Hands:

OBHT:
 Focus on the person and the impact of the diagnosis on their life
• Client-centered
• Participatory in nature
• Focuses on contextualizing the injury
• Use of both ‘typical treatment’ as well as
occupations & activities
• Objective & subjective measures that focus on
occupation e.g. DASH/
• Satisfaction is derived from improved ability to
perform daily activities

Outcome Measures
• DASH
• COPM
• Psychosocial yellow flags: • FFQ
• CIEQ-C & CIEQ-C • PHQ-9

Initial observations
• Colour changes
• Wounds (open/closed) • Scars
• Atrophy
• Contractures
• Deformities
• Nail
• Dryness/skin integrity
• Palpate
• Observe natural movements
Questions to Guide Intervention
• What are the client’s circumstances and individual needs, and how may they affect
intervention?
• What is the cause and nature of the diagnosis? [consider the anatomy and
physiology related to the diagnosis]
• At which stage of tissue healing is the client?
 What are the implications of the diagnosis on occupational areas and body
structures and functions?
 Which of these problems could be addressed with occupational therapy?
 What OT intervention should be provided at different stages of healing?
 Which treatment modality/approach will best solve these problems? What is
the evidence base for these modalities/approaches?
 What could the long-term and short-term goals be for this client?
Therapeutic Techniques
• Occupation-based intervention
 Client engages in client-directed occupations that match identified goals’
•Purposeful activity
 Client engages in specially selected activities in order to develop skills that
enhance occupational engagement
• Preparatory methods
 Methods and techniques that prepare the client for occupational
performance

Conceptual considerations in Clinical Reasoning

1. Tissue healing
2. Positioning to counteract deforming forces
3. Identifying which structures are restricted
4. Preventing and controlling pain

• 0-6 days
• Vascular & cellular response (removal or microorganisms, foreign
material & necrotic tissue) • Vasodilation & increased blood flow to the
area
• Mobilisation of epithelial cells across the defect
• IMMOBILISATION/REST

• 5-36 days
• Migratory fibroplats enter wound & begin synthesizing scar tissue •
Debris removed by leucocytes
• Fibroblasts migrate in with fibrin strands
• Capillaries begin regrowth & granulation tissue formed
• MOBILISATION (light loads applied)

• 4 weeks – 2 years
•Fibroplastic phase: dense, randomly orientated collagen fibres
•Scare maturation: collagen fibre assumes a more organized pattern
•May take place over a number of years: change in
size/shape/colour/texture/strength •Continuous collagen production &
breakdown
•Breakdown>synthesis = less bulky, softer scar
•Vascularity restored
•MOBILIZATION (prolonged stretch; higher load)

Positioning
 Used to counteract deforming forces
 Oedema management
  Maintain full PROM
 Maximise function (e.g. splints should only include joints as needed)

Identifying restricted structures

• Not enough to identify a general problem, e.g. decreased ROM
• Must understand & treat the structures causing the restriction • Intrinsic vs extrinsic tightness
• Joint end-feel
• Muscular vs. tendon/ligament vs. bone
• Pain/self-limited movement

The 3 Common Culprits of Stiffness

◦ IMMOBILIZATION
◦ Limited movement in multiple joints causes tissue changes ◦ Tissue layers to adhere to one
another and shorten

◦ OEDEMA
◦ Lack of motion = diminished pumping ability of lymphatic system

◦ Chronic oedema becomes fibrotic and causes tissue adherence ◦ CHANGE IN CORTICAL
MOVEMENT PATTERN

◦ Motor cortex in brain hold patterns for movement

◦ If there is no movement, this area of the brain goes ”dark/dull”
◦ Adhesions make normal patterns of motion impossible
◦ Leads to long term repetition of awkward, ineffectual movements ◦ This becomes dominant
patterns in motor cortex

o Collagen fibres provide tensile strength of tissue

o Collagen fibres are inelastic
o The movement between them provides

tissue elasticity

o Immobilization = lack of normal stress on tissues - no gliding

o Leads to crosslinks forming between tissue planes

o Joint tightness: structures shorten if joint not moved through full range

o Muscle-tendon tightness: fibres shorten when not moved through full

range (intrinsic vs extrinsic)

o Skin tightness: scar

Mild oedema is necessary for healing - brings necessary inflammatory cells
Unresolved oedema
◦ Fluid becomes like a thick honey like substance known as pitting oedema
◦ Delays healing, results in pain, stiffness and loss of function
The longer it stays - the more chance the tissue becomes fibrotic

o Fluid finds space – dorsum, joint capsules and then stretches these tissue
spaces
o Pulls MCPs in to extension

