601 unit 1

what is the main focus of the biomechanical FOR?

remediation for musculoskeletal or orthopedic conditions

what approach is the biomechanical FOR?

bottom-up approach

What conditions or diagnoses would benefit from interventions that follow the biomechanical FOR?

Fractures/broken bone, tendon/nerve gliding issues, tendon tears, stroke, age, after injuries that require long term immobilization, CP, spina bifiida, ASD, downs yndrome, developmental delays, cardiopulmonary, athletes

assumptions of the biomechanical FOR

Remediation may occur by decreasing or removing an impairment

-This may be done through interventions that improve strength, mobility, and/or endurance

once the impairment is remediated occupational performance will imrpove

examples of OT assessments fit within the lens of the biomechanical FOR?

-ROM, MMT, DASH, Berg’es perceived exersion test, dynamometer, pinch gauge, sensory tests, oculomotor, feeding/eating assessments

What EHP intervention approaches do biomechanical interventions represent?

establish/restore, prevent

What are the main intervention types that match with the biomechanical FOR?

interventions to support occupations, education

benefits of client-centered care

-client buy-in and intrinsic motivation

-clients increased performance efficacy

-client satisfaction

-clients increased carry-over of interventions

-better results from interventions

-clients reduced duration of rehab facility stay

when is the biomechanical FOR used?

-when remediation is possible and the person is expected to achieve full or near full return to prior level of function.

functions of the skin

• prevents infection by creating a barrier from outside sources

• protection from heat, cold, etc.

• regulates body temperature

• permits sensation

• plays a role in fluid and electrolyte balance to prevent dehydration

encouraging healthy skin and preventing infection

• must be washed regularly with soap and water for cleanliness

• should be lubricated but not overly moist

• skin inspections are important, especially in those with impaired sensation and/or mobility

• skin should not be overly dry—> lead to cracks in the skin which welcomes bacteria and causes infection

• ^different lotions and savs can help

risk factors for pressure injuries and skin breakdown

• impaired sensory perception (primary risk factor)

• moisture

• activity level

• mobility

• nutrition (healing of wounds are compromised)

• friction and shear

-on the Braden Scale we want to keep a score of 18/19 or above

Common pressure points

bony prominences

• back of head

• shoulder/scapula

• elbow

• ischial tuberosities

• heel

• ball of foot

goal in interventions for pressure injuries and skin

-establish interventions to PREVENT pressure sores and skin breakdown

-this is why we assess risk and provide interventions based on those findings

-however, shi still happens

assessing and documenting pressure injuries

• must be specifically assessed and documented

• photos are helpful to include in the medical chart to determine wound changes and progression of healing

• highest height, widest width, and deepest depth

OT role in wound management

in the scope of practice as long as you have established competency

-common wound care interventions:

• application of wound dressings and wound closure strips

• removal of sutures, staples, wound closure strips

• monitoring wound status

• debridement

• application of topical agents to promote healing

• negative pressure wound therapy (wound vac)

• PAMs

OT contributions and goals to wound healing

-protect wound fluids-moist wounds heal faster than dry wounds

-prevent and/or control infection

-minimize adverse mechanical influences

• edema, hematoma, tension at wound site, foreign bodies and necrotic tissue

wound closure methods

-primary intention

• closed with sutures, adhesives, staples, wound closure strips

• heals quickly, little risk of infection, good approximation, little scar

-secondary intention

• wound closes spontaneously with epithelialization and wound contraction

• burns, pressure ulcers, wounds with large pieces of skin missing

• longer healing time, risk for infection, more scar formation

barriers to wound healing

• low blood oxygen content (smoking)

• infection

• lack of blood flow

• sustained pressure

• malnutrition

• systemic diseases (ex, diabetes)

• prescription immunosuppressants

• age (younger people heal quicker)

wound assessment

must document the following

• risk factors for altered healing

• presence/absence of infection

• anatomical location

• size

• appearance (color)

• stage of healing

• edema (take measurements)

• presence of hematoma

red wounds

-not infected

-defined borders

-granulation tissue

-apparent revascularization (wound bleeds a little)

yellow wounds

• creamy ivory to canary yellow in color (doesnt mean infected)

• if the wound has an odor, infection possible

• pus, yellow fibrous debris, viscous surface exeduate+ odor (probs infected)

• wound won’t close until infection is controlled—> goal is to make it a red wound

black wounds

covered with eschar (scab) which impedes cellular migration and proliferation by acting as a mechanical block while also improving a medium for bacteria to proliferate

• makes it hard to stage a wound, goal is to get rid of eschar….

