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Notes on Hand Functions_Punita V. Solanki

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Notes on Hand Functions_Punita V. Solanki

  1. 1. Disclaimer The occupational therapy undergraduate notes have been prepared by Ms. Punita V. Solanki (Ex- Assistant Professor, Occupational Therapy School and Centre, Seth G. S. Medical College and King Edward VII Memorial Hospital, during her teaching tenure) as per the Maharashtra University of Health Sciences University curriculum requirements, between the years 2001 and 2012 and the references of the textbooks have been listed at the beginning or the end of each topics. Occupational therapy students are directed to refer the latest editions of the listed references or additional references to upgrade the latest information for the concerned topics and keep up-to-date with the latest evidence-based practice literature. However, these notes will be useful guide for preparing updated notes as per the latest syllabus requirements set by the concerned university. For further information may contact Ms. Punita V. Solanki. MSc (OT); Fellow ACOT, ADCR (Mumbai) ֍ www.orthorehab.in
  2. 2. Ms. Punita V. Solanki. Assistant Professor (Occupational Therapy). Notes for First BOTH. October 2009 Revised Syllabus: Fundamentals of Occupational Therapy - II: Theory: Course Content: No: 7: Hand Function and Evaluation Methods: a) Functional Anatomy of Hand. b) Prehension and Grasp Patterns. c) Grip and Pinch Strength. d) Functional Evaluation of Hand. e) Oedema Assessment. References 1) Occupational Therapy for Physical Dysfunction – Catherine A. Trombly. 4th Edition 1997 Chapter 6: Evaluation of Biomechanical and Physiological Aspects of Motor Performance. Page No’s: 106- 107, 150-152. 2) Occupational Therapy for Physical Dysfunction - Catherine A. Trombly, Mary Vining Radomski. 5th Edition 2002 Chapter 4: Assessing Abilities and Capacities: Range of Motion, Strength and Endurance. Page No’s: 81-82, 128-130 & Chapter 42: Hand Impairments. Page No’s: 931-937. 3) Occupational Therapy: Practice Skills for Physical Dysfunction – Lorraine Williams Pedretti, Mary Beth Early. 5th Edition 2001 Chapter 31: Orthotics. Page No’s: 531-540 & Chapter 44: Hand and Upper Extremity Injuries. Page No’s: 841-843. 4) Willard and Spackman’s Occupational Therapy – Helen L. Hopkins & Helen D. Smith. 8th Edition 1993 Chapter 18: Functional Restoration: Section 4: Hand Rehabilitation. Page No’s: 678-684. 5) Joint Structure and Function: A Comprehensive Analysis – Cynthia C. Norkin, Pamela K. Levangie. 2nd Edition 1998 Chapter 9: Wrist and Hand Complex. Page No’s: 290-296. Functional Anatomy of Wrist and Hand Wrist Complex (Radiocarpal Joint Structure) is formed by the radius and radio-ulnar disk proximally and by the scaphoid, lunate and triquetrum distally. Wrist complex is a biaxial joint with 2 degrees of freedom of motion. The hand consists of 5 digits; or 4 fingers and a thumb. Each digit has a carpometacarpal (CMC) joint and a metacarpophalangeal (MCP) joint. The fingers each have two interphalangeal (IP) while the thumb has only one. There are 19 bones distal to the carpals and 19 joints that make up the hand complex. While there are structural similarities between the joints of the fingers and the joints of the thumb, function differs significantly enough that the fingers shall be examined separately from the thumb. The functional position of the wrist and hand is: 1) Wrist complex in slight extension (20°) and slight ulnar deviation (10°).
  3. 3. Ms. Punita V. Solanki. Assistant Professor (Occupational Therapy). Notes for First BOTH. October 2009 2) Fingers moderately flexed at the MCP joints (45°), slightly flexed at the PIP joints (30°) and slightly flexed at the DIP joints and thumb in opposition. The wrist position optimizes the power of the finger flexors so that hand closure or all hand functions can be accomplished with the least possible effort. Prehension and Grasp Patterns Prehension: is defined as a position of the hand that allows finger and thumb contact and facilitates manipulation of objects. These are of three types: a) Lateral Prehension (Pad to Lateral Pinch). b) Palmar Prehension (Pad to Pad Pinch or Palmar Pinch or Three Jaw Chuck). c) Tip Prehension (Tip to Tip Pinch). a) Lateral Prehension (Pad to Lateral Pinch): In lateral prehension the pad of the thumb is positioned to contact the radial side of either the middle or distal phalanx of the index finger. Most commonly this pattern of prehension is used in holding an eating utensil and holding and turning a key. b) Palmar Prehension (Pad to Pad Pinch or Palmar Pinch or Three Jaw Chuck): In Palmar prehension the thumb is positioned in opposition to the index and long fingers. The important component of motion in this pattern is thumb rotation, which allows for pad to pad opposition. This prehension pattern is used in lifting objects from a flat surface such as paper, in holding small objects as pen, beads, small grains etc and in tying a shoe lace or a bow. c) Tip Prehension (Tip to Tip Pinch): In tip prehension the IP joint of the thumb and the DIP and PIP joints of the finger are flexed to facilitate tip to tip prehension. These motions are necessary to pick up a pin or a coin. Once a pin is in the hand, tip prehension will be converted to palmar prehension to provide more skin surface area to retain a small object. Grasp: is defined as a position of the hand that facilitates contact of an object against the palm and the palmar surface of the partially flexed digits and the thumb is involved in all types of grasps except that of hook grasp. These are of following types: a) Cylindrical grasp. b) Spherical grasp. c) Hook grasp. d) Intrinsic plus grasp.
