Occupational therapy programs tables of content


PROCEDURE: FINE MOTOR COORDINATION



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PROCEDURE: FINE MOTOR COORDINATION
DESCRIPTION/PURPOSE:
Fine motor coordination tasks, exercises and activities are used to treat a variety of upper extremity disabilities that result in loss of functional abilities. The treatment of hand function is primarily concerned with the normal prehensile functions of power grip (grasping an object between the palm and finger), and precision handling (fine manipulative movement of objects between the thumb and fingertips).
OBJECTIVES/GOALS:


To improve grip and prehension strength.

To improve functional range of motion in the fingers, thumb, wrist, and forearm.

To increase tactile awareness and discrimination.

To improve manipulation dexterity.

To improve bilateral coordination skills.

To improve functional hand positions, including grasp and pinch patterns.

To decrease edema.

To decrease pain.

To improve functional performance in the areas of work, self care, and play/liesure within appropriate temporal and environmental contexts.
INDICATIONS:


Loss of functional hand abilities related to traumatic injury or illness.

Weakness in the hand, wrist and forearm.

ROM deficit in the hand, wrist, and forearm.

Edema and/or pain that interferes with manipulation skills.

Loss of sensory registration and processing.
CONTRAINDICATIONS:


Resistive activities or exercises may be contraindicated for some diagnoses (i.e., Rheumatoid Arthritis, fracture).

Post-operative limitations for hand and wrist ROM per specific surgical procedure.

Fine Motor Coordination (cont.)
PRECAUTIONS:


A resident with decreased sensation may use too much force to perform simple activities which may result in soft tissue damage.

Lack of sensation is usually accompanied by lack of sweating, which results in dry, cracked skin which is more likely to be damaged from daily use.


EQUIPMENT FOR INTERVENTION:


Theraband

Theraputty

Pegboard

Bead maze

Cloths pin tree

Busy board

Pipe tree

Bold board

Pronation/Supination wheel

Hand grip exercises

Games

Functional activities


ASSESSMENT:


1 Standardized tests are recommended as a means of comparing the resident’s abilities to norms for age and sex. Formal testing also provides measurable criteria of progress throughout the course of treatment.

Commonly used tests:

Nine Hole Peg Test

Jebson Hand Function Test

Purdue Pegboard Test

Minnesota Rate of Manipulation Test


2 Other assessment tools:

goniometer

dynamometer

volume meter

pinch gauge

manual muscle test


self report of pain

patient/family interview

interest check list

chart review

clinical observation

Fine Motor Coordination (cont.)




Assessment of sensory functioning should be completed, as an impairment in fine motor coordination may be accompanies by sensory loss which is necessary for skilled movement.
Assess general hand function by asking the resident to reach, grasp, carry and release objects.
If a unilateral deficit is present, compare the performance of the uninvolved hand with the involved hand.
Assess proximal segments of the upper extremity including scapula, shoulder, trunk and elbow.
Assess postural stability and positioning.
PROCEDURES:


General principles:

a If edema is present, this must be a primary focus of treatment as chronic swelling can lead to permanent dysfunction. Effective treatment for edema includes positioning (arm elevated above heart), active movement to encourage venous return, graded pressure such as retrograde massage, string wrapping, or Isotoner gloves; or quickly dipping the hand in ice water to constrict blood vessels.

b Grade motor tasks from gross (grasp) to fine (prehension).

c Treat proximal to distal. Check trunk control and shoulder position. Note ability to stabilize the wrist and forearm. Improved proximal stability will improve prehension skills.

d The two primary components of coordination are speed and accuracy.

e Teach the individual compensatory strategies if complete return of hand function is not likely.



Treatment strategies:

a Increase range of motion through daily living activities, creative activities, or prescribed exercises.

b Increase grip and pinch strength using Theraband, therapy putty or grippers.

c Provide practice in the use of hand positions through activities or games that require various hand positions to perform a task.

d Increase coordination and dexterity through activities or games involving small pieces or parts.

e Provide instruction in one handed activities, if needed, especially during recovery stage.

f Make recommendations for modification of self-care, homemaking, and leisure activities to accommodate temporary or permanent disability.

g Consider splinting to maintain the hand position, prevent deformity or contracture, or improve functional performance (see Clinical Procedure: Hand Splinting)



h Privide sensory re-education if indicated.

