What intervention does the nurse perform to test the Stereognosis of a patient?

6 How can you appreciate the sensory discrimination of a finger pulp?

By using the two-point discrimination test described by Weber. The points of calipers are held against the skin at different distances from each other. The test determines the minimal distance at which the patient can distinguish whether one or two points are in contact with the skin. The patient must be comfortable, and the examiner must avoid pushing against the calipers with his/her fingers, thereby artificially increasing the pressure. The higher the pressure, the wider the area of skin that is deformed and stimulated. One or two points are touched in a random sequence along a longitudinal axis in the center of the finger tip. The American Society for Surgery of the Hand recommends seven correct answers out of 10 for two-point discrimination.

Discrimination

Discrimination, the second level in the sensibility assessment continuum, assesses a patient's capacity to perceive stimulus A from stimulus B. This requires detection of each stimulus as a separate entity and the ability to distinguish between the two. Discrimination requires finer reception acuity and more judgment on the part of the patient than first-level detection does.

Weber's two-point discrimination test is the most commonly used method of assessing sensibility of the upper extremity. Affording better accuracy and consistency, specialized commercial, handheld, two-point instruments have replaced the once used unfolded paperclip. With the instrument tips oriented longitudinally on the digit, the examiner randomly applies one or two points to the hand, relying on absence of skin blanching to control the amount of force applied. Following each stimulus, the patient reports whether he feels one or two points. The narrowest tip width at which the patient makes 7 of 10 correct responses is the distance reported. (Note: The number of correct responses required may vary slightly from examiner to examiner.) Bell and Buford reported that, even with experienced examiners, the amount of force applied between one and two points easily exceeds the resolution or sensitivity threshold for normal sensation.6,8 They also noted that the tremendous variance in pressures applied resulted in poor levels of interrater reliability. This perhaps explains some of the lack of agreement in reporting discriminatory function.

Sensory Examination

The sensory examination is the most difficult component of the neurological examination to perform accurately. It depends on patients' alertness, audition, ability to cooperate and comprehend, and understanding of questions about subtle differences. Unlike tendon reflexes or the cranial nerve examinations, the sensory examination is strictly subjective (DeJong, 1967, pp. 58–61). The sensory examination is optimally performed at the mid-point of neurological examination, after the possible confounding factors listed above are apparent to the examiner. The elements of the sensory evaluation are performed preferably in this order: light touch, pain, temperature, vibration, position sense, two-point discrimination and judging of weights, as the latter three functions depend on the integrity of the first four elements of the sensory examination (Monrad-Krohn and Refsum, 1958, pp. 156–161).

The multiple types of stimuli employed in the modern sensory examination evolved from several basic observations about sensation. Ernest Heinrich Weber (1795–1878) distinguished light touch from pain. Weber tested the ability of subjects to distinguish two sharpened points as two loci of pain. His method of testing is used today as the so-called two-point discrimination test of cutaneous sensitivity (Weber, 1846).

Johannes Müller (1808–1858) provided the theory of specific nerve energies, that a specific nerve carries only a specific sensation to the sensorium (Boring, 1942). Max von Frey (1852–1932) postulated that specific end-organs of cutaneous nerve fibers detect specific sensations. He invented a method of grading pressure sensitivity with horse hairs that are calibrated to provide information about the amount of pressure that patients can detect (von Frey, 1896). Nylon monofilaments of various thicknesses replaced horse hairs, still called von Frey hairs, to gauge pressure sensitivity.

To test temperature sensation accurately, Mills suggested that “objects of different temperatures, but same size and same thermal conductivity,” should be applied to the skin (Mills, 1898, p. 156).

Mills and Gowers suggested using the two points of a drawing compass to test the smallest distance at which these points can be distinguished as double (Mills, 1898, p. 155; Gowers, 1888, pp. 30–31). They advised that the skin must be touched simultaneously and with equal pressure to accurately test two-point discrimination. These authors concurred that the tip of the tongue (1.5 mm) and finger tips (2–3 mm) were far more sensitive than the cheeks and the back of the hands (12 mm).

