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OT in Surgical Conditions (23AOT-501) - Detailed Descriptive Answers

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1. Brief Review of Methods of Evaluation and Therapeutic Principles

Methods of Evaluation in OT

• Patient history: mechanism of injury, occupation, handedness, prior surgeries
• Pain assessment: Visual Analogue Scale (VAS), Numeric Pain Rating Scale
• Functional history: activities of daily living (ADL) limitations, vocational impact

• Range of Motion (ROM): Measured with a goniometer for all joints; total active motion (TAM) and total passive motion (TPM) scores are used specifically in hand conditions
• Muscle Strength: Manual Muscle Testing (MMT) graded 0-5 (MRC scale); pinch and grip dynamometry (Jamar dynamometer)
• Sensory Testing: Semmes-Weinstein monofilaments (for threshold testing), static and moving two-point discrimination (2PD), Tinel's sign, Phalen's test
• Edema Measurement: Volumetry (water displacement) or circumferential tape measurement
• Functional Tests: Jebsen-Taylor Hand Function Test, Purdue Pegboard Test, Minnesota Manual Dexterity Test, DASH (Disabilities of Arm, Shoulder, Hand) questionnaire
• Wound Assessment: Appearance, stage, exudate, scar maturity (Vancouver Scar Scale)
• Psychological Assessment: Depression screening, motivation, compliance assessment

Therapeutic Principles in OT

1. Restoration of function - restoring maximal functional independence
2. Prevention of deformity - through splinting, positioning, and early mobilization
3. Purposeful activity - using occupation-based interventions rather than rote exercises
4. Graded activity - progressive increase in resistance, complexity, and duration
5. Patient education - home exercise programs, joint protection, energy conservation
6. Orthotic intervention - static (immobilization) and dynamic (mobilization) splints
7. Pain management - modalities such as TENS, ultrasound, fluidotherapy, paraffin wax bath
8. Psychological support - addressing fear-avoidance, body image concerns, return to work

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2. Objectives and Role of Occupational Therapy

• Reduce pain and edema
• Restore or maintain joint ROM and muscle strength
• Prevent secondary complications (contracture, adhesions, deformity)
• Restore sensory function and re-educate sensation
• Enable return to ADL, work, and community participation
• Fabricate and fit orthoses as needed

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A. Hand Injury

a. Review of Hand Evaluation

• Measured with a finger goniometer
• Composite fist, hook fist, table-top position used to identify zone of restriction
• TAM formula: sum of MCP + PIP + DIP flexion minus extension deficit

• Jamar dynamometer at position II for grip (normal ~46 kg men, ~26 kg women)
• Tip pinch, lateral (key) pinch, palmar (3-jaw chuck) pinch with pinch gauge

• Protective sensation: Semmes-Weinstein monofilament 2.83 = normal threshold
• Discriminative sensation: Static 2PD (normal < 6 mm in fingertip), Moving 2PD
• Tinel's percussion test along nerve course for reinnervation tracking

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b. Nerve Injuries - Classification, Repair, and Management

Classification of Nerve Injuries

• Grade I: Neuropraxia (conduction block only)
• Grade II: Axon disrupted, endoneurium intact
• Grade III: Axon + endoneurium disrupted, perineurium intact
• Grade IV: Axon + endoneurium + perineurium disrupted, epineurium intact
• Grade V: Complete nerve division

Nerve Repair Process

1. Wallerian degeneration occurs distal to the injury within 2-3 days
2. Schwann cell proliferation forms "bands of Bungner" as a scaffold
3. Axonal sprouting begins from the proximal stump
4. Regeneration rate: ~1 mm/day (or 1 inch/month)
5. Tinel's sign advances distally as regeneration progresses
6. Sensory re-education is needed once protective sensation returns

Management of Ulnar Nerve Injury

• Low ulnar palsy (wrist level): Loss of intrinsic muscles (interossei, hypothenar, 3rd/4th lumbricals). Results in claw hand (ring and little fingers - Benediction sign). Loss of key pinch. Froment's sign positive.
• High ulnar palsy (elbow level): Additional loss of FCU and medial FDP. Paradoxically, the claw is less severe (no FDP action to produce DIP flexion).

