Chapter 14: Dupuytren’s Disease

Chapter 14: Dupuytren’s Disease

I’m tackling another common upper extremity condition today – Dupuytren’s Disease.

What is Dupuytren’s Disease?

Dupuytren’s is a condition in which the palmar fascia of the hand progressively tightens (Coppard, 2020). Fascia is connective tissue that sits right under the skin. Fascia holds nerves, muscles, and tendons in place. When this tightens, the finger(s) are pulled into a flexed position (pulled in towards the palm).

Risk factors for Dupuytren’s include genetics, diabetes, alcoholism, trauma, & epilepsy (Coppard, 2020). Unfortunately, due to the genetic predisposition of Dupuytren’s, there is a chance the disease will eventually return after surgery.

What does Dupuytren’s Disease “look like”?

Typically, Dupuytren’s affects the ulnar side of the hand (the pinky side); therefore, the pinky and ring fingers are commonly pulled into a flexion contracture (Coppard, 2020). A contracture is a fixed position of a joint(s). In this case, the pinky & rings fingers are unable to extend or straighten. They are essentially “stuck” in a flexed position.

Along with the flexion contracture, nodules often appear at the distal palmar crease (Coppard, 2020). Imagine nodules as permanent tiny little bumps. The distal palmar crease (DPC) can be located by trying to practice palm reading. The DPC is “highest” most crease before reaching the base of the fingers. If you begin to flex your fingers down, this is the first crease you see wrinkled. The nodules may not be painful at first but can most definitely impact the ability to perform daily tasks.

The severity of the contracture will influence the type of treatment provided. Severe contractures (>30 degrees of flexion) often warrant the need for a surgical procedure (Coppard, 2020). Contractures <30 degrees of flexion are typically treated with conservative treatment (Coppard, 2020).

How do OTs help individuals with Dupuytren’s Disease?*

Humans use their hands for basically every task of the day. Next time you pick up your phone to talk to text, try keeping your pinky & ring fingers flexed into your palm. Not so easy, right? Or try typing on your computer using only your thumb, pointer, and middle fingers. Dressing would become more difficult. Reaching into the pocket of your jeans for your wallet or keys may become troublesome. OTs consider all these tasks (and more) when working with an individual with Dupuytren’s. How can we adapt activities in a way to promote independence and successful engagement?

Certified hand therapists (OTR/L, CHT) may frequently work with individuals with Dupuytren’s, especially post-surgery; however, there is a chance that OTs outside of the hand therapy environment may work with an individual with Dupuytren’s.

Conservative treatment may include soft tissue manipulation using Graston (a “knife”-like tool) and functional adaptations (Coppard, 2020). Soft tissue manipulation is completed in hopes of “loosening” the soft tissue that is pulling the fingers into flexion. Functional adaptations are recommended to promote engagement in occupation and to slow the tightening of the fascia over time.

Non-conservative treatment involves surgery. There are multiple surgeries that could be performed. The surgical procedure would depend on the surgeon’s preference, the disease’s severity, and the disease’s location. OTs would be highly involved in the post-surgical process by fabricating an orthosis and recommending exercises to help with healing, educating individuals on tendon glides, and providing treatment for scar management for optimal scar healing (Coppard, 2020). As mentioned previously, there is a high likelihood that Dupuytren’s could return even after surgery; therefore, it is important to optimize healing and educate individuals on ways to slow the progression of Dupuytren’s occurring again.

I hope you learned something from today’s post! Stay tuned for more!

*Note: These examples of OT involvement are strictly my own. Information on this post was provided through the reference referred to below.

Reference: 

Coppard, B.M. (2020). Hand immobilization orthoses. In B.M. Coppard & H.L. Lohman (Eds.), Introduction to orthotics: A clinical reasoning and problem solving approach (5th ed., pp. 187-212). St. Louis, MO: Elsevier.

 

Chapter 13: Carpal Tunnel Syndrome

Chapter 13: Carpal Tunnel Syndrome

Moving right along to carpal tunnel syndrome! Most people can say they’ve heard of carpal tunnel somehow at one point in their lives. I’m here to explain the anatomy, the causes, and the ways that OTs can help an individual with carpal tunnel.

