Shoulder Impingement Syndrome By: Ashim Bakshi MHS, OTR, CHT

EHT continues to stay busy ensuring your CEU experience is positive and unique. We update our website frequently with movie clips, podcasts, quiz corner, case studies, news and more. Check it out at www.handtherapy.com

EHT is looking for instructors for neurological disorders (CVA), geriatrics, pediatrics and more. If you are interested in teaching please contact EHT for more information: info@handtherapy.comEHT has some great new courses you don’t want to miss. Check out the new releases: Dr. Schwartz, Dr. Montmeny, and Susan Weiss present the best Wrist Secrets course on the market. We also

have a fantastic sports rehabilitation course, and a much needed course on managing assistants and techs; and this is just a few of the ongoing continuing education EHT releases. Read about EHT’s new releases on page 13. Thank you to our sponsors for making this magazine possible. Please click on their ads (if viewing online) to learn more.EHT’s magazine is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis or treatment. Content is the opinion of the contributors and not necessarily of EHT.ENJOY!

From The Editors Desk

Nancy Falkenstein OTR, CHT, CEES

Susan Weiss OTR, CHT

Management of Subacromi-al Impingement Syndrome- A Combination Approach Using Manual Therapy and Supervised Exercises

Shoulder disorders are among the most common musculosk-eletal disorders, with the sub-acromial impingement syn-drome considered to be one of the most common forms of shoulder pathology. Shoulder subacromial impingement was defined by Neer (1972) as the compression of the subacro-mial structures like the rotator cuff, bursa, and biceps tendon against the anterior one-third of the acromion and the coracoacromial ligament, as the greater tuberosity passes

below, especially during the elevation of the arm. (Fig 1)

Biomechanics and EtiologyMultiple factors have been proposed to contribute to the symptoms related to impinge-ment syndrome. These factors are broadly characterized as primary or secondary (Bigli-ani& Levine, 1997). Primary impingement occurs as a result of extrinsic and

intrinsic factors that include:Weakness of the rotator cuff that results in the loss of humeral head depres-sion and enhances its proximal migration es-pecially during overhead movements of the arm. (Harryman et al,1990)

(Fig 2)

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www.handtherapy.com

In This IssueFeatured Article .......................................1

Splinting Tips ...........................................5

Learn & Earn ..........................................6

Political Corner ......................................10

Burn Wound Care ..................................10

Quiz Corner. ..........................................12

Newly released courses ........................13

Ergo Corner ...........................................14

Robotic Hand .........................................16

Whazzz up .............................................17

Modalities ..............................................20

Volume 7, Issue 2 July -Sept 2007

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Over use of the shoulder causing inflammation of the subacromial tissues (Morrison et al, 1997).Posterior capsule tightness that leads to anterior humeral head translation and loss of internal rotation (Tyler at al 1999) and increased superior migration of the humeral head (Matsen & Arntz 1990).Anatomic variations of the acromion process - Type I (flat); Type II (curved) ; Type III(hooked).Degenerative changes in the in the rotator cuff related to natural progression in age.Postural changes that lead to a forward head and rounded shoulder posture with components that include thoracic kyphosis, protracted scapulae and internal rotation

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of GH joint.(Donatelli, 1997)

Secondary impingement occurs principally due to glenohumeral and scapulothoracic instability and imbalance. The upward rota-tion of the scapula is an important component of elevation of the arm and functions to raise the acro-mion away from the humerus. The scapula force couple is formed by upper and lower trapezius, serra-tus anterior, and levator scapula. Parascapular weakness of these muscles limits the upward rotation of the scapula resulting in unsta-ble base of support for the humer-us, and its subsequent anterior and superior migration resulting in impingement.

Non- Operative TreatmentA review of the literature indicates

that most patients who have impingement syndrome eventu-ally recover with non-operative intervention (Neer, 1983; Butters & Rockwood, 1988; Kamkar et al, 1997). The most common inter-ventions included physical reha-bilitation programs, cortisone in-jections, NSAIDs and modification of activity. Morrison et al (1997) reported results on non opera-tive treatment of a large sample of patients with subacromial impingement, using a regimen of NSAIDs and a formal therapy program. Sixty seven per cent of the patients showed satisfactory results, while 28% had unsatisfac-tory results and were managed with subacromial decompression. More importantly, patients who

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had a Type-I acromion process were more likely to have a satis-factory result (91%) with conser-vative treatment than those who had a Type-II or Type-III acro-mion. managed with subacromial decompression. More importantly, patients who had a Type-I acro-mion process were more likely to have a satisfactory result (91%) with conservative treatment than those who had a Type-II or Type-III acromion.