◦ Treatment techniques for oedema

◦ Active motion for pumping ◦ Elevation
◦ Compression
◦ Contrast baths

Reduce Oedema: Active Motion

◦ Lymphatic system = no pump = muscles and gravity form pump

◦ 3 different pumping systems in hand – all activated by making a fist

◦ Doing this above the heart uses gravity to assist drainage

◦ Anti-oedema drills:

◦ Reach arm up to ceiling and spread fingers open wide ◦ Bring down to body
while squeezing a tight fist
◦ 20 times every hour

◦ Light cardio exercise assists with circulation

◦ Deep breathing – diaphragm movement assists with circulation and pumping

Elevation:

1. ◦ Pillows or pillow cases attached to a drip stand ◦ Consider patient’s

environment and give advice
2. Excessive elevation should be avoided, don’t keep elbow in flexed position
3. Prehension activities with hand in elevation – lightly resistive exercises in
elevation – sponge

Cortical Remapping Treatment

◦ Maintain cortical map as much as possible throughout immobilization

◦ Visualization of movement ◦ Mirror therapy

◦ Bilateral movements
◦ Use splints/PoP to reverse learned patterns of movement

◦ Eg immobilize MCPs to encourage bending through IPJs

Aims of Treatment

 Restore functional motion, strength and sensibility ◦ Control formation and remodelling
of scar tissue
 Reduce oedema
 Mobilize
 Re-educate normal movement pattern:
 ◦ Identify predominant dysfunctional movement pattern
 ◦ Selectively immobilizes proximal joints in a desired position while constraining distal
joint to move in a productive direction and range

 What can you expect when there is a peripheral

nerve injury

 Pain

 Reduced sensation or hypersensitivity

 Weak or absent movement

 Recovery can take up to a year (depending on level of

injury etc)
Mallet injury – extensor tendon rupture (vs avulsion which has bony involvement)

 Rupture of the terminal tendon from distal phalynx

 Caused by force onto tip of finger where PIPJ remains in extension
 Presents with an extensor lag at the DIPJ

True mallet:
• Tendinous – no bony involvement

 Healing time longer

 8 weeks full time splinting
 

Splinting
6-8 weeks full time splinting in HYPEREXTENSION
Once extension maintained
• Graded AROM exercises and strengthening
Treatment of Mallet injuries
Education Education Education
Immobilization of DIP to allow tendon to attach and strengthen
• Splinting: different options
• Full time: if DIP flexes – start at beginning
Maintaining unaffected joint ROM
• Full PIPJ and MCP extension and flexion in splint
Maintain skin integrity
• Skin sweats and macerates – keep dry
Address occupational needs
• Discuss activity modification to allow participation/engagement
Treatment of Mallet injuries: other
Oedema
• Compression
• Pressure garment finger sock, cohesive bandaging
• Ice
• Active movement of unaffected fingers
Wounds
• Check dressings, pressure on wound, breathable, oozing
Pain
Mallet Case study
• Oedema:
• Coban cohesive wrapping for compressions
• Splinting:
• Bivalve mallet splint issued (bivalve dipj immoblilisation)
• ROM:
• AROMs of MCP + PIPJ three times daily
• Education re: • Skin care
• Hygiene
• Precautions
• Splinting protocol

Full time splinting 8 weeks After 8 weeks:

 Splint weaning:

• Out of splint 4x daily for active DIPJ ROM exs

• Progress to on only for high risk activities and sleep

  Regain full AROM in DIPJ

• Always focus on active full extension – if lag returns keep splinting

• Graded improvement of DIPJ flexion

 Improve grip strength and hand function

 Resume/integration into daily activities

If untreated, could become swan neck deformity

Tendinous mallet injuries should be splinted in slight hyperextension to

promote tendon healing and no lengthening of the tendon

Mechanical Principles for splinting (Cullinan, 2008):

 Increase the areas of force application to disperse pressure

 Increase the mechanical advantage to reduce pressure and increase comfort

 Ensure three points of pressure

113

 Add strength through contouring perpendicular traction for dynamic or static

progressive splinting

 Acceptably pressure for dynamic splinting

 High versus low-profile outriggers.