What is carpal tunnel syndrome?

Carpal tunnel syndrome (CTS) is an upper extremity disorder caused by compression to the median nerve (Walsh & Chee, 2018). The median nerve provides sensory information along the volar aspect (palm side) of the thumb, pointer, and middle fingers, in addition to the medial aspect of the ring finger. The median nerve runs through the carpal tunnel along with multiple tendons that are responsible for flexing the fingers.

CTS is caused when the median nerve becomes compressed due to swelling or a smaller carpal tunnel (Walsh & Chee, 2018). Repetitive or sustained activities in which the wrist is flexed, extended, or ulnar deviated (positioned toward the pinky side of the hand) for long periods of time may cause the compression. Activities or work that involves repetitive forceful gripping or pinching may also cause compression. Lastly, prolonged exposure to vibration, cold, or constriction over the wrists could contribute to the existence of CTS. Pregnancy, rheumatoid arthritis, and congestive heart failure may also be contributing conditions to CTS as increased inflammation exists throughout the body (Walsh & Chee, 2018).

What does carpal tunnel syndrome “look like”?

Individuals with CTS will often report pain/tingling upon waking at night within the median nerve distribution (volar aspect of thumb, pointer, and middle fingers, medial aspect of the ring finger) (Walsh & Chee, 2018). An individual may also report that they frequently drop items. Pain/tingly during repetitive activities that require wrist flexion, extension, or ulnar deviation may also be a sign of CTS.

There are two tests to quickly assess for CTS. Tinel’s test involves tapping along the pathway of the median nerve. If paresthesia (tingling) is felt during the test, there is a possibility that CTS is present. Phalen’s test involves placing the dorsum (top) of both hands together in an upside downish position (very scientific description right?) so that the fingers are pointing towards the floor. The wrists should be flexed in this position. The individual stays in this position for up to 60 seconds. The individual is asked to report if/when tingling is felt within that time frame. If paresthesia (tingling) is felt during the test, there is a possibility that CTS is present.

How do OTs help individuals with CTS?*

There are a few ways that OTs can help individuals with carpal tunnel. Depending on its severity and potential interference with successful completion of daily tasks, an orthosis could be fabricated to help position the wrist in a less stressful way. Nerve glides could be taught to the individual which is a way of giving the nerve space to move. Education regarding safe and stress-free positioning would also be emphasized to relieve symptoms.

If conservative treatment is ineffective, a carpal tunnel release could be performed by a surgeon. The OT would then have a significant role post-surgery to ensure optimal scar healing and to prevent further or repetitive complications. If the release was done in the right wrist, it would be highly beneficial for the individual to learn ways to prevent carpal tunnel from occurring in the left wrist.

I hope you learned something from today’s post! Stay tuned for more!

*Note: These examples of OT involvement are strictly my own. Information on this post was provided through the reference referred to below.

Reference: 

Walsh J.M. & Chee, N. (2018). Hand and upper extremity injuries. In H. Pendleton & W. Schultz-Krohn (Eds.), Pedretti’s occupational therapy practice skills for physical dysfunction (8th ed., pp. 972-1003). St. Louis, MO: Elsevier.

Chapter 12: Multiple Sclerosis

Chapter 12: Multiple Sclerosis

Today I am reviewing multiple sclerosis (MS)!

What is multiple sclerosis (MS)?

MS is a degenerative disease involving nerves within the central nervous system (CNS). The CNS is composed of the spinal cord and the brain, both of which are essential structures that communicate and facilitate sensory and movement information throughout the body. Myelin sheath within the CNS becomes impaired and lesions (plaques) exist, causing a disruption in messages being sent throughout the body. MS is most commonly diagnosed between the ages of 20-40 years old (Schultz-Krohn, Foti, & Glogoski, 2018). MS involves periods of exacerbations (periods of time in which symptoms are present) and remissions (periods of time in which symptoms are not present).