Evaluation and PlanningProgram development for con-servative management of im-pingement syndrome follows a thorough physical evaluation and problem solving sequence. It is crucial to determine the causative factors and underlying dysfunc-tion for the prevalence of impinge-

ment syndrome, as well as stage of reactivity in a patient, before devising a rehabilitation program. Neer’s (1983) classification of patients with impingement syndrome is an excellent reference for conserva-tive management of those clients.Stage I impingement is character-ized by acute edema and hemor-rhage of the rotator cuff and is precipitated by overuse of the shoulder. The patient has func-tional active and passive ROM and presents with the painful arc syndrome. Stage II impingement develops with continued irritation of the subacromial structures re-sulting in fibrosis of the bursa and tendonitis. In addition to the Stage I symptoms, patients present with loss of ROM in the capsular pattern. Stage III impingement

presents with partial or full thick-ness tears and “squaring” of the acromion (Donatelli, 1997). Most of the research confirms suc-cessful outcomes with conserva-tive management of Stage I & II impingement.

Principles of Treatment Bang and Deyle (2000) dem-onstrated better outcomes in patients with impingement syn-drome, who received a combina-tion of manual therapy and super-vised exercises than those who just received therapeutic exercis-es. Additional studies (Sole, 2003) have reinforced the efficacy of utilizing manual therapy in conjunction with supervised exer-cises in managing impingement syndrome. In our practice, we

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Splinting Tips and Tricks by: Nancy Falkenstein OTR/L, CHTTrying to mobilize a stiff joint or a contracted joint? Stiff joints are always challenging to regain motion but rewarding when func-tional goals are achieved. Let’s look at a few different options we, as splint makers, have to mobilize those tough joints.

Unable to Extend:

For those stubborn flexion contractures you can try an easy to apply, low cost, plaster of Paris casting material. TRICK: to make it easy to remove dip the finger in paraffin before apply the casting material.

Another approach to reverse flexion contractures is to use thermoplastic

material. (photo above). Jewelry splints are also a nice option, especially for long-standing use.

Unable to Flex:

When mobilizing stiff joints to achieve a fist, you can try a few different approaches.

An inexpensive, easy and readily available device is the cinch

strap. This is excellent for PIPJs.

Another device I like to use is the Clik Strips static

progressive splinting device. It is sleek, light weight, effective and fun to fabricate/apply.

These are just a few of the many ways to achieve increased ROM.

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What do you do when… By Susan Weiss (AKA daughter that fixes all ailments)

Your father says “my shoulder hurts so bad I can’t lift my arm anymore”. You jump up and down because you know you have one up on him! Now, that wouldn’t be nice to say, would it? I guess what you do is in-vestigate all the options. And that is just what my father and I did. After seeing his x-ray I was shocked to see a bone on bone view of his glenohumeral joint with a few bonus spurs to assist with his pain production. I was hoping my father could get a shot of cortisone and call it a day. But as one would expect, not one but two surgeons told my father

a shoulder replacement was the only option. By the way, if you want to see a great animation of a shoulder replacement visit this site: http://www.shouldersur-geon.com/interactive_shoul-der/index.htm

Fortunately, we have an amazing surgeon in our backyard, which does a procedure that is much less involved surgically & has a shorter recovery time. This novel system is referred to as anatomic humeral head resurfacing.

Philip A. Davidson, MD has performed a large study on this procedure and was very optimis-tic that it would be a good choice for my dad. He shared with me and my dad a little about the pro-

cedure and my dad decided that was the way to go. My dad had his surgery and by the next day he could already tell the pain was a different pain than what he had prior to surgery. He only stayed for one night in the hospital and began with home rehabilitation the next day. As of this writ-ing, my dad is only four (4) days post surgery, so I can’t share too much of how he has done or his outcome. We will save that for another issue.

Let me share with you a mini review of the procedure. Compared to existing shoulder arthroplasty procedures, the HemiCAP® system is a joint

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Shoulder Resurfacing by: Susan Weiss OTR/L, CHT

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use manual therapy that includes, taping, joint mobilizations and myofascial manipulation (Cantu & Grodin, 2001) in combination with therapeutic exercises as a treat-ment intervention of choice, for subacromial impingement syn-drome.

The principles of treatment are based on tissue reactivity and dysfunction. In the more acute stage, the focus of treatment is to alleviate pain and edema. Pa-tient education and awareness is initiated and he/she is instructed in activity modification to prevent pain and advised to perform activ-ities in front and below the shoul-der level (below 70 degrees of el-evation). Modalities may be used at this stage to reduce pain. The use of tape has been reported in reducing pain, controlling posture at a joint, improving propriocep-tion and muscular effort (Host, 1995; Lewis, Wright and Green, 2005). We use taping early in the treatment to improve propriocep-tive feedback and reduce the forward shoulder position, scapu-lar protraction and anterior tilt, all

associated with the impingement process (fig. 3).

