Ortho / Burns / Vision / Work Rehab / Research

Superficial Burn

Non-surgical, no scarring, no contracture risk

Superficial Partial

Non-surgical, scarring, contracture risk

Deep Partial

Surgery possible, scarring, contracture risk

Full Thickness

Skin grafts required, severe scarring, severe contracture risk

Positioning Mnemonic for Burns

Vitruvian Man or Titanic

What positions should you avoid when treating individuals with burns?

Positions of comfort

What material should you avoid when splinting patients with burns?

Velco, use soft materials like gauze or elastic

Splint for Axillary Burns

Antideformity position with Airplane Splint

Splint for Elbow burns

Antideformity position with elbow extension orthosis

Splint for Hand Burns

Antideformity (Intrinsic Plus) with wrist neutral or slight extension

Splint for burn that affects webspace

Antideformity with opposition/abduction

Considerations for Dorsal Hand Burn Splinting

Antideformity with wrist in neutraul; Avoid composite flexion (ex. fist), increased risk of extensor tendon damage

Claw Hand Splint

Antideformity splint, dynamic/serial

Palmar Contracture Splint

Pan hand splint, baseball glove, dynamic / serial

Wrist flexion deformity splint

Wrist cock-up, dynamic / serial

Acute Phase of Burns

• < 72 hrs

• Focus on: Preventing Deformity

  • positioning/orthotics

  • AAROM, AROM

  • Scar/Edema Management (elevation)

Surgical/Post-Op Phase of Burns

• Post-skin graft: Immobilize ~ 1 week

• Focus on: Preventing Deformity

  • Positioning of involved joints

  • Therex of uninvolved joints

  • Adapt ADLs as needed

Rehabilitative Phase of Burns

• Starts at wound closure

• Focus on: ASSESSing Function to regain PLOF

  • ADL

  • Scar Management

  • Splint

  • Edema

  • Sensation

  • Strength

Mnemonic for Rehab Phase of Burns

ASSESS

• ADL

• Scar Management (lubrication, massage, pressure garments)

• Splint

• Edema - Compression (elastic wrap/isotoner gloves; 20-44 mmHg of pressure)

• Sensation - Desensitization (fluido, paraffin, hot packs)

• Strength

Impairments with Oculomotor Dysfunction

• Diplopia (difficulty with reaching for objects)

• Convergence (difficulty with up close tasks)

• Slow scanning

• Headaches / eye strain

Intervention for scanning deficit

Scanning/Tracking exercises

Intervention for Reading Difficulty

Anchors and line guides

Interventions for Decreased Convergence

Brock String

Intervention for Generic Oculomotor Issues

Computer games, Dynavision, modify environment (decrease clutter)

Visual Field Deficits

• Homonymous Hemianopsia

• Mobility Issues

• Problem finding everyday tasks

Intervention for Unable to Locate Items (visual field deficit)

Organization of environment

Intervention for bumping into environment (visual field deficit)

Organized scanning, awareness raining, organize environment

Intervention for Difficulty reading (visual field deficit)

Anchors / line guides

Hemispatial Neglect

Unable to attend to affected side, lacking insight

Interscapular Amputation

Entire scapula and below

Transradial Amputation

Somewhere along the radius

Transhumeral Amputation

Somewhere along the humerus

Hallmark issues/deficits of amputation

• Hypersensitivity, typically near residual limb

• Phantom Limb Pain

Intervention for Hypersensitivity

Desensitization → start with tolerable textures, grade from there

Progression of pressures for Desensitization

Light touch → rubbing → tapping → prolonged pressure

Phantom Limb Pain Interventions

• Mirror therapy

• Acupuncture

• TENS

• Relaxation

• Isometrics (~1 week post-surgery)

Pre-Prosthetic Phase

Prepare limb for prosthetic

• ADL retraining (Hemi Dressing, AE)

• Wound/scar management

• Educate on prosthetic option

• Desensitization

• Limb shaping ( figure 8, shrinker)

Myosite Testing

Testing electrical signals of residual limb for electric prosthetic

Basic Prosthetic Training

Everything but use the prosthetic

• Evaluate prosthetic (fit/function)

• Wear schedule (start with: 15-30 min, 3x/day)

• Don/doff

• Limb hygiene

• Prosthetic knowledge

• Care of prosthetic

Limb Hygiene

• Mild soap, pat dry, check for redness

• Barriers:

  • Socks, liners, antiperspirants

Intermediate Phase of Prosthetic Training

Learning to use prosthetic, NOT functional yet

• Control training: learning/practicing controls

• Use training (ex: picking up cones)

Advanced Prosthetic Training

Functional training

Body Powered Prosthetic

Low cost; decreased grip strength

Myoelectric Prosthetic

Increases grip strength/function, requires myosite activity

Hybrid Prosthetic

Electric grip strength, requires myosite activity

• Typically for elbow/humeral amputations

Passive Prosthetic

Cosmetic, not functional

Activity Specific Prosthetic

Interchangeable terminal devices for specific tasks

Transfemoral Amputation

Above knee (AKA)

Transtibial Amputation

Below knee (BKA)

Finish this statement: the most proximal an amputation

The more difficult function will be

Where will the COG be for a BLE amputatee?

