Physical Dysfunction OT
Orthopedic, neurological conditions and rehabilitation interventions
Table of Contents
1. Orthopedic Conditions
Total Hip Arthroplasty (THA) Precautions
Posterior/Posterolateral Approach (Most Common)
Avoid movements that stress posterior capsule:
- No hip flexion > 90°
- No adduction past midline
- No internal rotation
Remember: "FAI" - Flexion, Adduction, Internal rotation
Anterior/Anterolateral Approach
Avoid movements that stress anterior capsule:
- No hip extension past neutral
- No external rotation
- No adduction past midline
THA Adaptive Equipment
- Raised toilet seat - maintains < 90° hip flexion
- Long-handled reacher - avoid bending
- Long-handled shoe horn - donning shoes
- Sock aid - donning socks without bending
- Hip kit - combination of above items
Total Knee Arthroplasty (TKA)
OT Considerations
- No specific movement precautions like THA
- Focus on ROM exercises (flexion and extension)
- Transfer training with weight-bearing status
- Lower extremity dressing techniques
- Energy conservation during ADLs
- Long-handled devices may help during recovery
Fracture Management
| Fracture Type | OT Considerations |
|---|---|
| Colles' fracture | Distal radius; "dinner fork" deformity; wrist extension/supination affected |
| Smith's fracture | Reverse Colles'; volar angulation |
| Scaphoid fracture | Snuffbox tenderness; risk of AVN; prolonged immobilization |
| Hip fracture | Follow weight-bearing precautions; similar to THA precautions |
Rheumatoid Arthritis (RA)
Joint Protection Principles
- Respect pain
- Balance rest and activity
- Reduce effort of tasks
- Avoid positions of deformity
- Use strongest/largest joints
- Avoid sustained grip
- Avoid ulnar drift forces
RA Hand Deformities
- Ulnar drift: MCPs deviate ulnarly
- Swan neck: PIP hyperextension, DIP flexion
- Boutonniere: PIP flexion, DIP hyperextension
- Z-thumb: MCP flexion, IP hyperextension
2. Neurological Rehabilitation
Stroke/CVA
Hemiplegia affects the contralateral side of the body from the lesion. Left CVA = Right hemiplegia; Right CVA = Left hemiplegia.
| Left Hemisphere (Right Hemi) | Right Hemisphere (Left Hemi) |
|---|---|
| Aphasia (language impairment) | Left neglect (unilateral neglect) |
| Right visual field cut | Left visual field cut |
| Apraxia | Impulsive, poor safety awareness |
| Slow, cautious behavior | Spatial/perceptual deficits |
| Difficulty with sequencing | Difficulty with facial recognition |
Brunnstrom Stages of Motor Recovery
| Stage | Characteristics |
|---|---|
| 1 | Flaccidity; no voluntary movement |
| 2 | Spasticity develops; synergy patterns begin |
| 3 | Spasticity peaks; voluntary synergies with no isolated movement |
| 4 | Spasticity decreases; some movement outside synergy |
| 5 | Further decline in spasticity; isolated movements |
| 6 | Spasticity minimal; near-normal coordination |
| 7 | Normal motor function restored |
Upper Extremity Synergy Patterns
Flexor Synergy
- Scapula: Retraction, elevation
- Shoulder: Abduction, external rotation
- Elbow: Flexion
- Forearm: Supination
- Wrist/Fingers: Flexion
Extensor Synergy
- Scapula: Protraction
- Shoulder: Adduction, internal rotation
- Elbow: Extension
- Forearm: Pronation
- Wrist/Fingers: Flexion
Parkinson's Disease
Cardinal Signs: TRAP
- Tremor - resting tremor ("pill rolling")
- Rigidity - cogwheel or lead-pipe
- Akinesia/Bradykinesia - slow/absent movement
- Postural instability - shuffling gait, festination
OT Interventions:
- External cues (visual, auditory) for movement initiation
- Large amplitude movements (LSVT BIG)
- Home safety and fall prevention
- Energy conservation
