AOP adults II final

Wheelchair seat width

across widest point of hip or thighs and add two inches

wheelchair arm height

seat upholstery surface to point of bent elbow with upper arm and elbow straight down

add one inch

wheelchair seat depth

seated, measure rear of buttocks to behind bent knee; subtract 2-3 inches

back height

sweat level to armpit area and subtract 4 inches (standard back height)

top edge of back upholstery should be slightly below shoulder blades

seat height and foot rest adjustment range

lower leg from behind bent knee to bottom of heel with foot approximately 90 degrees to lower leg (lowest minimum practical seat height)

step plate should have at least 2 inches clearance with floor

wheelchair measurements

basic parts of the wheelchair

door openings for wheelchairs

32 inches minimum requirement

ideal is 36 inches

ramp ratio for wheelchairs

1-12 (1 inch of rise = 12 inch ramp)

3 inch rise = 36 inch ramp

ramps in public places must have a railing and curb with a four foot landing at the top

space needed for a 360 degree turn in a wheelchair

5 ft by 5 ft

ideal position for wheelchair

1. 90-90-90 angles 

   1. Thigh to trunk

   2. Thigh to lower leg

   3. Lower leg to foot

   4. Elbow 

2. Symmetry of trunk (side and front)

3. Head and neck midline

4. LEs supported

5. Balanced pelvis!

purpose of a caster wheel on a wheelchair

smaller, helps with turns and maneuverability

recommendations for wheelchairs

1. When going up a ramp, it helps to lean forward to prevent tipping backwards

2. Going down a ramp: wheelie position or backwards

When a patient in a wheelchair is standing up, you should move the _____ out of the way.

casters

During a sliding board transfer with a patient in a wheelchair, you need to move what?

arm rests

For a stand pivot transfer for a patient in a wheelchair, you need to move what?

foot plates

What are the goals of wheelchair positioning?
-prevent _____/_____ (sitting in prolonged static position with bad positioning can cause this)
-decrease _____ problems (pressure sores, abrasions, shearing)

contracture deformity

skin

True or False: A sling wheelchair position is supportive and functional.

false

basic spinal precautions

BLT: no bending, lifting, twisting

physical agent modalities

physical agents such as heat, cold, water, light, sound, and electricity applied to impact functions of the body

reduce or modulate pain, reduce inflammation, increase ROM, promote circulation, decrease edema, facilitate healing, stimulate muscle activity, facilitate occupational performance

superficial thermal agents

hot packs, paraffin, hydrotherapy, cryotherapy

for hot packs, cold packs, and paraffin check skin before, during, after

head indications and contraindications

1. Heat indications

   1. Chronic or subacute conditions

   2. Increase extensibility of collagen tissue

   3. Decrease joint stiffness

   4. Analgesic effects

   5. Sedation

   6. Increased blood flow

   7. Tissue repair

   8. requirements

      1. Need to be able to follow directions/cognitively intact, need to be extra cautious if not

         1. Need family member to recite back the instructions if they are going to do heat themselves if the individual can’t 

      2. Not for acute flareup 

         1. Chronic and subacute okay 

      3. Not with swelling 

      4. Not good for MS population

         1. Low endurance, sluggish 

      5. Not good for advanced cardiac patients

         1. Fatigue, shortness of breath 

      6. Increasing blood flow and circulation with heat so be careful with cancer patients

      7. Do not apply hot packs near cancer sites

         1. If they are in remission, speak with doctor and learn precautions 

      8. Be careful with someone with increased body temperature

         1. Pregnant people in third trimester

      9. People with hot flashes

      10. Patients with DVT (swelling and hot)

2. Contraindications: swelling

hot packs

15 to 20 minutes to reach therapeutic temeprature to stretch and move

stored between 160-165 degrees

never applied directly: 6-8 layers of toweling

check after 5 minutes: should be warm and red but no blisters

advantages: simple, widely available, can heat large surfaces, do at home

disadvantages: heaviness may be uncomfortable, doesn’t maintain max head, can’t conform well to small multi-surface body parts, static heat (must be non-mobile which limits AROM and AAROM)

heat increases blood flow: dilating vessels

• for spasticity you can use hot or cold and see how they respond

A hot pack cover counts as ____ layers of toweling, so then you would add _____ more layers of toweling.

