ppcm: systems based categories of disability

considerations for mobility will differ based on the patient's...

underlying pathology

patients in an acute/rehabilitation are often categorized into...

system related groupings or "tracks"

ex: Musculoskeletal, Neuromuscular/medically complex , Cardiac

Common Diagnoses in Musculoskeletal Track

Total joint arthroplasty

Fracture management

Spinal surgery

Limb amputation

Tendon/Ligament Injuries/repairs

Inflammatory /degenerative joint diseases

clinical impairments often presented in the musculoskeletal track

Impaired strength

Restricted/Limited ROM

Pain

Decreased endurance

Decreased functional UE usage

Possible sensory deficits (from scarring, swelling, nerve damage)

Decreased functional mobility independence

Important Considerations for Musculoskeletal Track

Specific joint motion contraindications

ex: Total hip replacement precautions + Spinal Precautions

Weight-bearing status

Resistance training limitations (no MMT immediately post op)

high infection risk

potential for blood status (lack of blood flow) and deep vein thrombosis

risk for anemia bc of blood loss during surgery

high risk for re-injury

Weight Bearing Status

Refers to the amount of weight an individual can placeon a limb that has sustained an injury or a surgical procedure

WE CANNOT DICTATE WEIGHT BEARING STATUS

Full Weight Bearing (FWB)

no restriction

Weight bearing as tolerated (WBAT)

The individual can place asmuch weight as is tolerated on the limb

Partial Weight Bearing (PWB)

Up to but not exceeding 50% ofthe body weight

Toe Touch Weight Bearing (TTWB)

Only the individual's toe can bear weight

Non Weight Bearing (NWB):

No weight permitted on the limb

Total Joint Arthroplasty

Joints most commonly replaced are weight-bearing joints and will have classic impairments in strength and ROM about the joint and pain throughout the limb

Postolateral Total Hip Arthroplasty (THA) Precautions

Avoid hip flexion more than 80-90 degrees, adduction, and internal rotation beyond neutral

Transfer to the sound side from bed to chair, chair to bed

Do not cross legs, rolling precautions

Keep knees slightly lower than hips when sitting

No low chairs, don’t bend trunk over legs with sit to stand

Used raised toilet seats

Use shower chairs

Pivot on the sound side

Sleep in supine with abduction pillow

Anterolateral and Lateral Total Hip Arthroplasty (THA) Precautions

Avoid hip extension, adduction and external rotation past neutral and avoid the combine motion of hip flexion, abduction and external rotation

Avoid tailor sitting: hip flexion, abduction and external rotation

Avoid hip hyperextension (past neutral) when ambulating

Fracture/Bony ReconstructionConsiderations

Careful monitoring of weight bearing status

Prevent bed rest!

Watch for signs of DVT ( painful, redness swelling and warmth in calf)

Be mindful of type of intervention used

Open Reduction Internal Fixation (ORIF

surgical repair of a fracture by making an incision into the skin and muscle at the site of the fracture, manually moving the bones into alignment, and fixing the bones in place with surgical wires, screws, pins, rods, or plates

typically do NOT have hip precautions

usually have weight bearing precautions

Closed reduction

nonsurgical realignment of broken bone ends and splinting of bone

External Fixator

external metal frame attached to bone fragments to stabilize them

mindful NOT to put pressure directly on fixator

watch pin sites for signs of infection

Spinal Precautions

•Think "B.L.T."

No bending: no hip bending (FWD or LAT)

No lifting: no more than 5-10 pounds (gallon of milk), no MMT of UEs, no more than 90 degrees shoulder flexion

No twisting: avoid trunk rotation

alternative: log roll or stand and pivot with the feet

Considerations for Lower Limb Amputation

avoid positions of comfort to prevent contracture development during positioning

Encourage Prone positioning to elongate hip flexors and hamstrings

aka residual limb

ensure protection of the incision site during mobility

why should you closely guard someone who has a lower limb amputation

Amputation alters the center of mass for individuals increasing fall risk

Even if the individual is strong and fit, they will need to re-learnhow to move

Common Diagnoses Neuromuscular Track

Cerebrovascular accident/stroke (CVA)

Brain Injury (BI): Traumatic or Non-Traumatic

Spinal cord injury (SCI)

Neurologic Diseases/conditions: Multiple sclerosis (MS) or Parkinson's disease (PD)

Important Considerations for Neuromuscular Track

Impaired coordination

Impaired motor control/strength

Abnormal muscle tone

Impaired sensation /functional neglect

Impaired executive functioning/safety/cognition/memory

Impaired vision/speech/communication

Impaired problem-solving skills

Inconsistency in performance

Possible systemic complications ie; seizures/unstable vital signs

Decreased functional independence

Cerebrovascular Accident

Individuals who have sustained a stroke typically present with unilateral physical impairments on the contralateral side of the body

Degree of impairment will vary based on the extent of brain damage

Right CVA =

Left sided deficit

hemiplegia or hemiparesis

Paralysis of one side of the body/weakness on one side of the body

Patients who have sustained SCI's present with varying degreesof paralysis/paresis which is dependent upon

the extent and level of injury in the spinal cord

Tetra/Quadri-plegia

injury occurs in cervical spine to T1 with resultant bilateral

Partial or complete paralysis of UE's, trunk and LE's

Will require assistance with all basic ADL's and most mobility

Paraplegia

injury occurs below T1.

Results in bilateral partial or complete paralysis of the LE'sand trunk musculature

May be independent in some basic skills but may requirebracing/AD for locomotion

Common Diagnoses for Cardiopulmonary Track

Congestive Heart Failure

S/P Myocardial infarction

Surgical patients post: Cardiac catheterization, Valve replacement, Bypass

Chronic obstructive Pulmonary Disease(COPD)/Restrictive lung disease

Patients status post lung resection surgery

Chronic Pneumonia

Patients on this cardiopulmonary track generally present with deficits in the following areas

Strength

Overall fitness / muscle endurance

Unstable/fluctuating vital signs

Systemic complications

Cardiopulmonary Track for Important Considerations

VITAL signs!!!! Close and consistent monitoring required

Chest incision site protection - "Sternal Precautions" (encourage flexion)

Encourage use of pillow against chest during coughing & mobility for pain control

Reduce strain of UE's pulling/pushing to prevent dehiscence of incision - Avoid UE horizontal abduction/adduction and overhead reaching

May have multiple IV's/lines/ O2 etc.

Be mindful and manage accordingly

Utilize perceived exertion scales to grade patient's effort