• Splinting: Anti-claw splint (MCP blocking splint) to prevent hyperextension of ring and little fingers; prevents secondary contracture
• Sensory re-education for ulnar nerve distribution (little finger, ulnar border of hand)
• ADL retraining for key pinch activities
• Strengthening of unaffected muscles; tendon transfer preparation
• Monitor for Tinel's progression

Management of Median Nerve Injury

• Low median palsy (wrist/carpal tunnel): Loss of thenar muscles (APB, OP, FPB-superficial head). Loss of opposition and precision pinch (ape thumb deformity). Sensory loss over thumb, index, middle, radial half of ring finger.
• High median palsy (elbow level): Additional loss of FPL, FDP to index/middle, pronator teres/quadratus, FDS. Loss of index/middle finger flexion and pronation.

• Opponens splint (short opponens splint) positions thumb in opposition to enable pinch
• Sensory re-education (tactile discrimination exercises, texture matching)
• Compensatory strategies for sensory-impaired dominant hand
• Progressive strengthening and functional re-education

Management of Radial Nerve Injury

• Classic presentation: Wrist drop (loss of wrist extensors, finger extensors, thumb extensors)
• High radial nerve palsy also loses triceps (elbow extension)
• Sensory loss over dorsoradial hand/first web space (superficial radial nerve)

• Dynamic wrist extension splint (lively splint) - restores functional grip by holding wrist in extension; prevents overstretching of extensors
• EDC-assisted extension dynamic splint for finger extension
• Saturday night palsy (humeral spiral groove injury) has excellent prognosis; wait-and-watch with serial EMG
• Tendon transfer preparation if no recovery by 3-6 months

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c. Tendon Injuries - Repair and Post-operative Management

Flexor Tendon Injuries

• Zone I: Distal to FDS insertion (only FDP)
• Zone II ("No Man's Land"): From A1 pulley to FDS insertion - most difficult; prone to adhesion
• Zone III: Lumbrical origin to A1 pulley (palm)
• Zone IV: Within carpal tunnel
• Zone V: Proximal to carpal tunnel (wrist/forearm)

1. Controlled passive mobilization (Kleinert protocol): Dynamic traction splint; active extension + passive flexion via rubber band traction from fingernail to wrist. Starts day 1-3 post-repair.
2. Controlled active mobilization (Belfast/Manchester protocol): Place-and-hold technique; active flexion initiated early (day 1-3). Stronger repair required (4-6 strand).
3. Immobilization protocol: Used when compliance is poor; wrist in 20-30 flexion, MCPs in 60-70 flexion; only for unreliable patients.

• Week 0-3: Passive mobilization, edema control, scar management
• Week 3-6: Gentle active motion, progressive range
• Week 6-8: Resistive exercises begin
• Week 12: Return to work (light); heavy work at 4-6 months

Extensor Tendon Injuries

• Zone I: DIP joint - mallet finger
• Zone II: Middle phalanx
• Zone III: PIP joint - boutonniere deformity risk
• Zone IV: Proximal phalanx
• Zone V: MCP joint
• Zone VI/VII: Dorsum of hand/wrist

• Mallet finger (Zone I injury): DIP held in flexion; extensor tendon avulsion. Treat with DIP extension splint for 6-8 weeks (uninterrupted)
• Boutonniere deformity (Zone III injury): Central slip rupture; lateral bands migrate volarward. PIP flexion + DIP hyperextension. Splint: PIP extension splint; DIP free/flexed to pull laterals dorsally.
• Sagittal band rupture (Zone V): EDC subluxation; finger deviates on fist

• Dynamic extension splint with resistance to flexion
• Yoke splint for zone V-VI injuries
• Progression similar to flexor protocol but earlier active use due to better vascular supply

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d. Soft Tissue Injuries

• Contusions: Blunt trauma; hematoma, edema, no skin break
• Abrasions: Superficial; risk of traumatic tattooing
• Lacerations: Sharp or blunt; may involve underlying structures
• Avulsion: Skin/soft tissue torn away; ring avulsion injuries (Urbaniak classification)
• Degloving: Circumferential avulsion; requires flap coverage

• Wound care and dressing (moist wound healing principles)
• Edema management: elevation, retrograde massage, compression garments
• Scar management: silicone gel sheets, pressure therapy, scar massage
• Desensitization for hypersensitive scars or re-innervated tissue
• ROM exercises once wound healing permits
• Protective splinting during healing