(Fig 3) taping to reduce forward shoulder position

In addition, Maitland’s (1991) grade I & II glenohumeral joint mobilizations can be introduced to reduce pain; these are generally done as cau-dal glides to additionally facilitate mechanoreceptors and reduce superior migration of the humeral

head. If there is any tightness in the upper trapezius and levator scapulae, then the glide can be

done in conjunc-tion with soft tis-sue mobs to those structures (fig. 4).

(Fig 4) grade II glide with upper trap. stretch

Soft tissue mobilization is also utilized to alleviate tightness in subscapularis and pectoralis major and minor. Scapular setting is performed early in rehabilitation to reposition the scapula in the resting position. Gentle manual resistance is provided against the medial border of scapula to facilitate parascapular muscles and enhance patient’s awareness to that contraction (fig. 5).

(Fig 5) manual resistance to facilitate parascapular muscles

With the reduction in the tis-sue reactivity and associated pain, scapular stabilization and strengthening is started to rees-tablish the scapulothoracic rhythm and force couple mechanism. Closed kinetic chain exercises (fig.6) can be initiated early in the rehabilitation phase since they are done with the arm at 60-90 degrees GH elevation without stressing the subacromial structures (Kibler, 1998). Seated/standing rows (fig. 7) and scapu-lar retraction exercises are used to strengthen the rhomboids while

shrugging exercises and seated press-ups are used to facilitate upper and lower trapezius.

(Fig 6A) closed kinetic scapular clock exercises (fig 6 B) closed kinetic Scapular clock exer-cises.

(Fig 7) scapular stabilization exercise

Posterior capsule tightness is a common prevalence in impinge-ment syndrome since it causes anterior and superior migration of the humeral head during eleva-tion.

Grade III and IV posterior glides (fig. 8) and cross body adduction can be utilized to stretch the pos-terior capsule.

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(Fig 8) posterior glide

If there are continued deficits in PROM of the shoulder in flexion and abduction (as may be seen in Stage II impingement), Grade IV caudal glides are performed at different levels of GH elevation (fig 9), while anterior glides are

performed to improve exter-nal rotation.

The importance of home exercis-es is reinforced and the patients are also taught pain free ROM and stretching exercises, posture exercises that include chin tucks, scapular retraction and self-mo-bilization techniques especially caudal/inferior glides. As the PROM in the GH joint increases with a corresponding reduction in pain, the patients are started on the three basic rotator cuff exercises 10 reps - 2 sets, using the theratube (fig 10). These included shoulder external and internal rotation with elbow flexed and tucked in close to the body, and shoulder extension with elbow extended. We start with level 1 tubing or the light-est weight on the cable column,

progressing to higher resistance contingent on the patient’s re-sponse. As the patient is able to perform rotator cuff and scapular strengthening without significant pain, progression is made to-wards more strenuous cuff exer-cises using dumbbells (Fig 11) and PNF D1/D2 diagonal exer-cises. In our practice, we utilize Hughston’s exercises to enhance contraction of the rotator cuff and scapular stabilizers. These exer-cises are performed in the prone position and should be pain free and comfortable (Fig 12 a & b). The Hughston’s exercises include prone rows, prone horizontal abduction in neutral and external rotation and prone extension. The patient is also encouraged to gradually return to his/her prior activity/work/sport level at this time.

(Fig. 10 a-c) Isotonic strengthening of the cuff muscles using Cable Column

(Fig 11) full can exercises

(Fig 12a) Hughston’s exercises

Conservative management of the impingement patient has been shown to be successful while recent research has demon-strated even better outcomes in combining manual therapy with supervised therapeutic exercises. However, it is imperative to devise a specifically tailored rehabilita-tion program that is based on physical examination and objec-tive findings.

Ashim Bakshi Bio:Ashim received Bachelor of Science degree in Occupational Therapy in 1995 at Delhi University in New Delhi, India.

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(Fig 9) caudal glide

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(Fig 12 A) Hughston’s exercises

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AOTA Opposes Truth and Trans-parency Legislation

Representative John Sullivan (R-OK) recently reintroduced legislation entitled the Truth and Transparency Act of 2007 (H.R. 2260). AOTA, in coalition with PARCA, a coalition of non-MD/DO providers, have joined together in opposition to the leg-islation. The bill applies sanctions against mislead-ing statements regarding creden-tials, training, or skills to all health care providers, excluding medical doctors and os-teopathic physicians, AOTA agrees that individuals who are not qualified and/or not appropriately licensed to provide health care services should not be permitted to treat patients.

Commercial fraud and misrepre-sentation are already prohibited by federal and state laws. H.R. 2260 will only create confusion for con-sumers and may even limit availabil-ity of care. Continue to watch the AOTA Legis-lative Action Center for more details on this legislation.

