AOP adults Midterm

contact isolation

• When: known or suspected illness easily transmitted by direct patient contact or indirect contact with object in environment

• Examples: gastrointestinal, skin infection, wound infections, multi-drug resistant organisms, MRSA

• Intervention: 

  • glove and gown: don prior to entering room, remove prior to leaving, hand hygiene

  • Wash hands: gel or washing

  • Equipment: disposable if possible; patient dedicated equipment, disinfect before using with another patient, approved EPA disinfectant, bleach for c-diff

droplet isolation

• When: used for infections transmitted by large respiratory droplets that travel on short distances and do not remain in the air for long periods of time, usually generated by sneeze, cough, talking

• Examples: influenza, pneumonia, neisseria meningitis, mumps, covid

• Intervention

  • In single room 

  • Surgical mask (must) and eye protection (plus may use gowns and gloves)

respiratory isolation or airborne isolation

• When: used for infections transmitted by airborne droplets; can be supposed in air for long period of time and can travel long distances

• Examples: tuberculosis, smallbox, measles, chickenpox, severe acute respiratory syndrome (SARS), disseminated herpes zoster

• Intervention

  • In single room with negative pressure: airborne infection isolation room (AIIR)

  • Staff and visitors required to wear a fit tested NIOSH N-95 respirator 

Covid Precautions (NYP)

• Contact and droplet

• Wash hands, avoid touching face

• Gowns, gloves, n-95 masks, surgical mask, face shield and/or goggles

• Tend to wear head coverings (scrub caps or surgical bouffants)

dyspnea

condition where a person is short of breath or having difficulty breathing (feeling out of breath, labored breathing, air hunger)

dyspnea index

• Dyspnea index: one measure of shortness of breath for determining exertion levels

  • Test: deep breath in and count to 15

  • Level 0: no shortness of breath; can count to 15 (takes about 8 seconds) without taking a breath in the sequence

  • Level 1: mild shortness of breath: can count to 15 but must take one short breath; can count to 15 but must take one short breath in the sequence

  • Level 2: moderate shortness of berath; need to take 2 breaths to count to 15 in the sequence

  • Level 3: definite shortness of breath; must take three breaths in sequence counting to 15

    • Reduce level of intensity and use breathing control techniques

  • Level 4: severe shortness of breath; unable to count or speak 

    • Stop activity immediately 

SOAP Goals

1. Subjective, objective, assessment, plan 

SOAP: S

1. Subjective

   1. Report anything significant that the patient and/or family says about their treatment 

   2. If unable to speak, report non-verbal communication

   3. If patient is unable to speak or has cognitive/perceptual deficits, you can use the primary caregiver

   4. You can quote the patient, paraphrase but be concise 

   5. Use this time to listen and ask pertinent questions (how are you today? Are you in any pain? How do you think you are doing in therapy? Do you have any questions about your home exercise program or discharge? 

   6. Mrs. P is recovering from a bilateral knee replacement and during the second session she makes the following statement

      1. I am still having difficulty with the lb dressing adaptive equipment, can we go over it again? 

      2. My knee pain is 5/10 with movement

SOAP: O

1. Start with length of OT session and setting

2. Observations: measurable (grading and cueing) what did you do? 

3. Picture of the intervention session

4. Adverse event or different behavior and what you did

5. E.g. patient received 30 min OT at bedside for bed mobility, dressing, and toilet transfer, patient reported 2/10 pain at rest in bilateral knees….

SOAP Goals: A

1. Assessment

   1. Interpret objective

      1. Problems (contributing factors) still limiting ADL

      2. Progress, decline, same

   2. Rehab potential and why needing more OT

   3. Pain improved from 5/10 to 2/10 pain in bilateral knees at rest…

SOAP Goals: P

1. Future treatment

   1. Frequency and duration

   2. What will you be working on? 

   3. Referral with justification

2. Relate from o and a 

3. Patient to continue with OT for 1 weeks to address functional mobility, lb dressing and to educate client and caregiver on use of shower chair and adaptive equipment for bathing

COAST Goals

• Client, occupation, assist level, specific condition, timeline to achieve the goal 

blood pressure

• Normally should be less than 120/180 mm/Hg (millimeters of mercury) for an adult

• Elevated: 120-129/<80

  • Blood pressure that stays between 130-139/80-89 is considered hypertension/stage 1

  • Above this level (>/= 140/90 mm Hg or higher) is considered high: hypertension/stage 2