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e. Fractures of the Hand

• By location: Phalangeal (distal, middle, proximal), metacarpal, carpals
• By pattern: transverse, spiral, oblique, comminuted, avulsion
• By stability: stable vs. unstable (rotational or angular deformity)
• By articular involvement: extra-articular vs. intra-articular

• Boxer's fracture: 4th/5th metacarpal neck; apex dorsal angulation
• Bennett's fracture: Intra-articular fracture at base of 1st metacarpal with subluxation
• Rolando's fracture: Comminuted Bennett's
• Mallet fracture: Bony avulsion at DIP

• Immobilization phase (0-3 weeks): Splinting in position of safe immobilization (POSI): wrist 20-30 extension, MCP 70-90 flexion, IPs in extension; prevents intrinsic-plus contracture
• Mobilization phase (3-6 weeks): Active and active-assisted ROM; composite flexion exercises; buddy taping for adjacent digit stability
• Strengthening phase (6-12 weeks): Putty exercises, grip strengthening, pinch strengthening
• Scar and edema management throughout
• Return to work assessment

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f. Management of Crush Injury with Emphasis on Hand Rehabilitation

• Compartment syndrome: measure intracompartmental pressures; fasciotomy if >30 mmHg or within 30 mmHg of diastolic BP
• Vascular compromise: Doppler assessment, urgent revascularization if ischemia
• Degloving, fractures, tendon/nerve disruption

• Edema control: elevation above heart, compression, retrograde massage
• Wound management: debridements, dressings, skin grafting
• Splinting for joint protection and anti-deformity positioning
• Pain management: modalities (TENS, ice/heat)
• Gentle passive ROM to maintain joint mobility

• Progressive ROM (passive → active-assisted → active)
• Scar management: silicone, massage, pressure therapy
• Sensory re-education if nerve involved
• Desensitization for hypersensitivity
• ADL retraining

• Strengthening: putty, hand exercisers, resistance bands
• Coordination and dexterity training: pegboards, fine motor tasks
• Work simulation and work hardening
• Functional capacity evaluation (FCE) before return to work
• Vocational rehabilitation and adaptive equipment if permanent deficit

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B. Burns

Types of Burns

Classification of Burns by Depth

• Epidermis only (e.g., sunburn)
• Red, dry, painful; no blisters
• Heals in 3-5 days; no scarring

• Epidermis + superficial dermis
• Moist, blisters, red, very painful
• Heals in 7-14 days; minimal scarring

• Extends to deep dermis
• White/pale, less painful (nerve damage), wet
• Heals 21-35 days with significant scarring; often needs grafting

• Entire epidermis and dermis
• Leathery, dry, brown/black, painless (nerves destroyed)
• No self-healing; requires skin grafting

• Through skin to fat, muscle, bone
• Severe; amputation often required

• Head and neck: 9%
• Each arm: 9%
• Anterior trunk: 18%; Posterior trunk: 18%
• Each leg: 18%
• Perineum: 1%

Recovery Process (Wound Healing Phases)

1. Hemostasis/Inflammation: 0-5 days; cytokine release, eschar formation
2. Proliferative phase: Day 5-21; granulation tissue, collagen deposition, wound contraction
3. Remodeling phase: Weeks to years; collagen cross-linking, scar maturation

Post-burn Complications

• Most common post-burn complication in OT practice
• Result from wound contraction across joints
• Common sites: neck (neck flexion contracture), axilla, elbow (flexion), hand (intrinsic minus, web space), knee, ankle
• Prevention: Correct anti-deformity positioning, serial splinting, early ROM
• Treatment: Splinting, serial casting, Z-plasty, skin grafting (contracture release)

• Abnormal bone formation in soft tissues, especially at elbow after electrical burns
• Presents as pain, swelling, decreased ROM
• Diagnosed by X-ray or bone scan
• Treatment: NSAIDs (prophylaxis), ROM within pain-free range, surgical excision after maturation (18-24 months)

• Raised, red, firm, pruritic scar confined to wound margins
• Different from keloid (which extends beyond wound margins)
• Begins 6-8 weeks post-injury; may resolve over 1-3 years
• Treatment:
  • Pressure garments: 23-24 hours/day; 25 mmHg pressure; worn for 12-24 months
  • Silicone gel sheeting
  • Scar massage
  • Intralesional steroid injections (triamcinolone)
  • Laser therapy, surgical excision + grafting in severe cases

