Rehabilitation intervention for patients with upper extremity dysfunction: challenges of outcome evaluation

Upper extremity (UE) dysfunction attributed to overuse is an increasingly prevalent problem managed with interdisciplinary rehabilitation. Outcome evaluation of these programs is limited by a number of factors. First, patients with UE dysfunction include a wide variety of pathophysiologic processes and diagnoses that are associated with multiple secondary impairments, disabilities, and handicaps that limit personal performance. Second, the particular experience of disablement and expectations each person brings to the rehabilitation process necessitates an individualized program with unique goals. Successful outcome measurement of the rehabilitation process must take into account the achievement of individual goals as well as objective scalar quantification of impairments, disabilities, and handicaps that are comparable between groups. Understanding of the relationships between UE impairments and given functional outcomes will come from controlled, dosed treatment studies in "pure" diagnostic patient groups. Outcomes research applied to UE rehabilitation as it is currently practiced should include individually devised patient assessments of accomplishment and satisfaction in addition to long-term quantitative reassessment of the person under all domains of disablement and work performance.

[Unidimensionality of a functional measure for patient with an injured upper limb]

The construction of an instrument including a number of tests requires an analysis of its structure and its unidimensionality (which allows calculation of global score), and the determination of the difficulty level of various tests. This study examined a tool including 67 tests designed to evaluate the functional ability of patients with an injured upper limb. The patients seen in a rehabilitation centre during 12 months (173 subjects) were evaluated by the occupational therapists familiar with the tool. The statistical analyses were made using the principal component analysis method (PCAM), the Cronbach's coefficient and the Rasch model. The PCAM showed 3 principal factors which explained 44%, 10% and 4% of the total variance respectively in the case of patients with injured dominant limb. The predominance of the first axis and the high ratio of first by second eigenvalues suggested the unidimensionality of the tool. The Cronbach's value of 0.97 attested the good congruence of the items. The results obtained with the Rasch model seemed to be consistent with the hypothesis of the unidimensionality of the tool. This analysis also provided the difficulty scale of various tests. Similar results were obtained in patients with injured non dominant limb or with all the sample. The methods used provide complementary results.

Bilateral musculocutaneous nerve palsy. A case report

A case of bilateral, isolated, proximal musculocutaneous nerve palsy is reported. Initial physical and electromyographic examinations demonstrated complete denervation of the biceps brachii, brachialis, and coracobrachialis muscles bilaterally. Nerve conduction studies of the musculocutaneous nerves initially revealed no evoked potentials. The patient underwent resection with end-to-end anastomosis on the left and neurolysis without resection on the right. Significant functional recovery was noted bilaterally but was more rapid and complete on the side that underwent neurolysis without resection.

Computer-assisted evaluation of hand and arm function after thermal injury

Comprehensive care of the burned upper extremity requires accurate and complete evaluation of function, including two-point discrimination, active and passive range of motion, and grip strength. These evaluations, when performed serially during a course of therapy, are time-consuming and manpower-intensive. We tested the utility and accuracy of a commercially available computer-assisted impairment evaluation system when used to automate and standardize measurement of upper-extremity function. The function of 80 upper extremities was evaluated with both the conventional and the computer-assisted methods. The time required to perform a complete examination with each method was recorded, and measurements of grip strength and total active motion made with both methods were compared. Complete upper-extremity evaluation required an average of 20.3 minutes with the computer-assisted method, compared to 62.9 minutes with conventional means. Measurements of extremity function with computer-assisted and conventional methods had correlation coefficients of 0.984 for grip strength and 0.996 for total active motion. The computer-assisted impairment evaluation system was found to be a useful and accurate adjunct in the acute and rehabilitative management of burned upper extremities.

