Evaluation of the Hand. Learning Objectives. Sitting down with the Client. Observation 2/16/2012

Transcription

1 Introduction to Hand & UE Rehabilitation Hand Evaluation Basics J. Robin Janson, MS, OTR, CHT Indiana University Department of Occupational Therapy Learning Objectives After actively engaging with this presentation, you should be able to: 1. Identify a minimum of four evaluations used to assess to the hand. 2. Appreciate the importance of informally assessing a client s psycho-emotional health. 3. Identify a pain assessment that is more detailed than the numeric pain rating scale. 4. Describe how to perform zone 7 (fingertip) sensory testing of the fingers for 2-Point Discrimination and Semmes Weinstein Mononfilaments. 5. Interpret sensory tests (Semmes Weinstein and 2-Point Discrimination). Where to Start Prior to sitting down with the client Ask client to complete a functional outcome measure such as the ULFI, DASH, or QuickDASH. To save time, have client complete outcome measure prior to being seen in therapy. Carefully review orders from physician. If available review medical chart, read operative report, review X-rays. Calculate the number of weeks/months post onset of condition/injury and or postsurgery (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 1

2 Observation Skin Color -bruising, redness, discoloration,etc. Temperature Texture Scars, wounds, lack of skin creases, callouses Overly moist or dry skin Observation Hair & Nails Excessive hair growth (hypertrichosis) Nails pitted, discolored, and/or deformed Edema pitting, brawny Muscle Atrophy Physical Exam Palpation Use contralateral extremity for comparison Provocative testing (when indicated) Variety of tests for different conditions/diagnoses Document findings Mental Health MANY clients experience fear, stress, anxiety, depression, etc. related to their condition/situation. Consider how you might feel in the same situation. Initiate conversation with your client addressing how they are coping with their condition. Be supportive. Recognize when your client is not adjusting well. If there s an issue talk with client re: your concerns and encourage client to talk with their physician. Mental Health Status When necessary, make referral to the appropriate mental health care professional (Get approval from client s physician). I cannot over emphasize the importance of one s mental health and it s impact on the rehabilitation process. YOUR THERAPEUTIC USE OF SELF CAN DO WONDERS IN HELPING YOUR CLIENT THROUGH A DIFFICULT TIME. Mental Health The Challenging Client One Example - Client expresses anger DO NOT REACT NEGATIVELY! YOU WILL ONLY FUEL THE ANGER IT IS NOT ABOUT YOU! Often the anger is displaced important to find source to help diffuse it I would say You seem angry is there something I ve done to make you angry? [Client usually said No ]. I would respond with Would you like to talk about it? I m a good listener. DO NOT TAKE SIDES OR MAKE JUDGMENTS! JUST LISTEN-ENCOURAGE PT TO BE ASSERTIVE IN RESOLVING ISSUE. 2

3 Pain Subjective Numeric Intensity Rating Scale Commonly used 0-10 scale Read icahe pp Pain Questionnaires Short-Form Mcgill Pain Questionnaire -icahe pp 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 contralateralextremity for comparison Compare measurements from previous therapy visit to document increases/decreases Circumferential Tape Measurements Used for monitoring the inflammatory response, edema, or atrophy Volumeter Left ring finger PIP= 5.5 cm Left WFC = 15.8 cm Measure edematous areas and compare contralateral measurements as well as previous visit measurements Measure the amount of H 2 O 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 3

4 RIGHT THUMB ROM R Thumb MP / ( / ) IP / ( / ) 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 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 RDN UDN ZONE 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 4

5 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 Interactive Hand-Image reproduced with permission- Primal Pictures Available in two kits: 20 Monofilament Kit: Monofilaments ranging from: 1.65 to 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. Touch Threshold Norms Monofilaments Normal light touch Diminished light touch Diminished protective sensation Loss of protective sensation Deep pressure sensation 6.65 Unresponsive to 6.65 Monofilament handles color coded according to the level of touch threshold represented. Procedure: 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 seconds to the skin in a perpendicular fashion until it bows. Procedure (con t): 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. 5

6 Procedure (con t): 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 If not accurately perceived, follow the procedure testing only once for monofilament Document unable to be tested-does not perceive 6.65 for clients who do not perceive the 6.65 monofilament Right Hand Zone 7 Documenting Results TH I L R S RDN UDN Semmes Weinstein Touch Threshold Norms Mini-Kit Monofilaments Normal light touch 2.83 Diminished light touch 3.61 Diminished protective sensation 4.31 Loss of protective sensation 4.56 Deep pressure sensation 6.65 Unresponsive 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 Various Two-Point Testing Instruments Dellon Disk-Criminator 2-point discriminator Lafayette Two-Point Aesthesiometer TIPS SHOULD BE BLUNT! Image from html 6

7 Right Hand Zone 7 Documenting 2 Point Results TH I L R S RDN <5mm <5mm <5mm <5mm 15mm UDN <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: JebsenHand 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 -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). 7