4; 4

Considerations for PAMs:
-Check _____
-_____ referral
-Review medical _____
-Check _____
-Remove _____
-Check skin _____
-Evaluate _____
-Position of _____ during application

licensure
-MD
-records
-equipment
-jewelry
-integrity
-sensation
-comfort

paraffin

paraffin wax and mineral oil

120-130 degrees F

able to heat irregular surfaces

moisturizing, scar management

good for rheumatoid arthritis

dip method

• boy part should be washed

• Immerse hand in bath for 1-2 seconds and pull out 

• Dip 5-10 times (presentation says 3-5 times)

• Wrap in plastic bag and put a towel around it

• Dont move for 8-10 minutes

• Sometimes you can put a hot pack around the towel 

• Can use coban to apply stretch before dipping

immersion method- glove formed as above then body part immersed in paraffin bath

brush on method: paint paraffin on person for larger areas

advantages: irregular surfaces, simple, cheap, can do at home

disadvantages: static (no PROM, AROM, AAROM), does not maintain max heat (can use hot packs), small areas

1. Don’t use on open wound or burn, if wound is healed then it can be good for wound management and scar care

fluidotherapy

1. A whirling mixture of dry heat and particles (corn husks) 

2. Doesn’t lose heat

3. Good for desensitization, light massage, and provides all effects of heat

4. Therapist can assist inside the machine 

cryotherapy

superficial cold

1. Vinyl pouches with silica gel kept in freezer at -12.2 C

2. Cools by conduction 

3. Wrapped in damp towel, applied to skin for 20 minutes (NEVER direct to skin)

4. Damp towel between skin and cold pack/wet paper towel (will penetrate quicker)

5. Can also be a dry towel 

6. Ice massage: small paper cups filled with water with tongue depressor frozen inside; ice rubbed over area for 10 minutes to reach analgesia; good for small area

7. Also vapocoolant spray or gel, aerosol spray

8. Cold reduces edema and circulation

9. Don’t keep on longer than 15-20 minutes

10. Not for people with decreased circulation/circulation problems/neuropathies

11. Not for anemia, decreased RBC, decreased WBC/platelets (cancers), not for lupus 

12. Not for open wounds 

    1. Need to be well protected and get clearance

deep thermal agents

ultrasound and phonophoresis

ultrasound

conversion heat transfer

Should NEVER be used in isolation

use of high frequency sound waves that produce thermal and non-thermal effects on the tissue

1. Generator with power source, coaxial cable, hand held transducer, crystal 

2. Requires gel, use circular movements

3. 3 MHz: 1-2 cm depth

   1. 3.3- superficial area

   2. Fingers, lateral/medal epicondyles, patellar tendons 

   3. Heats up quicker 

4. 1 MHz: 3-5 cm depth

   1. Heats up slower, penetrates deeper (quads, hamstrings, deep shoulder/rtc/capsule)

1. Duty cycle: % of time ultrasound introduced into body 

   1. 100% = continuous (thermal) for adhesive capsulitis, bursitis, tendinitis, epicondylitis

   2. 50 or 20 % = pulsed (non-thermal)

2. Intensity: strength 

3. Can apply directly or through immersion (for small joints)

Contraindications: heat precautions, do not do over organs, areas of infection, tumor, epiphyses of developing bones, bony prominences, pregnant individuals, cardiac pacemaker, STOP if burning, Not over open wound, wound must be closed for wound healing (NOT GOING OVER WOUND), Not over pacemakers

ultrasound: continuous waves

thermal effects: deep heat (continuous waves)