AHS 3107W Written Hands Question

Question Answer
Mrs KB is a 49 year old lady from Khayelitsha. She was mugged and assaulted on her
way to work. She sustained a stab to her right dominant volar wrist resulting in a
complete ulnar nerve injury as well as a laceration to her left palm resulting in an injury
of the tendons to her index finger (FDS and FDP). She is a wife, mother and grandmother
and works as a domestic worker for a family in Constantia. Both of her injuries were
repaired on the day of the injury and she is referred to you 3 days after surgery.
1. The surgeon refers the patient to you to 1. Eliminate tension on healing
splint post-surgery (he prefers to use structures / protect repair (1) and
thermoplastic splints rather than plaster of maintain joint ROM/prevent joint
 stiffness through safe immobilization
paris). (1)
2. Left: Dorsal forearm-based blocking
1. What would the goal of splinting be splint (1/2) with forearm in neutral
for the left and right hand? (2) (1/2) wrist in 0 -30 flexion (1/2),
2. Describe the type of splints that MCPJ at 70 flexion (1/2) and IPJs fully
you would make for each hand extended (1/2), thumb excluded
during the acute phase, specifying from splint (1/2)
the exact degrees of the forearm,
wrist, MCPJs and IPJs as well as the Right: Dorsal forearm splint (1/2)
position of the thumb. (6) with forearm in neutral (1/2), wrist in
approximately 30 flexion (1/2), MCPs
8 free/90 flexion (1/2), IPJs free/full
extension (1/2), thumb free (1/2)
2. What is the main goal of rehabilitation
of her flexor tendon injury? Please make Maximize tendon glide (1) while protecting
your answer specific to her tendon injury. repair (1)
2
Decrease Oedema – Elevation and active
2. Describe 5 specific performance movement
component goals of your rehabilitation Prevent Joint Stiffness / Loss of ROM –
with this patient and describe one Splinting, active movement through
modality that you would use to achieve engaging in activities
each goal (mention each modality only
once)? Optimize sensory recovery – mirror
therapy/GMI, traditional sensory retraining
5x2= 10 Muscle strengthening – use of activity as a
means, home programme
Improve grasps / hand function – assistive
equipment, home programme, activity as
means etc
Promote Psychological well-being –
counseling, referral to social worker etc
Should mention the following areas with
clear examples for each:
3. Discuss how her injury will impact her • Work
occupational performance giving specific
examples to illustrate.  Leisure
 ADLs
5  iADLs, e.g. shopping
 Other, e.g. caring for grandchildren
Question 2

Hands
Edwin is a 25-year-old man who was involved in a motor vehicle accident a month ago.
The accident resulted in a C5 and C6 brachial plexus traction injury to Edwin’s non-
dominant arm. He has started getting sensory and motor recovery and has the following
muscle strength:

Muscle group Oxford Scale Grade

Shoulder (all movements) 3
Elbow flexors (*therefore ant.) 2
Elbow extensors, forearm, wrist and
4+
hand

Edwin lives with his parents and younger brother. He works as a teller in a bank and
enjoys playing cricket and soccer in his leisure time

1. 2.1.  Describe the performance component deficits you would expect to identify
during your assessment of Edwin. (6)
2. 2.2.  Name and discuss your splinting recommendations for Edwin. In your
answer, ensure you cover the following:
 Type of splint
 Purpose of the splint you recommend
 Reason for your choice of splint (3)
3. 2.3.  Discuss how the injury is likely to impact Edwin’s occupational performance
areas. (8)
4. 2.4.  Briefly discuss the priority short-term goals for intervention for the next 3
months. In your answer include your approach to intervention and examples of
modalities that could be used.

(8)

Total: 25 marks

1. Question 2

Memorandum

1. Oedema unlikely to be present at this stage

May have some loss of ROM in shoulder, elbow (flexion) and possibly pronation
and supination (depending on whether he received PT or OT from the outset)
Decreased muscle strength as outlined in the question
Absence / impaired sensation in C5, C6 dermatomes
Hand function, e.g. decreased grip strength – precision and power grip
Posture may be affected due to loss of muscle strength
 Emotional/psychological response
Pain (6)

2. Type: Dynamic elbow flexion splint

Purpose: assist elbow extension against gravity
Reason: to enable him to use his non-dominant arm in bilateral activities (3)

1. Work- difficulty with bilateral activities, e.g. reaching for objects needed during his
work, counting out money, weighing coins
Leisure – gripping cricket bat , bowling may be awkward/challenging; soccer –
difficulty handling the ball, could damage arm if plays too early Self-
maintenance – ADLs (e.g. shaving, eating) and iADLs (e.g. driving)

2. Goals:
Related to remediation, e.g. improve muscle strength Optimize sensory
recovery – mirror therapy/graded motor imagery, traditional sensory
retraining

