Biomechanical Approaches

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avblok
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Biomechanical Approaches
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2015-08-15 17:39:23
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  1. biomechanical model
    focuses on ROM, strength, and endurance required to perform an occupation

    most commonly used to treat patient with LMN deficits and orthopedic problems

    should not be used in isolation(most effective when combined with other OT treatment approaches focusing on client's engagement in meaningful and desired occupations)

    • Settings that commonly use this approach are:
    • hand clinics
    • work programs
    • physical medicine and rehabiliation
    • ergonomics programs
  2. Range of Motion (ROM)
    measurement tool: goniometer consisting of an axis, stationary and moveable arms

    • Types of ROM
    • functional ROM: ROM needed to perform functional movements (Reach the top of head, small of back, etc.)

    AROM: active ROM movement produced by one's own muscles

    PROM: passive ROM; movement produced by an external force

    AAROM: active assistive ROM; movement produced by one's own muscles assisted by an external force

    • Finger ROM: total active motion (TAM) and total passive motion (TPM);measures tendon excursion
    • add extension deficits and subtract from flexion measurement

    • MCP 10-50
    • PIP 15-75
    • DIP 0-10
    • TAM 110

    • Recording measurements
    • starting positions/ending position (e.g. 0-150 degrees)
    • do not used negatives
    • WFL: ROM is functional
    • WNL: ROM achieves normal ranges
    • Table 11-1 for ranges
  3. Muscle Strength
    • Break MMT is the most common
    • Test positions: gravity minimized vs against gravity
    • Stabilization: usually proximal to the joint the muscle crosses over; do not hold over the muscle belly or on a joint)
    • Resistance: applied in opposite direction of movement; should be gradual.


    • Resistance Test
    • Resistance is applied thoughout the range
    • individual can compensate easily
    • requires experienced therapist

    • Table 11-2 MMT grades
    • 5- normal;full ROM against gravity and Max resistance supported
    • 4- Good;full ROM a.g. and mod resistance supported
    • 4-; Good minus; full ROM a.g. and takes less than mod resistance
    • 3+ (fair plus): full ROM a.g. and takes min resistance before it breaks
    • 3 (fair): moves through full ROM; unable to take resistance
    • 3- (fair minus): part moves less than full ROM a.g.
    • 2+: (poor plus): part moves through full ROM in a gravity-minimized position and takes min resistance
    • 2(poor): part moves through full ROM in gravity-minimized plane
    • 2- (poor minus):part moves through less than full ROM in gravity minimized plane
    • 1 (trace):tension is palpitated, but no motion occurs
    • 0- no  tension is palpitated in muscle or tendon
  4. Grip Strength
    • Measurement tool: dynamometer
    • Position of the UE: shoulder adducted to side, elbow flexed to 90 degrees, and forearm in neutral
    • Dynamometer handle placed on position #2;mean of three trials of each hand is compared to the norms
    • (One trial in all 5 positions for each hand will create a bell curve if individual is apply max effort)
    • ***Sphygomanometer cuff or vigorometer/bulb dynamometer should be used to evaluate the grip strength of someone with arthritis**
  5. Pinch strength
    • measurement tool: pinchmeter
    • Position of the UE: shoulder adducted to side, elbow flexed to 90 degrees, and forearm in neutral

    • Types of pinch strength tested:
    • key or lateral pinch: thumb pulp to the lateral aspect of the index middle phalanx
    • Three jaw chuck: (palmar pinch)pulp of thumb to pulps of index and middle fingers
    • Tip to tip: thumb pulp to pulp of index finger

    Three trials on each hand are obtained for all pinch strengths and the mean of the trials are compared to the norms
  6. Endurance/Activity Tolerance
    • Count number of reps per unit of time
    • determine percent of maximum heart rate
    • measure time until fatigue
    • use METS levels
  7. Edema
    • Body's initial response to injury
    • Transfer of exudate in which the fluid from the blood stream moves to the interstitial tissue
    • Can be localized or diffuse

    • Types:
    • pitting- acute (can test by pushing finger or thumb for about a minute and seeing if it comes out slowly)
    • Brawny- chronic

    • Evaluation of cirumference
    • measurement tool: tape measure, recorded in centimeters
    • compare extremities, document landmarks
    • to measure entire hand use the figure or eight method as it is the most reliable (starts at pisiform on palmar side,wraps around hand to metacarpals and back down to pisiform)