There are four types of MS which include the following:

  • Relapsing-remitting (85% of those diagnosed with MS): This type of MS involves periods of exacerbations and remissions with symptoms disappearing after each exacerbation or the appearance of residual deficits occurring after each exacerbation (Schultz-Krohn, Foti, & Glogoski, 2018).
  • Primary progressive (10%): This type of MS involves a steady progression of deficits after each exacerbation resulting in progressive deficits as the course of MS lengthens (Schultz-Krohn, Foti, & Glogoski, 2018).
  • Secondary progressive: This type of MS initially begins as relapsing-remitting MS but progresses with fewer remissions, resulting in decreased independence and more deficits (Schultz-Krohn, Foti, & Glogoski, 2018).
  • Progressive relapsing (5%): This type of MS involves steady declines from the beginning but deficits do not occur as quickly as with primary progressive (Schultz-Krohn, Foti, & Glogoski, 2018).

Honestly, it has been difficult for me to wrap my brain around each type and their differences; however, I think if you take the time to understand and interpret the name of each type, it will become clearer which is which.

What does MS “look like”?

MS presents itself differently in each individually. The most common symptoms include fatigue, numbness/weakness in 1+ limbs typically on one side of the body, vision problems, bowel/bladder dysfunction, and cognitive deficits (like a “fog”) (Schultz-Krohn, Foti, & Glogoski, 2018). Individuals may also experience motor disturbances including tremors, decreased coordination, unsteady gait (causing balance concerns!), dizziness, slurred speech, and sexual impotence (Schultz-Krohn, Foti, & Glogoski, 2018).

Individuals diagnosed with MS are cautioned to avoid extremely hot temperatures (Schultz-Krohn, Foti, & Glogoski, 2018). During exacerbations, individuals with MS should rest as much as possible. Vision may fluctuate; therefore, it is important one’s meaningful occupations are adapted or flexible when needed. Cognitive changes may also occur, including deficits in short-term memory, attention, and orientation (Schultz-Krohn, Foti, & Glogoski, 2018). In continuation, individuals may experience difficulty with fine motor skills related to sensory loss which could impact one’s ability to complete daily tasks.

How do OTs help individuals with MS?

OTs can work with individuals with MS during periods of exacerbations and remissions. During exacerbations, in which the individual may be on bed rest, OTs can utilize passive range of motion to prevent loss of joint mobility, modify activities to minimize exertion, and provide education to family members to promote optimal care.

During remissions, OTs can help an individual return to their prior level of function through physical conditioning (when appropriate), providing adaptive equipment, and educating an individual on energy conservation and fatigue management. Such recommendations may include establishing a sleep routine, encouraging healthy diet choices, and stress management techniques.

Energy conservation is also important as fatigue is often one of the most influential barriers to independence and quality of life. The checkbook analogy explained in “Chapter 11: Osteoarthritis & Rheumatoid Arthritis” would be applicable for individuals with MS. Likewise, strategies for energy conservation could expand into other occupations such as bathing/dressing, meal preparation, shopping, and leisure activities. These general recommendations may include:

  • Prioritizing what needs to be done throughout the day. Can some items on the to-do list wait until tomorrow or later in the week? Balance that checkbook!
  • Planning what needs to be done strategically. Plan for periods of activity versus periods of rest throughout the day.
  • Sit to work when possible. Sit while cutting veggies for dinner or while doing dishes. Use a riding mower instead of push mower when cutting the grass. Sit to dress or shower (tub bunch required).
  • Use appliances. A dishwasher saves you energy from scrubbing dishes. A dryer saves you energy from hanging clothes on the clothes line. An electric can opener saves you energy from using a typical twisty can opener. Use them when possible!
  • Plan your shopping trips. Make a list. Try to visualize the store to avoid walking down aisles multiple times. If fatigue is too limiting of a factor, try Instacart in which a personal shopper will do all the shopping for you and deliver to your home!

If vision and cognition are impacted, remedial or rehabilitative strategies would be recommended by an OT. Magnifiers or audiobooks could be recommended to ensure participation in meaningful activities. Phone reminders for important appointments or events could be implemented to compensate for memory deficits. Cognition apps, such as Lumosity, could be recommended for daily cognitive activities.