1. Continuous/thermal 

   1. Sound waves coming through continuously per second, no pause

   2. Thermal ultrasound

   3. Can help healing process

      1. Break up scar tissue

      2. Would still use 3 if healing the area that is superficial 

ultrasound: pulsed

1. Non-thermal effect: mechanical vibration, cellular level without increased heat (pulsed)

   1. nonthermal/pulse ultrasound

      1. Usually start at 20%

      2. Allows tissue to rest in between pules, not generating heat

      3. Something like lateral epicondylitis 

         1. E.g. the area is hot and inflamed; pulsation will help the area flush out toxin/fluid buildup 

electrotherapeutic agents

stimulate excitable membranes of nerve and muscle to facilitate return of function, address pain, muscle activity, improve tissue healing, decrease swelling and muscle spasms

influence physiological change in tissue

facilitate neuromuscular or sensory changes

current: direct, alternating, pulsed

amplitude, pulse/phase duration, duty cycle, frequency, modulation (ramp up/down time)

electrodes: various sizes, shapes, self adhesive

• smaller electrodes: more stimulation

• close together: current passes superficially

• further apart: current passes deeper

TENS: pain

• stimulation competes with pain

NMES: encourage muscle contracture, muscle reeducation, alternating current

NMES

1. Neuromuscular E-Stimulation (NMES) (also FES): stimulate innervated nerves

   1. Pulsating to activate muscles

   2. NMES: decrease muscle spasms, edema, spasticity, strengthen muscles, maintain muscle mass

   3. FES: target muscles to facilitate functional activities or movements

   4. Peripheral nerve

   5. Need to do FES: functional electrical stimulation 

      1. Need to stimulate and work with it in function 

      2. Stimulate; open the box 

      3. Document that you are doing FES 

      4. Do not do if they have a pacemaker, metal replacements, automatic defibrillator, not near tumors or active cancer, infections, do not do at bladder site or uterus, cuts, skin issues, check for adhesive allergies, impaired sensation, cognitive impairments

         1. Person needs to be able to tell you what they feel/give feedback 

         2. Person needs to be able to follow directions

   6. 15 min at a time

considerations for PAMs

All modalities: inspect skin before and after

1. Can inspect skin during

2. Check on them to make sure they can tolerate the modality  

2. Remove jewelry

3. Evaluation sensation 

4. Position of comfort

1. Impaired or absent sensation never use heat or cold

common hand/wrist deformities

1. Claw hand: ulnar nerve deformity 

2. Combined ulnar and median: intrinsic minus? 

3. Drop wrist: radial nerve

3 phases of healing for tendons

1. 3 phases of healing: inflammation, fibroplastic/reparative, remodeling

extrinsic healing

1. Extrinsic healing: fibroblasts and inflammatory cells migrate from outside the tendon; adhesion formation

   1. Phases: inflammation, fibroplastic/reparative, remodeling

      1. Inflammatory 

         1. Immediately after injury for 5-7 days

         2. Edema formation peaks

         3. Migration of inflammatory cells

         4. Release of mediators and cytokines to begin/prepare for repair

      2. Proliferative phase

         1. Several days to 21 days after injury 

         2. Fibroblast start laying down collagen to create scar

         3. Adhesion formation begins about 7 days

         4. Collagen production peaks at 21 days

      3. remodeling/maturation

         1. 3 weeks to 1 year

         2. Excess collagen degrades

         3. Conversion of type III to type I collagen 

intrinsic healing

1. Intrinsic healing: migration of cells from endo/epitenon 

tendon injuries

1. Outcomes for extensor tendon injuries are better, more predictable

2. Early active motion protocols are standard, early passive and immobilization programs are used sparingly and only for specific reasons

3. Rationale for early active motion is that tendons that are stressed with just the right amount of loading exhibit significantly higher tensile strength and fewer adhesions

flexor tendon injuries

1. Key factors

   1. Zone of injury 

      1. 1-2 most common (2 most complicated)

      2. 3-5 less concern for adhesions, can be progressed through stages faster typically 