Medicaid

Medicaid reform has been delayed for over a month now, but the Sen-ate seems ready to take up the is-sue in late October as part of budget reconciliation. Concerns over the extent of the cuts continue to grow because of the need to pay for the costs of Katrina relief. Originally, Medicaid cuts were expected to be around $10 billion dollars, but now the amount of cuts could increase by several billion dollars. AOTA has worked hard in coalition with other

consumer and provider groups to eliminate changes to rehabilitation and targeted case management reimbursement from both House and Senate plans. While we have been successful so far, the chance of their inclusion in the final bill remains possible, especially as the call for even deeper cuts grows among fiscal conservatives. See the new Medicaid action alert posted on the Legislative Action Center at: http://capwiz.com/aota/mail/one-click_compose/?alertid=8117546

Check AOTA.org Legislative Action Center to stay up to date regard-ing political actions affecting your profession.

Used with permission from AOTA. Join AOTA now and become active in your political future.

Political Corner

Post Burn Scar Treatment

Initially, it is very difficult to deter-mine the amount of scar someone will develop post burn. Many factors contribute to scar development such as depth of the wound, length of time for skin to heal, & diet to men-tion a few. Although scars are part

of the healing pro-cess post burn, (even grafted burns) we want to minimize the complications. Scars are thicker, firmer and

raised above the normal level of skin. The color of scars varies from dark pink to purple & eventually will start to become more like the pa-tient’s own skin as the scar matures. Scars look the worst around 4 to 8 months post burn and gradually improve about 6 to 12 months later. Scars can grow for up to two years post burn. Types of scar:

Hypertrophic – remains within wound site; most common typeKeloid – overgrowth outside of wound

Scar Treatment most often consists of pressure garments. There are different types of compres-sion for scars ranging from elastic bandages, pre-fabricated gar-ments to custom made garments. All types of compression garments must be worn 23 hours a day for 2 years. The pressure from the garments is effective and acts to inhibit capil-lary dilatation which restricts blood flow to the scar, creating a hypoxic environment aiding collagen bundle realignment in a more parallel fash-ion. Garments also reduce fibroblast proliferation in the cells, reduces col-lagen synthesis, & decrease itching. Garments also assists in circulation

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by preventing venous congestion. Pressure as low as 15 mmHg have been shown to be effective. Pres-sure above 40 mmHg is contraindi-cated in the burn patient.

Splinting and posi-tioning are advocat-ed to help normal-ize motion which is critical to prevent future scar develop-

ment and enhance the exten-sibility and flex-ibility of

the skin. Burn splint positioning is the key element to prevent hand deformi-ties due to scaring. The position of

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Completed Graduate Hand Ther-apy Fellowship at Baylor College of Medicine and Texas Woman’s University in Houston, Texas in 2002. Ashim completed his Mas-ters in Health Sciences in Occu-pational Therapy ( Orthopedics) from University of Indianapolis in 2007. He has been practicing as a hand therapist since 1999 and has been a Certified Hand Therapist since 2003. Presently, Ashim is the owner and Director of an outpatient practice in Terre Haute Indiana.

Special & Personal interests Shoulder rehabilitation, conserva-tive management of sports inju-ries, manual therapy, fracture & tendon injuries to the hand, travel-ing, hiking and mountain climbing, reading, & music.

References:Bang MD, Deyle GD. Comparison of super-vised exercises with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop.Sports Physical Therapy 2000; 30.Bigliani LU, Levine WN. Current Concepts. Subacromial Impingement Syndrome. J Bone Joint Surg. Am.1997; 79 1854-1860.Butters KP, Rockwood C. Office evaluation and management of shoulder impingement syndrome. Orthop.Clin.North America.1988; 19:755Cantu RI, Grodin AJ. Myofascial Manipula-tion. Second Edition. Gaithersburg, Aspen Publication, 2001.Donatelli RA. Physical Therapy of the

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Shoulder. Fourth ed. St. Loius, Churchill Livingstone, 1997.Harryman DT, Sidles JA. Translation of the humeral head on the glenoid with pas-sive glenohumeral motion. J Bone Joint Surg.1990; 72A:1334-1343.Kamkar A, Irrgang JJ. Non-operative man-agement of secondary shoulder impinge-ment syndrome. J Orthop.Sports Physical Therapy.1993; 17:212-220.Kibler WB. Current Concepts. The role of scapula in athletic shoulder function. Am J Sports Med.1998; 26:334-335.Maitland GD. Peripheral Manipulation.3rd ed.Oxford:ButterworthHeinemann.1991.Matsen, FA Arntz CT. Subacromial impinge-ment in the shoulder. Vol 2 .Philadelphia, W.B. Saunders, 1990.Morrison DS, Frogameni AD, Woodworth P. Non operative treatment of subacro-mial impingement syndrome. J Bone Joint

Surg.1997; 79A:732-734.Neer CS. Anterior acromioplasty for the chronic impingement syndrome in the shoul-der. J Bone Joint Surg. 1972; 54A.Neer CS.Impingement lesions. Clin Or-thop.1983; 173:70-77.

