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HandTherapyReviewCourse

WashingtonUniversity
St.Louis,MO
April79,2017

Evaluation

SusanneHigginsOTD,OTR/L,CHT

Rationale Criteria
Establishbaselines Accurate
Determinelimitations Standardized
Createatreatmentplan Reliable
Settreatmentgoals Reproducible
Determinetreatmentresultsandoutcomes Valid
Progressormodifyplanofcare Feasible
Determineefficacyoftreatment Systematic

Methods StandardizedAssessments
DASH&QuickDASH
FunctionalOutcomeMeasures
PatientRatedWristEvaluation
Observation PatientRatedElbow
MichiganHandQuestionnaire
Interview MayoScore(elbow,wrist)
Clinicalexam ASES(elbow,shoulder)
Oxford(shoulder,elbow)
Measurements PatientSpecificFunctionalScale
Performancetests e.g.Sollerman,JebsenTaylor
Conclusion
FunctionalCapacitytests

Skirven,etal.,2011)
Observation Interview
Posture Demographics:Age,handdominance,occupation,
hobbies,medications
Positioning
History:
Neglect
Dateofinjury,surgery,oronset
Nailcondition Diagnosticsperformed
Atrophy Previoustreatment
Edema Fullmedicalhistory:
Color Otherconditionsorillnesses
Tremors Alcoholortobaccouse

Interview Pain
Symptoms(objectify): ThefifthvitalsignAmericanandCanadianPain
pain,numbness/tingling,weakness, Societies
deformity,poorcoordination,functional Affectsqualityoflife
deficits Usedtoevaluatetheeffectivenessofinterventions
Patientreportisgoldstandard
Consider:quality,intensity,location,behavior,interference,
PatientGoaloftreatment impactonfunction
Secondarygain?

Pain Pain
NumericRatingScale measurespainintensity
Ordinal11pointscale:0=nopain;10=?(undefined)
Trackschangeovertime(2pts =substantialchange) VisualAnalogScale(VAS)
PsychometricpropertiesforUEunavailable(resultsopenfor
SimilartoNRSinthatanchorsaredescribeinthesameway
interpretation)
Verbalorwritten Consistsofasinglestraightline
Nocosttouse Patientmarkspointonlinewherepainintensityfalls
Method Evaluatormeasuresinmmfrom0point
Gather14responses Ratiolevelcontinuousscale,oftenpreferredbyresearchers
Recordandinterpreteachscoreseparatelyoraveragethe4 (lendsitselftostatisticalanalysis)
measures
Currentpain
Worst/least/averagepaininpast2weeks
Pain Pain
BriefPainInventory(BPI) measureschangeover PainQualityAssessmentScale(PQAS) evaluates
timeinintensityandinterference.~5minutes intensityandchangeovertimeinneuropathicpainconditions.
4subscales:location,intensity,medicationusage, Alsousedfornonneuropathicpainconditions.
interference Writtenformat
Requires6th gradereadinglevel 3subscales:paroxysmal,superficial,anddeeppain;20items

McGillPainQuestionnaire(MPQ) measures PressureandThermalPainThreshold usedfor


fibromyalgiasyndrome
sensory,affective,evaluative,andintensityaspectsofpain
Notforhyposensate
experience.~10minutes
Mustbeabletorememberandfollowdirections
3domains:presentpainintensity,bodydiagram,and Method:applicationofpressure,heatapparatus,immersion
painratingindex(whichitselfhas4domains:sensory, inicewater,orelectrodes.Patientreportswhenstimulus
evaluative,affective,miscellaneous) changesfrompressuretopain

Pain ClinicalExam
WongBakerFacesScale Appearance
Usefulforchildren,nonEnglishspeaking,andcognitively
impaired
Wound
Edema
ROM
Sensibility
Strength
Palpation Diagnostic
Providesanatomicallandmarksassourceofpain
Beginproximalanddistaltotargetarea,movetowardsit
Startwithgentlepressure

Appearance Appearance
CMCShouldering
Normalcascade Nailcondition,e.g.nailclubbing
Deformities swanneck,boutonniere Congenitalconditions
ArthriticNodesHeberdens(DIP) Preexistinginjuries
Bouchards(PIP)
Appearance
Appearance
Vascular VascularAssesspulses
PALE:mayindicatearterialinsufficiency Subclavian sternal endofclavicleinscalene(mm.)
RED:mayindicateinfection/irritability Axillary centerofarmpit.
CYANOTIC:mayindicatevenousinsufficiency Brachial superiortoantecubital fossa,medialto
bicepstendon.
duetodecreasedcirculation Radial justproximaltowristcrease,volarradial
wrist.
Ulnar justproximaltowristcrease,volarulnar wrist.
Capillaryrefilltest:applypressuretopulpofnail,
normal=3sec.