Fine Motor Coordination (cont.)
DOCUMENTATION:
Documentation must reflect the need for skilled therapy, support the skilled nature of the Fine Motor Coordination program, present objective and measurable progress and the individual’s improvement as related to functional abilities. Also include the individual’s response and tolerance to the treatment procedure; to activity/training provided to family/staff, and post therapy recommendations.
Procedure for Completing the Nine Hole Peg Test
The pegboard is to be centered in front of the subject, with the pegs placed in the container next to the board on the same side as the hand being tested. The dominant hand (the hand used for writing) is to be tested first. The following instructions are to be given to the patient and briefly demonstrated by the examiner.
Pick up the pegs one at a time, using your right (or left) hand only and put them into holes in any order until all the holes are filled, then remove the pegs one at a time and return them to the container. Stabilize the pegboard with your left (or right) hand. This is a practice test. See how fast you can put all the pegs in and take them out again. Are you ready? Go”
After the patient has completed the practice trial, the examiner will say:
This will be the actual test. The instructions are the same. Work as quickly as you can. Are you ready? Go!” (During test) “Faster.” (As soon as the last peg is in the board) “Out again.....faster.”
The stopwatch is started by the examiner as soon as the patient touches the first peg and stopped when the last peg hits the container. The container is then placed on the opposite side of the pegboard. The test is repeated in the same way for the nondominant hand.
It is assumed that the patient is seated on a standard height chair at a standard height table. Any variation should be recorded on the evaluation sheet. The score is the number of seconds elapsed from the time the patient touches the first peg until the last peg is replaced in the container.
If the patient drops a peg on the floor or table, the test should be repeated for that hand.
Test each hand twice:

Dominant, nondominant

Dominant, nondominant


See attached for ranges of normal time. Indicate on evaluation actual time, normal range, and if score is within, above, or below normal limits.

THERAPEUTIC EXERCISE GUIDELINES
MUSCLE RE-EDUCATION:
Definition: Therapeutic exercise for the encouragement of voluntary muscular movements within the functional limitations of the patient, based upon a controllable number of range of motions, with the proper graded activity and observance of the basic physiological promise of therapeutic exercise–that of contraction, relaxation and rest.
Effects: To restore the neuromuscular control of motion, coordination, and strength which has been either disturbed, disrupted or partially destroyed.
STRETCHING:
Definition: A force applied against a contracted muscle or limiting soft tissue structures.
Effect: To restore range of motion.
PASSIVE EXERCISE:
Definition: Passive exercise requires no muscle contraction or effort on the part of the patient, and is performed by an outside agent or person without assistance or resistance of the patient.
Effects: Passive exercise is employed to prevent atrophic changes in fibrous tissues, bones, and areas about joints, and to assist in keeping up good circulation. Passive exercise prevents adhesions between muscle planes, maintains suppleness and helps to prevent contractures. Purely passive motion has no effect upon muscle atrophy or power.
ACTIVE EXERCISE:
Definition: Active exercise requires the ability to carry a movement unassisted through a complete range of motion.
Effects: To assist in increasing and in building up muscle power, coordination and strength.
PROGRESSIVE RESISTANCE EXERCISE:
Definition: A form of active exercise in which activities are performed against outside resistance, such as gravity, weights, and tools. Resistance is commensurate with muscle strength.
Effects: To build up muscle power, strength and increase range of motion for those patient usually past the acute stage.