Occupational handicap in victims of limb injuries

The authors analysed 115 victims of limb injuries due to traffic accidents, to compare the medico-legal assessment by the rate of permanent disability (PD) with a tridimensional evaluation of the damage (lesion, function and situation), from a professional aspect. There was a high correlation between PD and lesional and functional sequelae. However, in professional situations only with those who were working full-time was there a high correlation with PD. PD gives only a lesional assessment. The authors propose a professional damage evaluation which considers the handicap of the individual in her/his ordinary work besides the lesion and function, as long as the assessment is personal and it is meant to reintegrate the victim completely in her/his professional life.

[The restoration of the sensitive function of the nerves in replanted upper extremities]

The investigation of both dynamics and peculiarities of restoration of sensitive functions of radial, ulnar and median nerves was performed in terms of dependence upon the time after trauma in 76 patients which underwent replantation of large upper limbs' segments associated with traumatic amputation. Some delay behind was revealed in restoration of ulnar nerve's sensitive function during the second and the third half-years after operation as compared with radial and median nerves' functions. These differences disappeared one and a half-two years after trauma. It is necessary to take this into consideration. In of rehabilitation on the patients either with new traumas or after replantation of large segments of upper limbs.

[Rehabilitation of war injuries associated with peripheral nerve lesions]

The objective of this study was to examine frequency, characteristics and results of hospital medical rehabilitation of war injured patients with peripheral nerve lesions. War injured patients with peripheral nerve lesions make 10.83% of all war injured hospitalized patients. The major etiologic factor in these injuries were firearms. Most injured aged 26 to 36 years of age, whereas men were injured more often than women. The injuries were primarily localized in the regions of axilla, upper leg and upper arm. In regard to upper extremities injuries most often occurred on the right side or bilaterally. Injuries of n. ischiadicus, combination of n. ulnaris and n. medianus occurred more frequently than injuries of other peripheral nerves. Electromyoneurographic and neurosurgical findings point to frequent partial-severe and complete nerve lesions. After hospital treatment lasting 4.6 months on the average, unsatisfactory functional reparation was found in most injured patients. This demands further control, continuous medical as well as social and professional rehabilitation.

Outcomes measurement of assistive technologies: an institutional case study

The assistive technology (AT) community has been challenged to effectively measure the outcomes of AT services. There has been much discussion recently in the literature about how to conceptualize and respond to this challenge. In this paper, we suggest that these objectives are best accomplished when AT services are understood within the contexts of the total rehabilitation of AT users and the institutional culture in which services are delivered. We provide examples of outcome priorities we have identified and the tools and approaches we have used. These include projects in the areas of clinical, functional, and psychosocial outcomes assessment of ATs.

Psychosocial consequences of upper limb injury

Upper limb surgeons have little in the way of training in the identification or management of the psychological aspects of limb injury. Surgeons in training tend to see their specialty in technical terms, only slowly appreciating that the psychological state of the patient profoundly affects outcome in many cases. The case report that follows charts the psychological progress of a patient following severe upper limb injury. Surgeons usually view rehabilitation in physical terms. This report emphasizes the psychological aspects of a major limb injury to a policeman (MP) who subsequently studied psychology at PhD level.

[Experience with physiotherapy in a posttraumatic neurodystrophic syndrome of the extremities]

Combined pathogenetic treatment including physiotherapy, drugs, massage, exercise was tested in 98 patients with posttraumatic neurodystrophic syndrome in phase II and III. The responses achieved made it possible to recommend the above regimen for wide application in rehabilitation centers and clinics.

The conservative management of the unstable shoulder including rehabilitation

The conservative management of shoulder instability depends on a well-defined program that emphasizes early diminution in the patient's symptoms, appropriate immobilization, and a well-defined precise rehabilitation program that can be individually tailored to meet the patient's needs. Immobilization should be considered in younger patients less than 20 years of age for between 3 to 4 weeks in order to enhance capsulolabral complex healing. Older patients may be immobilized for a shorter period of time. Analgesic medication and local physical therapeutic modalities may be used to decrease the patient's symptomatic complaints. Once the immobilization period has ended, a precise and specific rehabilitation program tailored for the individual needs of the patient should be undertaken. The rehabilitation program should emphasize early and safe regaining of normal ROM, strengthening of the dynamic stabilizers of the shoulder, and strengthening of the scapular stabilizing muscles of the shoulder. Finally, rehabilitation programs that enhance the patient's neuromuscular control over the glenohumeral joint should be considered in the conservative management of the unstable shoulder.

