Occupational therapy in orthopaedics and rheumatology

In short

Occupational therapy in orthopaedics and rheumatology restores a person's ability to do everyday occupations - self-care, household work, study, paid work, leisure - after fractures, joint replacements, hand injuries, amputations, spinal pain and inflammatory or degenerative joint disease. The OT combines remediation (range of motion, strength, hand function), compensation (assistive devices, adapted methods), protection (splints, joint protection, energy conservation) and environmental and work modification. It is a core paper of the BOT/MOT clinical curriculum and is heavily examined in university theory and practical/viva examinations, and in the entrance and interview rounds for jobs in Indian hospitals. Employers include AIIMS and PGIMER, CMC Vellore, Sancheti and Breach Candy, Apollo, Fortis, Max, Manipal, Ganga Hospital Coimbatore, ESIC and state government hospitals, National Institutes under DEPwD (NILD Kolkata, SVNIRTAR Cuttack, NIEPMD Chennai, PDUNIPPD Delhi) and ALIMCO-linked limb-fitting centres. Practice is regulated by the National Commission for Allied and Healthcare Professions Act, 2021; the Rehabilitation Council of India Act, 1992 covers OT training for disability work, and AIOTA is the professional body.

Explained

Scope, frameworks and the OT process

• Occupational therapy - use of purposeful, client-chosen occupation to develop, restore or maintain function and participation; the deficit is defined by lost occupation, not only by lost degrees of motion.
• Frameworks examined: OTPF domains (occupations, client factors, performance skills, patterns, contexts); ICF (body structure/function - impairment; activity limitation; participation restriction) - ICF language is what Indian disability certification and reports use.
• Models: Biomechanical model (ROM, strength, endurance - the main orthopaedic model), Rehabilitative/compensatory model (devices, adaptation), MOHO (volition, habituation, performance for chronic rheumatic disease), PEO/CMOP-E for home and workplace fit.
• OT process: referral → screening → occupational profile and occupational history → assessment → problem list and goal setting (SMART, client-centred) → intervention plan → intervention → re-assessment → discharge planning and home programme → follow-up.
• Stages of orthopaedic rehabilitation: acute/protective (oedema, pain, positioning, uninvolved-joint ROM), subacute/mobilisation (active ROM, light ADL), restorative (strength, endurance, dexterity), vocational (work conditioning, work hardening, return to work).

Assessment in orthopaedics and rheumatology

• Observation and screening: posture, gait and aid use, deformity, swelling, scar, colour, trophic changes, guarding, willingness to use the limb.
• Pain: VAS/NRS 0-10, body chart, pain behaviour, night pain (inflammatory) versus activity pain (mechanical).
• Oedema: circumferential tape measure at fixed landmarks; volumetric (water displacement) for the hand - a 10 mL difference is clinically meaningful.
• ROM: universal goniometer (joint axis, stationary and moving arm); finger ROM by small goniometer; composite finger flexion by pulp-to-distal-palmar-crease distance; TAM (total active motion) = MCP + PIP + DIP active flexion minus extension deficits; normal TAM about 260°.
• Strength: manual muscle testing (MMT, Medical Research Council grades 0-5 with +/−); grip by Jamar-type dynamometer (second handle position, mean of three trials); pinch by pinch gauge - tip, lateral/key, three-jaw chuck.
• Sensation and nerve: light touch, Semmes-Weinstein monofilaments, two-point discrimination (normal fingertip ≈ 2-5 mm), Moberg pick-up test for functional sensibility, Tinel and Phalen for median nerve at the wrist.
• Dexterity and hand function: Nine-Hole Peg Test, Purdue Pegboard, Minnesota Rate of Manipulation, Jebsen-Taylor Hand Function Test, Sollerman grip-function test.
• Prehension patterns to document: power grasp, cylindrical, spherical, hook, lateral/key pinch, tip pinch, three-jaw chuck.
• ADL and participation: Barthel Index, FIM, Katz; upper-limb PROMs - DASH/QuickDASH, PRWE (wrist), MHQ; lower limb - WOMAC (hip/knee OA), Harris Hip Score, KOOS, LEFS; spine - Oswestry Disability Index, Roland-Morris; rheumatology - HAQ/MHAQ, AIMS, DAS28 (medical), BASDAI/BASFI for ankylosing spondylitis.
• Work assessment: job analysis (physical demands, postures, loads, cycle times), functional capacity evaluation, workstation and tool assessment, ergonomic risk screening (RULA, REBA for posture; NIOSH lifting equation for manual handling).
• Home assessment: doorway widths, Indian-style squat toilet, bathroom thresholds, floor-level kitchen tasks, floor sitting and sleeping, steps without handrails - all common in Indian homes and decisive for device choice.