Related to prevention, e.g. prevent injury due to sensory loss; prevent joint
stiffness / loss of ROM through splinting and active movement (engaging in
purposeful and meaningful activities)
Related to promotion, e.g. promote engagement in previous occupations
through liaising with employer to see if he can be accommodated to return to
work even if half day; promote psychological well-being through counselling
and referral if necessary

Related to adaptation, e.g. adapted methods of performing ADLs/iADLs

Specific components:

 ROM

 Muscle Strength

 Sensation

 Skin integrity

 Pain

 Oedema
  Hand function
How to assess and mx these in orig lecture ppt

CASE STUDY 2:

Xolani is a 35-year-old male who lives in Langa and works as a machine

operator in a shoe factory. He was stabbed whilst walking home and his right
(dominant hand) median nerve was lacerated at the wrist level. The nerve was
repaired on the same day and he has been receiving occupational- and
physiotherapy and sees the doctor at the Groote Schuur Hospital Hand Clinic for
regular check-ups. He is now 6 months post nerve repair and has protective
sensation in his fingertips.
What is the Sensory problem?
Sensation in his dominant hand is impaired and this impacts on his ability to perform his
everyday activities resulting in frustration, etc.
What approach (technique/s) would you take to this problem?
Sensory re-education is a method that helps the client to re-interpret the altered profile of
neural impulses reaching his conscious level. The client re-teaches himself by
interacting with the environment under guidance of the therapist. Sensory re-education is
started when protective sensation is present, i.e. impaired but not absent sensation. The
client must be able to learn the techniques, motivated and able to carry out a structured
programme daily. This technique is appropriate for nerve injuries, replantations, toe to
thumb transfers, skin grafts and CVA’s.
Goal:

To re-educate sensation by assisting the client to learn the meaning of the "new"
sensation (in relation to old sensory memories) in order to carry out his daily occupations
effectively.
List the Give some examples How would you grade your
principles you of activities that intervention?
would use to could be used to
achieve this goal: achieve the goal.  ▪size:large→smallobjects
 ▪weight:heavy→lightobjects
1. (a)  focus  ▪identificatio  ▪texture:coarse→finetextures
attention on n of different  ▪complexity:simple→complexsha
residual shapes, pes,
sensory
cues textures, objects and tasks
temperatures,
Early phase weights, e.g.  ▪numberofstimuli:one→many
education:
moving Velcro shapes stimuli/objects
touch;
localisation  ▪identificatio  ▪temperaturedifferences:large→s
of constant n of everyday mall
touch/pressu objects placed
 re; late
phase
education
(when
moving
touch and within hand
constant
touch can be  ▪picking up
localised): objects from
tactile background
gnosis,
object medium of
manipulation sand, gravel,
differences in temperature
pebbles, shells,
2. (b)  heighten
 ▪coordination:gross→finecoordina
sensory stryrofoam –
tion
awareness don’t use food:
and rice/pasta
attention
through  ▪textured
sensory dowel sticks /
input, i.e. fabrics –
tactile
stimulation/ matching same
temperature/ textures
propriocepti
on
(resistance,
weights,

GENERAL INTERVENTION PRINCIPLES: SENSATION Page 2 of 7

traction).  ▪games and tasks

(c) apply the sensory puzzles
stimulus with occluded  ▪letter  ▪objects with greater
identification – differences in size,
vision, then repeat stimulus sandpaper, velcro,
with vision and verbalisation, shape & texture→those
and then without vision for 3-D cut outs with more
maximal integration of
learning.  ▪braille designs subtle differences
and finger mazes
4. (d)  sessions should  ▪grab bag  ▪therapeutic support:
be brief (10-15 mins) (identifying maximal
yet frequent common objects)
(repeated 3-4 times  ▪sorting different therapeutic support to
daily) as intense objects into
concentration is

needed for maximal  ▪texture sorting
learning
 ▪functional
5. (e)  learning
principles, i.e. active
attention to task,
verbalisation, visual
feedback, memory,
repetition
6. (f)  active involvement
of the client (utilise
client’s positive
attitude, persistence
and motivation for
recovery of function)
7. (g)  use of the hand in
functional activity to
maintain and
increase gains made  ▪simulation of
in the retraining
programme
8. (h)  environment must
be distraction-free to  ▪making of an
allow for optimal
concentration
independence
different  ▪training in
localisation→discrimina
compartments tion
(tactile gnosis)
activities, e.g. tying  ▪specific isolated
activity using vision
shoelaces, doing →
buttons; writing;
using tools; pottery; activity without constant
collage; baking, etc vision
- especially those
requiring
 ▪increase
manipulation of
opportunities for use of
objects without
hand
vision – link to his
work as a machine
in functional activities
operator
 ▪compensating with
activities linked to other senses →
his work as a
machine operator total reliance on tactile
sensation
item; working with
leather so that  ▪3-dimensional→2-
client can feel dimensional
texture on hand,  ▪place object in
including weight etc client’s hand initially
→

search for named

object among others
What precautions should be taken into account?
▪Frustration as a result of activities that are too challenging for client’s level of sensory
recovery ▪Decreased motivation/boredom
▪Injury – rough surfaces/instruments, pressure sores, burns, etc.

