Introduction
Patients with neurologic problems like peripheral nerve injury, stroke, multiple sclerosis (MS), traumatic brain injury (TBI), cerebral palsy (CP), and spinal cord injury (SCI), and benefit from upper extremity orthoses (Lansang Jr, 2006.)
Initially, proper evaluation and treatment planning is considered. After the rehabilitation team gathers all the data, it is possible to determine which kind of orthoses would be best suited for an individual (Lin & Cardenas, 2003). Along with the physical aspects like the neurological level of injury, ambulatory status, and the presence of pain, psychosocial issues are also important. In addition, questions related to occupational goals, etc also play a role in choosing the appropriate orthosis (Lin & Cardenas, 2003).
Main body
The functions of upper extremity orthoses are: to increase the range of motion, correct deformities, provide traction to correct or prevent contractures, enhance the function of the limb, serve as an attachment for assistive devices, and block unwanted joint movements (Lansang Jr, 2006.)
The occupational therapist must consider the following key points in the evaluation and treatment planning of the orthosis (Lin & Cardenas, 2003):
- After an objective physical evaluation, the therapist must observe the function of the hand and evaluate whether the tenodesis action is functional, how the person picks up objects and manipulates them, and whether the tenodesis action can be enhanced by splinting, etc.
- In order to assess the tetraplegic hand, some hand tests like the Jebson hand test, Sullerman hand function tests, etc are useful. The pinch and grip strength is also measured in case the finger and thumb muscles are present.
- Sensory tests of pain and light toughness and proprioception are also checked.
- It is common to choose orthoses for both upper limbs with static, positioning splints. Mobile arm supports are prescribed both unilaterally or bilaterally according to the pattern of upper limb weakness. An optimal function can be achieved by the patient by using one orthosis and using the other hand as an assist. The choice of a more permanent orthosis is made after various orthoses have been tried.
- In order to determine the initial orthotic selection, it is important to consider the type of orthoses, which are needed to prevent further deformity and complications, as well as which orthoses would optimize arm function for achieving the person’s occupational goals.
- An extension assist component may be present initially in the orthosis but as the wrist strengthens and as endurance improves, the extension component may not be required.
For a patient with neurological deficiency of the upper limb the orthoses, which may be useful include: clavicular and shoulder orthoses, functional arm orthoses, forearm-wrist-thumb orthoses, dynamic hand orthoses, and upper extremity orthoses with special functions (Lansang Jr, 2006.)
Orthotic fitting
The orthosis must be carefully evaluated to ensure proper fit and function because an improper fit will compromise function. Close communication between the therapist, orthopedist, and the patient is essential. All team members must provide feedback for best fit and use (Lin & Cardenas, 2003). Initially, the orthosis is placed for about 30 minutes; it is then removed and any red areas are noted and evaluated again 1 hour later.
Adjustments may be necessary in case the redness has persisted (Lin & Cardenas, 2003). In order to prevent excessive pressure and skin breakdown, the patient must be advised to inspect the skin regularly. Wearing tolerance is gradually increased till optimal tolerance is achieved (Lin & Cardenas, 2003)
The success of the orthotic management is ensured only if the patient participates and understands the program completely. The patient must be able to show a knowledge of the overall purpose of the orthosis, whether it is positional or functional (Lin & Cardenas, 2003). Although static orthoses require less training than dynamic/functional ones, they should not be neglected. It is important to ensure that the family members and attendants of the patient learn to apply the orthosis correctly and demonstrate the ability to adequately care for the orthosis, before the patient is discharged (Lin & Cardenas, 2003)
It will be helpful if the patient is made to watch a video or observe another patient using the device. In case of hand sensory impairment is present, the patient must learn to compensate with greater visual attentiveness (Lin & Cardenas, 2003.)
The patient has to practice grasping, placing, and releasing objects; it is ideal, to begin with soft, medium-sized objects. It may be helpful to play board games. After the patient has mastered basic manipulations, functional training can be started (Lin & Cardenas, 2003.)
In order to ensure that the patient achieves optimal independence, the patient must be able to put on and take off the orthosis without any assistance. The patient and attendants must have easy access to professional help, in case any problems arise. After discharge, it is important to schedule periodic follow-up visits for the maintenance of the orthoses and for re-evaluation of the patient’s goals and need for orthoses (Lin & Cardenas, 2003)
Peripheral nerve lesion and spinal root-lesion
In order to distinguish the sensory loss due to a root lesion from that due to a peripheral nerve, knowledge of the cutaneous distribution of the nerve roots (dermatomes) and peripheral nerves is helpful (Petty & Moore, 2001). In order to distinguish between motor loss due to a root lesion from that due to peripheral nerve lesion, knowledge of the muscular distribution of nerve roots (myotomes) and peripheral nerves enables is helpful (Petty & Moore, 2001)
In case the lesion occurs at the nerve root level, then all the muscles supplied by the nerve root (the myotube) will be affected, whereas if the lesion occurs in a peripheral nerve, then the muscles that it supplies will be affected (Petty & Moore, 2001.)
To examine the integrity of the peripheral nerves, 3 tests are done: skin sensation, muscle strength, and deep tendon reflexes. If a nerve root lesion is suspected, the tests carried out are referred to as dermatomal (area of skin supplied by one nerve root), myotomal (group of muscles supplied by one nerve root), and reflexive (Petty & Moore, 2001.)
Conclusion
Skin sensation is tested by monofilaments, cotton wool, etc. Pain sensation is tested by pinprick. Other tests include deep pressure, 2-point discrimination, vibration, hot/cold sensation, proprioception, and stereognosis. Muscle strength is tested by isometric contraction of a muscle group for few seconds. Deep tendon reflexes are tested by tapping the tendon (biceps, triceps, patellar, and tendocalcaneous) a number of times (Petty & Moore, 2001)
Reference
Lin, VW, Cardenas, DD (2003). Spinal Cord Medicine: Principles and Practice. Demos Medical Publishing, LLC.
Lansang Jr, RS (2006). Upper Limb Orthotics. Emedicine. Web.
Petty, NJ, Moore, AP (2001). Neuromusculoskeletal examination and assessment: a handbook for therapists. Elsevier Health Sciences.