   2. Repair construct

      1. Number of core strads cross the repair side

      2. Epitendinous suture

   3. Nature of injury 

      1. Associated neurovascular injuries, soft tissue, avulsion vs. laceration, osseous injuries, repairs made under tension

   4. Timing of repair

   5. Patient

2. Goals of treatment

   1. Protect repair and prevent rupture

   2. Facilitate development of not only a strong repair but also one that glides freely in both directions

   3. Prevent flexion contracture

   4. Not trying to get full ROM 

protocols for tendon injuries: immobilization

for kids and unreliable patients

protocols for tendon injuries: early PROM

not common

1. Modified standard

2. Kleinart protocol 

3. OT starts 3-5 days post op, PROM only no AROM allowed

protocols for tendon injuries: early active motion

1. Most widely used now, several variation exists

2. OT starts at ideally 1-3 days post op 

   1. Next day is too soon 

3. Ranges from place and hold, short-arc > full flexion 

4. Only real way to achieve meaningful proximal tendon excursion 

5. Patient needs to be smart, motivated, responsible

6. At least a 4 strand repair with epitendinous suture

7. Ideally OT should start right of way 

8. Edema and stiffness ideally no more than mild-moderate; severe edema and stiffness can prohibit use of EAM 

WALANT

wide awake local anesthesia no tourniquet

zone 1-2 early active motion week 0-4

1. Week 0-4

   1. Fabricate dorsal block splint at 1st post op visit

   2. Wrist in neutral, MPs at 60-70 and IPs at 0 

   3. Wound care

      1. Take bulky dressing down, placement of non-adherent dressing

   4. Accurate assessment of tendon gliding: quantify disparity between A and PROM in flexion 

   5. Passive stretching and retrograde massage to ensure flexibility and reduce resistance to flexion

   6. With wrist in 20-30 degrees extension assess ability to hold fingers in flexion after passive placement into half fist

   7. Key factors for accurate assessment of TG: drag from stiffness and swelling, trapping with adjacent digits, inefficient activation of muscles, overactive intrinsic, palpate for tension in tendon 

   8. Individual tissue response dictates progression of treatment

   9. Each session do thorough eval of TG and monitor flexion lag

   10. Prevent flexion contracture and promote distal TG: composite MP/IP extension

       1. Full IP extension if no tension on repairs or digital nerve repair

       2. Ife tension, do isolated PIP or DIP extension with adjacent joints in flexion 

       3. Separate IP extension splints to be worn with DBS for night wear

       4. LMB splint in extreme cases

1. Early active motion zone I-II weeks 4-???

1. D/C splint

2. Base decisions on individual tissue response

3. Be careful with grip strengthening

   1. If needed, must wait minimum 8-12 weeks but not recommended

4. Composite wrist and digit extension

5. Blocking splints as needed

1. Modified Duran zone I-II weeks 0-¾

1. Dorsal block splint to wear all the time

2. Wound care

3. Edema control 

4. PROM only 

5. A/PROM IP extension (no composite MP/IP)

6. Evaluate tendon gliding as previously described

7. If disparity is significant then proceed with hierarchy of exercises; if not, focus on gentle active flexion 

extensor tendon injuries

1. More predictable outcomes

2. Immobilization and early passive protocols

3. Active motion 

   1. Similar model as flexor tendon 

   2. Not as widely used

mallet finger

1. Mallet finger: zone I extensor tendon injury 

   1. Injury to terminal extensor tendon

   2. DIP drops down into flexed position 

   3. Custom stack Splint 24/7 for 6-8 weeks

      1. Skin care critical to complete splinting

   4. Can allow MP/PIP flexion right away (DIP extension splint) 

closed mallet finger

1. Zone I

2. Self management by patient

3. Initiate AROM at 6-8 weeks beginning with DIp blocking exercises with PIP in slight flexion 

4. Limit DIP flexion to 20-30 degrees initially 

5. Increase about 10 degrees per week if no lag develops

6. Progression of exercises and splint wear schedule dependent on extension lag (if lag is less than 10 degrees, progress to DIP blocking with full PIP extension, composite flexion)

closed boutonnière

1. Closed boutonniere: Zone I-III

   1. PIP extension splint 24/7 for 6-8 weeks

   2. DIP flexion blocking to offset hyperextension tendency 

   3. After 6-8 weeks, same as mallet

thoracic outlet syndrome

1. Causes: trauma, poor posture, anatomical defects, repetitive overhead use, scapular dyskinesis, tumor

2. Symptoms: pain, sensory disturbances, heaviness of arm, fatigue and weakness

   1. Vascular: acute upper extremity swelling, cyanosis, heaviness, pain

   2. Neurogenic confirmed by detailed history and exam

3. Exam: head/neck, posture, upper limb neural tension test

   1. EAST: elevated arm stress test with shoulders in 90 degrees abduction and ER, elbows flexed to 90 degrees, patient slowly opens and closes hand for 3 minutes

