIVELY! YOU WILL ONLY FUEL THE

ANGER –IT IS NOT ABOUT YOU!

– Often the anger is displaced –important to find source to

help diffuse it

– I would say…“You seem angry…is there something I’ve

done to make you angry?” [Client usually said “No”]. I

would respond with “Would you like to talk about it? I’m

a good listener.” DO NOT TAKE SIDES OR MAKE

JUDGMENTS! JUST LISTEN-ENCOURAGE PT TO BE

ASSERTIVE IN RESOLVING ISSUE.

2/16/2012

3

Pain• Subjective

• Numeric Intensity Rating Scale

– Commonly used 0-10 scale

– Read iCAHE –pp. 20-23

• Pain Questionnaires

– Short-Form Mcgill Pain Questionnaire -iCAHE –pp. 33-35

• What pain relief measures work for client

– Document what the patient does to relieve/decrease the

pain (e.g. rest, pain medication, TENS)

Edema

• Objective

• Circumferential tape measurements and/or

volumeter

– Measure contralateral extremity for

comparison

– Compare measurements from previous therapy

visit to document increases/decreases

Circumferential Tape Measurements

Left ring finger PIP= 5.5 cmLeft WFC = 15.8 cm

Measure edematous areas and compare contralateral

measurements as well as previous visit measurements

Volumeter

• Used for monitoring

the inflammatory

response, edema, or

atrophy

• Measure the amount

of H2O displacement

bilaterally and

compare

Wounds

• Objective

– Color

– Drainage: quantity, color

– Odor

– Exposed structures? (bone, tendon, etc.)

– Measure length, width, and depth (sterile)

• Sketch or photograph wound details

Range of Motion

• Movement

– Is the patient willing to move/use the extremity

– Extensor habitus (with a finger injury)

– Abnormal movement patterns

• ROM Screening

– “Simon Says”

– Observation of Task Performance

• Measurement & Documentation

– AROM

– PROM

2/16/2012

4

R Thumb

MP / ( / )

IP / ( / )

RIGHT THUMB ROM

MP

IP

Sensibility Testing

• Aid in confirming diagnosis

• Monitor return of sensibility

post nerve injury

• Aid in disability assessment

• Determine need/readiness for

sensory re-education, patient

education for any sensory

losses

Commonly Used Sensibility Tests

• Semmes Weinstein Monofilaments– Assess cutaneous pressure thresholds.

– Test determines the minimum stimulus that can be perceived.

– Tests light touch to deep pressure

• Two-Point Discrimination (Static)– Assesses functional level of sensation.

– Test determines the minimum distance a client can distinguish between one point and two point stimuli.

– Measures slowly adapting fibers

Sensory

Testing Zones

Zone 7 Digital tips –Most

frequently tested area

ZONE 7

1

2

3

4

6

7

5

UDNRDN

General Sensibility Testing Procedures

• Client’s vision is occluded

– Ask client to close eyes or look away

– Or use a visual barrier

• Test in a distraction free area of the clinic

• Follow standardized testing procedures

• + / - Use of putty or other support for hand

• Ideally, the same therapist should always re-test

the same client on subsequent therapy visits

• Make sure client understands directions for

examination

2/16/2012

5

Semmes Weinstein Monofilaments

Interactive Hand-Image reproduced with permission-Primal Pictures

Semmes Weinstein Monofilaments

• Monofilaments numbered by the amount of force

applied when applied to the skin. With the 1.65

monofilament applying the least force (.008g) and

the 6.65 monofilament applying the greatest force

(300g).

Monofilament numbers represent:

• logarithm of 10 times the force in mgs required to bow

filament when applied perpendicularly to the skin

Semmes Weinstein Monofilaments

• Available in two kits:

• 20 Monofilament Kit:

– Monofilaments ranging from:

1.65 to 6.65

• 5 Monofilament Kit:

– 2.83, 3.61, 4.31, 4.56, and 6.65

– Monofilaments in this kit are

the from each of the touch

threshold norms.

Semmes Weinstein MonofilamentsTouch Threshold Norms Monofilaments

• Normal light touch 1.65-2.83

• Diminished light touch 3.22-3.61

• Diminished protective sensation 3.84-4.31

• Loss of protective sensation 4.56-6.45

• Deep pressure sensation 6.65

• Unresponsive to 6.65

Monofilament handles

color coded according to

the level of touch

threshold represented.

Procedure:

Semmes Weinstein Monofilaments

Mini-Kit

• Follow general sensory testing procedures.

• Instruct client to say “touch” each time they feel

the monofilament.

