AOTA Packet: Musculoskeletal Conditions

Most common type of amputation - congenital or trauma?

Trauma and lower limb amputations are more common than UE

Most common cause of lower limb amputation?

peripheral vascular disease

Goal of surgery for amputations?

1. preserve as much limb length
2. residual limb is pain free and functional

Phantom limb

sensation that missing limb is still there (does not mean there is pain)

Phantom sensation

sensation that occurs in missing limb; can be any type (cramping, relaxed, numb, cold, burning)

Post op and preprosthetic phase signs and sx

• Pain Skin complications (delayed healing, necrosis, skin graft to bone)

• Edema of residual limb bone spurs

• neuroma on distal end of residual limb

• Phantom limb

Prosthetic phase signs and symptoms

Skin ulcers as a result of ill fitting prosthesis socket or wrinkles in prosthetic sock

sebaceous cysts resulting from torque of prosthetic socket

Edema resulting from ill fitting socket or too tight prosthetic sock

Sensory changes

transfemoral

above the knee

transtibial

below the knee

transmetatarsal

below the ankle

transhumeral

above the elbow

transradial

below the elbow

trasnmetacarpal

below the wrist

disarticulation

across a joint, such as hip, wrist elbow or shoulder

symes amputation

ankle disarticulation

Preprosthetic training (from postsurgery until the clinet receives permanent prosthesis)

1. psychological aspects: self-esteem, self-efficacy, body image, shock, belief, grief, guilt, etc.
2. optimize wound healing
3. residual limb shrinkage and shaping
4. desensitive residual limb with rubbing, tapping, using different material
5. maintain ROM, strength
6. ADLs
7. explore prosthetic options

Wearing schedule for prosthetics

start with 15-30 minutes and then take off.

**If there is no redness after 20 minutes then increase the wearing time by 15-30 minutes until wearing prosthesis full time

Upper limb amputations have:

more limitations in tasks related to manipulation of objs

Prosthetic training

1. don and doff independently
2. care of prosthesis
3. increase wearing schedule
4. independent use of prosthesis

Self Care activities eval

with and without prosthesis

Uninvolved hand eval

motor skills of the uninvolved hand should be assess in prep for training in one hand techniques

OT intervention for preprosthetic

1. limb shrinkage/shaping
2. desensitization
3. flexibility and strength of residual and remaining limbs
4. wheelchairs
5. reduce edema
6. wound healing (whirlpool/massage)
7. limb hygiene

Limb shrinkage and shaping

Train client to wrap the residual limb in an elastic bandage to reduce edema and develop a tapered shape

Limb shrinkage and shaping (client unable)

use elastic shrinker or removable rigid dressing

Desensitization of the residual limb

• weight bearing on various surfaces

• massage

• tapping and rubbing

What is a terminal device (TD)?

it's on the end of a prosthetic - foot or hand

Passive TD

for cosmetic purposes. nonfunctional hand

Active TD

functional; body-powered; hook or hand; hook is more functional for grasp, lower cost, lesser weight, visibility of object being grasped

Hook vs hand

hooks is more functional than the hand bc of:
greater percision
greater visibility of obj being grasped
lesser weight
lower cost
greater relaibility
ability to fit in close quarters

Using a myoelectric device

pt's must have 2 superficial muscle sites tha can fit within the prosthesis socket w enough EMG signals to power the hand

Socket attaches to

prosthesis of the residual limb

Harness and suspension system

holds the prosthesis on the residual limb

Prosthetic sock of gel liner

protects the residual limb and improves the fit of the socket

Upper limb prosthesis

control system is combined with harness to transmit body forces to control the cable that operates the TD

Lower limb prosthesis

pylon used to connect the TD to the socket

Cleaning routine of prosthesis

1. clean every day with warm water and soap
2. inspection of stump for redness, wound
3. clean hook
4. clean interior with mild saop and water
5. replace batteries in myolectrically controlled prosthesis

Prostheis control training

operation of each component of the upper limb prosthesis

prosthesis use training

integration of prosthesis components for efficient assist during fx use

Prepositioning training

ID of the optimal position of each positioning unity to perform an activity or grasp obj

Prehension training

TD control during grasp activities

Functional training

control and use of the prosthesis during gx activities

Contracture

fixed posture; due to shortening of skin, ligaments, joint capsule, tendons, and muscles

soft tissue

responds to therapy

boney block

requires surgery to release

3 steps in tx of contractures:

1. superficial or deep heat
2. slow stretch
3. static splinting

types of splints to reduce soft tissue contractures (lumbrical bar splints)

to reduce MCP hyperextension and IP flexion contractures MCPs are splinted to block hyperextension

types of splints to reduce soft tissue contractures (resting hand, ball, and cone antispasticity splints)

purpose is to decrease tone

types of splints to reduce soft tissue contractures (Serial Casting)

position clients with increased tone and over time stretch out soft tissue contractures

types of splints to reduce soft tissue contractures (soft neoprene splints)

position thumb an dforearm: commonly used w clients w rheumatoid arthtiis or ceerebal palsy to icnrease functional use of hand

types of splints to reduce soft tissue contractures (splint to prevent foot drop)

below the knee splint to keep ankles at 0 deg for possible future ambulation

types of splints to reduce soft tissue contractures (Dynamic Splinting)

may involve metal loop components; angle of pull needs to be 90 degrees for most effective outcome