Common orthopaedic conditions and OT management

• Fractures - general: OT begins during immobilisation - oedema control (elevation, retrograde massage, active pumping), ROM of all free joints, one-handed ADL training, positioning, education against disuse. After union/removal: graded active and resisted ROM, scar management (silicone, pressure, massage), desensitisation, functional and work retraining.
• Colles / distal radius fracture: the commonest OT referral; watch for stiff fingers, shoulder-hand syndrome and CRPS. Shoulder and finger motion from day one; after cast removal, wrist and forearm ROM, grip strengthening with therapy putty, PRWE for outcome.
• Humerus and shoulder: pendular exercises, wall-climbing and shoulder-wheel activities, graded overhead reach; avoid abduction/external rotation stress after anterior dislocation repair.
• Hand and tendon injuries: flexor tendon repair - dorsal blocking splint and protected protocols (early passive or early active mobilisation per surgeon); extensor repair - relative motion or static splinting by zone; mallet finger - DIP extension splint 6-8 weeks. Tendon gliding and blocking exercises, no resisted work until the surgeon permits.
• Peripheral nerve injury: splint to prevent deformity (cock-up splint for radial nerve palsy, opponens/C-bar for median, MCP-flexion/knuckle-bender for ulnar claw), sensory re-education, protection of anaesthetic skin, motor re-education as reinnervation appears.
• Total hip replacement (posterior approach) precautions: no hip flexion beyond 90°, no adduction past midline, no internal rotation - so no low chairs, no squatting, no sitting cross-legged, no squat toilet, no bending to the floor. Train with raised toilet seat/commode chair, long-handled sponge, shoe horn, sock aid, reacher, and side-sitting car transfer. Anterior approach restricts extension and external rotation instead.
• Total knee replacement: early transfers and gait with walker, extension emphasis (avoid pillow under the knee), graded sit-to-stand and stair training, toilet and bathing setup; squatting and floor sitting generally not advised long term.
• Amputation: pre-prosthetic phase - stump hygiene, compression bandaging in a figure-of-eight, desensitisation and tapping for phantom and residual limb pain, contracture prevention (no prolonged hip/knee flexion), change of dominance training for upper-limb loss, one-handed ADL; prosthetic phase - donning/doffing, terminal-device control (body-powered: scapular abduction and humeral flexion; myoelectric: site selection and muscle training), wear tolerance schedule, bilateral and functional task practice, ADL with prosthesis.
• Low back pain and spinal conditions: back-care education, neutral spine, log-roll, hip-hinge lifting, load close to the body, avoid combined flexion-rotation, pacing and graded activity, core and postural retraining, workstation and seating correction, avoidance of fear-avoidance behaviour; OT addresses lifting technique in porters, nurses, drivers and farm workers.
• Soft-tissue and overuse: lateral epicondylitis (counterforce brace, grip-tool modification, eccentric loading), carpal tunnel syndrome (neutral wrist night splint, tool and keyboard change, nerve-gliding), de Quervain's (thumb spica), frozen shoulder (ROM, functional reach, sustained stretch in activity), trigger finger.
• Burns and trauma to the hand: anti-deformity positioning (wrist extension, MCP flexion, IP extension, thumb abduction), pressure therapy, splinting across healing tissue, early functional use.