• Pigmentation changes (hypo/hyperpigmentation)
• Facial disfigurement: nasal/ear deformity, microstomia, ectropion
• Microstomia splint to maintain oral aperture
• Psychosocial impact: depression, social withdrawal; body image rehabilitation needed

Pre-operative OT Management (Burns)

• Edema reduction and positioning
• ROM maintenance through active/passive exercises
• Serial splinting to prevent contracture before grafting
• Patient/family education on wound care
• Psychosocial preparation for surgery

Post-operative OT Management (Burns)

• Skin graft: immobilize for 5-7 days (graft take phase); then progressive ROM
• Pressure garments custom-fitted after graft maturity (~3 weeks)
• Scar management program (massage, silicone, pressure)
• Splinting to maintain corrected position
• ADL training, adaptive equipment
• Community reintegration and return to work

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C. Cardiothoracic Surgery - OT Management

Review of Cardiothoracic Surgical Procedures

• Coronary artery bypass grafting (CABG)
• Valve replacement/repair (aortic, mitral)
• Pulmonary resection (lobectomy, pneumonectomy)
• Thoracotomy for pleural disease
• Pericardectomy
• Heart transplantation
• LVAD (left ventricular assist device) insertion

Pre-operative OT Management

• Functional assessment: ADL capacity, exercise tolerance, prior function
• Education: Explanation of post-operative precautions (sternal precautions after median sternotomy - no pushing/pulling >2.3 kg for 6-8 weeks), breathing exercises
• Energy conservation and work simplification techniques taught pre-operatively
• Anxiety management: Relaxation techniques, mindfulness
• Upper extremity ROM baseline documentation
• Adaptive equipment introduction (grab rails, raised toilet seat, bath bench)

Post-operative OT Management

• Avoid lifting, pushing, pulling > 2-5 kg
• No bilateral arm elevation above shoulder simultaneously
• Support chest when coughing ("pillow hugging")
• Duration: typically 6-8 weeks; based on sternal healing

• Bed mobility and transfers with precautions
• Basic self-care (washing face, feeding) - low-demand ADL
• Sitting out of bed, standing tolerance
• Deep breathing exercises and splinted coughing
• Edema management if saphenous vein graft harvest site is present (compression stocking)
• Cardiac monitoring during all activities

• Graded ADL progression using metabolic equivalents (METs): Start with <2 MET activities (brushing teeth, light hygiene), progressing to 3-4 METs (walking, light housework)
• Energy conservation: sit to perform tasks, avoid Valsalva maneuver (no breath-holding during exertion)
• Dyspnea monitoring using Borg Scale
• Upper extremity exercises progressing in intensity
• Driving restriction education (usually 4-6 weeks post-CABG)

• Cardiac rehabilitation program participation (Phase II)
• Return to work assessment (sedentary jobs at 4-6 weeks, manual labor at 3-6 months)
• Vocational rehabilitation if prior work is now contraindicated
• Psychosocial support (depression affects ~30% of post-cardiac surgery patients)
• Sexual activity resumption counseling (~6 weeks for most patients)

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D. Plastic Surgery - OT Management

Brief Review of Surgical Procedures

• Split thickness skin graft (STSG): Epidermis + partial dermis; harvested with dermatome; donor site heals itself; used for large areas (burns)
• Full thickness skin graft (FTSG): Epidermis + full dermis; better cosmesis and durability; limited donor areas (groin, retroauricular); used for face, hands
• Composite grafts: Include cartilage, fat; used for ear, nasal reconstruction

• Local flaps: Rotation, transposition, advancement (Z-plasty, V-Y)
• Regional flaps: Pedicled flaps (groin flap, forehead flap)
• Free flaps (microsurgical): Complete detachment and vascular anastomosis at recipient site (radial forearm free flap, ALT flap, latissimus dorsi free flap)

• Hand/face transplantation (composite tissue allotransplantation - CTA): Lifelong immunosuppression required; OT plays major role in sensorimotor rehabilitation

• Rhinoplasty, rhytidectomy (face lift), mammoplasty, liposuction, abdominoplasty, blepharoplasty

Pre-operative OT Management (Plastic Surgery)