    • Evaluation of hand and arm mass
    • Measurement tool: volumeter, recorded in ML
    • significant change in edema would be more than 10 ML
    • Only true objective tool
  8. Sensation
    • Demonstrate sensory test with vision, then occlude vision for actual testing
    • Test uninvolved side first (apply stimulus to volar and dorsal surfaces)
    • SCI are tested proximal to distal following dermatome pattern
    • neurological disorders assess for dermatome pattern
    • peripheral nerve injuries are tested distal to proximal following peripheral nerves
    • Peripheral nerve injuries assess for peripheral nerve involvment
    • ***Order of return: pain,moving touch, static light touch, and touch localization***

    • Types of sensory testing:
    • Light touch (cotton swab): Person responds "yes" or "touched" when touched. Scoring: + (intact), - (impaired), 0 (absent)

    • Localization: (cotton swab): person responds "yes" when touched and then with vision points to the area touched.Scoring +, -, 0.
    • Pain:(paper clip):Person responds "sharp" or "dull" Scoring: S+, S, S-, D+, D, D-

    Temperature sensation: test tubes or thermal kit. Person responds "hot" or "cold" Scoring+,-,0

    Stereognosis: recognition by touch of common objects (no vision). Scoring: number of correct objects. (Second set of identical  common objects should be used for individuals with expressive aphasia to match)

    • Moving two point discrimination: Disk-criminator or caliper.
    • Testing begins with points 5-8mm apart.
    • applied proximal to distal on fingertips, in horizontal orientation
    • Person responds to the number of points they feel "one" or "two"
    • 7/10 responses must be correct before decreasing the distance of the two points
    • scoring: normal = 2mm

    • Static two point discrimination
    • disk-criminator or caliper
    • test begins at 5mm
    • applied to fingertips in a longitudinal orientation
    • Person states "one"or "two" in response to the points they feel
    • distance between points is increased until 7/10 responses are correct
    • Test is stopped at 15mm
    • Scoring:
    • normal=5mm
    • Fair=6-10mm
    • poor=11-15mm
    • Protective= one point perceived
    • anesthetic= no points percieved

    • Proprioception:
    • position sense
    • Therapist positions involved extremity
    • Person duplicates position with contralateral extremity

    • Kinesthesia: movement sense
    • Therapist moves segment and person responds with "up" or "down"

    Table11-3 Reviex dermatomes

    • CN V anterior facial region for mastication/ingesion
    • C3- neck region (sternocleidomastioid,upper trapezius) for head control
    • C4- upper shoulder region (trapezius, diaphragm) head control
    • C5- lateral aspect of the shoulder (deltoid, biceps, rhomboid major and minor) for elbow flexion
    • C6- Thumb and radial forearm (Extensor carpi radialis, biceps) for shoulder abduction and wrist extension
    • C7-middle finger (triceps, extensors of wrist and fingers) fortenodesis
    • C8- little finger,ulnar forearm (flexor of wrists and fingers) for finger flexion
    • T1- Axilla and proximal medial arm (hand intrinsics) for ab/duction of fingers
    • T2-T6 intercostals for respiration
  9. Coordination and dexterity assessments
    • Purdue Pegboard
    • Test of fingertip dexterity and assembly job simulation
    • Subtests:
    • Thirty-second test: Right hand, left hand, both hands (# of pins placed in the board)
    • One minute test: assembly (# of parts assembled) White board with pins, washers, etc.

    • Minnesota manual dexterity test
    • test of gross hand and arm movements
    • subtests:
    • Placing test: measures rate of hand movement (one hand only)
    • Turning test: measures rate of finger manipulation(bilateral)
    • Scoring: time to complete the board. one practice and four scored trials


    • O'Connor Tweezer Test
    • Test of eye coordination using tweezers
    • Scoring: number of seconds to place all pins in board using tweezers.

    • Crawford Small Parts Dexterity Test
    • Test of FM dexterirty using small tools (tweezers and screwdriver)
    • Scoring: time to complete assembly

    • Nine Hole Peg Test: measures finger dexterity
    • Scoring:time to place the nine pegs in a square board and to remove them
    • Purdue Pegboard ispreferredover the nine hole peg test because it is unilateral and bilateral and is more reliable

    • Jebson Hand Function Test (over 5 years of age)
    • Test of hand function.
    • Seven subtests:
    • Writing
    • simulated page turning
    • picking up common objects
    • simulated feeding
    • stacking
    • picking up large light objects
    • picking up large heavy objects
    • Scoring: time to complete each subtest
  10. informal assessment of coodination should include
    Fine motor- observation of routine taske performance, handwriting, manipulation of various sized objects, handling money, cutting food, and buttoning are examples of daily tasks