OT role in scar management

• increase ROM if scar is crossing a joint

• reduce the appearance of scars and improve scar mobility

• desensitization

*all wounds become scars

*most importantly, you must address the psychosocial impacts

What to avoid if a client has right sided heart weakness

extreme positions of elevation, as this can cause the fluid to empty into the heart too fast

what is at risk if the client has untreated edema/lymphedema?

-infection, joint contractures, adhesions, weakness

why is it important to know the stage of edema or lymphedema?

-to know the differences in stages of edema for treatment or to know if it is lymphedema at all

what stage of lymphedema would refer to CLT

stage 2

why is it important to treat edema or lymphedema?

• to treat ROM, increase sensation, heal pain and decrease risk of infection, there could also be an impingement we could help fix

cellulitis

-signs and symptoms: red and hot

-even if you are not treating lymphedema, you need to be aware and educate your client to watch for signs/symptoms

-if untreated, it spreads throughout the body and person becomes septic

-this is absolutely an emergency and NO JOKE

positioning intervention for acute/subacute edema

-elevate the edematous limb above the level of the heart

• avoid use of shoulder slings for “elevation” (there is no research supporting the use of this)

-this uses gravity to improve venous and lymphatic flow and reuptake of interstitial fluid

Active and/or passive ROM exercises or functional activities intervention

• AROM, PROM, and light isometrics stimulate the “pumping” mechanism of the lymphatics (AROM>PROM)

• choice of AROM, PROM, or light isometrics will depend on the clients level of healing

• may educate the client in rote exercises to ensure they are performing full ROM of the involved joint

• this may also be achieved through functional activities

• appropriate intervention for acute/subacute or chronic edema, but all just depends on client factors

Compression as intervention

• assists with pushing the fluid from distal to proximal

• off the shelf or custom garments

• OT is responsible for recommending, fitting, and training in the use of appropriate compression garments

• appropriate for all stages, just have to determine the appropriate level of compression

• contraindicated for individuals with impaired vascular status

Levels of compression

-compression must be less than 60 mmHg otherwise the pressure will collapse the lymphatic pathways

-specialized compression garments are labeled with compression level or “CCL”

• CCL I = 2-30 mmHg (most common)

• CCL II = 3-40 mmHg (person needs to be relatively strong to don on/off)

• TED hose have 7-10 mmHg

• Isotoner gloves have 23-32 mmHg

• Tubigrip offers three compression options (light tissue, medium tissue, or high tissue support)

compression wrapping

• compression wrapping for acute or sub-acute edema = long-stretch bandages (coban, ACE wraps, etc.) stretch > 100% original length

• for chronic edema = short-stretch bandages stretch approx 60% of original length which results in greater compression than long stretch bandages and uses a similar wrapping technique

compression + chipbags as an intervention

• chip bags can be placed under compression garments, wraps, or within orthoses to soften edema that has more protein in it

• the various densities of foam help to create little channels for the fluid to flow

• can make them with scrap foam padding and kinesiotape or stockinette or order them from specialized medical supply store

• appropriate for all stages of edema

kinesiotape as an intervention

• elastic tape provides light tension on skin to facilitate opening of the lymphatic capillaries

PAMs as an intervention for edema

• cryotherapy

• thermotherapy

• E-stim/ NMES

Manual Edema Mobilization (MEM) as an intervention

• a set of techniques to facilitate normal flow of the lymphatic system using pressure gradients to draw lymph proximally—> start proximal, move distal, end proximal

• uses light skin tractioning massage and ROM excercises to open the lymphatic capillaries