• Baseline ROM and sensory documentation
• Psychosocial preparation and goal-setting (especially for disfiguring injuries)
• Positioning education to optimize flap vascular access post-op
• Splint pre-fabrication for post-op immobilization positions
• Education about post-operative care and expectations

Post-operative OT Management

• Immobilization of graft site for 5-7 days (bolster dressing phase)
• After take confirmed: progressive ROM, scar management
• Donor site wound care and protection
• Pressure garments over graft once healed

• Protect pedicle/vascular anastomosis; no compression on pedicle
• Positioning: Elevate; avoid kinking of pedicle
• Temperature monitoring of flap (hourly initially)
• Once flap viable (1-2 weeks): progressive ROM, ADL reintegration
• Sensory re-education once reinnervation begins (in neurosensory flaps)

• Intensive sensorimotor rehabilitation for 12-18 months
• Cortical remapping support via mirror therapy, sensory re-education
• Splinting for anti-deformity positioning
• Progressive functional use - tendon gliding, dexterity training, ADL retraining

• Scar management
• Activity restrictions post-abdominoplasty or mammoplasty (core loading precautions)
• Return to daily activities counseling

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E. Oncological Rehabilitation with Emphasis on Post-operative Management

Introduction

Common Surgical Procedures Requiring OT

• Mastectomy / Lumpectomy (breast cancer)
• Amputation (osteosarcoma, soft tissue sarcoma)
• Neck dissection (head and neck cancer)
• Lung resection (lung cancer)
• Limb-sparing surgery (sarcoma)

Post-operative OT Management

• Lymphedema management: Complete decongestive therapy (CDT) = manual lymphatic drainage + compression bandaging + skin care + exercise. Begin when lymphedema detected; lifelong maintenance.
• Shoulder ROM exercises: begin gentle pendulum exercises day 1-2 post-op; avoid aggressive abduction/flexion until drains removed (~week 1-2)
• Axillary web syndrome (cording): Stretching and specific mobilization techniques
• Scar management: massage, silicone for mastectomy scar
• ADL modifications: avoid heavy lifting on affected side; protective strategies for lymphedematous limb
• Prosthesis/orthosis fitting: breast prosthesis fitting after wound healing; adapted bra fitting

• Pre-operative: phantom limb pain education, prosthesis counseling
• Post-operative: Residual limb shaping (figure-8 bandaging or shrinker sock)
• Edema control, desensitization, positioning to prevent contracture (hip extension for AK, knee extension for BK)
• Upper limb amputation: myoelectric or body-powered prosthesis training; ADL retraining
• Phantom limb pain: mirror therapy, graded motor imagery
• Vocational rehabilitation and home modification

• Shoulder dysfunction (trapezius weakness after neck dissection) - ROM exercises, strengthening
• Dysphagia management (OT or SLP - swallowing rehabilitation)
• Lymphedema of face/neck
• Trismus (jaw contracture after radiation): progressive jaw opening exercises, Therabite device

• Cancer-related fatigue: Energy conservation, activity pacing, graded aerobic activity
• Chemotherapy-induced peripheral neuropathy (CIPN): Sensory re-education, safety strategies, adaptive equipment
• Cognitive effects ("chemo brain"): Cognitive rehabilitation strategies, memory aids, routines
• Psychosocial: Depression, anxiety, adjustment to disability, role loss, return to work
• Return to work/school planning; workplace modifications
• Community reintegration and leisure re-engagement

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F. Brachial Plexus Injury

Anatomy

• Roots (C5, C6, C7, C8, T1)
• Trunks: Upper (C5-C6), Middle (C7), Lower (C8-T1)
• Divisions (anterior and posterior)
• Cords: Lateral, Medial, Posterior
• Terminal branches: Musculocutaneous, Axillary, Radial, Median, Ulnar

Mechanisms of Injury

• Traction/stretch (motor vehicle accidents, motorcycle crashes, shoulder dystocia in neonates)
• Compression (cervical rib, Pancoast tumor, hematoma)
• Direct trauma (stab/gunshot wound, iatrogenic)
• Avulsion (root torn from spinal cord; worst prognosis - no regeneration possible)

Classification

• Horner syndrome = T1 avulsion (pre-ganglionic)
• Absent sensory nerve action potentials (SNAP) despite anesthesia = post-ganglionic
• Rhomboid (dorsal scapular nerve from root, not trunk) function = root intact