Appearance Wound
AllensTestforradialorulnararterialpatency
Palpateradialandulnararteriesatthewrist,andapply
pressuretooccludeboth. Tissue:slough,eschar,granulation,
Exsanguinate thehandbyhavingthepatientopenandclose macerated,dessicated,necrotic
fistseveraltimes,thenopenthehandtoarelaxedopen
position. Woundedges:defined,attached
Releaseoneofthearteries
Notequalityandtimeforthehandtoreperfuse.
Normalis35seconds.
Signsofinfection:pain,redness,streaking,
warmth,pus,
fever,odor

Wounds
Shape
Color black,yellow,red
Size:lengthxwidthxdepth
Woundedges:defined,thickened,fibrotic,attached
Undermining Tunneling
Undermining:involvingwhat%ofmargin
Tunneling:depth(ifdeterminable)
Exudate:serous,sanguinous,serosanguinous,purulent
Tissue:slough,eschar,granulation,macerated,dessicated,
necrotic
Location
Signsofinfection:inflammation,erythema,streaking,
pain,heat,pus,odor,malaise,fever Describethese
wounds
Wound Edema
Howwouldyoudescribethis?
Volumetry
Location Figureofeightmethod
Size: Circumferentialmeasurement
Color ASHTdoesnotrecommendforroutineuseunless
Odor consistenttensionisappliedwithspecific
landmarksutilized
Temperature
Integrity(undermining,tunneling)
Exudate
Anythingelse?

Volumetry Volumeter
Pros Method
accuracyofmeasurement(validity) Forearmneutralposition;palmfacespatient
Reproducability (reliability) Water6895degreesF
Cons Volumeter onlevelsurface
Timeconsuming Drybeakerbelowspout
Messy Removejewelry
Notforwounds Handvertical,slowlyimmerse,donttouchsides
Document 3rd webspacerestsondoweluntilwaterceases
Sittingorstanding toflowout
Timeofday Measuremlofwatercollected,orweighcontents
Comparetocontralateral

Figureofeightmethod Figureofeightmethod
Pros Method
Reliable Beginradialvolarwrist,proximaltoDWC
Valid Wrapulnarly todorsalwrist
Easierthanvolumeter Obliquelyacrossdorsalhandtomid2nd MChead
Okwithwounds Palmarly inlinewithDPCto5th digit
ArounddorsallyinproximalobliquedirectionoverAPL
Cons requirestrainingtoperformcorrectly RealignwithDWCandreturntostartingpoint

Document
Timeofday
Contralateralmeasurement
Circumferentialmeasurements RangeofMotion(ROM)
Pros
Easy
Reliable(intraandinterrater)
Cons
Questionablevalidity,dependentonconsistenttension
Document
Timeofday
Anatomicallandmarksused
Method
Useflexibletapemeasure
Donotindentskinwithtapemeasure
Comparetocontalateral

ROM (ROM)
Goniometer mostcommonmethodof
measurement;measuresmotioninoneplane. ASHTrecommendationsforROM:
0isneutral
+ishyperextension
Ifmeasuring: isanextensiondeficit
Onejoint:placeadjacentjointsinrelaxedposition
Muscle/tendonlength:placealljointssuchthatsoft Measurementsshouldbewrittenas
extension/flexion(e.g.10/85)
tissuesareatfulllength
Avolar/dorsalplacementisgenerallypreferred
MCID:measurementchangesshouldexceed5 overlateralplacementforfingerorwristE/F;
althoughdeformities,swelling,orotherfactors..
degreesperjointwithsameexaminer Suggestlateralplacementcouldbeused.

ROM ROM
AccessorymeasurementsofROM

Fingertiptopalm
LinearMeasurementsincm: Measureincm
Distancetodistalpalmarcrease
(recordedas4/3/3/2)
Digitalabductionfrommidline
Webspace (e.g.thumbIPJtoindexPIJ) Fingertiptodistal
palmar crease
(DPC)

Hunter,Mackin,Callahan;RehabilitationoftheHand,5thedition,Mosby
ROM ROM
AMAGuidetoEvaluationofPermanent
Kapandji Scale opposition
Impairment,severityscaleforROMDeficits
GradeModifier Severity RangeofMotion
Papertracing
0 Normal 10%tofull