• Orthostatic hypotension

  • Change in posture causes change in blood pressure

  • Therapy 

    • Gradually increase head in bed from supine 

    • Slow transitions; gradually raise head

    • Compression stockings sometimes we ace wrap

    • Binding corset

    • Overhead pumping fist

    • Marching in place (legs pumping) 

heart rate/rhythm

• Pulse

  • Radial or carotid pulse

• Stethoscope

  • Apical of heart

• Tachycardia > 100BPM

• bradycardia < 60 bpm 

• Normal heart rate bpm 

  • Newborn: 12-160

  • 6-12 months: 90-140

  • 6-12 months: 80-140

  • 1-3 years: 80-130

  • 3-5 years: 80-120

  • 6-10: 70-110

  • 11-14 years: 60-105

  • Adults: 60-100

• Oxygen saturation 

  • PaO2

  • SpO2

HR BP response to activities

• Response to exercise/activities

  • Normal response

    • Hr and bp go up but should not be extreme

    • Respiration rates will increase a little and blood flow will increase (change of color) 

  • Abnormal response (STOP) 

    • Drop in heart rate

DVT

• Blood clot that forms in the vein deep in the body 

• Most common in leg and pelvis, less common in UE

• Can break off and travel to the lungs and cause a pulmonary embolism 

• DX: doppler ultrasound

• If symptoms, tell nurse and do not treat patient; have patient sit until pt taken for tests

• Will be sent for tests to confirm 

• If confirmed, will be place on blood thinner (heparin, coumadin, warfarin)

  • Do not treat patient utnil on therapeutic dose and cleared

  • Prothombin time is a test to evaluate blood clotting

    • Measure the amount of time

    • International normalized ratio (allows for easier comparison form different labs)

      • Normal is 2-3 but may vary per person 

• After stroke (if not hemorrhagic), some patients are placed on DVT prophylaxis to prevent dvt

DVT risk factors

Risk factors: immobilization, postoperative state, cardiac disease, older than 40, obesity, coagulation disorders

DVT symptoms

•  redness, swelling, pain, tenderness, some people have none

  • If in leg, usually behind knee or calf

DVT propholaxis measures

• Mechanical:

  • Compression stockings: applies pressure to legs (get amount of pressure from MD, to improve blood flow and decrease chance of clots)

  • Intermittent pneumatic compression pumps: these fit around the lower legs and provide an intermittent pumping (inflation/deflation) to help improve blood flo

• Pharmacological prophylaxis

  • Medications to prevent blood clots; also, aspirin which helps to prevent platelets frm adhering to one another

Decubiti

• Disorders of the skin 

  • Pressure injuries: also known as decubiti, bed sores, pressure ulcers

  • Pressure injuries are localized damage to the skin and underlying soft tissue, usually over a bony prominence; caused by prolonged or severe pressure including shear and friction forces

  • Areas of concern 

    • Where skin and bones are close; blood is then cut off

  • Now the national pressure injury advisory panel 

    • Resources and webinars

stages of pressure sores

• Stages of pressure sores: national pressure injury advisory panel 

  • Stage 1: skin is intact; red skin that does not blanch or become pale when pressure is applied; erythema remains for 1+ hours after relief or pressure

  • Stage 2: partial thickness loss of skin with exposed dermis

  • Stage 3: full thickness wound that extends down to subcutaneous and possibly muscle tissue

  • Stage 4: full thickness wound that extends down through skin, tendons, bone, and joints

  • Unstageable: full thickness loss of skin that is covers by eschar or slough 

  • Deep tissue: kin si no blanchable with discolored skin that is maroon or purple 

skin disorder assessment

• Assessment

  • OT might be part of skin rounds with team approach 

  • Work together to stage and measure with a ruler the shape, size, depth

  • Take photos

skin treatment

• OT management and prevention

• Medical 

stage 1 and 2 skin treatment

• stage 1 and 2 (see slides)

  • Teach to skin check 

  • Disperse weight, teach weight distribution every 30 minutes for 1-2 minutes offload; weight shifting forward, side to side, arm pushups; tilt in space w/c for people who can’t weight shift

  • Appropriate cushions (ROHO and gel and air for wheelchair, gel cushions for back of chair, air mattress for bed)

  • Movement and shifting weight changing bed position every 2 hours; avoid moisture, changing clothing after incontinence

  • Podus boot

  • Elbow padding

  • Nutrition and hydration

stage 3 and 4 skin treatment

• Stage 3 and 4 (see slides)

  • Pressure relief or off area completely 

  • Debridement and dressing of wound area, keeping area clean and dry, antibiotics, surgery to close wound

  • Proper nutrition and hydration 

orthotics: dual obliquity

• Dual obliquity: oblique angle and metacarpal heads

safe position orthosis

Safe position: MCPs flexed IP joints extended; thumb in opposition (not doing opposition but facing that direction); do not flex wrist 

MCPs flexed, IPs extended

dynamic splints

Low load prolong stretch

Dynamic orthotic

• Moving part, used to augment motion and improve prom 

• Line of pull must be at 90 degere angle; low load, prolong stretch

Dynamic splinting outrigger: 90 degree angle

Purpose of static orthosis

• No moving parts, used to put structures at rest, support and protect

serial static orthosis

• Remolded as ROM improves

• Focus is to increase PROM

status progressive orthosis

• Uses velcro, hinges, screws, and turnbuckles to improve PROM without having to remold