To control the subjectivity of the sensory examination, Monrad-Krohn advised that the examiner avoid making suggestions and employ various stimuli in a given area of the body in order not to lull the patient into inattention. The patient should point to or draw the line of demarcation between decreased and fully sensate areas (Monrad-Krohn and Refsum, 1958, pp. 154–156). A sharp end of a broken wooden cotton-tipped applicator stick can be used conveniently for testing pain. The cotton-covered remainder is reserved for testing sensitivity to light touch. To affirm validity of light touch or pain loss, DeJong cautioned that the zone of demarcation between normal sensation and decreased sensation should be retested with eyes closed (DeJong, 1967, pp. 58–61).

Gowers' and Mills' texts, and the many editions of Church and Peterson up to 1925, did not include vibration in their battery of sensory testing. In 1929, Jelliffe and White listed vibration testing as one of their 20 tests for sensation. These authors recommended testing for vibration sense with 64 to 512 Hz tuning forks. Monrad-Krohn and Refsum, 1958, (pp. 164–165) noted that the perception of vibration disappeared first for 512 Hz rather than lower frequencies in patients with tabes dorsalis. Vibratory sensory threshold increases with age (Pearson, 1928). These authors included tests never used today, such as testicular sensitivity to light and painful pressure (Jelliffe and White, 1929, pp. 125–126).

Knowledge about the dermatomes, regions of skin supplied by each dorsal root, was roughly mapped by 1900. Charles Sherrington (1857–1952) working primarily with monkeys, cut the roots above and below the one he then tested and mapped (Sherrington, 1898). Otfrid Foerster (1873–1941), a German neurologist and neurosurgeon, cut dorsal roots in a number of patients suffering from herpes zoster or war wounds and mapped out the dermatome schema that we commonly use today (Foerster, 1933).

Henry Head and Gordon Holmes found that parietal lobe lesions impaired patients' ability to recognize objects placed in their hands (astereognosis), to accurately discriminate two-point from one-point stimulation, and to localize stimuli applied simultaneously to opposing parts of the body (Head and Holmes, 1912).

Sensory Function

Refer to Chapter 5 for specific evaluation protocols. The following is meant to serve as a review of the pertinent tests and the procedures used in evaluating clients with nerve injury:

Semmes-Weinstein Pressure Aethesiometer.

This is a graded light touch testing instrument consisting of a kit of 20 nylon monofilament probes. The monofilaments are used by the therapist to map light touch sensibility in the hand. An abbreviated kit is also available.

Two-point discrimination testing.

According to Moberg (cited by Callahan13) (1995), one of the best indicators of eventual function following a peripheral nerve injury is the return of two-point discrimination. Static two-point discrimination13 and moving Two-Point Discrimination Tests assess the client's ability to discriminate between one point and two points of pressure applied randomly to the fingertip.

Localization of touch.

Neither of the aforementioned tests requires the client to identify the location of the stimulus. Localization requires a more integrated level of perception than simple recognition of a stimulus.13 Localization is appropriate for testing after a nerve repair because difficulty with localization of a stimulus is a common phenomenon following nerve injury. Poor localization can impair function significantly.

The therapist can catalog the client's accuracy in localizing light touch stimuli by using the lowest Semmes-Weinstein monofilament that can be perceived in the area of dysfunction. Ask the client to close the eyes and to indicate verbally if he or she feels the stimulus. Each time the client answers in the affirmative, ask the client to open the eyes and to point to the exact spot touched. The therapist should record the client's results on a gridlike map of the hand, indicating the actual location of stimulation and the sites of referred touch perception. The therapist can draw arrows on the grid to indicate referred perception sites. This test has no formal interpretation or scoring; rather, evidence of poor localization is useful when determining the need for and when planning a sensory reeducation program.

Moberg Pickup Test.

This is a useful test for assessing median nerve function. The test may be helpful for testing children or adults who have cognitive involvement or who may have secondary agendas that prevent them from full participation in other sensory tests.

Hoffmann-Tinel sign.

Following trauma, gentle percussion along the course of the injured, regenerating nerve produces a temporary tingling sensation in the distribution of the injured nerve up to the site of regeneration. The tingling persists several seconds. Test from distal to proximal for best accuracy. If this sign is absent or is not progressing distally as would be expected with a healing nerve, there is a poor prognosis for continued nerve recovery. Likewise, a progressing Tinel's sign is encouraging but does not necessarily predict complete recovery.

Table 12-3 gives a summary of light touch sensibility testing, standardized tests, and techniques for administration and scoring and interpretation of scores.