  4. 4. Ms. Punita V. Solanki. Assistant Professor (Occupational Therapy). Notes for First BOTH. October 2009 a) Cylindrical grasp: Cylindrical grasp the most common static grasp pattern is used to stabilize objects against the palm and the fingers, with the thumb acting as an opposing force. This pattern is assumed for grasping a hammer, pot handle, drinking glass or the handhold on a walker or a crutch. b) Spherical grasp: Also called ball grasp, this pattern is assumed for holding a round object such as a ball or apple. It differs from cylindrical grasp primarily in the positioning of the fourth and fifth digits. In spherical grasp the two ulnar digits are supported in greater extension to allow a more open hand posture whereas in cylindrical grasp the two ulnar metacarpals are held in greater flexion. c) Hook grasp: Hook grasp is the only prehension pattern that does not include the thumb to supply opposition. The MCP joints are held in extension and the DIP and PIP joints are held in flexion of all the four digits. This is the attitude the hand assumes when holding the handle of a shopping bag, a pail or a briefcase. d) Intrinsic plus grasp: Intrinsic plus grasp is characterized by the positioning of all the MCP joints of the fingers in flexion, the DIP and PIP joints in full extension and the thumb in opposition to the third and fourth fingers. This pattern is used in grasping and holding large flat objects such as books, folders, files or plates etc. Grip and Pinch Strength: The standard methods of measurement are recommended by the American Society of Hand Therapists (ASHT) 1981. The subject should be seated with his shoulder adducted and neutrally rotated, elbow flexed at 90°, the forearm in neutral position and the wrist in 0° to 30° extension and between 0° to 15° of ulnar deviation. The hip and knees when seated should be at 90° of flexion with feet flat on the ground. Three trials are taken of each hand with a 2-3 minute rest between trials and the score is the average of the three trials. Grip strength assessments are done by a) Jamar Dynamometer (Set at the second position from all of 5 positions as per ASHT): It is a reliable, valid and an accurate method of grip strength assessment. b) Vigorometer: is an acceptable alternative hand strength measuring device which is commercially available for patients whose diagnoses contraindicate stress on joints and or skin. c) Adapted Sphygmomanometer: is an alternative method of grip strength measurement used for rheumatoid arthritis patients. d) The power grip attachment of the Baltimore Therapeutic Equipment Work Simulator.
  5. 5. Ms. Punita V. Solanki. Assistant Professor (Occupational Therapy). Notes for First BOTH. October 2009 Pinch Strength (All 3 types): is tested using a pinch gauge or a pinch meter. The pinch gauge made by B and L Engineering has been found to be the most accurate. As with the grip dynamometer, three successive trials should be obtained and compared bilaterally. These instruments are calibrated and set at 0 to start. The readings are noted in kilograms or pounds. Functional Evaluation of Hand Hand evaluation includes general physical examination of hand for pain, tenderness, wounds, scars etc, assessment of range of motion, manual muscle strength testing, oedema assessment, grip and pinch strength measurement, sensibility, dexterity and hand function. Sensibility: The Semmes Weinstein monofilaments are used to assess pressure threshold. The two point discriminator is used to assess density of receptors for two point discrimination. Dellon’s modification of Moberg Pickup test is a functional hand function test for assessment of sensations. Dexterity and Hand Function Tests a) Jebson Taylor Hand Function test. b) Purdue Pegboard test. c) Minnesota Rate of Manipulation test (MRMT). d) Crawford’s Small Parts Dexterity test. e) Box and Block test. f) Nine Hole Peg test. g) O’Connor’s Dexterity test. Oedema Assessment: Oedema is an abnormal accumulation of interstitial fluid beneath the skin, or in one or more cavities of the body. Hand volume is measured to assess the presence of extracellular or intracellular edema. Methods of assessment of oedema are: 1) Volumetric measures by Volumeter. 2) Circumferential measures by circumference tape or jeweller’s ring size standards or an external calliper. Volumeter: Volumetric measures document changes in the mass of a body part by use of water displacement. It is most often used to measure hand oedema. The voltmeter has been shown to be accurate to 10 ml, when used in a prescribed manner. It consists of a water vessel with a spill over spout near the top of the water level and a graduated beaker.
  6. 6. Ms. Punita V. Solanki. Assistant Professor (Occupational Therapy). Notes for First BOTH. October 2009 The evaluation is performed as follows: 1) A plastic voltmeter is filled and allowed to empty into a large beaker until the water reaches the spout level. The beaker is then emptied and dried thoroughly. 2) The patient is instructed to immerse the hand in the plastic voltmeter, being careful to keep the hand in the mid position. 3) The hand is lowered until it rests gently between the middle and ring fingers on the dowel rod. It is important that the hand not press onto the rod. 4) The hand remains still until no more water drips into the beaker. 5) The water is poured into a graduated cylinder or a beaker. The cylinder or a beaker is placed on a level surface and a reading is made in millilitres. An oedematous hand displaces more water than an unswollen hand so that a lower reading is considered an improvement. Sitting or standing significantly affects the scores of volumetric measurement so it is important to standardize the administration procedure. Circumferential measures by circumference tape or jeweller’s ring size standards or an external calliper: is a method of assessing oedema of an individual finger or a joint. Circumferential measurement is quick to perform and provides a good alternative when it is not possible to use a voltmeter. Be consistent with measuring tape, placement and tension. An external calliper is an alternative method of assessing smaller diameter areas. Again consistent instrument placement and tension are important for maintaining accuracy.

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