OT Management of Brachial Plexus Injury

• Shoulder subluxation: arm sling or humeral cuff to support glenohumeral joint
• Wrist drop: wrist extension splint
• Claw hand: anti-claw/lumbrical blocking splint
• Elbow flexion assist if biceps paralyzed: elbow flexion assist splint

• Passive ROM of all affected joints to prevent contracture
• Active exercises for any recovered muscles
• Strengthening as motor return progresses
• PNF techniques (proprioceptive neuromuscular facilitation)

• One-handed ADL techniques if severe/total palsy
• Adaptive equipment: rocker knife, one-handed cutting board, button hook
• Bimanual activities to encourage cortical plasticity

• Protect surgical repair initially
• Train target muscle once reinnervation confirmed
• Cognitive retraining to use new nerve-muscle connections (e.g., "breathe" to flex elbow after intercostal transfer)

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G. Erb's Palsy

Definition

Mechanism

• Birth (obstetric): Shoulder dystocia - excessive lateral neck flexion against fixed shoulder during delivery; large-for-gestational-age infants, forceps use, prolonged second stage
• Adults: Motorcycle accidents, shoulder depression injuries (fall on shoulder with neck forced away)

Clinical Features - "Waiter's Tip" Deformity

Prognosis

• 90% of obstetric cases recover spontaneously within 6-12 months

• Biceps function by 6 months = good prognostic sign
• Lack of biceps function at 6 months → microsurgical nerve grafting indicated

OT Management

• Passive ROM daily - parents trained to perform shoulder elevation, abduction, external rotation, elbow and wrist movements
• Prevent internal rotation contracture of shoulder
• Prevent progressive glenoid hypoplasia (seen in 70% with persistent internal rotation contracture)
• Positioning: Avoid Statue of Liberty position (prolonged abduction); protect against hyperextension
• Splinting: gentle positioning in external rotation when sleeping
• Developmental activities to encourage use of affected limb
• Sensory stimulation of affected limb

• Shoulder abduction assist splint
• Elbow flexion assist splint
• Dynamic wrist extension splint if wrist extensors involved
• Sensory re-education
• ADL training - one-handed or bimanual strategies
• Post nerve surgery: retraining of transferred muscles

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H. Klumpke's Paralysis

Definition

Mechanism

• Excessive upward traction on abducted arm
• Arm caught above head during a fall
• Birth: breech presentation with arm raised above head
• Pancoast tumor (apical lung tumor compressing lower plexus)

Clinical Features - "Claw Hand" Deformity

• All intrinsic hand muscles: interossei (dorsal and palmar), lumbricals (3rd and 4th), thenar (APB, FPB, OP), hypothenar (ADM, ODM, FDM), adductor pollicis
• Flexor digitorum profundus (ring and little fingers) - C8
• Flexor carpi ulnaris - C8/T1
• Flexor pollicis longus - C8 (anterior interosseous nerve)

Prognosis

• Poorer than Erb's palsy
• Pre-ganglionic (avulsion with Horner's) = no spontaneous recovery possible
• Surgery (nerve grafting, nerve transfer, tendon transfer) is often necessary

OT Management

• Intrinsic-plus splint (anti-claw splint): Blocks MCP hyperextension while allowing IP extension; prevents secondary contracture of MCP collateral ligaments
• Thumb opposition splint to position thumb for functional pinch
• Wrist support splint if FCU weak

• Passive ROM to all hand joints to prevent joint stiffness
• Maintain MCP flexion and IP extension ROM
• Active exercises for any spared muscles (e.g., wrist flexors if partially intact, extrinsic muscles)

• Protective sensation program for insensate ulnar border of hand
• Safety education: avoid burns, cuts, pressure ulcers on insensate skin

• Grip and pinch compensatory techniques
• Adaptive devices: universal cuff, built-up handles, button hooks
• Bimanual task adaptations
• Handwriting and keyboard adaptations

• After tendon transfers (e.g., ECRL to ADM for small finger abduction, FDS to intrinsics for lumbrical substitute): protect transfer for 3 weeks, then progressive retraining of new muscle action
• After nerve transfers: train reinnervated muscles; use biofeedback, EMG-guided exercises
• Cortical reorganization support via mirror therapy and sensory stimulation

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Summary Table: Key OT Splints by Diagnosis

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