TOS ot management

1. OT management

   1. Education about positioning to relieve symptoms including sleeping posture

   2. Postural remediation

   3. Scalene stretching

   4. Diaphragmatic breathing

   5. Nerve glides/tensioning

   6. Manage associated conditions 

ergonomics

1. rgonomics: fitting the place station and or environment to the worker to decrease the risk of injury

   1. Traditionally through video display terminal analysis, performance evaluations, workstation modifications, job task analysis

   2. Modify behavior/cognitive functions: change or modify old habits, identify situations that increase stress/anxiety/psychosocial issues, body mechanics

   3. Physical performance: physical fitness level (strength, ROM, endurance), body mechanics, nutritional habits, physical stressors, job rotations, forceful exertions

   4. Positioning: repetitive motions, awkward positioning, prolonged static/dynamic activity 

   5. Environment: workstation, temperatures, noise levels, lighting, spaces

ergonomics as a prevention program

1. Looking at computer work station

2. What is proper position of body at computer work station 

3. E.g. 90 degrees, wrist in neutral, top of screen no higher then eye level

work conditioning and work hardening

Treatment: medically necessary, developed by team and worker, return to work goals based on job analysis, job simulation, individualized goals, average 8 weeks 2-4 hours 3-5 days per week

work hardening

1. Work hardening

   1. MD referral, WC insurance authorization, evaluations, treatment plan, discharge, return to work 

   2. Strengthening, cardiovascular conditioning, body mechanics training, job simulation of tasks, ergonomic and energy conservation techniques, holistic approach 

   3. Appropriate when unable to return to work due to lack of strength, conditioning, confidence, no longer needs skilled PT or progressing in PT

work conditioning

1. Work conditioning

   1. No longer needing skilled therapy manual treatment

   2. Worker needs to increase strength and conditioning to return to full duty, full work day, or is not ready for work hardening program 5 times per week 

   3. Job simulation tasks to transition to work hardening or full duty 

   4. Strengthening, conditioning, ergonomic training, body mechanics training

2. Requires MD referral, worker compensation insurance authorization, initial eval, customized treatment, discharge to work or FCE

functional capacity evaluation

1. Assortment of standardized and un-standardized tests to assess clients overall physical ability 

2. Encompasses physical demands of work as defined by US department of labor

3. Purposes: Determine rehab potential, determine return to work status, settlement of case, disability status, pre-employment/post offer testing

4. Valid and reliable, objective, standardized instructions, clear instructions, practical, safety and wellbeing 

5. Components: full review of medical records and official job description, musculoskeletal screening, physical ability testing, physical effort testing, sincerity of reports regarding pain and disability 

6. Physical ability testing: lifting, standing/sitting tolerance, gait analysis, static/dynamic balance testing, job simulation tasks, functional mobility/positional testing, cardiovascular, dexterity 

7. Physical effort testing: determine if client is providing full effort with testing procedures 

8. Discrepancies with reports of pain and disability: discuss to allow for self correction

9. Reading and using a report

   1. Think about general impression of client, figure out what questions need to be answered, determine if full effort was given, look at abilities at limitations

psychosocial adjustment model

1. Process by which individuals can manage psychosocial issues to more fully participate in occupation 

2. Stages: denial, anger, depression, acceptance

cognitive behavioral therapy

1. Cognitive beliefs can hinder recovery 

2. Public stigma: negative beliefs about people with disabilities, belief that individuals with behavioral health issues and substance use disorders can never recover