Rheumatology: joint protection, energy conservation and work simplification

• Conditions: rheumatoid arthritis (symmetric, small joints, morning stiffness > 30-60 min, systemic), osteoarthritis (load-bearing, activity pain, crepitus), ankylosing spondylitis (inflammatory back pain, chest and spine stiffness), juvenile idiopathic arthritis, gout, SLE, fibromyalgia, osteoporosis.
• RA deformities to recognise: ulnar drift at MCPs, swan-neck (PIP hyperextension, DIP flexion), boutonnière (PIP flexion, DIP extension), Z-deformity of the thumb, trigger finger, wrist volar subluxation and radial deviation, hallux valgus, hammer toes.
• Joint protection principles (classic exam list): respect pain; balance rest and activity; use the largest and strongest joints; distribute load over several joints; avoid sustained static grip and prolonged positions; avoid positions of deformity (no tight pinch - use lateral or two-handed grips); use correct patterns of movement; reduce force and effort with levers and built-up handles; avoid stopping an activity you cannot complete comfortably; use assistive devices and labour-saving equipment.
• Energy conservation (the four P's): Plan, Prioritise, Pace, Position. Also - sit to work, keep items within reach, alternate heavy and light tasks, rest before exhaustion, delegate, batch errands, use wheeled trolleys.
• Work simplification: eliminate unnecessary steps, combine tasks, slide instead of lift, use both hands symmetrically, store at waist height, use lightweight utensils, pre-soak instead of scrubbing, use mixer/pressure cooker instead of grinding by hand - directly relevant to Indian kitchen routines.
• Exercise prescription: gentle active/active-assisted ROM daily even in flare; isometrics during acute inflammation; isotonic strengthening and aerobic work once inflammation settles; avoid resisted exercise in an actively inflamed joint; hydrotherapy where available.
• Modalities as adjuncts (not substitutes): paraffin wax bath and hot packs for chronic stiff hands before activity; cold for an acutely inflamed joint; TENS for pain - used to make occupation possible, then withdrawn.
• Flare management: reduced activity, resting splints, cold, positioning, carer education; escalate to the rheumatologist for medication review.
• Patient education: disease nature, drug adherence (DMARDs, biologics), foot care and footwear, fatigue, sleep, mood, sexuality, pregnancy planning, nutrition and bone health.

Splinting and orthotics

• Purposes: protect and rest, immobilise healing tissue, prevent or correct deformity, substitute for lost motor power, position for function, mobilise a stiff joint, restrict unwanted motion.
• Classification by action: static (no moving part - resting pan splint, cock-up, thumb spica), serial static (remoulded progressively), static progressive (inelastic adjustable component applies stress), dynamic (elastic/spring force - outrigger with finger loops, knuckle-bender), functional/tenodesis (uses one motion to produce another).
• Classification by purpose: protective, corrective, functional/assistive, substitutive.
• ASHT nomenclature pattern: name the joint(s) included and the direction - e.g. wrist extension immobilisation orthosis, MCP flexion mobilisation orthosis.
• Materials: low-temperature thermoplastics (softened at about 60-70 °C in a hydrocollator/water bath; perforated for ventilation, self-bonding or non-bonding), plaster of Paris for serial casting, neoprene and elastic for soft supports, aluminium strips, wire outriggers, Velcro straps.
• Biomechanical rules: three-point pressure principle; longer lever arm reduces pressure; wide straps and contoured troughs spread force; 90° line of pull for dynamic traction; low-load prolonged stress remodels tissue better than high-load brief stress; respect arches of the hand and bony prominences; two-thirds forearm length and one-half forearm circumference for a forearm-based splint.
• Common splints: resting hand splint (RA, burns) - wrist 20-30° extension, MCPs 60-70° flexion, IPs near extension, thumb abducted; volar cock-up for carpal tunnel - wrist near neutral (0-10°); ulnar deviation/MCP alignment splint; swan-neck (figure-of-eight silver ring) splint; thumb CMC stabilising splint for thumb-base OA; dorsal blocking splint after flexor repair; mallet finger DIP splint; dynamic MCP flexion splint; knuckle-bender for ulnar claw.
• Precautions and review: check for pressure areas, numbness, oedema distal to straps, skin breakdown in anaesthetic hands; give a written wearing schedule; teach exercises out of the splint; review fit as oedema settles; in hot humid Indian conditions prefer perforated material and washable liners.