Assessment of Sensory Function

•

Semmes-Weinstein monofilament testing: This is a graded light-touch testing instrument consisting of a kit of twenty nylon monofilament probes. The monofilaments are used by the therapist to map light-touch sensibility in the hand. An abbreviated kit is also available.

Two-point discrimination testing: According to Moberg, a good indicator of eventual fine motor function following a peripheral nerve injury is the return of two-point discrimination.18 He asserts that 6 mm of two-point discrimination is needed to wind a watch, 6-8 mm for sewing and 12 mm for handling precision tools. Static two-point discrimination and moving two-point discrimination tests assess the client’s ability to discriminate between one point and two points of pressure applied randomly to the fingertip. Moving two-point discrimination returns before static two-point discrimination.

Localization of touch: Neither of the aforementioned tests requires the client to identify the location of the stimulus. Localization requires a more integrated level of perception than simple recognition of a stimulus. Localization is appropriate for testing after a nerve repair because difficulty with localization of a stimulus is a common phenomenon following nerve injury. Poor localization can impair function significantly.

The therapist can record the client’s accuracy in localizing light-touch stimuli by using the lowest Semmes-Weinstein monofilament that can be perceived in the area of dysfunction. Ask the client to close the eyes and to indicate verbally if he or she feels the stimulus. Each time the client answers in the affirmative, ask the client to open the eyes and to point to the exact spot touched. The therapist should record the client’s results on a grid-like map of the hand, indicating the actual location of stimulation and the sites of referred touch perception. The therapist can draw arrows on the grid to indicate referred perception sites. This test has no formal interpretation or scoring; rather, evidence of poor localization is useful when determining the need for and when planning a sensory reeducation program.

Moberg pickup test: This is a useful test for assessing median nerve function. The test may be helpful for testing children or adults who have cognitive involvement or who may have secondary agendas that prevent them from full participation in other sensory tests.

Hoffmann-Tinel sign: Following trauma, gentle percussion along the course of the injured, regenerating nerve produces a temporary tingling sensation in the distribution of the injured nerve up to the site of regeneration. The tingling persists several seconds. Test from distal to proximal for best accuracy. If this sign is absent or is not progressing distally as is expected with a healing nerve, there is a poor prognosis for continued nerve recovery. Likewise, a progressing Tinel’s sign is encouraging but does not necessarily predict complete recovery. Table 24-3 gives a summary of light-touch sensibility testing, standardized tests, and techniques for administration, scoring, and interpretation of scores.

Typical Clinical Presentation

Paresthesia, pain, and numbness or tingling in the palmar surface of the hand in the distribution of the median nerve (Fig. 7.2) (i.e., the palmar aspect of the three and one-half radial digits) are the most common symptoms. Nocturnal pain is also common. Activities of daily living (such as driving a car, holding a cup, and typing) often aggravate pain. Pain and paresthesia are sometimes relieved by the patient massaging, shaking the hand, or placing it in a dependent position.

Several provocative tests should be considered to aid in the evaluation and diagnosis of CTS. No one test has been identified as a gold standard for identifying CTS. In a meta-analysis of the literature (Keith et al. 2009) Phalen test results ranged in sensitivity from 46% to 80% and in specificity from 51% to 91%. The Tinel sign ranged in sensitivity from 28% to 73% and in specificity from 44% to 95%. The median nerve compression test, Durkan test (Durkan 1991), ranged in sensitivity from 4% to 79% and in specificity from 25% to 96%. Combining the results of more than one provocative test might increase the sensitivities and specificities. For example, combined results of the Phalen and median nerve compression tests yielded a sensitivity of 92% and a specificity of 92%.

The Sense of Touch

Our senses are the windows through which we perceive our environment. Hearing, vision, taste, smell, and the sense of touch together provide our mind with an inner picture of the outer world. For the sense of touch, the hand is a key organ with huge cortical representation, and the sensation has therefore a vital role in hand function. Lost or impaired hand sensation after nerve injury is a major problem, causing not only considerable body function impairment but also substantial disability and reduction in life quality.

Four major modalities of somatic sensibility can initially be defined: the pure and discriminative touch, proprioception, nociception, and temperature sense. For clinical examination of hand sensibility, a hierarchy of sensory functions can be identified: if detection of touch is present, the next level is to examine if the patient can discriminate the touch—the most basic tactile gnosis. Two-point discrimination test is the classic test here—although the validity and reliability is disputed. Localization of touch is also an aspect of discriminative touch. Identification by active touching is the third level—a more refined tactile gnosis. Functional sensibility—or what some name haptics—is the endpoint where tactile gnosis acts in concert with muscles and joints for a useful grip function.