Functional soft-tissue coverage in skeletonizing injuries of the upper extremity using the ipsilateral latissimus dorsi myocutaneous flap

The concept of early "functional" soft-tissue coverage is demonstrated in three cases of severe skeletonizing avulsion/contusion injuries of the upper extremity, including the replantation of a "frozen" arm. According to the MESS score, all extremities would have been allocated to the amputation group. Therapeutic strategy consisted of primary repair of all neurovascular structures, serial debridements, and early definitive coverage with simultaneous restoration of the elbow flexor or extensor muscles. Flap survival was 100 percent in all patients, and the muscle strength achieved after vigorous physical therapy was rated M3 to M5. One patient was even able to return to competitive tennis.

[The use of physical factors in the combined treatment of traumatic damages to the nerve trunks of the extremities]

Traumatic impairment of peripheral nerves in the limbs requires multimodality treatment including physiotherapy, chemotherapy, orthopedic methods, massage, manual therapy. The above complex produced responses in the majority of patients treated.

Functional rehabilitation for the upper and lower extremity

Functional rehabilitation is an extension of the traditional elements of physical therapy, the purpose of which is to return the athlete to highly complex movement patterns such as athletics. As well as the traditional elements of physical therapy such as strength and flexibility, the functional rehabilitation program incorporates agility and proprioceptive/kinesthetic training, which enables the athlete to participate at preinjury levels of activity while reducing the risk of recurrent injury. The functional rehabilitation program is designed to progress the athlete from simple activities, such as walking or jogging, to highly complex sport-specific activities that require refined levels of proprioceptive acuity. The final phase of the functional rehabilitation program is determining when the athlete is ready to resume participation in their respective sport. This is a very important and sometimes overlooked component of the functional rehabilitation program. The decision for returning an athlete to participation should be made using objective assessments of function that simulate sport activity whenever possible. Last, return to sport activity should be done gradually. Progression into the sport activity is essential to a full and healthy return to participation.

Reinjury prevention follow-through for clients with cumulative trauma disorders

OBJECTIVES

Fifteen subjects with upper extremity work-related cumulative trauma disorders were involved in a quality improvement study to determine their self-reported degree of follow-through with reinjury prevention regimens. The effect of cuing was also studied.

METHOD

During occupational therapy, subjects were involved in an educational session that focused on recommendations in ergonomic equipment, therapeutic maintenance techniques, body mechanics, and work simplification techniques. Follow-through with reinjury prevention education was evaluated and rated via telephone interviews approximately 2 weeks (T1) and 4 weeks (T2) after the educational session. Subjects did not know the questions they would be asked at T1, but were cued that their progress would be checked again at T2. Dependent t tests were conducted to compare the mean number of recommendations for which complete follow-through was expected with the mean number of recommendations at T1 and T2 that were implemented completely.

RESULTS

A significantly lower degree was found of absolute completion of recommendations at T1 and T2 than had been anticipated (p < .002). No significant difference between T1 and T2 was found, indicating that cuing at T1 had little effect on subjects' actual follow-through rate.

CONCLUSION

The implications of these findings for occupational therapists support the need for further research in reinjury prevention and employer education.

Occupational cumulative trauma disorders of the upper extremity

The umbrella term cumulative trauma disorders (CTDs) (also known as repetitive strain injuries, overuse syndromes, and repetitive motion disorders) covers a number of similar conditions arising from overuse of the joints or soft tissues of the upper extremity. Occupational CTDs have become a common problem in the workplace. These disorders are costly to the employer, the worker, and society in terms of time lost from work and resulting disability. Within the past decade, occupational therapists and physical therapists specializing in rehabilitation of work-related musculoskeletal injuries have seen an increase in the incidence of CTDs of the upper extremity in the workplace. Therapists are called upon not just to treat these injured workers, but also to help them regain a functional level for work reentry and to educate them to prevent reinjury. This article reviews the literature on the epidemiology, etiology, pathophysiology, and management of upper-extremity occupational CTDs. Because the ultimate goal of the workplace is to maintain the health and safety of the employee, an educational approach to hand, wrist, elbow, and shoulder use is essential to prevent, decrease, or eliminate the risk of occupational CTDs of the upper extremity.