• general order:

1. heat modality (possibly) —> diaphragmatic breathing—> shoulder A/PROM

2. light skin tractioning proximal to distal (chest to hand)

3. A/PROM to each joint

4. flow massage (light skin tractioning distal to proximal)

5. pump point massage to high lymph node areas (axilla, medial elbow)

-appropriate for all stages of edema

MEM contraindications

• congestive heart failure and other severe cardiac diseases, renal failure, liver disease, severe pulmonary problems-can overload an already overloaded cardiovascular system which can cause death

• active cancer- can facilitate spread of cancer

• infection- can facilitate spread of infection

• hematoma or blood clot- opportunity to move the clot

MEM precautions

-diabetes- can alter blood sugar

-hypotension- can further decrease blood pressure

-pregnancy- can increase morning sickness

manual lymphatic drainage (MLD) as an intervention

• must be performed by a CLT

• with compromised lymphatics, the fluid is rerouted to a healthy lymphatic area

acute edema interventions

-elevation, cryotherapy, light compression, kinesiotape, A/PROM

subacute edema interventions

-modalities (heat and e-stim), MEM, compression garments/wraps, compression+chip bags, kinesiotape

chronic edema interventions

-all the same as subacute + compression wrapping with short stretch bandages

lymphedema

• some similar interventions as those used for chronic edema; however, required CLT

muscle that is 1/5 or 2/5 strength

• strengthening in grav elim position

• no resistance

muscle that is a 3/5 strength

• strengthening against grav

• may begin to add small amount of resistance (maybe 1 lb)

muscle that is 4/5 strength

• strengthening against gravity

• use resistance that is challenging but achievable

can use PAM’s to…

• modulate pain

• facilitate or stabilize movement

• decrease edema

• increase blood flow

• increase tissue extensibility

• improve ROM and functional movement

• improve strength

• facilitate scar maturation

consideration for use of PAM’s in OT

• AOTA’s position on the use of them in intervention

• personal competency in the specific modality you are using

• federal, state, and institutional rules for using them in OT practice

competency in PAMs

AOTA specifically states that OTs using PAMs must have “documented evidence of possessing the theoretical background and technical skills for safe, competent integration of the modality into OT intervention plans.”

arguments against PAMs in OT practice

-”lack of evidence”

-inconsistent parameters making it difficult to compare outcomes

-terminology is inconsistent in the literature

-often is not a direct occupation-based intervention (which makes it up to me to connect the use of this to interventions)

Phase 1 of wound healing (inflammatory)

-first 3-4 days

-vasodilation= bleeding, cleaning

-vasoconstriction=coagulation, encapsulation

-fluid release=swelling

-redness, heat, swelling, pain

phase 2 of wound healing (proliferative)

• 3 days to 3 weeks

• macrophages clean

• fibroblasts= new collagen

• wound contraction

• angiogenesis= new capillaries

• epitheliazation= protective barrier

phase 3 of wound healing (maturation)

• 3 weeks to 2 years

• new tissue modified and gains strength/flexibility as greater forces and energy are systematically applied

• remodeled tissue has approx 80% pre-injured strength

phase 1 wound healing and PAMs

• facilitate the role of the macrophage and minimize prolonged inflammation

• wound cleaning, dressing

• cryotherapy

• low intensity, pulsed US

-intervention to support occupation

phase 2 wound healing and pams

• facilitate the role of the fibroblast

• low intensity, pulsed US

• E-stim

-intervention to support occupation

phase 3 wound healing and pams

• foster differentiation, tissue extensibility, and function

• thermotherapy

• E-stim

• thermal US

intervention to support occupation and concurrently with purposeful or occupation-based interventions

conduction

-direct contact between modality and tissue

• hot packs, ice massage, ice packs

convection

-energy circulates around the body part and transfers heat through air, liquid, etc.