• Begin with the 2.83 monofilament (normal light

touch)

• Apply monofilament for 1-1.5 seconds to the skin

in a perpendicular fashion until it bows.

Procedure (con’t):

Semmes Weinstein Monofilaments

Mini-Kit

• Monofilaments marked 2.83 & 4.31 are applied up to 3

times to a specific area.

• If the client accurately perceives any of the first three

applications, document the monofilament number for that

area and move on to the next area to be tested with the

2.83 monofilament.

• If the client doesn’t perceive the 2.83 monofilament after

three applications, retest with the 4.31 monofilament apply

up to the three times. If accurately perceived, document &

move on to the next area to be tested starting with the

2.83 monofilament.

2/16/2012

6

Procedure (con’t):

Semmes Weinstein Monofilaments

Mini-Kit

• If the client doesn’t perceive the 4.31 monofilament after

three applications, test the area one time only with the

4.56 monofilament. If accurately perceived document 4.56.

If not accurately perceived, follow the procedure testing

only once for monofilament 6.65.

• Document “unable to be tested-does not perceive 6.65” for

clients who do not perceive the 6.65 monofilament

Documenting Results

Right HandRight Hand

Zone 7Zone 7THTH II LL RR SS

RDNRDN 4.31 4.31 4.31 4.31 2.83

UDNUDN 4.31 4.31 4.31 2.83 2.83

Semmes WeinsteinTouch Threshold Norms Mini-Kit MonofilamentsNormal light touch 2.83Diminished light touch 3.61Diminished protective sensation 4.31Loss of protective sensation 4.56Deep pressure sensation 6.65Unresponsive to 6.65

Static Two Point Discrimination

• Static 2 point test (Weber 1835)

– Tests constant touch-slowing adapting fiber receptors

Two-Point Discrimination

• Place instrument on fingertip parallel to the long axis of the finger (do not apply perpendicular to finger)

• Apply light pressure and stop just to the point of blanching (Problem-How can you reliability use the same amount force? No way to know).

• Begin testing each zone 7 digital nerve distribution at the 10mm interval and decrease interval until patient can no longer accurately distinguish 1 point versus 2 points 7 out of 10 times.

• Document the smallest mm interval that a client can distinguish between one and two points.

Various Two-Point Testing Instruments

• Brass Sliding Gauge

• Lafayette Two-Point Aesthesiometer

TIPS SHOULD BE BLUNT!

Various Two-Point Testing Instruments

• Dellon

Disk-Criminator

2-point discriminator

Image from

http://www.bpp2.com/physical_therapy_products/1227.

html

2/16/2012

7

Documenting 2 Point Results

Right HandRight Hand

Zone 7Zone 7THTH II LL RR SS

RDNRDN <5mm <5mm <5mm <5mm 15mm

UDNUDN <5mm <5mm <5mm 1 point 1 point

Two-Point NORMS

Normal <5mm (or <6mm)

Fair 6-10mm

Poor 11-15mm

Protective only 1 point perceived

Anesthetic no points perceived

Strength

• Manual Muscle Testing

• Pinch- Pinchometer

• Grip- Dynamometer

• Other Strength Testing

Measures (BTE, etc.)

Performance Evaluations

• Observe client’s occupational performance

during selected activities

• Have client complete questionnaires that

rate functional abilities.

• Functional Tests: Jebsen Hand Function test,

Minnesota, Purdue Pegboard, Nine hole

Peg, Valpars & more.

ANSWERS

Slide #19 Right Thumb ROM Results

R Thumb

MP 0/45 (0/51)

IP 0/ 28 (0/28)

Active extension / Active flexion

(Passive extension / Passive flexion )

ANSWERS

• Slide #21 Sensory Distribution of the Hand

– Blue = Ulnar nerve

– Purple = Median Nerve

– Yellow = Radial Nerve (superficial branch)

• Slide #32 Semmes Weinstein Monofilaments - Sensory

issue along the median nerve distribution of zone 7 (thumb,

index, long, and radial half of ring finger). Normal light touch

(2.83) in ulnar half of ring and small fingers. Diminished

protective sensation (4.31) along MN distribution.

ANSWERS

• Slide #36 The tester applied the instrument with too much

force as evidenced by the tips denting the fingertip and the

two points were applied across two testing zones –when they

should be applied longitudinally within the same zone 7

digital nerve distribution.

• Slide #37 2-Point Discrimination Sensory issue along the

ulnar nerve distribution of the ring and small fingers with

poor sensation at the radial side of the small finger and

protective sensation at the ulnar digital nerve distributions of

the ring and small fingers (zone 7-fingertips).