    Gross motor- tossing a ball, reaching into cabinets or specific items,and dressing
  11. Interventions for increasing ROM
    • Passive ROM and passive stretching
    • PROM is moving the joint to the desired end range using external force
    • Passive stretching is PROM with overpressure
    • A careful review of the physician's orders is paramount to distinguish the type of passive exercise being requested
    • Heat prior to stretch increases extensibility
    • Joint mobilization requires special training; more effective if done before PROM
    • Manual stretching within individual's tolerance
    • Codman's exercises: common form of PROM used for post-surgical shoulder patients
    • Instruction in HEP; stress importance of home exercises to facilitate change in tissue length
    • splinting: dynamic and serial splinting
    • Exercise equipment: continuous passive movement (CPM), pulleys, etc.

    • AROM
    • Should be performed when PROM is > AROM (likely due to weakness)
    • Differential tendon gliding exercises: differentiates tendon movement and increases tendon excursion
    • Blocking exercises: used to isolated joint motion.
    • Emphasize functional use; encourage use for ADL and role activities
    • Preparatory interventions: wall walking, AROM, Cane exercises
    • Purposeful and occupation based activities: ADL, work activities, crafts, games, sports. ***incorporate individual's leisure interests.

    Precautions:myositis ossification's (bone growth in muscles) may result from over stretching
  12. Increasing strength
    high resistance, low rep

    • Types of contractions:
    • Isometrics: contraction without movement
    • ***Isometric contractions are contraindicated for persons with persons with HTN and cardiovascular problems as they can increase BP and HR.

    • Isotonic: contraction with movement
    • Eccentric- lengthening
    • Concentric- shortening
  13. Increasing  Endurance
    • Work at 50% of max resistance or less
    • Increasing repetitions, and duration, not resistance
    • Use energy conservation methods
  14. Edema Reduction Techniques
    • Elevation: extremity should be placed above the heart.
    • ***Elevation is contraindicated if the individual has circulation problems

    Manual Edema mobilization: hands on technique that activates the lymphatic system to remove edema (requires specialized training)

    • Retrograde massage assists the return of blood and lymphatic fluids to venous system (slowly being replaced by manual edema mobilization); involves stroking in centripetal direction with the extremity elevated
    • ***Manual edema mobilization and retrograde massage are contraindicated when cardiac edema is present***

    • compression garments prevent re-accumulation of fluids following retrograde massage
    • Common types:
    • Isotoner gloves
    • Tubigrip(stockinet with elastic)
    • Ace wraps
    • Custom made compression garments
    • Coban wrap (digit wrapped distal to proximal); effective for decreased edema in a digit; avoid too much tension; can exercise and use hand for ADL and role activities when wearing Coban wrap.

    Cold packs: most effective when combined with elevation; monitor vascular status

    • Contrast bath:
    • Technique of immersing the hand in warm water (temp or bath water) and cold water; evidence of effectiveness in reducing edema is conflicting

    • Other edema techniques
    • string wrapping, ace bandage wraps, and intermittent compression pump


    ****Heat is commonly contraindicated

    • **Contraindications/Precautions
    • Infection
    • Grafts or wounds
    • Vascular damage
    • Unstable fractures
    • CHF
  15. Scar Management
    • ROM: early mobiliation programs are most effective
    • Massage (circles and friction)
    • Compression: Coban for digits,isotoner glove for hand and tubigrip for UEScar pad with compression
    • Splinting to prevent contractures resulting from scar
    • Edema control:especially in acute phase
  16. Sensory Training
    • Desensitization for hypersensitivity
    • If post surgery, begin in periphery ofthescare and as tolerated work over the scar
    • massage
    • textures
    • vibration
    • three phase desnsitizationkit
    • fluidotherapy

    • Sensory re-education
    • Same as above; review safety precautions

    • Compesnation
    • Avoid use of hands where vision is occluded
    • Observe safety precautions