Orthotics safety 

• Perform skin checks

• Protect skin with stockinette

• Protect bony prominences

• Do not impinge upon creases of the hand

• Use a pattern 

• Monitor water temperature: dry material 

• Follow the MDs orders

• Follow mechanical principles

• Educate in wear and care

• Watch for fragile skin, infants and children, post surgical, sensory impairment fractures

Elbow fractures causes

• Falls, direct trauma

• Radial head fractures most common: fall directly on elbow with forearm pronated

• Olecranon fractures: second most common caused by fall on bent elbow

• Other: coronoid, supracondylar, distal humerus, ulnar

elbow fracture complications

• Elbow flexion contractures, heterotopic ossificans, complex regional pain syndrome

elbow fracture complications

• Stiffness

• Infection

• Malunion

• Nonunion

• Neuropathy

• Arthropathy 

• Heterotopic ossification 

  • Bone that forms in non-osseous tissue

  • Symptoms: pain, swelling, redness, and loss of motion

  • Close communication with the MD is critical 

  • Focus on increasing ROM, pain management, engage in ADLs

elbow fracture OT intervention

• Fabricate elbow orthosis to be worn for protection in between exercise sessions; elbow orthosis most commonly positioned in 90 degrees of flexion 

• Gentle AROm to elbow and forearm and to near by uninvolved joints

• Edema management: elevation, cold packs, massage (gentle) and light compression wraps (tubi grip)

• Surgeon will guide when therapy can progress to PROM and strengthening 

• Restore prior level of functioning

lateral epicondylitis

• Tennis elbow

• Tendinopathy, repetitive microtrauma of the extensor carpi radialis brevis 1-2 cm distal to origin at lateral epicondyle

• Extensor digitorum can be involved

• Repetitive wrist extension under load, forceful gripping, status wrist extension while gripping 

• Pain throughout forearm, into wrist; source of problem is at origin 

• Evaluation

  • Perform complete OT evaluation with profile, determine source of problem

  • Assess grip strength with elbow extended

  • Standardized pain assessment

  • Mill’s tennis elbow test

    • Palpate at the most tender area near the lateral epicondyle

    • Place client’s shoulder in neutral with elbow partially flexed, pronate forearm and flex wrist

    • Therapist moves the elbow from flexion to extension 

    • Pain in the area of the lateral epicondyle is positive

  • Maudsley’s resisted middle finger test

    • Resist middle finger extension while palpating the lateral epicondyle 

• Intervention

  • Elbow strap (counterforce strap)

  • Elbow strap and twist splint

  • Stretching of extensors (mills): keep it pain free

  • Ice pack or ice pop massage over painful area

  • Cross frictional massage

  • AROM, strengthening: start with gentle isometrics and then progress to isotonic exercises

  • Incorporate work and leisure activities 

medial epicondylitis

1. Pain at medial epicondyle

2. Pain can radiate into pronator/flexors of the forearm 

3. Causes are similar to lateral epicondylitis

   1. Repetitive wrist flexion and gripping activities 

   2. Static gripping (such as golfing) activities 

carpal tunnel syndrome (what it is and symptoms)

• Carpal tunnel syndrome 

  • Compression of median nerve at the level of the carpal tunnel (caused by swelling such as pregnancy or wrist fracture, anatomical anomalies, and cumulative trauma)

  • Symptoms

    • Numbness (night paresthesias) and tingling in the median nerve distribution 

    • weakness/atrophy of intrinsic muscles innervated by the median nerve (especially thenar muscles and lumbricals to digits 2 and 3)

    • Positive tinel’s sign and positive phalen’s sign; berger’s test (flexing fingers, pulls lumbircals into canals)

carpal tunnel syndrome interventions

• Conservative

  • Wrist orthosis in neutral: to be worn at night and during the day when experiencing numbness or performing awkward postures or repetitive movements

  • Median nerve glides and tendon glides

  • Sensory education: precautions

  • Activity modification to avoid awkward postures or repetitive movements (especially extreme positions of wrist flexion)

  • Ergonomics 

• Positive berger test: wrist splint above MCP joint

• CTS post surgical interventions

  • Edema control: elevation, isotoner gloves, tubigrip, retrograde massage

  • Scar management: scar pads, compression, massage

  • Nerve and tendon gliding

  • Sensory re-education

  • Sensory desensitization

  • Complication: pillar pain (ulnar aspect of hand)

  • Other common nerve compression to review

cubital tunnel syndrome

compression of ulnar nerve at elbow

• Causes: extreme elbow flexion and leaning on elbow

• Conservative tx: elbow orthosis at 30 degrees of elbow flexion, elbow pad, ergonomics and postural strengthening