RANGE OF MOTION EXERCISE:
Definition: The movement of a part through as complete an arc of motion as possible.
Effects: Range of motion exercise is employed to prevent atrophic changes in fibrous tissue, bones, and areas about joints and to assist in keeping up good circulation. Range of motion exercise prevents adhesions between muscle planes, maintains suppleness and helps to prevent contractures. Purely passive range of motion exercises has no effect upon muscle atrophy or power.
COORDINATION EXERCISE:
Definition: Exercised which encourage particular groups of muscles to perform in definite useful responses. Patients are frequently started on gross patterns of movement and progress to activity of a finer nature.
Effects: To encourage independence in activities of daily living and to restore function by harmonious working together of parts.
TOLERANCE EXERCISE:
Definition: Exercised or activities given to return to normal, or as near normal as possible, a person’s ability to tolerate a specific activity or position, i.e., standing tolerance, sitting tolerance, hand-arm performance.
Effects: To enable a person to endure continued or increasing participation in an activity.
GENERAL CONDITIONING EXERCISE:
Definition: Activities given to patients who have been bedridden or inactive for along period of time.
Effects: To increase or maintain muscle strength and joint motion; improve muscular tone, body function and physical tolerance.
POSTURE EXERCISE:
Definition: Exercises for the correct alignment of the structures of the body to make possible the best circulation of the blood and consequent nourishment of even the most distant muscles, joints and organs.
Effects: Correct posture results in increased vigor, lessened fatigue, and increased mental and physical efficiency.

DEXTERITY EXERCISE:
Definition: Activities of a finer nature for the fingers and the hands.
Effects: To promote quickness, skill and ease in using the hand or hands.

PROCEDURE FOR PASSIVE EXERCISE
DESCRIPTION/PURPOSE:
Passive exercise is movement within the unrestricted range of motion produced entirely by an external force without voluntary muscle contraction by the individual. The external force may be provided either by a mechanical device or the therapist.
OBJECTIVES/GOALS:


Maintain existing joint and muscle ROM when person is unable to move the extremity himself.

Minimize effects of the formation of contractures.

Maintain mechanical elasticity of muscle.

Assist in circulation.

Provide sensory stimulation.

Help maintain patient’s awareness of normal joint motion.

Assist in finding limitations of joint range.

Illustrate to the patient the type of motion desired prior to the active motion.


INDICATIONS:


Patients with loss of voluntary muscle control.

Immobility.

Decreased circulation.

Decreased sensation.

Decreased proprioception.

Post-operatively to maintain ROM when active muscle contraction is contraindicated.


CONTRAINDICATIONS:


Post-operatively, any motion that is to be avoided due to specific surgical technique or fixation devices utilized.

In area of recent fracture requiring immobilization.

Passive Exercise (cont.)
PRECAUTIONS:


Patients with impaired or absent sensation.

Osteoporosis

Abnormal tone
EQUIPMENT:
Gonimeter
ASSESSMENT:
Range of Motion and analysis.
PROCEDURES:


Prior to beginning treatment, review the medical record and obtain adequate knowledge of patient’s condition, disability, and referral for treatment.

Instruct the patient in procedure, length, goals of treatment and symptoms to notify therapist of if they should occur.

Place patient in a comfortable position with proper body alignment. (Consider alternative positions according to patient’s capabilities).

Free area from restrictive clothing, linen, splints, dressing, etc. Drape patient as necessary. Be certain there is sufficient space in which to perform all exercise patterns. (Move furniture, plinths, etc.) Be sure joint(s) to be treated have freedom of motion from external forces. Identify tubing (i.e., IV, trach, catheter) and wires and position to avoid dislodging.

Perform an initial, gross evaluation of patient’s joint range, affected and unaffected extremities. Determine factors of pain, contracture, and tone .

Generally, grasp at the joints of the patient. If joints are painful to touch, (arthritis, etc.), grasp the extremity at the muscle belly.

Support areas of poor structural integrity (flaccid joint, recent fracture site, etc.).

Perform passive range of motion throughout the complete, pain free, normal range. Perform movements smoothly and rhythmically. Do not force motion beyond the available range.

Use proper body mechanics.

Passive Exercise (cont.)


Perform each movement from 5 to 10 repetitions, based on patient’s condition and objectives of program. Less repetitions with prolonged holding at end of range may be appropriate.

Avoid pain whenever possible. Decrease range of exercise movement or terminate program if pain increases or persists for a prolonged time.

Determine patient’s general condition during the following exercise procedure:

Hear rate, respiration rate, warmth and color of extremity.

Gross evaluation of joint range as compared to initial evaluation.

