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GIVE ME A HAND!Learning to assess common upper extremity injuries and disorders that effect occupational performanceAndrew Bracken MOT, OTR/L, CHT

OBJECTIVES

•Identify and assess specific upper extremity injuries and disorders through clinical exam.

•Learn how to utilize functional outcome measures like the Canadian Occupational Performance Measure (COPM), Disability of the Arm, Shoulder, and Hand (DASH), and health-related quality of life Short Form-36 to determine the impact of an upper extremity injury on a person’s occupational performance.

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IMPACT OF UPPER EXTREMITY INJURIES ON LIVES

•Report inability to perform everyday tasks.•Consult with physicians more frequently.•Use prescription medication more often.•Report a decreased quality of life.

•Walker-Bone K, Palmer K, Reading I, Coggon K, Cooper S. Prevalence and impact of musculoskeletal disorders of the upper limb in the general population. Arthritis and Rheumatism, 51, 642-651. (2004)

•Moon DK, Park YJ, Song SY, Kim MJ, Park JS, Nam DC, Kim DH, NA, JB, Lee SI, Hwang SC, Park KS. Common Upper Extremity Disorders and Function Affect Upper Extremity-Related Quality of Life: A Community-Based Sample from Rural Areas. Yonsei Medical Journal, 5, 669-676. (2018)

OCCUPATIONAL THERAPY’S ROLE

•“Occupational therapy practitioners have a holistic perspective.”

•“Individualized evaluation, during which the client/family and occupational therapist determine the person’s goals.”

•“Customized intervention to improve the person’s ability to perform daily activities and reach the goals.”

•“Outcomes evaluation to ensure that the goals are being met.”•https://www.aota.org/About-Occupational-Therapy.aspx retrieved 8/29/18.

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NERVE INJURIES AND ENTRAPMENTS

PERIPHERAL NERVE SENSORY DISTRIBUTION

MEDIAL CUTANEOUS NERVE OF THE FOREARM

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RADIAL NERVE PALSY & PIN INJURY

•Radial nerve palsy- Inability to extend the wrist, digits, and thumb and weakness with supination due to loss of the supinator, ECRL, ECRB, ECU, EDC, APL, EPL, and EPB.

•Posterior Interosseous Nerve (PIN)- Inability to extend the digit and thumb due to loss of the EDC, APL, EPL, and EPB. Weakness with wrist extension due to loss of the ECU.•Cooper, S. Fundamentals of hand therapy: Clinical reasoning and treatment guidelines of common diagnosis of the upper extremity, Edition 2. (2014)

RADIAL TUNNEL SYNDROME

•Dull or achy pain in the lateral elbow and forearm.

•Does not produce tingling or numbness.

•Pain with resisted supination with the elbow extended.

•Pain with resisted middle finger extension with the elbow extended (“Middle Finger Extension Test”).•Cooper, S. Fundamentals of hand therapy: Clinical reasoning and treatment guidelines of common diagnosis of the upper extremity, Edition 2. (2014)

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ULNAR NERVE INJURY

•Presence of a “claw hand” due to loss of the 3rd

and 4th lumbricals.

•Atrophy of the 1st dorsal interossei and hypothenar muscles.

•Presence of a Froment sign and Jeanne sign.

•Presence of a Wartenberg sign.•Cooper, S. Fundamentals of hand therapy: Clinical reasoning and treatment guidelines of common diagnosis of the upper extremity, Edition 2. (2014)

Jeanne sign & Froment sign

Wartenberg sign

CUBITAL TUNNEL SYNDROME

•Pain, tingling, and numbness in the ulnar aspect of the hand.

•Pain and sensory impairment when the elbow is held in full flexion for 3-5 minutes (Elbow Flexion Test).

•Pain and sensory impairment with a Tinel’s Sign in the medial elbow.•Cooper, S. Fundamentals of hand therapy: Clinical reasoning and treatment guidelines of common diagnosis of the upper extremity, Edition 2. (2014)

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MEDIAN NERVE AND AIN INJURY

•Inability to perform opposition of the thumb due to loss of the opponens pollicis.

•Atrophy of the thenar musculature of the hand.

•Anterior interosseous nerve injury- weakness of the pincer movement due to loss of the FPL and FDP.

•Sensory deficits present with median nerve injury, but not present with an AIN injury.•Cooper, S. Fundamentals of hand therapy: Clinical reasoning and treatment guidelines of common diagnosis of the upper extremity, Edition 2. (2014)

CARPAL TUNNEL SYNDROME

•Pain, numbness, or tingling in the palm, thumb, index, middle, and radial aspect of the ring finger.

•Presence of a positive Tinel’s Sign over the carpal tunnel.

•Carpal Compression Test produces symptoms.

•Symptoms with a Phalen’s Test or Reverse Phalen’s Test.•Cooper, S. Fundamentals of hand therapy: Clinical reasoning and treatment guidelines of common diagnosis of the upper extremity, Edition 2. (2014)

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MUSCULOSKELETAL CONDITIONS

CMC JOINT OSTEOARTHRITIS

•Grind Test- Compression and rotation of the metacarpal base produces pain.

•MP Extension Test- Resisted MP extension produces pain.

•Lever Test- Mobilization of the 1st

metacarpal base radially and ulnarlycausing pain.•Model Z, Liu A, Kang L, Wolfe S, Burket J, Lee S. Evaluation of physical examination tests for thumb basal joint osteoarthritis. Hand. 11(1). 108-112 (2016).