• Pronator teres syndrome: may present like CTS but pain at proximal volar forearm; symptoms increase with repetitive pronation, note CTS symptoms are greatest at night

colles fracture and interventions/complications

• Colles’ fracture

  • Fracture of distal radius with dorsal displacement

• Closed reduction, ORIF, external fixation, fusion, joint replacement

• Evaluation for wrist fracture: address function, the DASH (disabilities of arm, shoulder, and hand) 

• Interventions

  • AROM, positioning, heat, strengthening, ADLS, IADLS, work and leisure

trigger finger and splint

• Stenosing tenosynovitis of the flexor tendon most commonly at A1 pulley can be caused by a nodule

• Cause: repetitive gripping and long periods of sustained grasp 

• Linked to diabetes and rheumatoid arthritis

• Symptoms

  • Pain upon palpation of A1 pulley 

  • Decreased ROM of finger flexion or extension 

  • Catching or sticking of the finge rin flexion, especially in the morning; often have to pull it open 

  • Snapping of the locked fingers into extension; causes a triggering-like movement

• More than one digit may be involved 

interventions for trigger finger

Interventions

• Orthosis

  • Gliding tendon a little bit but not a lot? 

• Activity modification: especially avoiding repetitive gripping activities (theraputty, pruning bushes, sustained grip, composite flexion exercises/activities)

• Ice and massage

• Position hold flexion (avoids triggering) or half fist

• Padded gloves and built up handles on tools

dupytrens contracture

• Disease of the fascia of the palm and can extend into digits

• Progressive flexion contractures of involved digits

• Treatment (post surgical)

  • Wound care, edema control, hand base finger extension orthosis (doesn’t need to include wrist), ROM as per surgeon, scar management once wound is healed, occupation activities 

ROM documentation

Begin with ROM screen 

Goniometer

AROm vs PROM

Documentation

Interpretation

biomechanics frame of reference

• Evaluation and treatment aimed at the impairment level (bottom-up approach)

• Remedial approach focusing on impairments that limit occupational performance

• Need direct connection between impairment and activity, roles, etc. 

• Focus on range of motion, strength, endurance

• Should never be used in isolation 

• Assumptions

  • Improvement at impairment level will improve performance

  • Human movement and physical activity enables occupational performance

  • Best suited for patients with intact CNS

  • Rest then stress

• Systems: peripheral nervous system, musculoskeletal, cardiopulmonary, skin disorders

• Assessments

  • ROM (goniometry), strength (MMT, grip, pinch), endurance (reps, time, distance)

rehabilitation frame of reference

• Compensatory and adaptive approaches when remediation of impairments is not possible

• Focus on abilities, tech, compensatory, modifications, orthotics and prosthetics

arthritis

• Common: osteoarthritis, gout, rheumatoid arthritis 

• Symptoms: pain, aching, stiffness, swelling in or around joints

rheumatoid arthritis

• Rheumatoid arthritis

  • Cause unknown, inflammatory disease

  • Autoimmune and systemic

  • Pathological changes

    • Synovitis, pannus, cachexia, joint instability, fatigue

  • Symptoms

    • Pain, symmetrical, morning stiffness, edema, fatigue

    • Stages: acute, subacute, chronic active and chronic inactive

    • Commonly begins by attacking the small joints of the hand

  • Pharmacologic interventions

    • DMARDs and biologics

  • Attacks synovial fluid/membrane 

  • Acute: active inflammation; painful, red, hot, swollen, difficulty moving due to stiffness

  • Subacute: less inflammation, stiffness remains, no joint deformities but joint destruction continues

  • Chronic active: less pain, deformities present

  • Chronic inactive: joint deformities and skeletal collapse

acute rheumatoid arthritis

Acute: active inflammation; painful, red, hot, swollen, difficulty moving due to stiffness

subacute rheumatoid arthritis

 less inflammation, stiffness remains, no joint deformities but joint destruction continues

chronic active rheumatoid arthritis

 less pain, deformities present

chronic inactive rheumatoid arthritis

• joint deformities and skeletal collapse

osteoarthritis

• Degenerative joint changes: damage to articular cartilage mainly caused by wear and tear and hereditary 

• Pathological changes include

  • Loss of articular cartilage

  • Osteophytes (bone spurs)

  • Some inflammation but not typical 

  • Symptoms: pain, joint stiffness, muscle weakness, decrease ROM, crepitus, nodes (bouchard and herberdens), commonly attacks IP joints, CMC joints and large weight bearing joints

• Pharmacologic interventions (nsaids, acetaminophen, cox-2)

•  Goes after cartilage and joint space, ligaments, joi

• Assess: strength, stability, fatigue, ADLs

RA and OA interventions

Goal: decrease pain, improve joint motion and improve function

patient education

physical agent modalities

therapeutic exercise to maintain mobility

splints

adaptive equipment/environment

arthritis: patient education

Patient education

• Joint protection techniques

  • Maintain ROM and strength

  • Minimize excessive loading on joints

  • Healthy respect for pain 

  • Balance rest and activity 

  • Avoid prolonged positions

  • Avoid positions of deformity 

• Energy conservation/work simplification 

arthritis: physical agent modalities

• Interventions to support occupation 

• Modalities are used to address pain and improve ROM 

  • ROM: hot packs, fluidotherapy and paraffin; prior to initiation of ROm and activities

