treatment by getting a before and after assessment of pain. These measures are also effective tools for the client to use at home to gain better understanding of the factors that influence pain, both positively and negatively. Provocative tests are another way for the PT or OT to determine the extent of joint damage or pain, and to make a differential clinical diagnosis. The grind test, shown in Figure 11, provides both objective and subjective data in the form of client reports of pain and the feel or auditory phenomenon of crepitus expe- rienced by the therapist (Badia, 2011). The test is performed as the therapist securely places the forearm of the client in neutral rotation and grasps and secures the wrist from a radial approach. The therapist holds the MCP and proximal phalanx of the thumb with the opposite hand. While pressing the metacarpal into the trapezium, the therapist moves the joint in a rotary motion—to grind the joint. The client is asked to report pain; the presence of pain indicates that the grind test is positive for joint cartilage change (Badia, 2011). Figure 11: The Grind Test
gagement if they are in chronic pain or believe engaging in the community exacerbates painful symptoms. Evaluation of client abilities, family and social support systems, financial needs, and the home environment makes it possible to tailor OA management to each situation. Individualized treatment involves obtaining a detailed assessment of a client’s hands and wrists; their pain; the impact of OA on their ADL, home, and work environments; and any specialized tasks they need to perform. Helping a client focus on abilities and strengths, rather than dis- abilities and weaknesses, is an essential component of the OT’s role (AOTA, 2020). Hand and wrist OA might make it difficult for a client to get dressed, tie shoelaces, handle clothing during toilet- ing, make beds, prepare meals, open jars, and handle money. Use of reachers, buttonhooks, elastic shoelaces, and other items en- ables a client to perform ADL without additional assistance, and enables the client to retain dignity and independence. Creative modification of kitchen, gardening, and work utensils by build- ing up handle thicknesses or improving ergonomic alignment can greatly diminish stresses on the hand and wrist. OTs work with clients to fabricate custom orthoses to ensure that joints are po- sitioned neutrally and avoid further irritation when functioning or sleeping. Some OTs and PTs specialize in the treatment of the hand and wrist. Hand therapy is a combined specialty of both OT and PT, each providing similar treatments that include physical agent mo- dalities to help with pain relief or stiffness. When joints are stiff and painful, OTs assist clients with using paraffin baths, fluidized therapy units, and warm-water baths to help improve range of motion (ROM). OTs and assistants do not need to be specialized to work with those experiencing OA, but should be well versed in the condition and competent in all techniques and modalities. This section discusses the role of the OT—from both a conserva- tive and a postsurgical viewpoint—when working with clients with OA of the proximal and distal finger joints, thumb CMC joint OA, and wrist OA. Therapeutic evaluation The first step in the treatment of OA is to determine the occupa- tions in which the client needs or wants to engage and to identify those that are difficult due to OA. This part of the assessment is known as the occupational profile (AOTA, 2020). As mentioned in the physical examination section, the therapist should assess pain, ROM, strength, and the presence of deformities of the hands/ wrists. Several psychometrically sound tools (i.e., outcome mea - sures) are available on the market or otherwise freely available for assessments of these areas. Some of the more popular tools include the Canadian Occupa- tional Performance Measure (COPM), used to assess a client’s perceived performance and satisfaction in all areas of occupation (Law et al., 2014); the Disabilities of Arm, Shoulder, and Hand as- sessment (DASH), which allows a client to identify areas in which the pathology is limiting function (Kennedy et al., 2011); and the Manual Ability Measure-20 (MAM-20), which allows a client to choose their level of function within 20 predetermined areas (Chen & Bode, 2010). MAM- 20 also includes a pain scale. The therapist must next determine the cause of the challenges from a client factor or skill perspective. The OT assesses the fac- tors and/or skills either separately or in the context of occupations themselves to determine the best course of treatment. This assess- ment is known as analysis of occupation (AOTA, 2020). A number of tools are used to assess client factors (e.g., ROM and strength) and their effect on impaired occupational participation. For ex- ample, goniometry assesses ROM; a visual analogue pain scale determines degree of discomfort; and tools to assess strength, including dynamometers and pinch meters, determine whether muscle weakness contributes to dysfunction. When assessing mo- tion, the therapist should know whether a subluxed joint is reduc- ible or if the deformity is fixed. Severe joint destruction with fusion and/or osteophytes can create lack of joint movement and give a bone-on-bone end feel when passive movement is attempted. Pain scales are also effective at determining a client’s response to
Source: Erin Peterson Finkelstein’s test assists with a differential diagnosis to ensure De Quervain’s stenosing tenosynovitis is not the reason for pain at the base of the thumb. Symptoms of De Quervain’s can be similar to CMC OA, but CMC OA does not typically include pinpoint pain at the base of the thumb, radiated proximally, or present with swelling at the base of the wrist in the area of the radial styloid. Finkelstein’s test (Figure 12) is typically positive for De Quervain’s but negative for OA. Finkelstein’s test is performed by having the client hold a flexed thumb in their palm with the digits fisted (Cooper, 2020). The wrist is then ulnarly deviated while keeping the thumb in the palm. A sharp pain extending along the thumb and into the radial wrist is a positive result, and could indicate De Quervain’s stenosing tenosynovitis. For some individuals, pain is naturally present during this maneuver, but is typically experi- enced to a lesser degree than in the presence of tenosynovitis. It is advisable to compare a client’s pain levels with pain levels on the noninvolved side, if possible, to determine whether the pain is indicative of an inflammatory condition. Tools that assess hand skills include the Jebson Hand Function Test, the Purdue Pegboard Test, and the Moberg Pick-Up Test (Cooper, 2020). These tools each have a structured method of administration and demonstrate reliability and validity (Cooper, 2020). In addition to known assessment tools, the therapist should use clinical observation skills. The therapist should observe the cli- ent during functional activities and note how they use the thumb and fingers. The therapist should perform cursory assessment of other joints of the hand and the more proximal upper extremity joints to determine their status and functional abilities. For exam-
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