3. Self-stigma: internalized negative beliefs

psychodynamic model

1. Focus on how memories of past experiences and unconscious processes affect current behavior

2. Used when conscious ego-focused tx does not produce results

transtheoretical change model

1. Precontemplation, contemplation, preparation, action, maintenance, termination 

evaluation of role loss

1. Role checklist, activity card sort, leisure interest checklist

2. Interventions: strengths, altering vocational course, finding leisure activities, re-designing an intimate partnership, rebalancing parenting roles, realistic expectations

SUDs

1. Evaluation of SUDs

   1. Substance abuse screening test, frequency of use, type of use, history, affect on rehab/work/school/parenting/social supports/other, SU cause of physical condition, physical condition cause SU, predisposing factors, need to refer

2. Interventions: motivational strategies, 12 step groups, psychoeducation on addiction, relapse prevention, time management, stress management, anger management, occupational engagement, sober leisure skills and friends

PTSD

1. Assessment

   1. Primary care PTSD screen 

   2. Symptoms: hyperarousal, nervousness, fearfulness, flashbacks, ruminations, emotional numbing, dissociation 

2. Intervention: develop a healthy relationship, safety, recalling memories and morning, reconnecting, commonality 

depression

1. Assessments for depression

   1. Beck depression inventory, general self-efficacy scale 6, rosenberg self-esteem scale, suicidality 

2. Interventions: problem solving, coping strategies, healthy expression/release of anger/frustration, cognitive restructuring, planning, social support, referral

breast cancer impact on occupational performance

Weakness, fatigue, body image, pain, lymphedema, limited ROM, brachial plexus injury, cognitive dysfunction

prostate cancer impact on occupational performance

1. Urinary incontinence, sexual dysfunction, lymphedema, fatigue, bowel problems from radiation therapy

lung cancer impact on occupational performance

Fatigue, dyspnea, weakness, limited ROM, limited endurance

colorectal cancer impact on occupational performance

GI problems, physical and psychosocial changes associated with colostomy or ileostomy, sexual dysfunction after rectal surgery

cancer related fatigue

1. Cancer related fatigue: distressing, persistent sense of physical, emotional, or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning

   1. Measured through self-report

   2. Results in altered lifestyle, decreased participation, decline in performance capacity due to inefficient use of energy, loss of control and identity, impaired volition and motivation, reduced ability to work, reduced self-efficacy, poor QOL, lack of social interaction, loss of important roles

cancer related fatigue interventions

1. Interventions: 

   1. mental health, LPCs, clinical social workers, psychiatric nurse practitioners

   2. Palliative care: prevent or treat symptoms of cancer and cancer related treatments

   3. Integrative oncology: yoga, acupuncture, meditation, tai chi

   4. Survivorship care: addresses physical, mental, emotional, social, and financial effects of life after cancer diagnosis, care for late effects of treatment and recurrence 

   5. Create and promote, prevent, establish and restore, modify, maintain 

cancer related cognitive dysfunction

1. Deficits in memory, executive functioning, attention span, processing speed

2. 30% prior to treatment, up to 75% during or after treatment

3. May be physiological or psychological 

4. Cognitive behavioral strategies, remediation/restoration, compensatory skills training, meaningful functional activity 

lymphedema

1. Lymphedema: condition caused by inadequate drainage of lymphatic fluid

   1. Most associated with breast cancer after lymph node removal

   2. Can be due to blockage by tumor, scarring/inflammation of lymph node, vessels from radiation therapy, surgical resection of lymph noes, can appear after surgery/radiation or many years later

   3. Interventions

      1. Gentle exercises and diaphragmatic breathing, compression garments, manual drainage, pneumatic compression, complete decongestive therapy

peripheral neuropathy

1. Peripheral neuropathy: impairment of peripheral nerves caused by neurotoxicity associated with chemotherapy drugs

   1. Motor, sensory, autonomic, mixed

   2. Earliest at fingertips and toes

   3. Pain can be associated with depression 

   4. Symptoms: neuropathic pain, allodynia, numbness/tingling/paresthesia, cold intolerance, impaired fine motor skills, mild weakness and decreased reflexes, decreased proprioception of LE