The eye is dominant over other senses such as hearing and touch. However, fine detail of microstructure obtained through touch will provide considerable additional detail. More than 100 years ago, von Frey and Weber investigated clinical methods to describe the capacity to detect touch and spatial acuity, respectively. Spatial acuity is the smallest discriminated distance between two points of contact. Moberg paid further attention to the importance of tactile discrimination, and established the term “tactile gnosis.” Tactile gnosis enables recognition of qualities and characters of objects without using vision, which is of utmost importance for functional sensibility—a prerequisite for what the hand can do. Napier described the hand as “an organ of touch which feels around corners and sees in the dark.” The sense of touch can provide us with information not only about shape and texture but also about temperature, consistency, elasticity, density, dryness, wetness, stickiness, and oiliness. Discriminative touch, the basis for tactile gnosis, is based on various types of sensory receptors found in the glabrous and hairy skin which are sensitive to mechanical stimulation, transducing mechanical stimuli such as pressure, vibration, and stretching. Afferent signals pass from cutaneous mechanoreceptors of dorsal root ganglion cell axons via the dorsal column-medial lemniscus pathway to the ventroposterior thalamus and somatosensory cortex. Signals elicited by touch primarily reach the contralateral hemisphere, but to a lesser extent also the ipsilateral somatosensory cortex. The somatosensory cortex has a complex multidimensional functional architecture with three major divisions: the primary (S-I) and secondary (S-II) somatosensory cortices and the posterior parietal cortex. In the primary sensory cortex there are four distinct somatotopic maps corresponding to the four areas of S-I that have been identified by Brodmann named 1, 2, 3a, and 3b; each map represents one sub-modality of sensation. Information from the skin, important for touch, is primarily represented in area 3b.

The Sense of Touch

Our senses are the windows through which we perceive our environment. Hearing, vision, taste, smell, and the sense of touch together provide our mind with an inner picture of the outer world. For the sense of touch, the hand is a key organ with huge cortical representation, and the sensation has therefore a vital role in hand function. Lost or impaired hand sensation after nerve injury is a major problem, causing not only considerable body function impairment but also substantial disability and reduction in life quality.

Four major modalities of somatic sensibility can initially be defined: the pure and discriminative touch, proprioception, nociception, and temperature sense. For clinical examination of hand sensibility, a hierarchy of sensory functions can be identified: if detection of touch is present, the next level is to examine if the patient can discriminate the touch – the most basic tactile gnosis. Two-point discrimination test is the classic test here – although the validity and reliability is disputed. Localization of touch is as well an aspect of discriminative touch. Identification by active touching is the third level – a more refined tactile gnosis. Functional sensibility – or what some name haptics – is the endpoint where tactile gnosis acts in concert with muscles and joints for a useful grip function.

In the interplay between the senses, the eye remains at the surface, while hearing and the touch of the hand obtain information on the inner of an object, the microstructure, thereby playing a great role in developing a belief in the reality of the external world. More than a 100 years ago, von Frey and Weber paid attention to clinical methods to describe the capacity to detect touch and spatial acuity, respectively. Spatial acuity is the smallest discriminated distance between two points of contact. Moberg paid further attention to the importance of tactile discrimination, and established the term ‘tactile gnosis.’ Tactile gnosis enables recognition of qualities and characters of objects without using vision, which is of utmost importance for functional sensibility – a prerequisite for what the hand can do. Napier described the hand as “an organ of touch which feels around corners and sees in the dark.” The sense of touch can provide us with information not only about shape and texture but also about temperature, consistency, elasticity, density, dryness, wetness, stickiness, and oiliness. The discriminative touch, the basis for tactile gnosis, is based on various types of sensory receptors found in the glabrous and hairy skin which are sensitive to mechanical stimulation, transducing mechanical stimuli such as pressure, vibration, and stretching. Afferent signals from cutaneous mechanoreceptors of the hand reach the somatosensory brain cortex after passing the dorsal root ganglia, the dorsal column of the spinal cord via the medial lemniscuses pathway, and intermediate relay stations situated in the cuneate nucleus in the brain stem and the ventroposterior nucleus in thalamus. Signals elicited by touch primarily reach the contralateral hemisphere, but to a lesser extent also the ipsilateral somatosensory cortex. The somatosensory cortex has a complex multidimensional functional architecture with three major divisions: the primary (S-I) and secondary (S-II) somatosensory cortices and the posterior parietal cortex. In the primary sensory cortex there are four distinct somatotopic maps corresponding to the four areas of S-I that have been identified by Brodman named 1, 2, 3a, and 3b; each map represents one subquality of sensation. Information from the skin, important for touch, is primarily represented in area 3b.