- Handwriting exercises (micrographia)
Traumatic Brain Injury (TBI)
Rancho Los Amigos Levels of Cognitive Functioning
| Level | Response | OT Focus |
|---|---|---|
| I | No response | Sensory stimulation, positioning |
| II | Generalized response | Sensory stimulation |
| III | Localized response | Purposeful sensory stimulation |
| IV | Confused-Agitated | Low stimulation, safety, structure |
| V | Confused-Inappropriate | Structure, simple ADLs, repetition |
| VI | Confused-Appropriate | ADLs, memory aids, structure |
| VII | Automatic-Appropriate | Community reintegration, IADLs |
| VIII | Purposeful-Appropriate | Vocational, independent living |
3. Hand Therapy
Peripheral Nerve Injuries
| Nerve | Motor Loss | Sensory Loss | Deformity |
|---|---|---|---|
| Median (High) | Thumb opposition, flexion; wrist flexion (radial) | Thumb, index, middle, radial ring (palmar) | "Hand of Benediction" when making fist |
| Median (Low/CTS) | Thenar atrophy, weak opposition | Same as above | "Ape hand" (thenar atrophy) |
| Ulnar (High) | Intrinsics (most), wrist flexion (ulnar) | Ulnar ring, small finger | "Claw hand" (ring/small) |
| Ulnar (Low) | Intrinsics (most) | Same as above | "Claw hand" (more severe than high) |
| Radial (High) | Wrist/finger extension, supination | Dorsal thumb web space | "Wrist drop" |
| Radial (PIN) | Finger/thumb extension (no wrist drop) | No sensory loss | "Finger drop" |
Ulnar Claw Paradox
In ulnar nerve injury, LOW lesions cause MORE severe clawing than high lesions. This is because with high lesions, the FDP to ring/small fingers is also denervated, so there's less flexion force at the DIPs.
Tendon Injuries
Flexor Tendon Zones
- Zone I: FDP insertion to FDS insertion
- Zone II: "No man's land" - A1 pulley to FDS insertion
- Zone III: Carpal tunnel to A1 pulley
- Zone IV: Carpal tunnel
- Zone V: Proximal to carpal tunnel
Flexor Tendon Protocols
- Duran: Passive flexion, active extension
- Kleinert: Rubber band traction, active extension
- Immobilization: 3-4 weeks (rarely used now)
- Early Active Motion: Place and hold
Common Hand Conditions
| Condition | Description | Treatment |
|---|---|---|
| Carpal Tunnel Syndrome | Median nerve compression; Phalen's, Tinel's positive | Wrist splint in neutral, nerve glides, ergonomics |
| De Quervain's | APL/EPB tendinitis; Finkelstein's positive | Thumb spica splint, activity modification |
| Trigger Finger | Stenosing tenosynovitis at A1 pulley | Splinting MCP in extension, tendon glides |
| Dupuytren's | Palmar fascia contracture; ring/small fingers | Post-surgery: extension splinting, ROM |
| Mallet Finger | Terminal extensor tendon rupture at DIP | DIP extension splint 6-8 weeks continuous |
4. Spinal Cord Injury
SCI Level Functional Expectations
| Level | Key Muscles | Functional Abilities |
|---|---|---|
| C1-C3 | None (ventilator dependent) | Mouth stick, sip and puff, eye gaze technology |
| C4 | Diaphragm, trapezius | Chin control power wheelchair; dependent ADLs |
| C5 | Biceps, deltoids | Feeding with setup, grooming with devices; power w/c with hand control |
| C6 | Wrist extensors (tenodesis) | Independent feeding, grooming, dressing upper; modified bathing; manual w/c |
| C7 | Triceps, finger extensors | Independent most ADLs; transfers; manual w/c; driving with hand controls |
| C8-T1 | Hand intrinsics | Independent ADLs; functional hand use |
| T2-T12 | Trunk muscles (progressive) | Independent ADLs, transfers; may ambulate with braces |
Tenodesis Grasp
Essential for C6 tetraplegia. When wrist extensors contract, fingers passively flex (grasp). When wrist relaxes, fingers extend (release).