   5. Intervention: prevent or lessen CIPN sensory symptoms, compensatory safety techniques, target fall prevention, ADL training, home modifications to support optimal engagement in daily life roles, energy conservation, home exercise, desensitization, medication 

vital signs

1. Target heart rate 70% of maximum HR

   1. Maximum heart rate calculation: 220-patient’s age

sternal precautions

1. Careful reaching away from the body 

   1. Especially bilaterally 

2. Dress in a tube

3. No lifting over 10 pounds

4. no pushing, abducting

MET levels

1. Met levels: the name for resting metabolic unit, independent of body weight; energy requirement or use

   1. At rest in semireclined position: 1 MET, 3.5 ml of oxygen per minute per kilogram of body weight

   2. What they are, how they correspond to three phases of cardiac rehab 

   3. When are they discharged from acute care to home? 

      1. 3-4: usually at least 3.5

energy conservation techniques

1. Energy conservation techniques, work simplification 

   1. Variables to grade activities

      1. Posture, rest breaks, shoulder inclusion, overhead, total body patterns, repetitions, length of activity, times per day, chaining of activities

1. When do you take vital signs on someone who just had cardiac injury? 

1. Before, during, after

phase 1 of cardiac rehab

1. Phase 1: inpatient care 

   1. Initiated almost immediately 

   2. Duration: 5-14 days

   3. Intensity: 1-4 METs

   4. Patient education: self-monitoring, discussion of fear related resuming daily activities 

   5. Risk factors: lifestyle modification and follow up compliance

   6. Progression of activities

   7. Sternal precautions

      1. No lifting, pushing, or pulling greater than 10 pound

      2. No bilateral stretching of UE’s

      3. No propelling of w/c with arms

      4. No UE hyperextension 

      5. Limit use of arms during bed mobility/transfers

   8. Resumption of sexual activities

   9. Energy conservation/work simplification

   10. Return to work 

   11. BADL training initiated day 2 (1-4 MET), graded progression through more difficult activities encouraged

   12. Engagement in leisure: table top, no resistance, socialization, discussion groups, socialization groups

   13. THEREX

       1. Progressive challenge to cardiovascular system

       2. Low weight/high resistance

       3. Consider sternal precautions

       4. Brief, multiple sessions

       5. Prevent adhesive capsulitis

       6. Progress resistance/MET level/repetition 

1. Phase II: outpatient program 

1. 8-12 weeks

2. Goal: progress to morbid activity level 

3. Resumption of IADL

4. Upgraded participation in leisure activities

5. Return to work preparation/job site analysis and adaptation

6. Therex: strengthening and endurance training, upper body ergometry 

7. Home exercise program 

8. Patient education: stress management, in-depth review of risk factors, integration of education into lifestyle

1. Phases III and IV: community based

1. OT as consultant

2. Work adaptations/modifications

3. Dealing with residuals of surgical complications

amputation: pre op and preprosthetic

1. Post op/preprosthetic stage

   1. Healing of surgical wound, minimize pain, protect amputated limb from trauma, preserve and improve ROM of entire body, reduce swelling and begin shaping of residual limb, begin controlled weight bearing, mobility aids for (I), (I) in functional activities, facilitate psychological adjustments to limb loss

   2. Prevention of soft tissue contracture: positioning with pillows in bed, wheelchair, manual activities 

   3. Wound healing and limb volume control: reduce pain, edema, foster healing, limb volume control, shape limb

   4. Residual limb shaping: smooth and wrinkle free, angular turns, end bandage with tape, velcro, safety pins

   5. Task specific strengthening: transfers and bed mobility 

   6. Generalized conditioning: UE strengthening, LE strengthening of residual limb

   7. Postural control 

   8. Desensitization 

   9. Phantom sensation/pain, local pain 

physical training with and without prosthesis, achieve optimal physical condition

1. Improve physical conditioning to enhance control and performance

2. Strength, muscle coordination, physical training exercises

3. Perform without prosthesis, with prosthesis, before fitting, during rehab

prosthetic training

1. Controls training: training without objects, get a feeling, passive and active functions, donning and doffing, manual wrist rotator

   1. Active prosthesis functions: optimal use, check for readjustments, voluntary opening and closing, adapt the cabling

2. Repetitive drills: prosthetic training with objects 

   1. Training with objects, grasping, holding, releasing, vary exercises and training; reliably and confidently handle objects using appropriate control