• fluidotherapy, whirlpool bath

conversion

-energy is transformed from one form to another

• US=sound waves—> kinetic energy causing vibration to tissue—> heat

• can be used as a superficial or deep heating modality

thermal agents: biophysiological effects

1. analgesic effects = decrease pain, elicit relaxation response

2. vascular effects

• vasodilation- increased blood flow, increased edema

• vasoconstriction- decreased blood flow, decreased edema

3. metabolic effects = increase or decrease in cellular activity

4. connective tissue response = increase or decrease in collagen extensibility

cryotherapy: biophysiological effects

• decreases tissue temp to a depth of 1-2 cm

• analgesic effects due to decreasing nerve conduction velocity of superficial sensory nerves

• decreases cell metabolism and slows the inflammatory process and edema

• decreases muscle spasms

• decreases muscle tone and spasticity in patients with upper motor neuron lesions

• vasoconstriction: cold applied for 15 min or less

• vasodilation: cold applied for 15 min+ (brings more swelling)

when to use cryotherapy

-acute injuries (inflammatory phase), post surgical procedures

-pain

-acute bursitis, acute tendonitis

-spasticity

-muscle spasm

cryotherapy contraindications

• hypertension

• raynaud disease

• RA

• local limb ischemia

• history of vascular impairment (frostbite for ex)

• cold allergy (cold uticaria)

• paroxysmal cold hemoglobinuria

cryotherapy precautions

• changes in skin temp occur quickly. monitor closely to avoid tissue damage

• decreased or impaired sensation

• skin may turn pink or light red. discontinue if skin turns bright red, white, pale or grayish yellow, or develops welts (this is often indicative of poor circulation or a cold allergy)

ice massage

• localized application of cold directly to skin surface

• usually for small areas (painful trigger point, muscle spasm, spasticity)

• to decrease edema, elevate the body part during treatment

• ice is rubbed in small, slow circles

• treat for 5-10 mins or discontinue once numb

• cooling stages: CBAN

cold packs

• bag of ice, frozen peas, or re-useable gel packs

• inexpensive and easily used at home

• conforms to body part

• a dry, thin towel or pillow case may be used as a barrier between cold pack and skin

• a wet towel will provide quicker energy transfer

• to decrease edema, elevate the body part during treatment

• treat for 10-15 min

• less intense than ice massage

cryotherapy effects on ROM and strength

• decreases edema which could limit ROM

• decrease muscle spasms causing guarding

• decrease muscle tone and spasticity to allow more freedom of movement

• decreases pain which may be causing guarding or limiting ROM past a specific point

when to use thermotherapy

-for subacute (proliferative phase of healing) and chronic conditions

-pain

-osteoarthritis, tendonosis

-muscle guarding, spasms

-spasticity, hypertonicity

-excessive scar tissue deposition causing stiffness

thermotherapy precautions

• elderly, obese, thin, fragile clients should be monitored for systemic reactions (assess blood pressure and respiration)

• follow all precautions to avoid burns

• individual sensitivity to heat varies

• adipose tissue acts as an insulator, so heating tissue will take longer

thermotherapy contraindications

-sensory loss

-confusion, comatose, impaired communication

-peripheral vascular disease

-active infection

-inability to regulate body temp

-cancer (in the area of applic.)

-acute inflammation

hot packs

• variety of shapes and sizes contour to body part

• moist hot packs are made of canvas, filled with clay, and stored in a hydrocollator with water at 158-168 degrees F

• dry hot packs have the same effect and are convenient for home use

• never place directly on skin

• check every 5 mins for redness, blistering, burns

• treat for 15-20 mins for optimum effects

parrafin bath

• application of warm melted mineral wax at a temp of 125

• all physiological effects of heating agents and softens skin and superficial scar

• also do not use with any open wounds, sutures, staples

• clients should immerse hand in wax for 1-2 sec, withdraw and allow to harden and repeat 8-10x. DO NOT move hand during the dipping process

• then wrap the hand/wrist with plastic and a towel

• may use in combo with hot packs

• may position digits on flexion or extension stretch during treatment

• treat for 15-20 mins

electrotherapy precautions

• impaired sensation

• imapired cog or comm

• skin conditions

electrotherapy contraindications

• pacemaker or autodefibrilator

• venous or arterial thrombosis (local)