Fine motor skills and sensory functions are often impacted; therefore, an OT can make recommendations for adaptive equipment or alternate strategies to promote independence. This may include use of built-up handles for kitchen and writing utensils. To promote independent medication management, if an individual has difficulty feeling the small pill within their fingers or knowing if they dropped it or not, the weekly medication box could be positioned on top of a baking sheet. Therefore, if the pill is accidentally dropped, the sound of the pill hitting the baking sheet would alert the individual that it had been dropped. Changing the environment in which medications are taken through this simple change could make a significant difference in prescription compliance.

Referrals to support groups for both the individual and one’s family member(s) may also be beneficial. This is a nice way of connecting individuals to support, educate, and inspire each other!

There are countless other ways that OTs can help individuals with MS improve their quality of life and independence. This is merely a brief overview of the OT-MS relationship. I hope you’ve been informed through this post and I hope to educate myself and you more in upcoming posts!

*Note: These examples of OT involvement are strictly my own. Information on this post was provided through the reference referred to below.

Reference: 

Schultz-Pendleton, W., Foti, D., & Glogoski, C. (2018). Degenerative diseases of the central nervous system. In H. Pendleton & W. Schultz-Krohn (Eds.), Pedretti’s occupational therapy practice skills for physical dysfunction (8th ed., pp. 871-903). St. Louis, MO: Elsevier.

Chapter 11: Osteoarthritis & Rheumatoid Arthritis

Chapter 11: Osteoarthritis & Rheumatoid Arthritis

Welcome to my 2nd educational post. Today we’ll tackle arthritis!

What is arthritis?

Arthritis means “joint inflammation” (Deshaies, 2018). There are two types of arthritis that I will review today: osteoarthritis (OA) and rheumatoid arthritis (RA).

What is osteoarthritis (OA)?

OA is a joint condition in which the cartilage between joints wears away, causing stiffness and pain (Deshaies, 2018). As the cartilage wears away, the bones within the joint begin to rub together.  This causes inflammation (swelling) and crepitus (noise of bones crunching or popping). Unlike rheumatoid arthritis (explained later), OA typically attacks individual joints such as a joint within the fingers (distal and proximal interphalangeal joints), knees, and hips.

What does OA “look like”?

OA presents with multiple symptoms including joint pain, stiffness, tenderness, limited range of motion (movement), inflammation, and crepitus (Deshaies, 2018). The symptoms typically present themselves after activity and will subside with rest or at night. An individual with OA may also experience morning stiffness or stiffness after prolonged sedentary activity (this is called “gelling”).

Nodules may also appear on either or both of the last two joints of the finger (distal interphalangeal (DIP) or proximal interphalangeal (PIP) joints). Nodules that appear at the DIP joint are called Herberden’s nodules. Nodules that appear at the PIP joint are called Bouchard’s nodules. A mnemonic to remember which is which is listed below:

HD = high definition = Herberden’s DIP

BP = blood pressure = Bouchard’s PIP

What is rheumatoid arthritis (RA)?

RA is a chronic, systemic inflammatory autoimmune condition (Deshaies, 2018). Let’s break that down. “Chronic” means long-term and “systemic” means within the whole body’s system; therefore, RA is a long-term whole-body inflammatory condition. Unlike OA, RA effects joints bilaterally (on both sides) rather than unilaterally (on one side). RA symptoms can occur acutely, chronically, or intermittently (with periods of exacerbations and remissions).

What does RA “look like”?

RA presents with the following symptoms, which are very similar to OA: inflammation, redness, prolonged morning stiffness (>1 hour), joint pain, generalized weakness, and/or low grade fever (Deshaies, 2018). Bouchard’s and Herberden’s nodules may also be present (do you remember which is which?!). Other deformities that may occur include ulnar drift (hand positioned more towards the pinky side of the hand), Boutenneire or Swan Neck deformity (google them!), and countless other wrist, elbow, and upper and lower body joint deformities.

How do OTs help individuals with OA & RA?*

Because there is no cure to either form of arthritis described here, treatment goals include relieving symptoms, improving function, limiting disability, and avoiding drug toxicity (via nonpharmacological treatments!).

OT treatment may include establishing a home exercise program to strengthen muscles in order to protect joints from further damage and to decrease stiffness. Low impact exercises are often recommended, such as walking, biking, or swimming.