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DEQUERVAIN’S TENOSYNOVITIS & INTERSECTION SYNDROME•Positive Finkelstein’s Test. Pain with wrist ulnar deviation and thumb flexion.

•DeQuervain’s tenosynovitis affects the 1st dorsal compartment. (APL and EPB)

•Intersection syndrome affects the 2nd

dorsal compartment as the ECRB and ECRL passes under the APL and EPB.•Cooper, S. Fundamentals of hand therapy: Clinical reasoning and treatment guidelines of common diagnosis of the upper extremity, Edition 2. (2014)

TRIGGER FINGER (STENOSING TENOSYNOVITIS)

•Finger locks in a flexed position.

•Can be straightened usually with a “pop”.

•When the “pop” occurs it is palpable at the A1 pulley

•Palpation of the A1 pulley also produces tenderness.•Cooper, S. Fundamentals of hand therapy: Clinical reasoning and treatment guidelines of common diagnosis of the upper extremity, Edition 2. (2014)

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DUPUYTREN’S DISEASE•Presence of “pits”, “nodules”, and “Cords” in the palm of the hand.

•Flexion contractures of the digits that can’t be straightened.

•Often impacts the small finger and ring finger.

•Progresses slowly, often taking years to develop into a contracture.

•Primarily affects older men of Northern European descent.•Cooper, S. Fundamentals of hand therapy: Clinical reasoning and treatment guidelines of common diagnosis of the upper extremity, Edition 2. (2014)

LATERAL EPICONDYLITIS•Palpation of the lateral epicondyle produces pain.•Positive Cozen Test- Pain with resistive wrist extension.•Grip strength measured with elbow extended produces a decreased grip strength.•Cooper, S. Fundamentals of hand therapy: Clinical reasoning and treatment guidelines of common diagnosis of the upper extremity, Edition 2. (2014)

•Dorf E, Chhabra A, Golish S, McGinty J, Pannunzio M. Effect of elbow position on grip strength in the evaluation of lateral epicondylitis. American Journal of Hand Surgery. 32, 882-886 (2007).

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MEDIAL EPICONDYLITIS

•Pain with palpation of the medial epicondyle.

•Golfer’s elbow test is positive. Pain with passive elbow extension, supination, and wrist extension.

•Resistive wrist flexion produces pain.•Cooper, S. Fundamentals of hand therapy: Clinical reasoning and treatment guidelines of common diagnosis of the upper extremity, Edition 2. (2014)

APPLICATION Case Studies

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CASE STUDY

•68 year-old man with a history of finger contractures that impacts his ability to use wood tools.

•What clinical exams would you perform?

•From your clinic exam what upper extremity condition do you believe is impacting his hand function?

CASE STUDY

•3 year-old preschooler who has a thumb contracture that makes it hard to pick up toys and finger foods.

•What clinical exams would you perform?

•From your clinic exam what upper extremity condition do you believe is impacting her hand function?

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CASE STUDY

•52 year-old woman with hand pain and numbness at night and while talking on her phone.

•What clinical exams would you preform?

•From your clinic exam what upper extremity condition do you believe is causing her hand pain and numbness?

CASE STUDY

•29 year-old female who recently had a baby and now has thumb and wrist pain, especially while holding her newborn.

•What clinical exams would you perform?

•From your clinic exam what upper extremity condition do you believe is causing her pain?

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CASE STUDY

•40 year-old construction worker with lateral elbow pain, primarily with lifting his tool box and using power tools.

•What clinical exams would you perform?

•From your clinic exam what upper extremity condition do you believe is causing his elbow pain?

FUNCTIONAL OUTCOME MEASURES COPM, DASH, and Short Form-36

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CANADIAN OCCUPATIONAL PERFORMANCE MEASURE (COPM)•Completed as an interview with the occupational therapist.•Designed to develop individualized, client centered goals.•Focuses on personal care, functional mobility, community management, work, household management, and leisure.•The client rates his or her performance and satisfaction with their performance on a 1- to 10- scale.•Case-Smith J. Outcomes in hand rehabilitation using occupational therapy services. American Journal of Occupational Therapy, 57, 499-506. (2003)

DISABILITY OF THE ARM, SHOULDER, AND HAND (DASH)• Self-report outcome measure for clients with

upper limb musculoskeletal injuries.

• Generally used with adults.

• Contains 30 total items.

• Clients identify the level of difficulty they experience performing daily activities & the severity of symptoms on a level of 1- to 5-scale.

• Case-Smith J. Outcomes in hand rehabilitation using occupational therapy services. American Journal of Occupational Therapy, 57, 499-506. (2003)

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RAND 36-ITEM HEALTH SURVEY (SHORT FORM-36)

•Self-reporting quality of life survey with 36 items.

•Measures quality of life in 8 areas of health: Physical function, role limitations due to health problems, bodily pain, general health, vitality, social function, role limitations due to emotional health, and mental health.

•Scores on the survey vary from 1- to 3-scale range to a 1-to 5-scale range. •Case-Smith J. Outcomes in hand rehabilitation using occupational therapy services. American Journal of Occupational Therapy, 57, 499-506. (2003)

COMPARING THE COPM, DASH, AND SHORT FORM-36•Clients made “strong, positive gains” according to all of the outcomes measures when engaged in occupational therapy.

•Sensitivity to client changes:

COPM DASH Short Form-36

•Case-Smith J. Outcomes in hand rehabilitation using occupational therapy services. American Journal of Occupational Therapy, 57, 499-506. (2003)

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QUESTIONS AND CONTACT INFORMATION

Andrew Bracken, MOT, OTR/L, CHT

andrew.bracken@imail.org