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Thank you Ashim.

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Test Your Knowledge

1. According to our featured article, what type of joint mobs are done as caudal glides to reduce pain?

2. Closed kinetic chain exer-cises are performed in early phases of rehabilitation with the shoulder at what degree(s) of ROM?

3. What is considered the most common form of shoulder pathology?

4. Name 3 of the 6 contributing factors for primary impinge-ment syndrome.

5.What is the name of the Ro-botic Hand?

6. What “trick” is used for easy removal of a finger plaster of Paris cast?

7. According to Ashim, why would you choose to tape the shoulder for impingement? (list at least three reasons)

8. Why would you use a cinch strap?

9. In reference to ergonomics, name three of the many disci-plines that study humans and their environments.

10. What field has been heralded as one of the top ten emerging practice areas to watch for in the new millennium in ergonomics?

Answers on page 19

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deformity is MCP extension and PIP & DIP flexion (we don’t want this). Due to post-burn edema the dorsal skin is drawn taut, the palmer arches flatten and flexion of the PIP’s with hyperextension of the MCP’s occur. This is why you must splint in the functional position to avoid the burn deformity. The functional position will maintain the balance between the lumbri-cals and the dorsal hood of the extensor mechanism and prevent the burn defor-mity. Burn rehabilitation is a challenging and rewarding area for the hand thera-pist. Our goals are to minimize scar, implement ROM, provide effective splint-ing and positioning and provide patient education. These are critical core skills a therapist needs to ensure success with burn care management.EHT has a fantastic Burn: Stop, Drop & Rehab DVD course.

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Newly Released and Popular CEU Courses

Wrist pathology is commonly encountered in the clinic both directly and in-directly. To pro-vide the highest quality of care for patients with wrist dysfunc-tion thorough knowledge is needed.

Wrist Secrets (Part 1) is a 4.0 hour AOTA CEU movie course designed to provide you with a comprehensive understanding of wrist evaluation and treatment. The therapist will learn the pertinent anatomy and biomechanics as it applies to evaluation and treat-ment. Emphasis will be on proper interpretation of special tests, manual therapy, connective tissue healing and treatment techniques. Part 1 is presented by Richard Montmeny PhD,PT,CHT,CEA.

Wrist Secrets (Part 2), presented by Susan Weiss, OTR/L, CHT is a 4.0 hour AOTA CEU movie course. Susan will bring you up close and personal during this in depth study of

the wrist. You will see a detailed clinical examination up close and have the ability to watch rewind and replay. In the palpation lab you will learn how to find the carpal bones with ease and the structures surrounding them. After the detailed examination Susan will lecture on wrist fracture, stiff hand treatment, TFCC care, carpal bone fractures, dislocations and instabilities. Learn skills you can use in your clinics immediately. After you view this

section you will feel confident in your exam skills and have a broader knowledge of the mysteries of the wrist.

Gary Schwartz, MD walks you through the Physicians Wrist Secrets (Part 3) in this 3.25 AOTA CEU movie

course. The MD’s approach is part 3 of the Wrist Secrets trilogy. Dr. Schwartz teaches with ease on various challenging wrist pathologies to intervention.

Dr. Schwartz addresses many questions you may have had about the physicians approach. Dr. Schwartz leads you down the path of wrist pathology and with his knowledge teaches you clinical gems that will assist your clinical reasoning skills. He answers questions about wrist pathology in an easy to understand fashion.

NOTE: Save $$$ and purchase WRIST SECRETS the trilogy

package.

Stiffness: Suggestions and So-lutions is a 3.5 AOTA CEU movie course presented by Nancy Falken-

stein, OTR/L, CHT. Excel-lent dynamic interactive course de-signed to give you sugges-tions and solutions to treating the stiff hand. Intermediate to

advanced movie course. Basic knowl-edge in wounds, intrinsics, edema,

joint mobilization and splinting is beneficial when viewing this course. The instructor discusses basic joint kinesology, anatomy, and pathology. Stiff joints are a common diagnosis therapists are faced with daily. This course will help you get ‘em movin.

Every practicing rehab professional has been faced with a dilemma at

some point in their career concerning assistants and techs. Who can supervise a PTA? Can a tech provide treatment? Is it legal? How should assis-tants and techs

be utilized? Assistants & Techs: The Good, The Bad, & The Ugly is a fantastic movie CEU course designed to answers your ethical and legal questions regarding therapy assis-tants and techs.

Have you ever had an athlete referred to your clinic and felt as though your treatment was inadequate? Have

you ever felt that your treat-ment approach is stale? Sports Reha-bilitation: Get-ting Off the Sideline and Into the Game is a course that will introduce the rehab pro-

fessional to the world of sports medi-cine and discuss the unique treatment of the athlete.