    • Improving coordination
    • Begin with gross motor activities and gradually grade to fine motor activities
    • selected activities in which the ROM required is within the person's reach yet challenging
    • Focus on accuracy and speed. Begin with slow gross movements and gradually progress to faster precise movements
    • Refine accuracy and speed
  17. Energy conservation and work simplification principles and methods
    • Plan short rest periods (5-10 minutes) during the daily routine
    • schedule tasks for the day, week, and month to alternate and balance heavy and light work tasks
    • organized tasks: gather all necessary items and equipment before beginning the task
    • Avoid multiple tripsto obtain itemsbyusing a utility cart,bucket, walker bag, backpack, etc to carry all items needed in one trip
    • Elimitane tasks that are nonessential
    • delegates taks that are beyond one's capacity
    • combine tasks to eliminate extraneous work
    • sit to work at a table or use a high stool for countertop work
    • organize cabintets so that items are easy to reach and in convienent locations
    • use adaptive equipment (i.e. reachers) to avoid bending and stooping)
    • Use electrical appliances (mixers)to decrease personal effort
    • slide rather than lift heavy items
    • use light weight equipment,tools and utensils
    • Rest before fatigue sets in; intermittent rest during an activity is more effective than resting after exhaustion has occurred.
  18. Joint Protection Priniciples
    • Maintain joint ROM by using maximal ROM during daily activities
    • Maintain muscle strength by using maximal strength during daily activities
    • Use the strongest and largest joint that is possible for task completion (use knees and hips for lifting, not the back; push large items that need to be moved with a full body rather than pulling; lift objects with both hands, palms up; carry purses, bags, etc rather than on wrist
    • Use each joint in its most stable and functional position(stand directly in front of the object;keep wrists and fingers in proper alignment)

    • Avoid holding joints in one position or sustaining muscle contractions for extended periods of time. (use adaptive equipment for long periods of time such as a book holder).
    • Avoid positions of deformity and activities in the direction of deformity (ulnar drift)
    • Do not start an activity that cannot be immediately stopped if it requires capacities beyond existing capabilties.
    • Recognize that discomfort may be a reality of activity but that pain is a warning sing indicating that an activity should be modified or stopped.
  19. Body Mechanics Priniciples and Methods
    • Do not move items that are too heavy; ask for assistance
    • slide or push an object along the surface rather than lift it, if possible.
    • Directly fave the object about to be lifted
    • Keep object close to body during lifting and carrying
    • hold object centered at waist level
    • feet should be kept flat on the floor; do not balance on toes
    • maintain a firm and broad base of support
    • bend at knees and hips, not at waist
    • keep theback as straight as possible
    • breathe while lifting
    • lift by straightening legs;do not pull upward with arms and back
    • move smoothly; do not jerk
    • do not rotate the trunk;pick up the object completely and the pivot the entire body
    • lower the body to the level of work
    • Lower the body to the level of work.
  20. Splinting
    • Types of splints
    • Static-has no resilient component and immobilizes a joint or part
    • dynamic-includes a resilient component (elastic, rubber band,or spring) which the individual moves; designed to increase PROM or to augment AROM

    • Purposes of splinting
    • Rest
    • Prevent deformities andcontnracture
    • Increase joint ROM
    • Protect bone, joint and soft tissue
    • Increase functional use

    • Hand splinting design standards
    • maintain arches of the hand (proximal transverse, distal transverse, longitudinal)
    • Do not impinge upon creases of thehand

    • Mechanical principles of splinting
    • Decrease pressure: wide,long splint base is the most desirable.Round edges are needed.
    • Using applied with a 90 degree angle of pull.
    • use low load to increase duration
    • maintain three point pressure versus circumference
    • Avoid the position of deformity:
    • Wrist flexion
    • MCP hyperextension
    • IP joint flexed
    • Thumb adducted

    • Select the appropriate splinting position
    • Restinghand splint: functional position
    • Wrist 20-30 degrees extension
    • MCPs 30-45degrees flexion
    • IPs 0-20 degrees flexion
    • Thumb abducted (aka opposition)

    • Safe position splint (intrinsic plus or anti-deformity splint)
    • Wrist 20-40 degrees extension
    • MCPs 70-90 degrees flexion
    • IPs in extension
    • Thumb abducted and extended

    • PRECAUTIONS
    • Check individual's skin condition before or after making splint
    • instruct splint wearer in procedures for splint maintenance and routine skin  inspection and care  (check skin when donning and doffing; provide wear and care form)
    • Ensure individual accepts and understands the purpose(s), function(s) and limitation (s) of the splint
    • Teach proper technique for donning and doffing
    • Provide functional training in use of splint in role activities
    • Reevaluate individuals use of splint at periodic intervals.

