hand evaluation basics 2012 - indiana universityiumsot/handout for...
TRANSCRIPT
2/16/2012
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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
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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.
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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
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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
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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.
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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
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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).