Occupational Therapy in Physical Dysfunction
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Direct answer
Physical dysfunction practice covers the orthopaedic, rheumatological, hand-injury, surgical and general medical conditions in which movement, strength or endurance — not cognition — is the limiting factor. Occupational therapy here runs on two frames: the biomechanical frame of reference, which rebuilds range of motion, strength, endurance and dexterity as measurable components and then feeds them back into function, and the rehabilitative or compensatory frame, which changes the method, tool or environment once restoration has plateaued. The treatment medium is graded purposeful activity — cooking, crafts, work simulation, self-care — supplemented by splinting, assistive devices and patient education, with progress tracked by goniometry, manual muscle testing, volumetry and functional scales such as the FIM.
What you must remember
- Biomechanical frame sequence: restore range of motion, then strength, then endurance, then coordination and dexterity, and only then retrain the functional task — treating out of order wastes both.
- Rehabilitative or compensatory frame: when recovery is capped, adapt the method (one-handed dressing techniques), the equipment (long-handled reachers, rocker knives) or the environment, and teach the residual skills to mastery.
- Manual muscle testing grades 0 to 5: 0 no contraction, 1 flicker, 2 full range with gravity eliminated, 3 full range against gravity, 4 against resistance, 5 normal; grade 3 is the pivot between gravity-eliminated and anti-gravity work.
- Oedema control ladder: elevation above heart level, active muscle pumping, retrograde massage, compression — measured objectively by water-displacement volumetry or the figure-of-eight tape measure.
- Timing follows healing: an upper-limb fracture typically needs about six weeks of protection, so therapy spends that time on the uninvolved joints, oedema and positioning rather than forcing the fracture site.
- Complex regional pain syndrome after wrist injury: disproportionate burning pain, colour and temperature change, hyperhidrosis and trophic skin changes — recognise early and refer; it is a medical emergency of trajectory, not a compliance problem.
- Acute care starts on day one: positioning, oedema management, early mobilisation of free joints and patient education all begin while the disease process is still active.
Six weeks after a Colles fracture
A 55-year-old teacher dominant-right arrives with her cast off after a fall on an outstretched hand. Assessment first, and in this order of threat: the shoulder, stiff from six weeks of guarding, is checked in flexion, abduction and rotation; the wrist and fingers are measured with a goniometer; oedema is recorded by figure-of-eight tape; grip is tested qualitatively against the left hand. Intervention then runs as a ladder. Warmth — a paraffin bath or warm soak — prepares the tissue; active range exercises move each joint to comfortable end-range; graded activity converts the range into function: cloth wringing for pronation-supination, rolling-pin work for wrist extension, pegboards and putty for dexterity, writing drills of increasing speed for her actual role. A volar cock-up splint supports the wrist between sessions for comfort. Goals are written measurably — wrist extension to 45 degrees and independent writing for ten minutes within three weeks — and reviewed against them. The red flag stays live throughout: if pain is burning, disproportionate and accompanied by shiny skin, the plan changes from exercise to urgent medical referral for complex regional pain syndrome.
How the BOT exam frames it
The practical short case almost always hands you a post-operative or post-fracture hand and asks two things: what are the goniometer and manual muscle testing readings, and what activity will you prescribe for them. Examiners distinguish sharply between exercise and activity — ten wrist curls are physiotherapy's grammar; kneading dough is occupational therapy's, because the occupation carries the movement. The frequent viva trap is the frame of reference question: a student who prescribes a long-handled shoehorn to a healed, stiff patient (compensation where restoration is due) or active exercises to an unstable fracture (restoration where protection is due) has reversed the logic. One sentence saves you: treat the component while healing allows, adapt the task when healing stops.
Frequently asked questions
Which frames of reference guide occupational therapy in physical dysfunction?
The biomechanical frame, which restores range, strength, endurance and dexterity before function, and the rehabilitative or compensatory frame, which adapts method, equipment and environment when restoration plateaus.
How is hand oedema objectively measured?
By water-displacement volumetry (the gold standard) or the figure-of-eight tape measure, both repeated under identical conditions to track change.
What clinical picture suggests complex regional pain syndrome after a Colles fracture?
Disproportionate burning pain with colour, temperature and trophic skin changes and stiffness out of keeping with the injury timeline.
What is the correct order within the biomechanical frame of reference?
Range of motion, then strength, then endurance, then coordination and dexterity, and finally retraining of the functional task itself.
When does the therapist shift from restoration to compensation?
When measured recovery has plateaued across re-assessments and the deficit is judged permanent — then method training and adaptation replace component building.