  • Pain: hot packs and paraffin; cryotherapy (ice packs, ice massage), 

  • Ice packs for acute flare up otherwise heat for discomfort and stiffness

arthritis: therapeutic exercises

Therapeutic exercise to maintain mobility 

• Focus on AROm or increasing mobility through function 

• Acute and subacute

  • AROm, avoid pain, only gentle if too weak

• Chronic: focus on AROM, avoid pain, gentle if too weak 

  • Strengthen using light activities, light isometrics and isotonic

  • Avoid pinching if thumb is unstable, avoid gripping if inflamed or triggering

arthritis: splints

Splints

• Rest, prevent deformity, enhance function

• Purpose: rest, prevent deformity, enhance function

• Hand based thumb splint: cmc arthritis,

• Wrist splint: wrist arthritis

• Trigger finger splint: blocks MCP flexion

• Finger troughs: support joint and prevents further deviation at PIP and DIP 

arthritis: adaptive equipment/environment

Adaptive equipment/environment: limit the amount of gadgets

• Modify functional use patterns, built up utensils, levers for door knobs, large diameter build up writing tool, etc.

RA deformities

Swan neck deformity 

Hyperextension of PIP, flexion of DIP 

Boutonniere deformity

Flexion of PIP, hyperextension of DIP 

• Resting hand splint, gutter splints, silver ring

Ulnar drift

Drifting occurs at the level of the MCP jts

EDC slips to ulnar side of the MCP jt (no longer centralized)

Most common hand deformity is ulnar drift and combined MCP subluxation 

Advanced: zigzag deformity and subluxations 

shoulder conditions assessment

• Symmetry, sleeping posture, functional assessments, functional movements 

• AROM: of all shoulder and scapula movements, note painful arc (60-120) and compensation

• Note end feel: End feel

  • What does it feel like on the end of the range of motion (passive)

  • Empty: stopping because of pain; doesn’t feel like it needs to stop 

  • Hard: cant go further

• MMT/resistance testing

  • Pain in relation to resistance

    • Pain before resistance: acute condition

    • Pain at resistance: subacute condition

    • Pain after resistance: chronic condition 

shoulder special tests

1. Neer impingement sign

   1. Lying down, forced forward flexion with IR, positive sign is face will express pain; overuse of supraspinatus and or long head of biceps

2. Hawkins test

   1. Shoulder and elbow flexed to 90 degrees followed by forced internal rotation; positive sign is patient will express pain 

   2. Overuse of supraspinatus and or long head of biceps

3. Painful arc test

4. Empty can 

5. Biceps speed test

   1. Shoulder flexed to 90, forearm supinated, elbow extended

   2. Resistance is applied to flexion; positive sign is pain over biceps groove; biceps tendonitis 

6. Drop arm test

   1. 90 degrees abduction; have patient slowly lower arm to sign; positive is patient drops arm to side; tear in rotator cuff

conservative treatment shoulder

1. Activity modification

2. Educate in sleeping postures

3. Decrease pain 

4. Restore pain free ROM 

5. Strengthening below shoulder level (everything is below shoulder level)

6. Occupation and role specific training

orthopedic management shoulder

1. Arthroscopic rotator cuff repair (95%); small, medium, and large tears

2. Open repair (not as common): medium, large, massive 

3. RTC protocols

   1. Vary depending on surgeon, size of repair, type of repair/tension, quality of tissue

   2. PROm, AAROM, AROM, strengthening, aquatic therapy

   3. Increase ROM, strength, function

4. Postop follow MD timeline

   1. Immobilization may range from 2-4 weeks

   2. PROM will vary: commonly 2-4 weeks

   3. Pendulum: using body to move extremity (passive only)

5. Weeks post op

   1. Passive elevation in plane of scapula ____

post op A/AAROM for shoulder

1. Can start as early as week 6 

2. Ideal to begin supine; prevents hiking

   1. Gravity lessened position

3. Progress to A/AAROm against gravity 

4. Wall walking shouldn’t begin until client’ is oked for AROM (if hiking or pain occurs, continue with AROM supine) consider towel glides on kitchen table; only wall walk if no pain 