- Preserve: Do NOT stretch finger flexors to preserve tenodesis
- Train: Wrist extension with objects
- Equipment: Universal cuff, tenodesis splint
ASIA Impairment Scale
A
Complete - No motor/sensory below level
B
Incomplete - Sensory but no motor below level
C
Incomplete - Motor < grade 3 below level
D
Incomplete - Motor ≥ grade 3 below level
E
Normal
SCI Complications
Autonomic Dysreflexia (T6 and above)
Medical emergency - BP can spike to dangerous levels
- Sit patient up (lower BP)
- Find and remove noxious stimulus
- Common triggers: full bladder, bowel, skin irritation
- Symptoms: headache, sweating above level, flushing
Other Complications
- Pressure injuries: Repositioning, weight shifts
- Orthostatic hypotension: Gradual position changes
- Heterotopic ossification: ROM, positioning
- Spasticity: Positioning, stretching
5. Cardiac & Pulmonary Rehabilitation
MET Levels for Activities
| MET Level | Activity Examples |
|---|---|
| 1-2 METs | Eating, desk work, sitting activities, washing hands/face |
| 2-3 METs | Level walking 2 mph, showering, dressing, light housework |
| 3-4 METs | Walking 3 mph, vacuuming, making beds, golf (cart) |
| 4-5 METs | Walking 4 mph, raking, sexual activity, heavy housework |
| 5-7 METs | Swimming, tennis, shoveling, climbing stairs |
| >7 METs | Running, competitive sports, heavy manual labor |
Cardiac Precautions & Vital Signs
Stop Activity If:
- Chest pain or discomfort
- Dizziness or lightheadedness
- Excessive fatigue
- Dyspnea at rest
- BP > 200/110 or drops >10 mmHg
- HR > target HR or doesn't rise with activity
- SpO2 < 90%
Sternal Precautions (Post-CABG)
- No lifting > 5-10 lbs (6-8 weeks)
- No pushing/pulling
- No overhead reaching
- Use log roll for bed mobility
- Hug pillow when coughing
- No driving 4-6 weeks
Energy Conservation Techniques
- Plan: Organize tasks, prioritize, schedule rest
- Pace: Work at moderate speed, take breaks
- Position: Sit when possible, use proper body mechanics
- Prioritize: Focus on essential tasks, delegate
6. ADL Training
Dressing Techniques
Hemiplegia Dressing Principles
- Donning: Affected side FIRST
- Doffing: Unaffected side FIRST
- Remember: "Dress the bad, undress the good"
One-Handed Techniques
- Button hooks, zipper pulls
- Elastic shoelaces
- Velcro closures
- Front-opening clothes
- Dressing stick
Transfer Training
| Transfer Type | Description | When to Use |
|---|---|---|
| Stand-pivot | Stand, turn, sit | Weight-bearing, can stand |
| Squat-pivot | Partial stand, turn | Limited weight-bearing |
| Sliding board | Slide across board | Can't stand; SCI, bilateral amputee |
| Two-person lift | Lift with two helpers | Dependent; temporary |
| Mechanical lift | Hoyer, sit-to-stand | Dependent; caregiver safety |
Hemiplegia ADL Considerations
- Transfers: Lead with stronger side toward target surface
- Wheelchair positioning: Brake on affected side; approach from unaffected
- Neglect: Position items in affected visual field; cueing
- Safety: Test water temperature with unaffected hand first
7. Adaptive Equipment
Equipment by Function
| Problem | Equipment Solutions |
|---|---|
| Limited grip/grasp | Built-up handles, universal cuff, rocker knife, plate guard |
| One-handed use | Rocker knife, dycem, suction brush, button hook, one-handed cutting board |
| Limited reach | Reacher, long-handled shoe horn, sock aid, dressing stick |