Shifts backward, making the pt susceptible to a tipping risk

Intervention for COG for LE amputees

• Shift COG forward (add cushion or adapt wheelchair)

• Anti-tippers

Limb Positioning for LE amputees

Risk of flexion contracture; promote knee extension (residual limb support)

3 P’s for Orthopedics

• Pain: cryotherapy for acute recovery

• Positioning

• Performance

Positioning Mnemonic for TKA

“Knees are Straight Forward” → Knee extension @ rest to prevent flexion contracture

Transfers / Movement for TKA

• OOB as soon as possible

• AE: grab bars, raised toilet seat/safety frame, non-slip mat, showerchair

ADL/AE for TKA

• Shoe horn, sock aid, reacher, dressing stick

• Long handled sponge

• Train to doff/don knee mobilizer

ORIF for Hip Fracture

• Screws

• Be considerate of weightbearing status

Hip Arthroplasty

• Artificial hip joint

• Be considerate of weightbearing status and precautions

Anterior Hip Precautions

No Extension, NO External Rotation, No ADDuction

Posterior Hip Precautions

No Flexion (>90), No Internal Rotation, No ADDuction

Education/Adaptation for Hip Fracture (ORIF/Arthroplasty)

• Fall prevention (lights on @ night, decrease clutter, no rugs)

• Home modification to decrease fall risk (grab bar, tub transfer bench)

What should you train pts with a posterior hip replacement to do when transferring?

Kick leg out

What positioning AE would be recommended for a pt with a posterior hip replacement?

Reclining wheelchair

What positioning AE would you recommend for posterior AND anterior hip replacement?

Abduction wedge to prevent adduction

Spinal Precautions

“BLT” → No bending, no lifting, no twisting

Compensations for Spinal Precautions

• Log roll

• Golfer’s lift (kick leg back when picking item off floor)

• Propping one leg up

What lower body dressing technique would you suggest for someone with spinal precautions?

Supine dressing

Hemi/Total Shoulder Replacement

Slow ROM progression; do pendulum swings

Reverse Shoulder Replacement

ROM progressives faster; no pendulum swings

Mobility progression for shoulder post-replacement

• Immobilization

• PROM - pendulum swings

• AAROM - pulley / hands-on

• AROM

• Resistive

Vision Loss Mnemonic

“Big, Bold, Bright”

Magnification, Contrast, Illumination

Illumination Intervention for Vision Loss

• Natural light

• LED lights

• Control glare

Sensory substitution for Vision Loss

Use touch to compensate

Intervention for Clothing Identification Visual Deficit

Raised dots, safety pins, groups similar items

Intervention for Appearance Visual Deficit

Wrinkle free, stain resistant fabrics

Intervention for Plate Orientation Visual Deficit

Clock method, caregiver orientation, contrast utensils, plate, glass to table

Intervention for Pouring Visual Deficit

Finger over the rim of cup

Intervention for Writing Visual Deficit

Boundary guide, high contrast writing utensil (black felt pen)

Intervention for Reading Visual Deficit

Magnification

Intervention for Identifying Medication Visual Deficit

Magnifiers, large/high contrast labels, tactile markings, prescription bottle reader

Intervention for Dialing Visual Deficit

Tactile buttons, large buttons, speed dial, voice activated device

Intervention for Bill Identification Visual Deficit (Money Handling)

Folding system, credit card

Intervention for Mobility Visual Deficit

• Trailing (using hands to trail object or surface)

• Sighted guiding (stand half step behind while holding arm above elbow

Screenings suggest vision issues, What do you do next?

Refer to optometrist/opthamologist, before intervention

Central Vision

Where we see detail, ex: faces or reading street signs

Peripheral Vision

Helps navigate, stay oriented

Ex: driving (without running into other cars)

Macular Degeneration

Central Vision loss

Macular Degeneration Deficits

• Decrease focus with reading

• Struggle with seeing faces

• Decreased fine motor abilities

Intervention for Macular Degeneration

Eccentric Viewing (using peripheral vision)

Glaucoma

“Tunnel vision” → peripheral vision loss

Glaucoma Deficits

• Mobility

• Blurriness

What should you keep in mind when using magnification as intervention for glaucoma?

Don’t use too much light

Cataracts

“Cloudiness” in vision

• Blurriness

• Decreased visual acuity

• Decreased contrast

• Glare

Diabetic Retinopathy

Blind spots (floaters)

Progressive

Diabetic Retinopathy Deficits

• Decreased contrast

• Decreased color vision

Comorbidities of Diabetic Retinopathy

• Distal sensory loss (neuropathy)

• CVA

• Amputation

• Heart Disease

Intervention for Diabetic Retinopathy

Moderate lighting (no more, no less)

Progression of Care (Work Rehab)

Injury → Acute Care → Work Conditioning → Work Hardening → Return to Work (modified/full duty)