Assistive devices, adaptation, work and Indian practice context

• Self-care devices: built-up handles, universal cuff, rocker knife, plate guard, non-slip mat, long-handled comb/sponge, button hook, zipper pull, elastic laces, sock aid, reacher, jar opener, tap turner, key holder, raised toilet seat, commode chair over a squat pan, grab bars, shower chair, bath board.
• Mobility and transfer aids: walker, elbow crutches, quadripod cane, transfer board, wheelchair cushion and seating; a device is prescribed only after measuring the user and the home.
• Home modification in the Indian setting: ramps, threshold removal, Western commode conversion or raised seat over a squat pan, grab bars at toilet and bath, anti-skid flooring, raised beds for THR patients, chairs with arms and firm high seats, kitchen counter height adjustment.
• Work and vocational OT: job analysis, work conditioning, work hardening, graded return to work, tool redesign, sit-stand alternation, micro-break scheduling, workstation ergonomics (monitor at eye level, elbows about 90°, feet supported, wrist neutral, document holder).
• Indian legal and policy context: National Commission for Allied and Healthcare Professions Act, 2021 - statutory recognition and registration of occupational therapists through central and state councils; RCI Act, 1992 - registration for professionals working in disability; RPwD Act, 2016 - 21 specified disabilities (including locomotor disability, muscular dystrophy, chronic neurological conditions), 40% benchmark disability, reservation and accessibility duties, certification by notified boards using gazetted guidelines for assessing locomotor disability (the 2018 Gazette guidelines, as amended) - OT findings feed the functional assessment; ADIP scheme (DEPwD) funds aids and appliances, often ALIMCO-supplied; Ayushman Bharat PM-JAY and CGHS/ESIC packages fund parts of rehabilitation; the four Labour Codes, in force from 21 November 2025, replaced the Factories, Minimum Wages, Industrial Disputes and BOCW Acts, and occupational safety and health of workers now sits under the OSH&WC Code - relevant where an OT advises on injured workers' return to duty. Employees' compensation for work injury continues under the law as consolidated in the Codes; name the provision rather than a section number unless certain.
• Documentation: SOAP notes, initial evaluation, goal sheet with timelines, re-assessment, discharge summary with home programme; medico-legal value in work-injury and disability certification cases.

Key points

• Occupation-centred goal - the OT goal is written as an activity ("feeds self with built-up spoon independently in 2 weeks"), not as "improve ROM".
• Biomechanical model - used in orthopaedics; assumes intact CNS and works on ROM, strength and endurance.
• TAM - total active motion of a finger = sum of active MCP + PIP + DIP flexion minus extension deficits; normal ≈ 260°.
• MMT grades - 0 none, 1 flicker, 2 full ROM gravity-eliminated, 3 full ROM against gravity, 4 against moderate resistance, 5 normal.
• Grip measurement - Jamar dynamometer, second handle position, mean of three trials, both hands compared; dominant hand usually about 10% stronger.
• Joint protection - respect pain, use the largest joints, distribute load, avoid static grip and deformity positions, reduce effort.
• Four P's of energy conservation - Plan, Prioritise, Pace, Position.
• Resting hand splint position - wrist 20-30° extension, MCP 60-70° flexion, IPs near extension, thumb abducted and opposed.
• Carpal tunnel night splint - wrist at or near neutral, not in extension, because neutral gives the lowest canal pressure.
• Posterior THR precautions - no flexion beyond 90°, no adduction past midline, no internal rotation; squat toilets and floor sitting are out.
• TKR emphasis - achieve and keep full knee extension; avoid a pillow under the knee.
• Pre-prosthetic training - stump care, figure-of-eight compression, desensitisation, contracture prevention, change of dominance.
• Static vs dynamic splint - static immobilises; dynamic applies elastic traction to allow controlled motion and remodel tissue.
• Low-load prolonged stress - the principle behind serial static and dynamic splinting for a stiff joint.
• RA deformities - ulnar drift, swan-neck, boutonnière, Z-thumb; splints align, they do not cure.
• Outcome measures - DASH/QuickDASH (upper limb), PRWE (wrist), WOMAC/KOOS (knee and hip OA), ODI (back), HAQ (RA), Barthel/FIM (ADL).
• Acute inflammation rule - isometrics and gentle ROM only; no resisted exercise in a hot, swollen joint.
• Indian statutes to quote - NCAHP Act 2021 (registration), RPwD Act 2016 (rights, 40% benchmark), RCI Act 1992, ADIP scheme for aids.

Formulas and examples

Example 1 - TAM after a flexor tendon repair. Index finger six weeks post-repair: active flexion MCP 80°, PIP 70°, DIP 40°; extension deficits MCP 0°, PIP 20°, DIP 10°.

• Flexion sum = 80 + 70 + 40 = 190°.
• Extension deficit sum = 0 + 20 + 10 = 30°.
• TAM = 190 − 30 = 160°; % of normal = 160/260 × 100 = 61.5% - "fair" by Strickland-type banding, so the plan continues with blocking and tendon-gliding exercises and a PIP extension mobilisation orthosis for the 20° contracture.