Terminate program, re-position patient for comfort and proper body alignment; cover patient, properly dispose of used linen. When repositioning tubing, always lay it over extremity. Prepare area (if in department) for next treatment procedure.

Chart significant differences in patient’s condition, response to treatment, etc.

Special considerations:

True passive relaxed motions may be difficult to obtain when muscle is innervated.

Passive motion will not:

Prevent muscle atrophy.

Increase strength or endurance.

Assist circulation to the extent that active voluntary contraction will. Passive motion will help to maintain circulatory flow when voluntary function is not present.

When active muscular contractions are possible and desirable, active motion, in most instances, is preferable to passive motion.

If patient exhibits increased tone, use inhibitive techniques (neutral warmth, rotation, hand placement).

Passive Exercise (cont.)


DOCUMENTATION:
Documentation must reflect the need for skilled therapy, support the skilled nature of the Passive Range of Motion program, present objective and measurable progress and the individual’s improvement as related to functional abilities. Also include the individual’s response and tolerance to the treatment procedure; to activity/training provided to family/staff, and post therapy recommendations.
RESOURCES:
Refer to Active, Active Assistive and Resistive Exercise.

PROCEDURE: ACTIVE, ACTIVE ASSISTIVE AND RESISTIVE EXERCISE

DESCRIPTION/PURPOSE:
Any exercise where movement is accomplished by voluntary contraction of a muscle with or without assistance or resistance. Contraction may be isometric or isotonic.


Isotonic: Concentric contraction - overall shortening of the length of the muscle. Eccentric contraction - overall lengthening of the muscle while fibers are contracting against a force. Applied external resistance should require the individual to contract specific muscles maximally in order to perform complete joint range.

Active assisted exercise - The force by the individual is supplemented by an external force which may be manual or mechanical.

Active exercise - The voluntary contraction of the muscle produces motion without aid or opposition from an external force other than gravity.

Resistive exercise - Voluntary contraction of the muscles is opposed by an external force; manual or mechanical.

Isokinetic: (A form of resistive exercise) - Voluntary contraction through the range where speed is controlled and resistance is matched with maximum tension produced by the muscle through the entire range.

Isometric: Voluntary contraction of muscle, but no movement of the joint. Applied external resistance should exceed the individual’s maximal muscle contraction and prevent or restrict joint movement.

Intermittent contraction and relaxation (“setting”).

Contraction against maximum force.
OBJECTIVES/GOALS:


Increases or maintains strength.

Increases endurance.

Hypertrophy with continued maximum demand.

Improves coordination.

Maintains joint range (except with isometric).

Maintains physiological elasticity of muscle

Provides proprioceptive stimulation and feedback.

Provides stimulus for development of normal bone.

Active, Active Assistive, Resistive Exercise (cont.)
INDICATIONS:


Decreased strength

Decreased endurance

Decreased circulation

Decreased proprioception

Decreased coordination

Decreased function secondary to any of the above


CONTRAINDICATIONS:


Post-operatively any motion that is to be avoided due to specific surgical techniques or fixation devices utilized.

Joints with acute inflammatory flare ups such as bursitis, tendonitis, etc.

In area of recent fracture.
PRECAUTIONS:


Stay within the physical capacity and needs of the patient. Encourage patient to perform at maximally tolerated level. Use caution with abnormally innervated muscles to avoid permanent damage (Post poliomyelitis, Guillain-Barre, etc.).

Avoid microtrauma to supporting structures, (i.e., overstretching of joints with excessive force, etc.).

Avoid abnormal stress or force to:

Spine


“Loose joints”

Areas where there has been prolonged immobilization

Site of a healing fracture

Denervated or anesthetic structure.

Caution the resident to avoid the Valsalva Phenomenon.

Avoid emphasis of abnormal muscle imbalance.

Remain within fatigue tolerance of resident.

Reduce program if pain increases or range decreases.

Stay with patient or be able to observe patient during entire exercise.

Be certain all attachments, cuffs, collars, etc. are securely fastened prior to exercise.