Sensory re-education needs to be continued for a long time – either until the client
returns to using the hand functionally or until recovery reaches a plateau.

CASE STUDY 3:

Mrs Abrahams had a carpal tunnel release 8 weeks ago. On seeing the doctor
for follow up, it is noted that the wound has healed well but Mrs Abrahams
 reports that the scar is very sensitive, and she cannot tolerate it being touched
by anything. Being a housewife, she is having great difficulty performing her
everyday activities as a result of the sensitive scar and tends to avoid using this
hand whenever possible. The scar extends from about 3cm proximal to the wrist
crease to 1.5cm distal to the wrist crease on the palmar aspect.
Problem:

Mrs A has hypersensitivity, a condition of extreme discomfort or irritability in response to

a usually non-noxious stimulus. This is affecting her function. This is also common in
other injuries/conditions such as frostbite, burns, nerve trauma and traumatic crush
injuries.

GENERAL INTERVENTION PRINCIPLES: SENSATION Page 3 of 7

Approach/technique and rationale:

Desensitisation – this is based on the belief that progressive stimulation will allow progressive tolerance. It goal is to
teach the person to filter out unpleasant sensations to permit accurate perception of sensory input.
Goal of intervention:

To reduce hypersensitivity so that Mrs Abrahams is able to perform her everyday activities (thereby preventing disability
through non- use of the hand).
Principles: Activities: Grading:

1. (a)  lubricatingandmassagingthe  ▪as for reduced  ▪texture:softtextures→hard→roug

sensitive areas – in one direction only, sensation but grading
not circular movements is slightly different,
2. (b)  usingrepetitive,gradedtactile e.g. search for objects
(texture and force of application) hidden in sand
stimulation to desensitise →gravel→smooth
3. (c)  compensating initially, e.g. pebbles→shells
protective splint, pad over sensitive  ▪taping of the area
area with a dowel stick or
4. (d)  shortfrequentsessions,i.e.10mins; sensation stick with
3-4 times daily different textures at
5. (e)  desensitisationprogrammecarried end in a rhythmical
out by the client under the direction manner regularly
and supervision from the therapist to  ▪washing of dishes
reduce the anticipation of pain in lukewarm water,
searching for cutlery
and crockery in bucket
or sink
 ▪best to make use
of activities that
encourage use of the
sensitive part of the
hand, e.g. washing
h textures
 ▪force of application: increase
force of application, i.e.
touch→rub→tap→prolonged
contact
 ▪resistance of tools: increase
resistance of tools
 ▪duration of stimuli: increase
duration of stimuli
 ▪increase weight-bearing
 ▪specific isolated
exercises/activities to
functional activities
 ▪decrease wearing time of
protective devices.
 ▪introduce progressively irritating
stimuli.
 dishes, washing
clothes by hand,
kneading dough,
hair washing, etc;
within Mrs A daily
routines

Problem:

The hypersensitivity persists.

Approach/technique and rationale:
Client needs to learn to compensate for permanent hypersensitivity so that she is still able to engage in and derive
meaning through her occupations. Protective devices may need to be fitted on a permanent basis, such as a splint or
pressure therapy; altering the method of engaging in activity and adapting the environment accordingly
Goal:

To compensate for permanent hypersensitivity so that Mrs Abrahams is able to engage in her daily activities or
otherwise, select other activities that are meaningful to her.

GENERAL INTERVENTION PRINCIPLES: SENSATION Page 4 of 7

Principles: Precautions:

(a) use work simplification methods ▪exposure to sun

(b) build up tolerance
(c) use padding to protect or cushion sensitive
areas (d) change positions regularly
(e) mobilising of limb as much as possible
(f) prevention of injury/pressure sores/pain
▪aggravating the skin in any way
▪be aware of skin breakdown or
blistering ▪repetition and friction
▪wound breakdown (e.g. burns)
▪do not exceed level of tolerance