The Evaluation

Begin your evaluation with an interview to determine the client’s expectations of the outcomes from the planned surgery. When working with a child, meet and discuss this with the family as well. The evaluation should also include the following:

Assess the client’s ability to comply with the postoperative rehabilitative protocol. It is helpful if you have already worked with the client through their post trauma rehabilitation, but you can still develop a rapport with the client at any point by explaining concepts; developing a working relationship as coach, educator, and partner; and forming a treatment plan geared toward function.

Record a detailed history of the injury, all of the surgical procedures, and all of the therapy that has taken place up to this point, leading to the decision for tendon transfer surgery.

Examine the affected extremity; observe and record the skin appearance and the placement of scars, adhesions, atrophy of muscles, prominent bony landmarks, and skin coloring.

Determine sensory status using the Semmes-Weinstein monofilament test, two-point discrimination testing, and/or stereognosis testing.9,14 When working with children, you will need to closely observe how they integrate the use of their involved hand into play. You can incorporate a game of stereognosis to determine their ability to interpret sensory input in their involved hand. Stereognosis refers to the ability to perceive and recognize the form of an object using cues from its size and texture. Evaluating a child may be a bit more challenging, but it is possible through creative and interactive play and by discussing your observations of the use of the affected extremity with the parents.9,13

Take active range of motion (AROM) and passive range of motion (PROM) measurements. Evaluate each joint carefully to ascertain whether it has a hard or soft end feel, and note whether a contracture is present or if there is ligament laxity in the joint. If a contracture is present, you need to address this prior to surgery. If the joint is extremely lax, you should mention this to the surgeon so that the proper amount of tension can be applied during the surgery.

Evaluate the current use of the hand through functional testing, such as the Jebsen Hand Function Test (JHFT), the functional dexterity test (FDT) (See Fig. 32-7), or the Moberg’s pickup test9,15.

In addition to the above assessments, observe the client’s movement patterns, and note all of the compensatory movement patterns.11,14 These are patterns of movement that your client may have begun to use to make up for the lack of normally functioning muscles. These movement patterns can lead to overstretching and weakening of muscles that are not yet injured. You will need to retrain your client not to use these patterns of movement after surgery. It is best to point these patterns out early and teach your client to recognize them. Instruct your client to avoid these movement patterns in preparation for the surgery.

Include one of the following client self-report outcome measures: the Canadian Occupational Performance Measure (COPM), Disabilities of the Arm, Shoulder, and Hand (DASH) or QuickDASH, or the Michigan Hand Outcomes Questionnaire (MHQ).13-17 These self-assessments contribute crucial information to an overall picture of how the client rates their own independent functioning, and theyhelp determine how your client views progress toward achievement of functional goals throughout the rehabilitation process.

Tips from the Field

A video recording and/or clinical pictures can greatly assist you in recording the preoperative functional level. You can even use your own cell phone or the client’s cell phone to do this. Just make sure to ask permission first. This is a great tool for assessing compensatory movement patterns, checking progress, and comparing how the client was functioning prior to surgery and after surgery in the course of rehabilitation.

At the conclusion of the assessments, record a list of the greatest functional needs of the client in their own words. Ask what they would most like to do with their involved hand. Hold a hairbrush? Drink from a soda bottle? Hold a water bottle so that they can open the cap independently? Do not make the mistake of telling the client what these goals should be. Let the client define in their own words what would they would like to accomplish. In the case of young children, let the parents step in and describe what they would like to see.

Perform manual muscle testing (Table 32-1) to determine what muscles are indeed paralyzed and what muscles may act as donor muscles. It is important to ensure that all possible donor muscles are strong enough to be transferred to new positions.2,4,13,18 Donor muscles should function at a grade of full ROM against gravity or higher.1,9 Selecting the muscles that are typically described as donor muscles in textbooks as being available without verifying that they are present and active is not enough. Not everyone may have a palmaris longus (PL) tendon available for transfer!3

Clinical Pearl

It is helpful to create a list of four muscle groups as follows:

What muscles are working? All muscles detected by manual muscle testing.