Standard active or resistive programs may not be appropriate for patients with abnormal tone. (Refer to clinical procedure: Tone Inhibition and Facilitation)
EQUIPMENT:


Weights

Theraband

Theraputty

Pulley system

Active, Active Assistive, Resistive Exercise (cont.)
ASSESSMENT:


Range of motion

Manual muscle test


PROCEDURES:


For active assistive exercise:

Demonstrate movement passively and request individual to perform exercise.

Guide extremity in proper pattern and correct individual’s movement providing support and/or stabilization as needed.

Require individual to perform with maximum effort.

For active exercise:

Demonstrate movement passively and request individual to perform.

Observe movement and correct movement verbally or by guiding.

Require individual to perform with maximal effort.

For resistive exercise (manual):

Demonstrate movement on individual and request individual to perform exercise movement. If proper motion is performed unassisted, resist against maximum effort of the individual being sure individual performs motion without substitution. (Substitution may be appropriate as a compensatory technique.)

Resist movement from direction opposite to plane of active motion.

Resistance may be any force.

The longer the force arm over lever arm, the less amount of resistence required, but also, the more control required for proper plane of motion.


Observe movement(s) during performance.

Correct pattern of movement if incorrect, verbally by demonstration or by guiding movement.

Require patient to perform with maximum effort though maximum range. This can often be done by varying resistance as you progress through the range.

Require individual to perform movement slowly and rhythmically, avoiding Valsalva phenomenon.

Observe pattern to make sure individual is performing desired function and contracting proper muscle group.

Active, Active Assistive, Resistive Exercise (cont.)


For resistive exercises (mechanically):

Pre-determine method of Progressive Resistive Exercise (PRE) you will use.

Determine resistant maximum (RM) of patient for movement(s) desired.

Use educated trial and error method.

Find a weight that is too heavy for the patient to lift through full available range.

Find a weight that is too light, but relatively near the heavy value.

Work down toward the lighter weight until a 10 RM or 1 RM is determined.

Encourage individual to perform maximally within tolerance.

Perform exercise routine as predetermined.

Stabilize and/or support structures to prevent unwanted movement and to provide adequate base of support. Use manual, positional or mechanical means of support and stabilization.

Be certain part performs through complete available range.

Performance should be smooth, rhythmical, and of moderate speed, avoiding Valsalva phenomenon.

Patients should “hold” contraction briefly at completed end of “action” range. Remember, there will be muscular contraction through contraction and relaxation phase of many exercise movements.

Pad or protect patients as required:

Where straps or cuffs are used.

Where rough or sharp surfaces are encountered.

Between skin and power board.

Check and recheck equipment for safety.

Terminate exercise when pre-established exercise program has been completed.

If using mechanical resistance, remove or disengage apparatus, weights, etc.

Determine individual’s general condition during the following exercise program:

Heart rate, respiration rate, warmth and color of extremity.

Gross evaluation of ROM and strength.

Endurance values

Chart significant differences in individual’s condition or response to treatment.
Active, Active Assistive, Resistive Exercise (cont.)


Special considerations

When working to increase strength, endurance is a byproduct and vice versa, if a state of stress is reached.

Isometric exercises reduce painful responses and increase strength, but contribute very little to cardiovascular fitness and joint flexibility.

A proper balance in strength between antagonistic muscle groups is important to maintain flexibility and prevent deformities.

Upper extremity exercise in general has higher oxygen consumption than lower extremity work. Working with upper extremities above the head has increased energy requirements.


DOCUMENTATION:
Documentation must reflect the need for skilled therapy, support the skilled nature of the Active, Active Assistive, Resistive Exercise program, present objectives and measurable progress and the individual’s improvement as related to functional abilities. Also include the individuals’ response and tolerance to the treatment procedure; to activity/training provided to family/staff, and post therapy recommendations.
HANDOUTS:
Therapeutic Exercise Guidelines

Range of Motion Exercise

Range of Motion Record

Manual Muscle Test Procedures

Nine Hold Peg Test Procedures

Interest Checklist Procedures

Progressive Resistive Exercise
RESOURCES:
Kisher, C. and Colby L.A. Therapeutic Exercise Foundation and Technique. Philadelphia: FA Davis Co.
Clarkson, Hazel and Gilavecky, G.B., (1989) Musculoskeletal Assessment. Baltimore: Williams and Wilkins.


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