Tonguedepressoryardstick toolforpatientto 1 Mild 6090%

gaugeprogress 2 Moderate 3060%

3 Severe <30%

4 VerySevere Jointankylosis

ROM
ROM
TAMexample:
ActiveandPassive
Addflexionofalljointsmeasured;subtract
Active=musclegeneratestheROM extensiondeficits
Passive externalforcegeneratestheROM MP 0/90
PIP 10/85
Documentwhichisbeingmeasured DIP 5/55
Requiresconsistencyintool,positioning,and TAM 215
landmarkorientation
TAM=(90+85+55) (10+5)=215
Totalactivemotion(TAM) combinedactive
motionof> 2joints Totalpassivemotion(TPM) sameformula
Totalpassivemotion(TPM) AmericanSocietyforSurgeryoftheHand.Thehand:examinationanddiagnosis,1978

ROM ROM

SomefactorsaffectinglimitedA/PROM
Pain
Capsularorligamenttightness
Passiveinsufficiency(muscle/tendonshortness)
Bonyblocks
Weakness IfPROM>AROMthenthejointisbeinglimitedby
Lossoftendonintegrity adhesions,weaknessesortendonintegrity.
Scaradhesions DocumentAROMandPROM.
HunterJM,SchneiderLH,Mackin E,CallahanAD.Rehabilitationofthehand:surgeryandtherapy.Mosby,2002
ROM ROM
IntrinsicTightnessTest
HoldMPJinext andpassivelyflexPIPjoint(PIPJ). ObliqueRetinacular LigamentTightnessTest
MeasurePIPjointflexion HoldPIJinextensionandpassivelyflexDIJ.Measure
HoldMPJinflexionandpassivelyflexPIPJ. DIJflexion
ComparePIPJflexiontofirstmeasure HoldPIJinflexionandpassivelyflexDIJ.MeasureDIJ
TestispositiveifPIPJflexionisgreaterwithMPJ flexion.
inflexionthanextension TestispositiveifDIJhasgreaterflexionwithPIJin
flexionthanextension.

ROM ROM

ExtrinsicTightnessTestforExtensors ExtrinsicFlexorTightnessTest
HoldMPJinextensionandpassivelyflexIPJs.Measure Placewristinneutralandpassively
IPJflexion. extendthedigits;thenslowly
increasewristextension(elbow
HoldMPJinflexionandpassivelyflexIPJs.Measureand extendedandforearmsupinated)
compareIPJflexiontofirstmeasure.
TestispositiveifgreaterIPJflexionwithMPJinextension Positivetestifpatientisunableto
thanflexion. passivelymaintainIPsinextension
asthewristextensionisincreased
**ResultsareexactlyoppositethanIntrinsicTightnesstest
RuleoutPIPorDIPjointtightnessby
WhatdoesitmeanifIPJflexionisthesameregardlessof evaluatingtheindividualjointstatus
withwristinneutralorslightflexion.
MPJposition?

Sensibility Sensibility
Sudomotor function Assessedthroughobservation
3Nervessupplymotorandsensoryfunctiontohand: andpalpation
median,ulnar,radial Sudomotor:sweating
Vasomotor:skincolorandtemp.
Sensibilityevaluationinvolvesonlysensoryfunction, Pilomotor:goosefleshresponse
notmotor Trophic:skintexture,softtissueatrophy(penciling
offingertips),nailchanges,hairgrowth,rateof
Sensibilityevaluationshouldincludeexaminationof healing
theskinforsudomotor function.

Skirven,Osterman,Fedorczyk,Amadio,RehabilitationoftheHandandUpperExtremity,sixthedition.
Sensibility Sensibility
Hierarchicalclassificationofsensorymodalitytests TouchThresholdTests
Sensibilitymodality Tests/Instruments SemmesWeinsteinMonofilament(SWM)
measureslighttouchtodeeppressure,
1.Touch threshold Monofilaments, includingprotectivesensation.Purposeoftest:
Lighttodeeppressure, vibrometers
staticandmoving Discriminatesab/normalthresholdsinnerve
2.Spatialdiscrimination Spatialthresholdtests:
compression
Localizing anddetermining 2PD,GOT,Touch Detectschangeovertimeinperipheralnerve
spatialresolution Localization regeneration
3. Identification Moberg pickuptest,
Shape,texture,andobjectID ModifiedMoberg,STI
test

Sensibility Sensibility
TouchThresholdTests
SWMMethod VibrationThreshold measurespallaesthesia (Gr.
Patientsitting,handsupinated vibratorysense)
Startwithsmallestfilament;apply Originallyusedtotestfastadapting
mechanoreceptors(Meissner andPacinian)
perpendicularlyuntilitbends
Measureschangeafternerverepair/reinnervation
Holdatleast1.5second
Weaktomoderatecorrelationtofunctional
1outof3responsesmustbecorrect sensibilitytests.
Nostandardprocedurere:whereinhandtostart Resultsnotquantifiable
orhowmanysitesmustbetested NolongerconsiderednecessaryasSWMmeasureall
mechanoreceptors