For a complete listing of EHT’s courses visit www.liveconferences.com

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Ergonomic History:The foundations of the science of ergonomics appear to have been laid within the context of the culture of Ancient Greece. A good deal of evidence indicates that Hellenic civi-lization in the 5th century BC used ergonomic principles in the design of their tools, jobs, and workplaces. One outstanding example of this can be found in the description Hip-pocrates gave of how a surgeon’s workplace should be designed (See Marmaras, Poulakakis, and Papak-ostopoulos 1999).

The term ergonomics (from the Greek words ergon [work] and nomos [natural laws]) first entered the modern lexicon when Wojciech Jastrzębowski used the word in his 1857 article titled: Rys ergonomji czyli nauki o pracy, opartej na prawdach poczerpniętych z Nauki Przyrody.

Later in the 19th century, Frederick Winslow Taylor pioneered the “Sci-entific Management” method, which proposed a way to find the optimum method for carrying out a given task. Taylor found that he could, for example, triple the amount of coal that workers were shovelling by incrementally reducing the size and weight of coal shovels until the fastest shovelling rate was reached. Frank and Lilian Gilbreth expanded Taylor’s methods in the early 1900s to develop “Time and Motion Stud-ies”. They aimed to improve effi-ciency by eliminating unnecessary steps and actions. By applying this approach, the Gilbreths reduced the number of motions in bricklaying from 18 to 4.5, allowing bricklayers to increase their productivity from 120 to 350 bricks per hour.

World War II marked the develop-

ment of new and complex machines and weaponry, and these made new demands on operators’ cognition. The decision-making, attention, situational awareness and hand-eye coordination of the machine’s operator became key in the success or failure of a task. It was observed that fully functional aircraft, flown by the best-trained pilots, still crashed. In 1943, Alphonse Chapanis, a lieutenant in the U.S. Army, showed that this so-called “pilot error” could be greatly reduced when more logical and differentiable controls re-placed confusing designs in airplane cockpits.

In the decades since the war, ergonomics has continued to flour-ish and diversify. The Space Age created new human factors is-sues such as weightlessness and extreme g-forces. How far could environments in space be tolerated, and what effects would they have on the mind and body? The dawn of the Information Age has resulted in the new ergonomics field of human-computer interaction (HCI). Like-wise, the growing demand for and competition among consumer goods and electronics has resulted in more companies including human factors in product design.

Foundations:Ergonomics draws on many dis-ciplines in its study of humans and their environments, includ-ing anthropometry, biomechanics, mechanical engineering, industrial engineering, industrial design, kine-siology, physiology and psychology.

Typically, an ergonomist will have a BA or BS in Psychology, Industrial/Mechanical Engineering or Health Sciences, and usually a MA, MS or PhD in a related discipline. Many

universities offer Master of Science degrees in Ergonomics, while some offer Master of Ergonomics or Mas-ter of Human Factors degrees.

More recently, occupational thera-pists have been moving into the field of ergonomics. Occupational Therapy focusing in ergonomics is heralded as one of the top ten emerging practice areas to watch for in the new millennium.

Applications:The more than twenty technical sub-groups within the Human Factors and Ergonomics Society, HFES, indicate the range of applications for ergonomics. Human factors engi-neering continues to be successfully applied in the fields of aerospace, aging, health care, IT, product de-sign, transportation, training, nucle-ar and virtual environments, among others. Kim Vicente, a University of Toronto Professor of Ergonomics, argues that the nuclear disaster in Chernobyl is attributable to plant designers not paying enough atten-tion to human factors. “The opera-tors were trained but the complexity of the reactor and the control panels nevertheless outstripped their abil-ity to grasp what they were seeing [during the prelude to the disaster].”

Physical ergonomics is important in the medical field, particularly to those diagnosed with physiological ailments or disorders such as arthri-tis (both chronic and temporary) or carpal tunnel syndrome. Pressure that is insignificant or imperceptible to those unaffected by these disor-ders may be very painful, or render a device unusable, for those who are. Many ergonomically designed products are also used or recom-mended to treat or prevent such

Ergonomic Corner

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disorders, and to treat pressure-re-lated chronic pain.

Human factors issues arise in simple systems and consumer products as well. Some examples include cellular telephones and other handheld devices that con-tinue to shrink yet grow more complex (a phenomenon referred to as “creeping featurism”), millions of VCRs blinking “12:00” across the world because very few people can figure out how to program them, or alarm clocks that allow sleepy users to inadvertently turn off the alarm when they mean to hit ‘snooze’. A user-centered design (UCD), also known as a systems approach or the usability engineering lifecycle aims to improve the user-syste.