| Limited ROM | Long-handled sponge, extended handles, angled utensils |
| Incoordination | Weighted utensils, weighted wrist cuffs, non-slip materials |
| Low vision | High contrast items, talking devices, magnification, large print |
Wheelchair Positioning
Proper Fit Guidelines
- Seat width: 2 inches wider than widest point of hips/thighs
- Seat depth: 2-3 inches from popliteal fossa to seat edge
- Seat height: Footrests 2 inches from floor
- Armrest height: Shoulders relaxed, elbows at 90°
- Back height: Below scapula (manual); may be higher (power)
Splinting Basics
Common Splint Types
- Resting hand splint: Functional position; spasticity, burns
- Wrist cock-up: Wrist extension; CTS, wrist weakness
- Anti-spasticity: Fingers abducted; stroke, TBI
- Dynamic splints: Movement assistance or resistance
Functional Position of Hand
- Wrist: 20-30° extension
- MCPs: 45-70° flexion
- IPs: Slight flexion
- Thumb: Abduction and opposition
8. Physical Dysfunction Assessments
Functional Assessments
| Assessment | What It Measures |
|---|---|
| FIM (Functional Independence Measure) | 18 items; 7-point scale (1=total assist, 7=complete independence); motor and cognitive domains |
| Barthel Index | 10 ADL items; 0-100 scale; basic ADLs and mobility |
| Katz ADL Index | 6 basic ADLs; hierarchical scale A-G |
| Lawton IADL Scale | 8 IADLs; phone, shopping, food prep, housekeeping, laundry, transportation, meds, finances |
| AMPS (Assessment of Motor and Process Skills) | Standardized observation; motor and process skills during IADL tasks |
Motor/Hand Assessments
Manual Muscle Testing (MMT)
- 0 (Zero): No contraction
- 1 (Trace): Palpable contraction
- 2 (Poor): Full ROM gravity eliminated
- 3 (Fair): Full ROM against gravity
- 4 (Good): Full ROM against gravity + moderate resistance
- 5 (Normal): Full ROM against gravity + maximum resistance
Grip/Pinch Strength
- Dynamometer: Grip strength; 2nd handle position
- Pinch gauge: Lateral, 3-point, tip pinch
- Compare to norms; dominant typically 10% stronger
- Bell curve pattern if faking weakness
Neurological Assessments
| Assessment | Purpose |
|---|---|
| Fugl-Meyer | Stroke motor recovery; UE and LE subscales; based on Brunnstrom |
| Modified Ashworth Scale | Spasticity; 0-4 scale (0=no increase, 4=rigid) |
| Nine-Hole Peg Test | Fine motor dexterity; timed |
| Box and Block Test | Gross manual dexterity; blocks moved in 60 seconds |
| Jebsen-Taylor Hand Function | Hand function; 7 subtests simulating ADLs |
Key Takeaways for the Board Exam
- ✓THA posterior precautions: No flexion >90°, adduction, internal rotation (FAI)
- ✓C6 SCI: Tenodesis grasp; wrist extension causes finger flexion
- ✓Right CVA: Left neglect, impulsivity, spatial deficits
- ✓Brunnstrom Stage 3: Spasticity peaks; synergy patterns only
- ✓Rancho Level IV: Confused-agitated; low stimulation, safety focus
- ✓Ulnar claw paradox: Low lesion = more severe clawing
- ✓FIM scale: 1-7 (1=total assist, 7=complete independence)
- ✓Autonomic dysreflexia: T6 and above; sit up, find trigger
Physical Dysfunction Topics
Orthopedic ConditionsNeurological RehabilitationHand TherapySpinal Cord InjuryCardiac & PulmonaryADL TrainingAdaptive EquipmentAssessments
OT Study Notes
• Foundations & Theories• Pediatric OT• Physical Dysfunction• Psychosocial OT• Assessment & Documentation