What muscles are not working? All muscles not detected by manual muscle testing.

What functions are needed? All motions needed to improve function.

What muscles are available? All expendable muscles with full ROM against gravity and some resistance13 (Fig. 32-8).

During the course of your evaluation, you can utilize an orthosis to simulate the proposed function of the tendon transfer. This can help a client see right away if changing the position of a specific joint can indeed improve function. For example, prior to opponensplasty (tendon transfers to restore thumb opposition), fabricate a short opponens thumb orthosis and observe the client’s ability to hold and/or pinch while wearing this orthosis.9-12 You may note that your client displays an improved pinch or an increased ability to hold a tool. Or you might try fabricating a wrist orthosis for a client contemplating tendon transfers for wrist extension. The ability to keep the wrist in extension greatly improves grasp and release patterns of the digits. Wearing a wrist orthosis might enable your client to demonstrate improved hand functioning. In addition, wrist support helps prevent shortening of the wrist flexors.9-12

Clinical Pearl

Help your client create realistic expectations and functional goals. Make sure they understand what the possible outcomes may be.

Explain terms and procedures so that your client can really understand you.

Once the donor muscles have been selected and a plan for surgical intervention is set, help the client prepare for the procedure both physically and emotionally.

Ask the surgeon if you, as the consulting therapist, can attend the tendon transfer surgery. This is a unique opportunity to gather information and make observations. It also allows you to see firsthand the status of the involved tendons, the strength of the repair, and what specific tendons were used (which might not be what was planned in advance).

What to Say to Clients

“The surgeon is going to reroute one of your working muscles to the joint where the muscle does not work. The therapy before the surgery is very important to get you ready and help make the surgery more successful. We need to make sure that your joints are nice and loose with passive motion exercises and stretching. We need to stretch the joint to full range of motion. In addition, I might have you wear an orthosis to maintain the stretch over time. I might have you wear the orthosis at night so that it doesn’t affect your ability to use your hand during the day. If your joint is tight, the donor tendon will not be able to move your joint through the full range of motion. We are going to try and exercise the donor muscle before the surgery to help it get stronger so that it will be ready to work in its new position.”

Donor muscle strengthening can be performed through progressive resistive exercises and/or through biofeedback and/or neuromuscular electrical stimulation9 (Fig. 32-9). An example of this would be strengthening of the pronator teres (PT) muscle prior to transferring this tendon to the insertion of extensor carpi radialis brevis (ECRB) for wrist extension after radial nerve palsy.

Clinical Pearl

It is extremely beneficial to enable your client to gain awareness of the donor muscle contraction and learn how to recruit it independently prior to surgery. Have your client place their noninvolved hand on the donor muscle belly during activity to feel the contraction. For example, let your client feel the PT muscle contracting during active pronation. If they cannot feel it easily, you can make their contraction stronger and more palpable by offering some resistance to their forearm in the direction of supination, and ask them not to let go. Let your client practice contracting this muscle first with self-applied resistance and gradually learn how to contract independently without resistance.

Make sure to inform clients of the loss of sensory input along the distribution of the injured peripheral nerve and the potential for burns and/or skin breakdown. It may be very obvious to your client when they have no feeling in the fingertips due to a median nerve or ulnar nerve injury. However, even the radial nerve has a sensory terminal branch, the dorsal sensory branch of the radial nerve. This area of insensate skin can be injured when the client begins to use their hand in activities of daily living (ADLs). Note bandage over dorsal first web in Fig. 32-10 where client burned herself removing items from a hot oven.

Throughout the course of the preoperative therapy program, engage your client in a discussion of realistic functional outcomes. Include the perspective of the surgeon in this dialog and the perspective of the parents if young children are involved. Discuss the time frame of surgery, postoperative immobilization, and postoperative course of therapy visits. Avoid surprises regarding the time and commitment expected afterward. Outline the schedule of follow-up visits with the surgeon as well, because many clients and their parents expect to see the surgeon at every therapy visit if therapy occurs in the physician’s office. Always strive to establish a genuine rapport with your client and create a solid working and trusting relationship.