Clients will also be educated regarding joint protection principles and ergonomics. This means that clients will be taught safer, more protective ways to prevent further damage to arthritic joints. Such principles may include avoiding positions of deformity. This could mean using adaptive devices to help open jars, lifting a coffee mug with two hands instead of one to decrease joint strain, and avoiding prolonged periods of the same joint position. Ergonomic recommendations could include the use of an adjustable desk to offer both sitting and standing options, keeping items close to the body when carrying heavy (or light) loads, or distributing a load across two joints instead of one. An example of this would be wearing a backpack instead of using a shoulder bag or purse to carry your items. Joint protection is key!

Clients will also be educated regarding adaptive equipment to promote joint protection. Adaptive devices may include electric can openers, utensils with built-up handles, dressing/bathing devices (refer to Chapter 10: Parkinson’s Disease for a list of such devices), doorknob levers, and/or extended key holders, among many other possible adaptive devices.

Education will continue with fatigue management/energy conservation strategies. These are best described using a checkbook analogy. Imagine all the energy you have reserved for one day as your entire checkbook. You must balance your checkbook in order to maintain the energy that you have earned through a full night’s slumber. To balance your checkbook, you may do some activities in the morning hours, followed by a period of rest, followed by a few more activities, followed by rest. You mustn’t expend all your energy in a small amount of time or your daily checkbook will quickly show zero. Energy conservation can be achieved by strategically scheduling your day to balance high exertion activities (i.e. cutting the grass or grocery shopping) with low exertion activities (i.e. reading the newspaper, managing your finances, or calling a friend). Alternating between high and low exertion activities is one way to balance your checkbook. Additionally, high exertion activities could be spread out over the course of a week, rather than a day. Perhaps Monday could become grass cutting day and Wednesday could be grocery shopping day. Energy conservation is important for individuals with OA/RA in order to prevent overstraining of joints or overexerting joints in awkward and/or strenuous positions. As mentioned previously, joint protection is key!

Depending on the severity of symptoms and related complications, orthoses may also be fabricated for individuals with OA/RA. Orthoses are “splints” made of hard material (kind of similar to the material you would see for a cast after a broken wrist) to protect joints, prevent further damage, and allow certain joints to rest. Entry-level OTs know how to make basic orthoses and, as long as materials are available, be able to make such orthoses for clients who might benefit from them.

There are countless other ways that OTs can help manage symptoms for OA/RA. This post provided a brief overview of what OA/RA is and how OTs help clients who have been diagnosed with arthritis. I hope you’ve been informed through this post and I hope to educate myself and you more in upcoming posts!

*Note: These examples of OT involvement are strictly my own. Information on this post was provided through the reference referred to below.

Reference: 

Deshaies, L. (2018). Arthritis. In H. Pendleton & W. Schultz-Krohn (Eds.), Pedretti’s occupational therapy practice skills for physical dysfunction (8th ed., pp. 945-971). St. Louis, MO: Elsevier.

Chapter 10: Parkinson’s Disease

Chapter 10: Parkinson’s Disease

I’m finally adding to my “OT Chronicles” page! I am in desperate need of a way to review for my upcoming fieldwork placement and (eventually) my boards. Writing is a way for me to solidify what I know and determine what I still need to learn; therefore, I’ve decided to start going in depth about certain conditions and injuries that OTs may work with. This is my way of educating myself and others by using both medical and layman’s terms. By doing so, I’ll learn all the “fancy” words and try my best to teach others in simpler terms. If you’re interested, keep on reading. If you’re not, keep on scrolling. I’m going to start this “series” with Parkinson’s Disease.

What is Parkinson’s Disease?

Parkinson’s Disease (PD) is a progressive neurodegenerative disease (Schultz-Krohn, Foti, & Glogoski, 2018). Let’s break that down. “Progressive” means that the condition and its related symptoms will slowly worsen over time. “Neurodegenerative” means that neurons within the brain are degenerating (breaking down). Neurons are the communicators within the brain. Neurons receive and send signals throughout the brain to help produce movement. As a result of the degeneration, movement becomes progressively impaired for individuals with PD.