Fibromyalgia

widespread musculoskeletal pain; must have 11 of 18 trigger point

Symptoms of fibromyalgia

• pain

• nonrestorative sleep

• fatigue

• inability to think clearly

• parethesias

• joint swelling

• depression

• anxiety

Dx of fibromyalgia

excessive tenderness in at least 11/18 trigger points

Intervention for fibromyalgia

1. education

2. general aerobic exercises, daily stretching, strenghtening,

3. cognitive behavioral therapy

4. sleep hygiene

5. fatigue management, pacing activities, work simplification, energy conservation

6. memory aids

7. modifications of environment/activity

8. myofascial realease and trigger point tx, massage, relaxation exercises, biofeedback

Risk Factors for Hip Fractures

Osteoporosis

reduced mobility

Primary cause for hip fratcures

trauma (fall)

Types of hip fractures

1. femoral neck fx: caused by slight trauma or rotational force; women with osteoporosis
2. intertrochanteric fx: blow between greater and lesser trochanter of femur; women younger than 60;
3. subtrochanteric fx: blow to lesser trochanter of femur; result of car accident or fall; women younger than 60

Types of hip fractures (femoral neck)

caused by slight trauma or rotational force; women with osteoporosis

Types of hip fractures (intertrochanteric)

blow between greater and lesser trochanter of femur; women younger than 60

Types of hip fractures (subtrochanteric)

blow to lesser trochanter of femur; result of car accident or fall; people younger than 60

ORIF

Open Reduction Internal Fixation:

involves weight bearing precautions (NWB, PWB, TTWB, WBAT, FWB)

TTWB and PWB

• 90% of body weight is placed on unaffected leg; toe touch for balance

• 50% of body weight placed on affected leg

Posterolateral approach for hip replacement

NO internal rotation, NO adduction, NO flexion of hips past 90 degrees

Anterolateral approach for hip replacement

NO extension, NO external rotation, NO adduction

How soon should OOB activity resume after hip replacement?

1-3 days

Role of OT in hip replacements

1. home safety recommendations
2. transfer techniques
3. ROM restrictions
4. strengthening, increasing joint motion
5. adaptive equipment
6. ADLs
7. PAMs

Cause of Low Back Pain (LBP)

poor physical fitness, obesity, reduced muscle strength, poor endurance (rarely the result of serious spinal disease)

Sciatic pain

nerve is trapped in herniated disc

Spinal Stenosis

narrowing of intervertebral foramen

Facet Joint Pain

inflammation or changes of spinal joints

Spondylosis

stress of dorsal to transverse process

Spondylolisthesis

slippage of vertebra out of position

Herniated Nucleus Pulposus

stress tearing of fibers of disc; cause outward bulging pressure on nerves

Role of OT in LBP

1. education
2. ergonomics
3. work/environment modifications
4. NEUTRAL SPINE
5. energy conservation
6. body mechanics

Semisquat, Squat, Stoop lift

1. semisquat: safest lift for back; ideal for heavy loads
2. squat: alternative to semisquat; people with LBP use this
3. Stoop Lift: used for light loads (

LBP Bathing

shower is better than bath because keeps spine neutral; items should be within use; handheld shower; bathmat

LBP Dressing

sit while dressing; lay while putting on pants, put belt on through pants before putting on to prevent twisting; bring foot to knee while putting on socks

LBP Mobility

logrolling; use arms to lower self to sit; keep spine neutral; don't sit for more than 15-20 minutes

LBP Personal hygiene

bathroom sinks are too low; use kitchen sink or sit;

LBP Sexual Activity

stretch beforehand; use towel under lower back; warm shower keeps muscles loose and reduces pain

LBP Sleep

firm supportive mattress; pillow under knees while on back; pillow between knees while sidelying; pillow not to cause neck flexion

LBP Toileting

reach between legs instead of twisting; straddle toilet and use tank to help get up

LBP Child Care

avoid sudden movements; changing surfaces should be elevated

LBP Computer

arms parallel to ground; forearms neutral; computer slightly below eye level; elbows at 90; feet flat on floor; avoid twisting

LBP Driving

sit on seat and turn body without twisting; schedule rest breaks; cruise control allows for body change positions

LBP Home Care

materials within reach; golfer's lift; adaptive equipment

Most common types of cancer

prostate, lung, breast, colorectal (cancer in colon to rectum); genetic and environmental

Chemotherapy

destroys cancer cells via toxic chemicals

Chemotherapy (side effects)

alopecia, fatigue, anemia, decreased hearing/vision

Chemotherapy precautions

• use of mask bc of compromised immunity

• resticted diet bc of yeast infection in mouth

• screening for anxiety

• depression

• fatigue

• extra care to avoid dropping things

• monitoring for excessive bleeding

Radiation

destroys cancer cells via radioactive material

Radiation (side effects)

burn

Radiation precautions

• assistance to maintain ROM while avoiding pulling burned skin

• use of water-based ointements

Surgery precautions

• refraining from bathing the area until staples or sutures removed

• prevention of dependent edema

Hormone therapy

hormones used to reduce estrogen levels because some cancers can increase spread from estrogen

Hormone therapy side effects

menopause like symptoms

Hormone therapy precautions

• monitoring room temp

• client mood

Immunotherapy

use of medicine to block or heighten immune system

Immunotherapy side effects

• skin welts precautions: avoidance of scratching skin