Last Updated Aug 2011
According to the National Institutes of Health, hand injuries account for one-third of all work injuries and one-third of all chronic injuries each year in the U.S. Most often the result of work-related tasks, recreational activities, home improvement projects or accidental falls, trauma to the fingers, hands and wrists requires timely diagnosis and treatment in order to prevent lasting damage and possible permanent disability.
Patient Evaluation: Critical Components
In order for therapy professionals to treat patients effectively, a thorough patient evaluation must be performed. Therapists must be able to apply essential anatomical knowledge while examining a patient’s occupational as well as medical history to develop a treatment plan that specifically addresses an individual’s functional deficits to ensure successful rehabilitation.
> Occupational History
Occupational history refers to information about an individual’s lifestyle. Typical information such as age, marital status, living situation, and what he or she does for a living, should be supplemented with more detailed questions such as:
• What roles does this person perform regularly?
• What are the specific tasks he or she must perform within each role?
• What specific occupational limitations does the patient have related to the injury?
Nowadays insurance companies are only willing to reimburse for therapy when the patient has a loss in function that can be documented and is expected to improve through your services, so therapists need to take into account what the individual is unable to do secondary to the injury.
> Medical History
A thorough medical history that includes both current and previous medical history as well as current and previous hand/upper extremity history is crucial for correct diagnosis and treatment of a hand injury. For example, carpal tunnel syndrome has different treatments associated with the acuity or chronicity of the diagnosis.
It is also very important to compare the patient’s report with the physician’s diagnosis. A physician may submit a blank diagnosis such as “hand pain” in the hope that the therapist will evaluate the patient for the proper diagnosis and treat him or her accordingly. Or, the physician may provide a diagnosis that does not fit the clinical picture once time is spent evaluating and/or treating the patient. The therapist’s feedback may assist with putting together the best treatment plan.
Essentially, to accurately quantify hand pain a therapist must know what to look for and what questions to ask. When conducted effectively, this combined evaluation can help document both the category of pain and the true source of the injury.
Documenting Hand Appearance
Even if you are not sure it is relevant to the case, it is important document any and all hand abnormalities as compared to the unaffected side. These include:
• Scars: Describe the length, width, and color of a scar. Some clinics have an evaluation that allows the therapist to “draw” in scars or other abnormal physical features on a picture of a hand.
• Amputations: Note which fingers are affected and at what levels the amputations occur.
• Trophic changes: Trophic changes are interruptions in nerve supply that result in changes in the nutritional status of tissues and may include:
o Skin texture
o Atrophy of finger pulps
o Nail changes
o Hair growth
o Future changes
• Discoloration
• Abnormal sweating
• Wrinkles
• Atrophy
• Edema
Therapists should also document the following:
• How is the Hand Used? Watch how the patient postures the arm while walking from the waiting room to your evaluation area. Is he or she: Holding any object in it while walking? Elevating it while walking? Cradling or guarding against movement or allowing it to swing at his or her side?
• Pain Level and Location: Correct identification of the magnitude and duration of pain is important for a variety of reasons. First, diligence in understanding pain will support the development of genuine rapport with your patient. If he or she believes you are committed to understanding and treating his or her pain, the patient is more likely to engage in therapy. Second, understanding the type, duration and location of pain offers concrete evidence for substantiating a diagnosis.
Categorizing Pain in Patients with Hand Injuries
Generally, pain can be categorized as follows:
• Acute pain: Acute pain is typically rapid onset and characterized by being sharp and localized.
• Chronic pain: Chronic pain involved a prolonged history with pain, with a slower onset than acute pain.
• Persistent pain: Pain that is reccurring or episodic is called persistent pain.
• Abnormal pain: Defined as pain that is outside of the scope of what is generally accepted for this diagnosis or stimulus. Neuropathic pain, for example, is pain in response to nerve injury or dysfunction that results in pain characterized as intense burning or electrical.
• Referral pain: Defined as pain that occurs at a site distant from the original source of pain.
Questions for Evaluating Hand Pain
With all types of pain, the therapist treating hand injuries must do a thorough evaluation to determine the actual source of injury. Use these types of questions to assist in finding relevant information:
• What is the specific pain for which we are treating you today? Differentiating pain involves determining the precise location, duration, intensity, and type of pain (acute, chronic, persistent, etc.)
• What is the pain intensity? Pain intensity should be considered an ongoing assessment each day of treatment, prior to beginning treatment, during and after. Many tools exist for measuring pain, such as the Wong-Baker FACES pain rating scale which classifies “No pain” as zero and “Worst pain possible/unbearable” as ten.
• Is the pain deep or superficial? The answer to this question may lead you to the structure that is injured.
• Is the pain constant or intermittent? Determine the intensity at different periods of the day. What is the duration of the pain if intermittent? Remember to use indicators for measuring progress with the relief of pain.
• When did the patient first notice the pain? When possible, determine the specifics of the injury, including how the hand was being held, what objects were involved, and whether the hand was the hand trapped as the result of an injury.
• Is there a difference between resting pain and movement-oriented pain? Document whether or not pain exists only with movement (specific movements, specific resistance) or whether pain exists also at rest.
• What improves pain and what aggravates pain? In many cases, clients know exactly what aggravates and relieves their pain. For example, irritants may be movement, the arm dangling at the side, or laying down to sleep. Examples of pain relievers may be rest, elevation, positioning, heat or ice, or activity adaptation. This knowledge provides key information for clinical reasoning in diagnosis and treatment.
Conclusion
When evaluating a hand injury, therapists should document any abnormalities as compared to the unaffected side such as scars, trophic changes, discoloration, sweating, wrinkles, and atrophy. In addition, to ensure a thorough evaluation the therapist should ask the client questions concerning the intensity, location, and intermittency of their pain.
For a more detailed look at hand injury evaluation and treatment options for therapy patients—including measuring edema as well as determining ROM, motor function and sensory function—view our comprehensive 3-hour course Introduction to Hand Evaluation and Treatment Concepts.
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