Example 2 - grip deficit and work readiness. Right-dominant 34-year-old mason, 10 weeks after a right distal radius fracture. Jamar, second position, mean of three trials: right 18 kgf, left 36 kgf.

• Grip deficit = (36 − 18)/36 × 100 = 50%.
• In newtons: 18 × 9.81 ≈ 176.6 N (right), 36 × 9.81 ≈ 353.2 N (left).
• His job needs sustained two-handed loads; at a 50% deficit he is not fit for full duty. Plan: 4 weeks of graded resistance plus work conditioning, target deficit under about 20% (allowing ~10% for dominance), with re-testing weekly and a brick-handling simulation at the end.

Example 3 - hand oedema by volumetry. Left hand (affected) 480 mL, right hand 420 mL by water displacement.

• Difference = 60 mL; % difference = 60/420 × 100 = 14.3% - well above the ~3-5% measurement-error band, so oedema is real. After 2 weeks of elevation, retrograde massage, compression glove and active pumping: left 438 mL → difference 18 mL (4.3%), a 42 mL reduction; progress to resisted grip work.

Example 4 - QuickDASH before and after. A 52-year-old teacher with lateral epicondylitis scores the 11 items as 4,4,3,4,3,4,5,4,3,4,4 at baseline.

• Sum = 42; mean = 42/11 = 3.818; score = (3.818 − 1) × 25 = 70.5.
• After 8 weeks (counterforce brace, grip-tool change, eccentric loading, board-writing modification) the items sum to 22: mean = 2.0; score = (2.0 − 1) × 25 = 25.0.
• Improvement = 70.5 − 25.0 = 45.5 points, far above the usual minimal clinically important difference quoted around 8-11 points for QuickDASH (the exact MCID varies by population).

Example 5 - lifting advice for a nurse with low back pain (NIOSH). Load 16 kg; H = 40 cm → HM = 25/40 = 0.625; V = 30 cm → VM = 1 − 0.003|30 − 75| = 1 − 0.135 = 0.865; vertical travel D = 50 cm → DM = 0.82 + 4.5/50 = 0.91; asymmetry 30° → AM = 1 − 0.0032 × 30 = 0.904; frequency 2 lifts/min for a short duration → FM ≈ 0.91; fair coupling → CM = 0.95.

• RWL = 23 × 0.625 × 0.865 × 0.91 × 0.904 × 0.91 × 0.95 = 8.84 kg (rounded).
• LI = 16/8.84 = 1.81 (> 1 → unacceptable risk).
• Intervention: bring the load to H = 25 cm (HM = 1.0) and start at V = 75 cm (VM = 1.0) → RWL = 23 × 1 × 1 × 0.91 × 0.904 × 0.91 × 1.00 = 17.2 kg (fair coupling scores CM = 1.00 once V ≥ 75 cm), LI = 16/17.2 = 0.93; combined with a two-person lift or a hoist, the task becomes safe.

Where it is used

• Hospital hand and trauma units: hand therapy after tendon, nerve and distal radius injuries - Ganga Hospital Coimbatore, CMC Vellore, Sancheti Pune, AIIMS, PGIMER, Apollo, Fortis, Max; OTs fabricate custom thermoplastic splints in-house.
• Arthroplasty and orthopaedic wards: pre-operative education and post-operative ADL training for hip and knee replacements, including training around squat toilets and floor-level living.
• Rheumatology clinics and arthritis clinics: joint protection and energy conservation groups, hand assessment, splinting, HAQ-based outcome tracking, patient-education sessions with the rheumatology team.
• Limb-fitting and rehabilitation centres: pre-prosthetic and prosthetic training at SVNIRTAR Cuttack, NILD Kolkata, PDUNIPPD Delhi, NIEPMD Chennai and ALIMCO limb-fitting centres; ADIP-funded aids.
• Occupational health and industry: ergonomic assessment, injured-worker return-to-work programmes and work hardening in IT parks, automobile plants, textile units and BPOs; worker safety now governed by the OSH&WC Code.
• Community, geriatric and private practice: home modification and falls prevention after hip fracture, osteoporosis education, assistive-device prescription, telerehabilitation follow-up; roles include Occupational Therapist, Hand Therapist, Rehabilitation Consultant, Ergonomics Consultant, Assistive Technology Specialist, and faculty posts in BOT/MOT colleges.