5. AROM can be achieved via ADLs: dressing, etc. 

1. Strengthening initiated when oked by surgeon; usually week 12

   1. Begins with submaximal isometrics (light resistance and only if ordered by MD)

      1. Hold for count of 5, perform 8-10 2x daily 

      2. ER, flex, elevation, abduction

shoulder fractures

1. One part, two part, three part, four part

2. Medical treatments: conservative with sleing, ORIF, hemiarthroplasty 

3. Timing of when ROM can be performed is based on clinical healing

4. Nonoperative: PROM, pendulum (wearing sling in between exercises), progress to AA/AROM when Oked by md

5. Operative: follows same sequence when oked by MD

cuff tear arthropathy

1. Cuff tear arthropathy (CTA)

   1. Irreparable RTC in combination with severe glenohumeral osteoarthritis

   2. Irreparable RTC in combination with humerus fracutre

   3. Humeral head migration 

   4. Orthopetic management

      1. Intact rotator cuff and osteoarthritis: hemiarthroplasty or total shoulder replacement

      2. Cuff tear arthropathy; total shoulder or reverse total shoulder replacement

      3. Fracture: hemiarthroplasty or total shoulder replacement

total shoulder replacement

1. Total shoulder replacement

   1. Postop 0-3 days

      1. Positioning: sling, pillow under elbow with shoulder in slight elevation while sleeping

   2. Postop 0-1 week

      1. AROm of uninvolved joints

      2. Pendulum exercises; passive only 

   3. 1-2 weeks

      1. Perform in supine 3-5 daily 

         1. Passive elevation

         2. Goal by day 5 must be over 90 degrees

         3. Passive ER: initially limited 0-30 degrees due to reattachment of subscapularis; can be performed by therapist with hands on or using a cane

         4. No aggressive ER

   4. Week 2

      1. Assisted IR with cane to stomach 3-5 times daily

      2. No active IR to small of back 

      3. Pulleys using uninvolved arm to move involved; forward elevation

   5. Week 3

      1. Begin gentle isometrics: flexion, elevation, ER

   6. Week 6-10

      1. A/AAROM: supine, table slides, wall walking

      2. Progress to light theraband exercises (dont need ot know weeks but should know progression) 

RTC pathology

1. Types of RTC pathology

   1. Tendinopoathy

   2. Partial tears

   3. Full thickness tears

   4. Irreparable tears

During AROm note painful arc (60-120) and compensation 

RTC conservative treatment

1. conservative treatment

   1. Activity modification

   2. Educate in sleeping postures

   3. Decrease pain 

   4. Restore pain free ROM 

   5. Strengthening below shoulder level (everything is below shoulder level)

   6. Occupation and role specific training

orthopedic management for RTC

1. Orthopedic management

   1. Arthroscopic rotator cuff repair (95%); small, medium, and large tears

   2. Open repair (not as common): medium, large, massive 

   3. RTC protocols

      1. Vary depending on surgeon, size of repair, type of repair/tension, quality of tissue

      2. PROm, AAROM, AROM, strengthening, aquatic therapy

      3. Increase ROM, strength, function

   4. Postop follow MD timeline

      1. Immobilization may range from 2-4 weeks

      2. PROM will vary: commonly 2-4 weeks

THR

1. Total hip replacement for fracture (THR or THA-arthroplasy)

   1. Preop 

      1. Education

         1. Equipment, what to set up, what is gonna happen when they go home

      2. Course of treatment

      3. Discharge

   2. Evaluation 

      1. Occupational profile

         1. PLOF: prior level of functioning

         2. Roles, work, hobbies, ADL

         3. Social hx and support

         4. Home environment

            1. Floors, bathrooms, steps, etc. 

2. DVT

   1. Watch for signs of deep vein thrombosis

1. Equipment: high chair, pillows to raise chair, raised toilet seat, bed raisers, adduction pillow

2. Children may have full casts or braces

THR weight bearing

1. NWB: nonweightbearing

2. TTWB: toe touch weightbearing

3. PWB: partial 

4. FWB: okay to put full weight

5. WBAT: tolerated; can put weight as they tolerate it

THP hip precautions: posterior approach

1. Posterior approach (most restrictive)

   1. No hip flexion past 90 degrees

      1. Not bending over, not sitting on a low chair, not reaching to toes

   2. No hip IR or adduction

   3. Do not cross legs (adduction)

hip precautions: anterior approach

1. Anterior approach 

   1. No hip extension (do not step backwards(

      1. If backing up, lead with unoperated leg

   2. No hip ER past neutral (do not turn leg outward)

   3. No hip abduction 

   4. Some surgeons have no precautions protocol (let pain guide)

hip precautions: global

1. Global (not common)

   1. No hip flexion past 90

   2. No hip rotation or adduction

   3. No prone

   4. No bridging

THR treatment

1. Goal: independence in chosen activities incorporating surgical precautions if needed

   1. Treatment

      1. Assistive devices are necessary for certain BADL/IADL (independence versus impairment recovery)

         1. LE dressing

         2. Bathing

         3. Toileting

         4. Upright funciton/ambulation

         5. Seated activities  

      2. Transitional movements and safety 

         1. Posterior THR precautions

      3. Increasing weight beating comfort/function/balance

      4. Strengthening

      5. Safety evaluation 

         1. Good lighting, no throw rugs

      6. Driving

         1. On doctor’s orders

      7. Work simplification

         1. Work activities in home, etc. 

      8. Relaxation

      9. CAMS

      
      