• occlusive vascular disease (could cause tissue necrosis)

• stimulation over the chest or carotid sinus

• cancer

• infection (local or systemic)

• TB

• active hemorrhage

• near superficial metal pins or plates

• over open wounds

• pregnancy- abdomen or lumbar spine

• C spine or craniofacial areas in clients with history of stroke or seizures

NMES- CNS injuries with intact PNS

• decrease muscle spasm

• strengthen muscle

• muscle re-education

• atrophy prevention

• stimulate muscle pumping to reduce edema

EMS- for denervated tissue (PNS injuries)

• prevent atrophy, degeneration, fibrosis

• may facilitate nerve regeneration and muscle re-innervation

FES

• will probs be used the most often

• NMES/EMS paired w functional activity (grasp/release, shoulder subluxation, foot drop)

NMES and EMS

• stimulation of muscle tissue to achieve a specific contraction

• used to maintain or increases muscle strength, increase ROM, muscle re-ed, orthosis substitution, reduce spasticity

• produces physiological processes equal to exercise

when to use NMES or EMS

-paralysis or paresis due to CVA, SCI, CP, BP injury, radial nerve palsy, etc.

-difuse atrophy

• prolonged immobolization, denervation, deconditioning secondary to prolonged illness

-edema

• pumping action of muscle contraction stimulates lymphatic system

NMES and EMS parameters….

• no true agreement in the literature as to the best way to set up parameters for optimum results

• once you truly understand the physiological effects of the parameters, you may use clinical judgement to adjust

• the higher the intensity (amplitude) and frequency of pulses, the stronger the muscle contraction

NMES/EMS electrode placement

• electrodes are the interface between skin and current flow

• come in several sizes, select the appropriate size based on muscle size

• placed on muscle belly parallel to direction of muscle fibers. one near PA and other near DA

• clean skin prior to application!

therapeutic US

• uses the same mechanical energy as imaging US

• a piezoelectric crystal, embedded within the soundhead, expands and contracts creating sound waves

• sound waves create vibrations at the cellular level which translate to kinetic energy and result in a heating effect

• a lubricant gel is required to transmit the soundwave to the body’s cells

acoustic impedance

• amount of resistance the US beam encounters as it passes through a tissue

• low impedance= low absorption

• high impedance= high absorption

2 primary effects of US

• non thermal- healing

• thermal- heating, usually deep heating

Non-thermal US effects

• increases phagocytic activity of macrophages/attracts immune cells to tissue

• increases protein synthesis

• increases capillary density

• regenerates tissue

Thermal US effects

• all the same effects as non thermal andddd

• increases extensibility of collagen fibers (muscle, tendon, ligament, scar tissue)

• reduces muscle spasms

• alters nerve conduction velocity/ diminishes pain perception

• increases blood flow and cellular metabolism

• raise tissue temp to about 110-113 F (must work quickly to take advantage of the increased collagen extensibility)

when to use non-thermal US

• to facilitate healing of acute or subacute injuries such as: tendinitis, bursitis, trigger points, contusions, pain, fractures, tendon, or ligament repairs

when to use thermal US

• to provide deep heat to promote soft tissue extensibility in chronic conditions

• facilitate lengthening of soft tissue (scar, tendon, muscle, ligament) in conditions like adhesive capsulitis and joint contracture

Therapeutic US instructions

• identify tissue healing phase

• determine depth required to effect the tissue

• apply gel to the treatment area

• educate client that they should not feel anything

US precautions

• acute inflammation or injury

• epiphyseal plates (closure in girls between 13-15 y/o and boys 15-17 y/o)

• fracture healing (no high intensity, continuous; low intensity, pulsed US ok)

• impaired circulation or sensation

• impaired cog or comm

• plastic or cement implants

• damaged or at risk skin

• chronic wound

US contraindications

• hemorrhagic conditions

• eyes, anterior neck, carotid sinus, reproductive organs

• DVT (local)

• infection or TB (local)

• malignancy (local)

• recently radiated tissue (local)

• pregnancy (local)

• skin disease (local)

• electronic device (local)