PD is associated with loss of dopamine and the presence of Lewy bodies (Schultz-Krohn, Foti, & Glogoski, 2018). Too many science-y words? Let’s break it down. Dopamine is a “chemical messenger” within the brain that is responsible for relaying messages that plan and control body movements. A loss of dopamine results in less effective message relaying, which, in turn, results in decreased ability to plan and control body movements. This causes the movement impairments mentioned in the previous paragraph. In continuation, Lewy bodies are globs of protein found in the brain which cause cell death. As a result of their presence, cognitive impairments occur.

What does Parkinson’s Disease “look” like?

There are three common signs/symptoms of PD: tremors, rigidity, and movement deficits (Schultz-Krohn, Foti, & Glogoski, 2018). Tremors often start unilaterally (on one side of the body) and tend to look like a “pill-rolling” motion. To understand the “pill-rolling” motion, rub your thumb in a constant circular motion over the palm side of your middle and pointer fingers. As PD progresses, the tremors will appear bilaterally (on both sides of the body). Rigidity is described as stiff movements. This means that movements aren’t as smooth as an individual who does not have PD. Movements are rigid.

Movement deficits vary. This may include akinesia (difficulty initiating movement), bradykinesia (slow movements), and hypokinesia (small movements). Individuals who experience akinesia may present with “freezing” which is a sudden cessation of movement or inability to initiate or maintain movement upon changing directions while walking and/or walking through doorways/thresholds. Individuals who experience bradykinesia will simply move slowly. Picture this as an individual who slowly reaches for their coffee mug or slowly walks through their home. This presents much differently than someone who is purposefully moving slow because they are distracted by their phone or a child who is moving slow to annoy their parent. Hypokinesia (small movements) sounds like what it is. Their steps while walking will be small. Their arm swing while walking will be small. Handwriting will become very small (this is called micrographia). As a result of these movement deficits, balance becomes impaired and fall risk increases, in addition to difficulty with movement in general.

Along with these primary signs/symptoms, PD includes a mask-like expression (also known as flat affect). This means that the individual may not change facial expressions upon hearing sad or happy news. They will appear “mask-like”. Similar to hypokinesia (small movements), an individual with PD will also have a “small voice” – muffled speech, monotone, and decreased volume (like a whisper). Just imagine everything “getting smaller” for an individual with PD. Other impairments include issues with attention, decision making (executive functioning), bowel/bladder function, sexual dysfunction, fatigue, and sleep disturbances, among others. Depression is also possible due to changes in function/independence or embarrassment of one’s presenting symptoms.

How do OTs help individuals with PD?*

OTs have a role in PD treatment throughout the disease progression. In the early stages when an individual with PD may still be working, OTs can educate the individual about workplace modifications to ensure safety. This may include requesting a different shift time or a shorter shift to accommodate for fatigue or altering one’s work environment to promote optimal posture, decreased fall risk, and energy conservation.

As PD progresses, home modifications could be recommended to decrease fall risk and to decrease the likelihood of  “freezing” in doorways or rooms. Such recommendations may include removing throw rugs, cleaning up clutter within the home, and making walkways as unobstructed as possible.

Adaptive devices will be beneficial as well. These may include built-up handles on utensils or writing devices (“built-up” just means thick/wide handles), use of bathing/dressing devices (i.e. long-handled sponge, reacher, dressing stick, shoehorn, sock aid), and installation of grab bars and a tub bench in the bathroom for increased safety and independence.

Special programs specifically for individuals with PD include Rock Steady Boxing and LSVT-Big. Both of these programs focus on making movements BIG. Punch big, walk big, dance big, big, big, big. OTs can become certified and specially trained for these programs or referrals can be made to locations that offer these programs.

There are so many other ways that OTs can help individuals with PD improve their quality of life and independence. This is merely a brief overview of the OT-PD relationship. I hope you’ve been informed through this post and I hope to educate myself and you more in upcoming posts!

*Note: These examples of OT involvement are strictly my own. Information on this post was provided through the reference referred to below.

Reference: 

Schultz-Pendleton, W., Foti, D., & Glogoski, C. (2018). Degenerative diseases of the central nervous system. In H. Pendleton & W. Schultz-Krohn (Eds.), Pedretti’s occupational therapy practice skills for physical dysfunction (8th ed., pp. 871-903). St. Louis, MO: Elsevier.