Interview questions

• Q: What is the difference between occupational therapy and physiotherapy in an orthopaedic ward? A: Both restore movement, but OT frames the goal as resumption of occupation - self-care, home, work - and adds splinting, assistive devices, ADL retraining, home and workplace adaptation; PT focuses mainly on movement, gait and exercise therapy.
• Q: List the joint protection principles. A: Respect pain; balance rest and activity; use the largest and strongest joints; distribute load over several joints; avoid sustained static grip and prolonged fixed positions; avoid positions of deformity; reduce force with levers, built-up handles and devices; use correct movement patterns.
• Q: What is the correct position for a resting hand splint in rheumatoid arthritis? A: Wrist in 20-30° extension, MCPs in 60-70° flexion, IP joints near full extension, thumb abducted and slightly opposed - the position that preserves the arches and discourages deformity.
• Q: Why is a carpal tunnel night splint made in neutral rather than in 30° extension? A: Carpal tunnel pressure is lowest near neutral; extension raises intracanal pressure and worsens nocturnal symptoms.
• Q: State the posterior total hip replacement precautions and give two Indian-context adaptations. A: No hip flexion beyond 90°, no adduction past midline, no internal rotation. Adaptations: a raised commode seat or commode chair placed over a squat pan, and a high firm chair with arms instead of floor sitting or cross-legged sitting.
• Q: Difference between a static progressive and a dynamic splint? A: A static progressive splint holds the joint at its end range with an inelastic adjustable component and the tension is changed manually; a dynamic splint applies a continuous elastic force and allows motion within it.
• Q: How do you measure and interpret grip strength? A: Jamar-type dynamometer at the second handle position, standard seated posture, mean of three trials for each hand; compare with the uninvolved side, allowing roughly 10% for dominance, and track change over time.
• Q: What does TAM tell you after a flexor tendon repair? A: It quantifies active finger motion - flexion sum minus extension deficits, normal about 260°; the percentage of normal grades the outcome and directs whether to work on gliding or on an extension contracture.
• Q: A rheumatoid arthritis patient's wrist is hot, swollen and painful today. What exercise do you prescribe? A: Gentle active or active-assisted ROM within pain limits and isometrics only, with a resting splint, cold and positioning; resisted exercise is deferred until inflammation settles.
• Q: What is energy conservation and when is it indicated? A: Planning, prioritising, pacing and positioning to spend less energy for the same output - indicated in RA, SLE, fibromyalgia, post-operative deconditioning and any fatiguing chronic condition.
• Q: Which Act gives occupational therapists statutory recognition in India, and which Act governs disability rights? A: The National Commission for Allied and Healthcare Professions Act, 2021 provides for registration and regulation of allied and healthcare professionals including OTs; the Rights of Persons with Disabilities Act, 2016 governs disability rights, benchmark disability and accessibility, and the RCI Act, 1992 covers registration for disability-sector work.
• Q: A labourer with chronic low back pain must return to lifting work. What do you do? A: Carry out a job and lifting analysis (NIOSH lifting index, REBA), run a graded work conditioning programme, retrain lifting technique (load close, hip hinge, no combined flexion-rotation), and negotiate task or tool modification with the employer before full return.

Common mistakes

• Writing impairment goals ("increase ROM by 10°") instead of occupation goals, and losing marks for not being occupation-centred.
• Making a resting hand splint with the MCPs extended and the wrist flexed - the position of deformity.
• Forgetting the uninvolved joints during immobilisation, so the shoulder and fingers stiffen while the wrist fracture heals.
• Applying resisted exercise to an actively inflamed rheumatoid joint, or stopping all movement during a flare instead of gentle ROM.
• Prescribing a device or home modification without measuring the patient and visiting or questioning about the actual home - a Western commode recommendation is useless where only a squat pan exists.
• Confusing static, serial static, static progressive and dynamic splints, or quoting dynamic traction without the 90° line of pull.
• Reporting raw dynamometer or ODI numbers without the comparison side, the denominator or the scale maximum, which makes the figure uninterpretable.

Related topics

Occupational therapy in neurological conditions: stroke, spinal cord injury and brain injury · Biomechanics and kinesiology of the upper limb · Prosthetics and orthotics · Occupational therapy in mental health · Ergonomics and work rehabilitation · Therapeutic exercise and physical agent modalities