      

THR: ambulation devices

1. Start with rolling walker with wheels usually 

2. Straight cane, walker, crutches, rollator

3. Proper height and usage is important (cannot be too low)

4. Choosing posture to perform activities

5. 15 degree elbow flexion 

6. Stay within the walker (not too fast or too close)

7. DAN: device, affected leg, nonaffected leg 

   1. Move device first, then affected leg, then nonaffected

   2. Therapist stands next to the person on the involved side 

8. Posterior precautions

   1. No pivoting

   2. No twisting to get items as that causes hip internal rotation

   3. Activity should be right in front of them

carpal bones

• Proximal row: scaphoid, lunate, triquetrum, pisiform

• Distal row: trapezium, trapezoid, capitate, hamate

intrinsic tightness

• Test: MCP in ext with PIP stretched to flexion then MCP in flexion and stretch PIP into flexion; if PIP can be flexed more with MCP in flexion than extension, there is intrinsic tightness

• If PIP is tight when MCP is flexed or extended, means ligamentous tightness

extrinsic tightness

• Extensor tightness: PIP and DIP flexion limited when simultaneous flexion of wrist, MCP, IP 

• Flexor tightness: PIP and DIP extension limited when simultaneous extension of wrist, mcp, ip 

claw hand

ulnar nerve injury

wrist drop

radial nerve injury; inability to extend MCP jts, thumb, wrist

Wrist Joint capsule and ligaments

1. Fibrous joint capsule surrounds radiocarpal and midcarpal joints

2. Ligaments: extrinsic

   1. Collateral ligaments

      1. Radial collateral ligament

      2. Ulnar collateral ligament

   2. Triangular fibrocartilage ligament: function is to stabilize the ulnocarpal joint and the distal radioulnar joint. Consists of the ulnar collateral ligament, TFC articular disc, the dorsal and volar radioulnar ligaments and the meniscus

3. Ligaments: intrinsic

4. Only attach to carpal bones: scapholunate and lunotriquetral (primary stabilizers)

• 
  Palmar carpal ligament

1. Roof of guyon's canal 

• Flexor retinaculum 

1. Transverse carpal ligament

2. Roof of carpal tunnel 

   1. Carpal tunnel floor: carpal bones

• Extensor retinaculum 

1. 6 dorsal compartments

2. l

dequervains tenosynovitis

• Abductor pollicis longus, extensor pollicis brevis

• Pain raidial wrist and thumb, positive finkelsteins, welling on radial side of wrist

• Repetitive wrist movements, gripping, pinching

• Intervention 

  • Forearm base thumb spica orthosis and rest 

    • Wear during the day during activity; if pain at night wear 

  • Gentle AROM 3-4 times daily 

  • Ice massage, cross frictional massage, iontophoresis with dexamethasone

  • Activity mod: avoid pain

  • Gentle passive stretching

  • Surgical intervention

spine

• Surgical procedures: fusion (two or more vertebrae fused together using screws, rods, bone grafts)

spine precautions

• BLT

  • No bending, lifting, twisting

  • Log roll to get out of bed

• Spinal precautions

  • Dependent on MD and surgery 

  • BLT (No bending, liting, and twisting) 

  • Avoid bending and twisting of back 

  • Avoid picking up items over 10 pounds

  • Avoid standing and sitting in the same position for more than 30 minutes

  • When going sit to stand bend knees and hips not back; use arms to help lower self to seat

  • Tlso or flexible lumbar corsets dependent on MD

  • Cervical patients

    • Avoid reaching above shoulder

    • Avoid reaching far distances and twisting neck 

    • Hard collar aspen collar; dependent on MD

spinal treatment

• Treatment

  • Preparatory to decrease pain, increase flexibility: heat, cold packs, tens

  • Assistive devices

  • Strength and endurance when oked

  • Energy conservation 

  • Work simplification 

  • Complementary and alternative therapies

  • Sleeping posture: supine with pillow under knees or side with pillow between knees and UE supported

  • Proper body mechanics

    • Back in proper alignment

    • Position close to and face task

    • Avoid twisting

    • LE power to raise and lower body 

    • Avoid prolonged repetitive activity or static positions

    • Balance activity with rest

knee precautions

NO PRECAUTIONS

1. Surgical procedures (knee) 

   1. Knee arthroscopy 

   2. Total knee arthroplasty (TKA) or replacement (TKR) (same thing) 

   3. Partial Knee Arthroplasty

treatment: knee

1. Treatment (knee)

   1. Preparatory interventions

      1. Continuous passive motion machines (CPMs)

      2. PAMs

      3. PROM, AROM

         1. Towel slides (working on knee flexion) 

         2. AROM in sitting

   2. Ambulation device choice (PT and surgeon)

   3. Proper posture to perform activities

   4. Transitional movements

      1. Bed mobility 

      2. Sit to stand

      3. Stand to sit

      4. Tub bench transfer

   5. Increasing weight bearing comfort/function

   6. Strengthening

   7. Safety evaluation 

   8. Driving

   9. Work simplification 

   10. Relaxation 

   11. CAMs

Introduction: An OT in an acute care hospital is referred a 72 y/o patient diagnosed with s/p (R) THR (posterior approach) 1 day ago. The patient will be discharged home tomorrow. The patient lives with their spouse and 22 y/o son. 