Engineering psychology:Engineering psychology is an

interdisciplinary part of Ergonom-ics and studies the relationships of people to machines, with the intent of improving such relationships. This may involve redesigning equip-ment, changing the way people use machines, or changing the loca-tion in which the work takes place. Often, the work of an engineering psychologist is described as making the relationship more “user-friendly.”

Engineering Psychology is an ap-plied field of psychology concerned with psychological factors in the de-sign and use of equipment. Human factors is broader than engineering psychology, which is focused spe-cifically on designing systems that accommodate the information-pro-cessing capabilities of the brain.

Resources:

Ergonomics for Beginners - Jan Dul and Bernard Weerdmeester - A classic introduction on ergonomics - Original title: Vademecum Ergonomie (Dutch)Bodyspace - Stephen Pheasant - A classic exploration of ergonomics.The Human Factor - Kim Vicente - Full of examples and statistics illustrating the gap between existing technology and the human mind, with suggestions to narrow it.The Design of Everyday Things - Donald Norman - An entertaining user-centered critique of nearly every gadget out there (at the time it was published).Evaluation of Human Work - Wilson & Corlett - A practical ergonomics methodology. Warning: very technical and not a suitable ‘intro’ to ergonomics.Engineering Psychology and Human Performance - Wickens and Hollands - Discusses memory, attention, decision making, stress and human error, among other topics.The Measure of Man & Woman - Henry Dreyfuss Associates - A human factors design manual that has controversial elements.

Ergonomics

From Wikipedia, the free encyclopedia

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Robotic Therapy Helps Restore Hand Use After Stroke

A robotic therapy device may help people regain strength and normal use of affected hands long after a stroke, according to a University of California, Irvine study.

Stroke patients with impaired hand use reported improved ability to grasp and release objects after therapy sessions using the Hand-Wrist Assisting Robotic Device (HOW-

ARD). Each patient had at least moderate residual weakness and reduced function of the right hand, although the affected hands were neither totally para-lyzed nor unable to feel. Seven women and six men who had suffered a stroke at least three months prior participated in the pilot study using this robotic device. “Most spontaneous improve-ment in function occurs in the first three months after a stroke, and after that things tend to plateau,” said Dr. Steven C. Cramer, senior author of the study and associate professor in neurology, anatomy and neuro-biology at UCI. “Robot-assisted therapy may help rewire the

Hot Products www.medicalnewstoday.com

continued on page 18

Interesting Information & Facts about Amputations

50,000 new amputations occur every year in the USA based on information from The National Center for Health Statistics Ratio of upper limb to lower limb amputa-tion is 1:4 Most common is partial hand amputation with loss of 1 or more fingers, 61,000Next common is loss of one arm 25,000Existence of 350,000 persons with amputations in USA, 30% have upper limb lossOf the above, wrist and hand amputa-tions are estimated to make up 10% of upper limb populationTransradial amputations make up 60% of total wrist and hand amputa-tions The above point means 70% of all persons with upper limb amputations have amputations distal to the elbow

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In US 41,000 persons are registered who had an amputation of hand or complete arm 60% of arm amputees are between ages 21 and 64 years and 10% are under 21 years of age Reasons for amputation include cardiovascular disease, traumatic ac-cidents, infection, tumors, nerve injury (trophic ulceration), and congenital anomalies Most frequent causes of upper limb amputation are trauma and cancer, followed by vascular complications from diseaseRight arm amputations are more frequently involved in work related injuries Congenital upper limb deficiency has an incidence of approximately 4.1 per 10000 live births Causes of Upper Extremity Amputa-tion (in percent)

Congenital . . . . . . . . . . . 8.9% Tumor. .. . . . . . . . . . . . . . 8.2% Disease . . . . . . . . . . . . . 5.8% Trauma . . .. . . . . . . . . . .. 77%

Only half of all upper extremity ampu-

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tees ever receive prosthetic services 30-50% of handicapped persons do not use prosthetic hand regularly

RESOURCES:http://biomed.brown.edu/Courses/BI108/BI108_2003_Groups/Hand_Prosthetics/stats.htmlhttp://cosmos.ot.buffalo.edu/t2rerc/index.htmlhttp://www.wws.princeton.edu/cgi-bin/byteserv.prl/~ota/disk3/1984/8405/840504.PDF

Facts and percents from one handed keyboards website. This is a nice resource if you are working with one-handed individuals. The website focuses on amputations but CVAs with hemiparesis may benefit from the products on this site. Also somone with a CTD may temporarily utilize a one handed keyboard. Check it out for some interesting one handed keyboard products. http://www.onehandedkey-board.com/

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Whazzzz up????

preserving procedure with minimal removal of bone stock, preservation of healthy cartilage, potentially reducing peri-operative morbidity.