    • Splints for common diagnoses
    • Brachial plexus- flail arm splint
    • Radial nerve plexus- dynamic wrist, finger, and thumb extension splint
    • Median Nerve Injury- opponens splint, C-bar or thumb post splint
    • Ulnar nerve injury- dynamic/static splint to position MPs in flexion
    • Combined median Ulnar: figure of eight or dynamic splint
    • Spinal Cord C6-7: tenodesis splint
    • Carpal Tunnel Syndrome: elbow splint positions at 30 degree flexion
    • DeQuervains: thumb splint, includes wrist,IP joint free
    • Skier'sThumb: UCL hand based thumb splint
    • CMC arthritis: hand-based thumb splint
    • Ulnar drift: Ulnar drift splint
    • Flexor tendon injury: dorsal protection splint
    • swan neck: silver rings or buttonhole
    • Boutonniere: silver rings or PIP extension
    • splint
    • Arthritis: functional splint or safe splint depending on stage
    • flaccidity: resting splint
    • stasticity: spasticity splint or cone splint
    • Muscle weakness(ALS, SCI, Guillian Barre) balancd forearm orthosis,deltoid sling/suspension sling
    • Hand burns:wrist 15-30 degrees extension, MCP 50-70 degrees flexion and IPs in full extension
  21. Physical Agent Modalities (PAMS)
    PAMS can be used as preparatory interventions in prep for pursposeful and occupation based activities

    **Not an appropriate occupational therapy intervention if used in isolation

    • Common types of PAMS used by entry level OTs
    • Superficial thermal
    • Paraffin
    • Hot packs
    • Fluidotherapy

    • Superficial cooling agents
    • Cold packs
    • Ice massage

    • Mechanotherapy
    • Ultrasound
    • Whirlpool

    • Electrical stimulation units
    • Neuromuscular electrical stimulation
    • Transcutaneous electrical nerve stimulator
    • Iontophoresis

    • Types of heat transfer
    • Conduction (hot packs, whirl pool, paraffin)
    • Convection (fluidotherapy)
    • RAdiation (laser)
    • conversion (ultrasound- heats deeper structures)

    • Benefits of superficial heat therapy
    • Relievespain
    • increases ROM
    • assists with wound healing (increased blood flow)
    • decreases muscle spasms

    • ***Contraindications for heat
    • Donnotuse heat with
    • postsurgical repairs
    • acute injuries
    • impaired sensation
    • impaired vascular supply
  22. Application of superficial heat modalities
    • Hotpacks
    • Check skin prior to and after application
    • Check temp of hydrocollator (165 degrees)
    • Place hot pack in cover and add 4 layers of a folded towel between skin and hot pack cover; check skin after 5 minutes to assess for burn or any other skin issues; remove hot pack after 20 minutes

    • Paraffin
    • Check skin prior to and after application
    • check temp of paraffin; 125-130 degrees is standard
    • washandd dry hand thouroughly;dip hand in paraffin and quickly pull out 8-12 x
    • following the dip method, the hand should be wrapped with cellophane and then covered with a towel
    • immersion method (not as common) people keeps his/her hand immersed in the paraffin for the duration of tx.

    • Fluidotherapy
    • Preheatthe machine (102-118 degrees)
    • adjust blowers to persons sensitivity
    • Place persons hand in fluidotherapy via sleeve on machine for 20 minutes

    • Whirlpool
    • To clean and debride wounds
    • Fill tank with water 100-108 degrees
    • maintain sterile technique
    • Adjust turbine and turn it on and check temp again
    • treament for 20 minutes
  23. cryotherapy and electical
    • Relieves pain
    • controls edema
    • decreases abnormal tone
    • facilitated muscle tone
    • commonly used to treat acute injuries and post surgical repairs

    • ****Precautions and Contraindications:
    • Do not use with:
    • Sensory deficits including hypersensitivity
    • apply a wet or dry towel between the clients skin and cold pack
    • check skin after 3-5 minutes
    • cold pack remains cold for up to 10 minutes

    • Electrical stimulation
    • Benefits of electrical stimulation
    • Pain control
    • decreases swelling
    • stimulates and strengthens muscles
    • muscle re-education
    • stimulates denervated muscle

    • ****Contraindications for electrical stimulation
    • Cardiac pacemakers
    • Phrenic or urinary bladder stimulators
    • presnesceof thrombosis orthrmobplhebitist
    • over caratoid sinus

    • Ultrasound
    • continuous
    • Benefits
    • increases ROMand decreases joint stiffness
    • reducespain
    • increases blood flow
    • reduces muscle spasms

    • Benefitsofpulsedultrasound
    • decreaes inflmamation
    • heals tissues

    • ***CONTRAINDICATIONS of ultrasound
    • active malignant tumor
    • pregnancy
    • areanearpacemenke
    • some joint replacements
    • Thrombophlebits
    • Precautions- fractures, growth plates, and breast implants

    • Guidelines for competent and ethical use of PAMS
    • PAMS should be used when they can benefit the individuals treatment program

    • General contraindications
    • cancer
    • pacemaker
    • pregnancy
    • cognitive impairment
    • sensory impairment
    • vascularimpairment
    • DVT

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