Section 1 of 4: Following the OT evaluation which interventions are most appropriate for the therapist and patient to work on?  3 are correct and 3 are incorrect.

Practice functional mobility from bed to bathroom using a wheelchair

Educate patient that there are no hip precautions except use pain as a guide

Practice lower body dressing using long handled equipment

Practice functional mobility from bed to bathroom using a rolling walker

Educate patient that they should avoid flexing past 90 degrees, no adduction or internal rotation

Practice transfers on and off a regular height toilet

Practice functional mobility from bed to bathroom using a wheelchair

Educate patient that there are no hip precautions except use pain as a guide

Practice lower body dressing using long handled equipment

Practice functional mobility from bed to bathroom using a rolling walker

Educate patient that they should avoid flexing past 90 degrees, no adduction or internal rotation

Practice transfers on and off a regular height toilet

A patient has been referred to OT with a diagnosis of (L) rotator cuff repair. The order is for PROM only. The patient reports a 4/10 pain level at rest. What best describes how the OT will treat the patient?

Teach the patient wall walking using the (R)UE to assist

Gently move the shoulder to end range and apply gentle over pressure

Practice towel slides from a seated position

Gently move the shoulder to end range

Teach the patient wall walking using the (R)UE to assist

Gently move the shoulder to end range and apply gentle over pressure

Practice towel slides from a seated position

Gently move the shoulder to end range

A patient was referred to OT with pain in both hands as a result of an acute flare up of her RA. You observe her small joints of her hands and wrists are red and swollen.  What would be the most effective intervention for this patient

Fabricate resting hand orthoses to be worn intermittently throughout the day

Teach the patient radial walks for both hands

Provide hot packs to both hands followed by gentle AROM

Fabricate bilateral wrist orthoses to be worn at all times

Fabricate resting hand orthoses to be worn intermittently throughout the day

Teach the patient radial walks for both hands

Provide hot packs to both hands followed by gentle AROM

Fabricate bilateral wrist orthoses to be worn at all times

An entry level OT is following a patient s/p Colles Fracture from a fall on an outstretched hand 4 weeks ago. The patient was treated with closed reduction and a SAC. The cast was removed yesterday. The patient has swelling, pain, limited motion and impaired sensation. The patient is referred to OT to begin therapy. What intervention would the new therapist begin with first?

AROM

PROM

Fabricate a dynamic wrist extension orthosis

Hot Pack

AROM

PROM

Fabricate a dynamic wrist extension orthosis

Hot Pack

While walking a patient in the OT gym the patient complains of pain in their calf that is red, and swollen. How would you proceed with the patient?

Finish the OT session and then alert the nurse of the patients pain

Have the patient sit down and contact the MD immediately

Have the patient walk to their hospital room and lie down with feet elevated

Provide gentle massage to the calf and have the patient do ankle pumps

Finish the OT session and then alert the nurse of the patients pain

Have the patient sit down and contact the MD immediately

Have the patient walk to their hospital room and lie down with feet elevated

Provide gentle massage to the calf and have the patient do ankle pumps

What best describes the focus of the biomechanical frame of reference?

Top down approach

Focus on abilities vs disabilities

Compensatory and Adaptive approaches

Remediation of ROM, strength and endurance

Top down approach

Focus on abilities vs disabilities

Compensatory and Adaptive approaches

Remediation of ROM, strength and endurance

An MD refers a patient to OT for a functional hand splint in the safe position. How would you position the patients hand?

Wrist extended, MCP jts flexed and IP joints slightly flexed and abducted

Wrist, MCPs and PIP/DIP joints all exten

Wrist in neutral, MCPs and IPs slightly flexed

Wrist extended, MCP jts flexed and IP jts extended

Wrist extended, MCP jts flexed and IP joints slightly flexed and abducted

Wrist, MCPs and PIP/DIP joints all exten

Wrist in neutral, MCPs and IPs slightly flexed

Wrist extended, MCP jts flexed and IP jts extended

What creases must be cleared when fabricating a wrist orthosis?

DPC and thenar crease

Thenar creas and distal wrist crease

DPC and proximal wrist crease

Proximal wrist crease and proximal palmar crease

DPC and thenar crease

Thenar creas and distal wrist crease

DPC and proximal wrist crease

Proximal wrist crease and proximal palmar crease