Injury in ballet: a review of relevant topics for the physical therapist

Currently, there is a need for a review of the literature on ballet injury as it pertains to the physical therapist. Relatively few articles have reviewed ballet injury prevalence and mechanisms of injury. The purpose of this paper was to provide a thorough literature review of the prevalence of ballet injury and mechanisms of injury. Environmental factors and footwear relating to ballet injury were also reviewed. The literature indicated that 65-80% of ballet injuries are in the lower extremity, 10-17% occur in the vertebral column, and most of the remaining percentage are upper limb injuries (5-15%). The etiology of common lower limb conditions included an incorrect turnout; soft tissue imbalances; reduced quadriceps performance; "rolling in of the foot;" inversion sprains; and frequent pliés, pointé, and demipointé work. Spinal conditions were reported to result from hyperextension and hyperlordosis of the lumbar spine as well as the psoas insufficiency syndrome. It was revealed that inappropriately fitting footwear lead to various foot conditions and abnormal lower kinetic chain biomechanics. Environmental factors, such as the dance surface, also have implications in ballet injury. The author concluded that ballet injuries have a multifactorial etiology that primarily involves the interplay of compensatory biomechanics in the spine and lower extremity, environmental factors, and footwear. In addition, some clinical recommendations have been made regarding the physical therapy management of ballet injuries.

Evaluation of topical therapeutic ultrasound to improve response to physical therapy and lessen scar contracture after burn injury

This study compared results of patients who received standard burn physical therapy and topical ultrasound with patients who received standard care alone to investigate the effect of topical therapeutic ultrasound on range of motion and pain in patients with burns. Fourteen burned extremities were studied. Eight joints were randomized to treatment with ultrasound followed by 10 minutes of passive stretching. Six joints received placebo ultrasound treatments and stretching. All treatments were performed every other day throughout a 2-week study period. Joint range of motion was measured before and after each treatment, and patients estimated the pain of the procedure. Patients and therapists were blinded to the treatment group. Analysis of the data revealed no differences in range of motion or perceived pain between the two groups. The effect of ultrasound on range of motion and pain was not predictable. We conclude that patients are not likely to improve from ultrasound treatment at our protocol parameters.

Sports medicine. 2. Upper extremity injuries

This self-directed learning module highlights recent advances in this topic area. It is part of the chapter on sports medicine in the Self-Directed Medical Knowledge Program for practitioners and trainees in physical medicine and rehabilitation. In this article, shoulder and elbow problems of the throwing athlete are emphasized. Common injuries involving the wrist and hand are also covered.

Multidisciplinary rehabilitation of chronic work-related upper extremity disorders. Long-term effects

