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Joe is currently a client receiving treatment at a hand therapy clinic, due to a traumatic injury to his left hand. Carpentry work has been Joe’s profession for many years. He suffered a debilitating injury to flexor tendons of the 2nd and 3rd metacarpals, fracturing the first metacarpal bone, severing the 4th finger and all innervation to the fingers. The flexor tendons are repaired, the first metacarpal bone has healed and the open wound in the palm of his hand has finally closed. Joe has severe disability to the left hand and is limited in function of all occupational areas. He has an extreme amount of stiffness, pain and weakness due to the tendon repair. This results in a limited active and passive range of motion in his wrist and fingers.
Goniometric assessment was chosen for Joe due to the weakness of the muscles and loss of innervation to the hand. A comprehensive evaluation of joint range of motion is appropriate to improve functional abilities of his hand. Due to the extreme amount of stiffness in the left hand, goniometric assessment will enable the therapist to assessment will enable the therapist to assess dysfunction and start a rehabilitative program. Measurements of Joe’s wrist and proximal interphalangeal finger joints were taken to provide new information on how the appropriate intervention activities were progressing him to a more functional range of motion. This was an appropriate evaluation tool because it provided information on how progression was made at each joint to alleviate stiffness and pain in Joe’s left hand. The passive range of motion measurements provided information on how much Joe has improved since the beginning of treatment.
Special tests and evaluation procedures that would be appropriate for this patient would be to test for a positive Tinel sign and testing opposition or pinching. The special test of Tinel sign would be performed to assess and determine the innervation that is returning back to the fingers. The therapist can tap over the volar surface of the wrist and proximal phalanges to show a positive sign of tingling over the fingers. The positive sign would show the return of innervation to the area. Joe had a positive Tinel sign over the proximal phalanges. Another evaluation procedure is testing opposition and pinching. Opposition of the thumb to the index finger is a recent range of motion returning to Joe’s left hand. This shows the reduced amount of stiffness in the finger flexors and the return of some functional mobility of the joints.
The process of evaluating Joe began by reviewing records to get an idea of his current symptoms and functional abilities. Palpation was used to locate specific bony landmarks in his wrist. There was some deformity of his wrist due to the trauma but the specific landmarks were located with some effort. Joe was very cooperative and willing to allow me to perform goniometric measurements on his wrist and hand. There were no problems with communication or positioning. Through this clinical assignment I learned that there is no magic cookbook in the way if positioning the patient. All bony landmarks must be in alignment and the fulcrum must be in the proper position. As long as these standards are followed, the patient can be positioned in a way that is most comfortable and what works best for the therapist. As students this is a great experience due to the fact that we have a limited amount of time while learning how to perform the measurements and must stick to the textbook. There were not any required adaptations to standard procedures. While administering this assessment, many additional facts were learned about the patient. Through verbal interaction I learned that Joe had a pure love and interest for carpentry throughout his life. There is an interest to return to productive activities and possibly work but this will not be a potential option due to the traumatic injury. Receiving occupational therapy on a weakly basis has enabled Joe to return doing things around the house. He can clean and rake leaves in the back yard. I learned through discussion with Joe, that suffering with a hand injury makes the hand hypersensitive. His hand has become hypersensitive to the cold weather and proper education is a necessity to protect the hand from any inclement weather. Through Joe’s occupational therapy, he has been able to improve the stiffness and dysfunction in his hand.
This has allowed him to perform more of the important activities of daily living. This clinic experience allowed me to evaluate a patient as opposed to another student. It was very different evaluating a patient rather than another student. Joe has significant limitations in his hand and wrist range of motion. Evaluating another student would not allow a dysfunction to this extent to be evaluated. Performing measurements on a student can not give the experience of working with someone you have not met before. Patients will have impairments that may be irreversible and permanent. These are situations that can not be seen in the classroom or learned in a textbook and provide a tremendous amount of learning.
Relevant occupational goals are to first increase the range of motion and to allow more activities of daily living to be performed with ease. Increase fine and gross motor control over fingers and hand. Reducing stiffness in the hand is very important as is increasing muscle strength. These are all functional abilities needed to perform occupational and recreational activities. Limitations that Joe has in his joint range of motion is going to limit many areas of his activities of daily living. Dressing is extremely difficult. Buttoning his shirt, putting a belt on and tying his shoes are all very difficult tasks. Due to these limitations suggestions were made to purchase clothing that is easier to put on and take off without any one being home. Most activities of daily living are difficult due to the amount of fine motor control and dexterity that is needed. Joe also has trouble with caring for his skin, nails and flossing his teeth. All of these activities require the use of both hands and a lot of fine motor control. Joe also has problems with these activities due to the loss of innervation. Without any innervation to his fingers fine motor control activities are increasingly difficult. Functional communication is difficult such as using the telephone, typing and using a computer will challenge Joe’s emerging abilities. Although these activities are not essential for Joes independence they would enable him more control over his life.
Joe has a lot of support at home to help him with occupational roles and performance areas. Joe will be receiving a tremendous amount of occupational therapy and in the end he will have more control and balance over his life. This clinical assignment allowed me to learn about and perform range of motion measurements on a patient as opposed to a student. Learning how to perform passive range of motion measurement is a fundamental component in evaluating the functioning of joints on a patient. This clinic visit allowed me to use my knowledge and apply it in a meaningful manner.
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