Sensibility Sensibility
SpatialDiscriminationTests 2PD Method
TwoPointDiscrimination(2PD) Testofspatial
threshold;dependentonreceptordensity Handsupinatedandsupported,visionoccluded
Measuressmallestdistanceatwhich2pointsare
perceivedas2 Pointsareappliedtodigitalpulpsinlongitudinal
orientation
Importantintactilegnosise.g.grasp,manipulating Mediannerve:Thumbandindex
objects,andidentifyingshape,form,texturewithout Ulnarnerve:smallfinger
vision
Startwithwidespace(e.g.12mm);apply
Population nerverepairs,HansensDz,diabetic randomlyindecreasingorderuntilpatientbegins
neuropathy,nervecompression togiveincorrectanswers
Sensibility Sensibility
Applyenoughpressuretodetectpressure;
blanchingnotagoodindicator Spatialdiscriminationtests
Musthave7correcttoprogresstonextlower
width
Someauthorssuggest2outof3;or4of7. Localization locognosia.Alsodependenton
receptordensity(like2PD).
ASSHInterpretationofresults Patientpointstohandcharttosignifywherehis
<6mmnormal handisbeingtouched.
610mm=fair
1115mm=poor
Comparetocontralateral

Sensitivity32%,Specificity81%

Sensibility Sensibility

IdentificationTests Assessusefulnessofsensibility IdentificationTests


Moberg PickupTest(alsoModifiedMoberg)
Tactilegnosis:Thecomplexabilitywhichgivesgrip **Bothversionsincludetestofmotorandsensory
sight.Moberg Moberg:Testsabilitytograspandplacesmallobjectsusing
thumb,indexandlongfingers
Modified:TestsabilitytoIDobjectswithoutvision
ShapeTextureIdentification(STI)TestPatient Notstandardized;normsnotavailable
identifies3shapesofdecreasingsize(cube,hexagon, Required:1012smallmetalobjects,stopwatch,blindfold
cylinder)and3discswithraiseddotsofdecreasing
size.

Sensibility LessstandardizedtestsofSensibility
Moberg method Tentest
Moberg:Patientaskedtomoveobjectsfromone Patientcomparesratingofsensibilityofonearea
containertoanotherasquicklyaspossible;3trials toareferenceareaontheotherextremity
withvision,getaverageoftimeinseconds.Repeat
withvisionoccluded.Compareresults.
ScratchCollapsetest
(refertoLornaspresentationfordetails)
Modified:Patientidentifiesobjectsinhandwith
visionoccluded.RecordtimetoIDandnumber
correct.
Sensibility Strength
ASHT/CARrecommendations:
Grip method
Evaluationoftouchthresholdinpatientswith
nervecompressionshouldbeacoreassessment 2ndrung(noteifusinganyother)
Evaluationoftouchthresholdcombinedwithan Examinersupportsbaseofdynamometer
identificationtestshouldbeperformedon all Pt seated,armadducted,elbow90,
patientswithnerverepair forearmneutral
Therapistsshouldbeawarethatthereisabasic
Avg of3trials(unlesspainful)
lackofstandardizationonmanysensorytests.
Minimizingdistractions,usingstandardized Holdgrip>3seconds;15secondrest
techniqueswhenavailable,andusingcalibrated between
toolsenhancesvalidityofmeasurements.

Strength Strength
Pinch tripod,tipandlateral
Method Dynamometer
Sitting,shoulderAd,elbow90/neutral,or
pronationfortipandtripodpinch
Examinersupportspinchgauge PinchMeter
Tripod:gaugeonsideandheldbetweenpulpsof Lateral
thumbandindex/long.I/LFondialside Tripod
Tippinch:heldbetweentipsofthumbandindex Tip
Lateral:dialfacesup.Thumbpulpondialside,
radialP2ofindexonbottom.
Pinchashardasyoucan.x3;average AmericanSocietyofHandTherapists,ClinicalAssessmentRecommendations,3rdEdition,2013

Strength FunctionalStrength
Tripod Lateral Twopoint
(3JawChuck) (key) (tiptotip) BTE
ThumbagainstIF&MF Thumbagainstradialsideof
IF
ThumbagainstIF
Cybex
Median n. injuries Ulnar N. (AdPol, 1st DI) AIN

Performanceofactivities
Evaluation Bibliography
Summarizedatatogetfullpicture AmericanSocietyofHandTherapistsClinical
AssessmentRecommendations,3rd Ed.,
Documentationisimportant
ImpairmentBasedConditions.2015.American
Setgoalsforcomponentstoachievelong SocietyofHandTherapists.
termfunctionalgoals
Reexamineatintervalstodetermine
progressandoutcomefromtreatment

Acknowledgement

Rhonda Powell OTD, OTR/L CHT