The Hemi-CAP® system was de-veloped so that it could be used with mini-mally disruptive surgical tech-niques. The HemiCAP® implants and instruments are designed to remove minimal bone stock and preserve functional structures and tissues. Visit the manufac-ture at the following web page:

http://www.arthrosurface.com/in-dex.php/content/view/58/65/to see an animation of the pro-cedure and other video clips about the procedure and how it

is utilized. Dr. Davidson’s study indicates the patients in the preliminary treatment outcomes of the series demonstrated sub-

stantial pain relief and functional improvement. Let’s cross our fingers my dad holds his trend of great outcomes. This looks like it may be a way of the future for shoulder re-placements.

Photos courtesy of:Dr. Philip Davidson6500 66th St. N.Pinellas Park, FL 33781Phone: (727) 347-1286http://www.tampabayortho.com/doctors/davidson.htm

OA gleno-humeral joint

HemiCAP®

Xray of the HemiCAP®

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brain and make weak limbs move better long afterwards.”

Previously, robotic devices have improved post-stroke shoulder and leg function. Cramer said this study is one of the first attempts to specifically aid hand function. Cramer presented HOWARD study findings at the American Stroke Association’s International Stroke Conference 2007 in San Francisco.

Developed by UCI research-ers, HOWARD aids patients as they grasp and release common objects. The robotic device wraps around the hand and couples with a computer program that directs patients though a rehabilita-tion (occupational or physical) therapy program. HOWARD users initiate hand motion, with the robot monitoring and assist-ing the activity in order to meet therapeutic goals.

“The HOWARD therapy isn’t pas-sive; the patient has to jumpstart the program and initiate the mo-tor command,” Cramer said. “But if the hand is weak and can only budge one-tenth of an inch, the robot helps to complete the task so the brain relearns what it’s like to make the full movement.”

In the UCI study, each patient, average age 63, received 15 two-hour therapy sessions, spread over three weeks, designed to improve their ability to grasp and release objects. All worked with HOWARD for the 15 sessions.

For seven patients, HOWARD shaped and helped complete movements across all sessions, while six had complete support from HOWARD for only the sec-ond half of the sessions.

At the end of three weeks, all patients had im-proved in their ability to grasp and release objects. Their aver-age score on an Action Research Arm Test -- which measures the ability to perform such real-world tasks as grasping a block, grip-ping a drinking glass, pinching to pick up a small marble or ball bearing, and putting your hand on your head -- improved by nearly 10 percent. And their average score rose by nearly 20 percent on the Box-and-Blocks Test, which assesses manual dexterity as one moves blocks from one side of a box to another in one minute.

The patients also developed a 17 percent greater range of motion in their hands and wrists and were rated as less disabled on a standard occupational therapy assessment tool called the Fugl-Meyer score. “Assessing changes in before-and-after scores within each subject, these were highly signifi-cant gains after three weeks of therapy,” Cramer said.

The UCI team is now using what they learned from study partici-pants to create a “son of HOW-

ARD,” with improved hand-robot connections and more software options to individualize therapy and keep patients interested.

Stroke is a major cause of long-term disability in the United States. More than 700,000 Amer-icans suffer strokes annually. Stroke is the third leading cause of death in the country. And stroke causes more serious long-term disabilities than any other disease. Nearly three-quarters of all strokes occur in people over the age of 65 and the risk of hav-ing a stroke more than doubles each decade after the age of 55, according to the National Institute of Neurological Disorders and Stroke.

Used with permission from www.medicalnewstoday.comand from http://today.uci.edu/news/release_detail.asp?key=1569

The robotic hand is an exciting and interesting device. I forsee endless opportunities for the robotic hand. Not only post stroke but perhaps after nerve injuries like radial nerve palsy. This is something to keep an eye on. (nf)

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Basics and Beyond:I’ve Got You Under My Skin

X-Rays

1.75 Contact Hour Movie course

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(USA) 727-341-1674Exploring Hand Therapy

1) Maitland’s grade I & II GH joint mobs are done as caudal glides

2) GH eleva-tion at 60 to 90 degrees

3) Subacromial impingement syndrome

4) Primary impingement factors contributing to pathology:

Weakness of the rotator cuffOver use of the shoulderPosterior capsule tightnessAnatomic variation of the acro-mion processDegenerative changes in the rotator cuff

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Postural changes leading to forward head and rounded shoulder (kyphosis, protracted scapulae, internal rotation)

5) Howard the Robotic Hand

6) Dipping the finger in paraffin before you make the plaster of Paris cast.

7) Tape is used with shoulder impingement for the following reasons:

reduce paincontrolling posture at a jointimproving proprioceptionimproving muscular effort

8) A cinch strap is used to gain flexion PROM and ultimately AROM of a stiff finger joint

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9) Ergonomics draws on many disciplines in its study of humans and their environments:

anthropometrybiomechanicsmechanical engineeringindustrial engineeringindustrial designkinesiologyphysiologypsychology

10) Occupational Therapy

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Answers to Quiz (from page 12)

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