The prevalence of work-related upper extremity disorders has significantly increased in the past decade. Persistent pain, loss of function, and associated work disability in patients with work-related upper extremity disorders appears to be affected by multiple factors including physical capabilities in relation to work demands, ergonomic risk factors on the job, and psychological factors related to worker traits, psychological readiness to return to work, and ability to manage symptoms. The complex nature of these disorders suggests the utility of a multidisciplinary program targeted at these factors. The present study is an investigation of the long-term vocational outcome of a multicomponent rehabilitation program that includes physical conditioning, work conditioning, work-related pain and stress management, ergonomic consultation, and vocational counseling/placement. Two groups equivalent on measures of duration of work disability, pain severity, fear of reinjury, psychological distress, perceived work environment, age, and education level were exposed to either the comprehensive work rehabilitation intervention (n = 19) or usual care (n = 15). Return-to-work status was determined at an average of 17 months posttreatment (range, 3 to 35 months) for the treatment group and an average of 18 months postevaluation (range, 5 to 30 months) for the usual care group. Findings indicated that 74% of the treatment group returned to work or were involved in state-supported vocational training in contrast to 40% of the control group (P < .05). For those who returned to work, 91% of the treatment group were working full-time in contrast to 50% of the control group (P < .05). Although the treatment group demonstrated a higher return-to-work rate than controls, the work reentry rate was not as high as similar approaches with work-related low back pain (80% to 88% return-to-work rate). These findings suggest the need to modify treatment components to facilitate an increased return-to-work rate. Areas that may prove useful include a greater emphasis ergonomic modifications at the workplace to reduce the risks of repetitiveness, force, awkward posture, and insufficient work/rest cycles, as well as efforts to modify work style directly in order to reduce the impact of ergonomic stressors on the ability to perform essential job tasks. In combination with traditional work hardening efforts directed at improving strength and flexibility of the upper extremities and work-related pain and stress management training, these ergonomic and work-style modification efforts may contribute to increases in the percentage of work disabled cases who successfully return to competitive work.

A dentist's experience with change of hand dominance

Ten years ago as a young dentist, the author found himself completely unable to engage in his practice as a result of a serious nerve injury permanently affecting his dominant right hand and forearm. Some unique opportunities and chance encounters have enabled him to overcome the permanence of the injury and to advance into a dental specialty field considered very demanding bimanually. Chronicled below are the process by which this occurred and, in particular, the author's assessment of what led to the necessary change of hand dominance. Also described is an interesting process that was required by the admissions committee of the postgraduate specialty training program as part of their assessment of the author's ability to adequately perform clinical procedures prior to his admission into the program. Descriptions of certain office design changes as well as changes in instrumentarium and techniques and the inventions to support those changes are described.

Upper extremity disorders in performing artists

Studies in the past decade have shown that a significant proportion of instrumentalists report musculoskeletal problems severely affecting their musical performance. Musicians endure daily intensive use of their upper extremities, frequently placing them in bizarre positions. Their training schedules are rigorous and long term Predisposing factors to, and treatment for, overuse syndromes, tendinitis, and tendon trauma commonly encountered by musical performers are discussed at length. Nerve entrapment has also surfaced as a major problem in musicians, and the means of evaluation and treatment and the role of surgery are put forth. Techniques for studying and analyzing the difficulties faced by instrumentalists are summarized.

Applied ergonomics: adaptive equipment and instrument modification for musicians

Failure or difficulty in treating musicians' overuse injuries is often due to overlooking aggravating roles of activities of daily living. Numerous devices are available for people with limited or painful hand function to protect joints and minimize stress of daily activities. The occupational therapist can evaluate the patient and determine which adaptations are appropriate. Instruments may be modified to render them more ergonomic and less likely to cause injuries; this is especially true for wind instruments. Biomechanically and ergonomically correct seating can minimize back and neck strain. Orthotics, such as modified chin and shoulder rests for the violin, may minimize the stress and strain of holding an instrument. Just as there is a drive to make buildings and public transportation barrier-free to the physically disabled, musical instruments can be made barrier-free with adaptations like terminal devices for upper extremity prostheses. Principles of industrial and occupational medicine, especially regarding ergonomics and adaptive equipment, can be applied to the musical patient for treatment and prevention of injuries.

The treatment of overuse injury syndrome

The emphasis on performance injury has shifted from epidemiology to prevention. Rest treatment, modified or radical, followed by rehabilitation, remains the cornerstone of treatment. The basic features, details of management, and side effects of these treatment phases are discussed at length, followed by a detailed description of the author's experience with 176 musicians seen for overuse injury syndrome. Forty-one patients were not prescribed rest treatment, refused rest treatment, or quit rest treatment early; 45 patients were prescribed a modified rest treatment program, of whom 87% were cured of symptoms; and 90 patients were prescribed radical rest treatment, with a final success rate of 87% also.