   2. Indirect gasping: passed from sound side to prosthetic hand

   3. Direct grasping

3. ADL training: transfer to daily routine, adapt to skills, increase independence, carry out functional activities confidently with both hands

to activate terminal device

1. To activate terminal device

   1. Below elbow: humeral flexon and scapula protraction 

   2. Above elbow: humeral flexion and scapula protraction: elbow component-scapula depression, extension, abduction 

1. Issues that may occur when working with someone with an amputation and what to do about them 

1. Flexion contractures; can use limb protector 

residual limb wrapping

1. For edema and shaping 

2. Edema

   1. Figure 8 if its finger and wrist

   2. Measure just proximal to amputation and compare to opposite hand

   3. Other landmarks and compare

   4. Compression: coban

   5. Massage

   6. Elevation 

2. Know how to wrap 

   1. Figure 8, tension greater distally, slowly lessens tension as you move proximally 

phantom limb pain

1. Check for phantom limb pain 

   1. Pain management: mirror therapy 

   2. Phantom limb pain and phantom limb syndrome

      1. Syndrome: person feels that the part that was amputated is still there

      2. Pain: pain in the area where the limb was amputated 

other treatment for amputation patients

1. Change of dominance activities: for indviiduals with full amputations of hand and proximal 

2. Strengthening: focus on strengthening muscles needed to use terminal device 

3. Sensory reeducation, sensory desensitization 

   1. Test sensory: ideally monofilament

   2. Use different textures

   3. ROM digits: blocking to joints proximal to amputation and tendon gliding 

non-invasive blood press remonitoring

1. Manual blood pressure cuff

2. Automatic blood pressure cuff

   1. Cuff remains on patient at all times

   2. Cuff is connected to the monitor via wire

   3. Cuff inflates periodically and displays the reading on the monitor

   4. The monitor stores several readings for comparison throughout the day

invasive blood pressure monitoring

arterial line, CVP, swan-ganz

aline

1. Arterial line

   1. Most commonly used invasive blood pressure monitoring line

   2. Location: laced 

   3.  

   4.  

   5.  Continuous blood pressure

   6. Frequent blood draws

   7. Clinical implications

      1. Do not bend wrist or hip

      2. Avoid blood pressure on ipsilateral side

      3. Alert nurse if patient was mobilized

      4. If line falls out, apply pressure and call for help

cvp line

1. Central venous pressure line

   1. Inserted into subclavian vein and threaded into right atrium

   2. Direct measurement of blood pressure in right atrium and vena cava

   3. Assess right ventricular function and systemic fluid status

   4. Sutured into place

   5. Clinical implications

      1. No real activity limitation

      2. Be mindful of line to prevent dislodging

      3. Alert nurse if patient was mobilized during session (re-calibration)

pulmonary artery catheter

1. Pulmonary artery catheter (swan ganz)

   1. Inserted into subclavian or internal jugular vein and sometimes femoral 

   2. Threaded to several locations (pulmonary artery and right atrium)

   3. 4-6 lines

   4. BP, cardiac output, medications

   5. Only used for critically ill patients, short-term

   6. moving/dislodging can cause serious complications

   7. No longer held from therapy 

pulse oximetry

1. Pulse oximetry

   1. Measurement of oxygen level in blood

   2. Healthy individuals 98-100%

   3. Aim for above 90 for most patients

   4. Can be measure non invasively and invasively 

   5. Displayed on monitor

   6. Non-invasive

      1. Measured using a pulse oximeter

      2. Three types

      3. Probe (finger, earlobe, foot in babies or skin) attached ot monitor for continuous monitoring

      4. Measure oxygen saturation and hr

      5. Can be altered by nail polish, excessive movement, cold hands

intravenous line

1. Intravenous lines 

   1. Inserted into peripheral vein

   2. Short-term venous access for administration of medications and fluids

   3. Can be attached to a pump mechanism for time-controlled release of medication

   4. Clinical implications

      1. Avoid BP on ipsilateral arm, do not pull