Conditions Unit 2 - Musculoskeletal Conditions

Limb Differences and Amputations

Overview of Amputations

Definition

Amputations are surgical procedures that involve the removal of a limb or part of a limb. They can be categorized into two major classifications:

  1. Major amputations: These are proximal to the wrist or ankle.

  2. Minor amputations: These are distal to the wrist (affecting hands and fingers) or ankle (affecting feet and toes).

Prevalence

Annually, over 185,000 people in the United States undergo amputation. Currently, there are nearly 2 million individuals living with limb loss, a figure projected to reach 3.6 million by the year 2050.

Causes of Limb Loss

Among individuals with limb loss, the primary causes include:

  • Vascular disease (54%): This category encompasses conditions like diabetes and peripheral arterial disease.

  • Trauma (45%): This includes injuries from incidents such as burns.

  • Cancer (less than 2%)

Occupational therapists (OTs) often work more frequently with lower limb amputees due to the prevalence of vascular disease, which leads to restricted blood supply and increased instances of tissue necrosis and infection.

Amputation Levels

The level of amputation is crucial, as it directly affects a person's ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs) due to the loss of joints and motion ranges. The higher the level of amputation, the greater the impact on functional performance.

Levels of Amputation

  1. Interscapular thoracic: Removal of the entire shoulder girdle.

  2. Shoulder disarticulation: Amputation through the shoulder joint.

  3. Transhumeral (Above-elbow or AE): Amputation above the elbow joint.

  4. Elbow disarticulation: Amputation through the elbow joint.

  5. Transradial (Below-elbow or BE): Amputation below the elbow.

  6. Wrist disarticulation: Amputation through the wrist joint.

  7. Fingers or partial hand: Includes transphalangeal (through the phalanges) or transcarpal (through the carpal bones).

Complications and Sensations Post-Amputation

Individuals with amputations may experience sensations or pain in the amputated area, known as phantom limb pain. This phenomenon occurs because the brain continues receiving nerve signals from pathways that are no longer functional due to the limb's loss.

Common Complications of Limb Absence

According to Latour (2022), complications include:

  • Terminal overgrowth: Growth or spurring of bone.

  • General residual limb pain: Pain resulting from the amputation.

  • Neuromas: Nerve tissue growth at the site of amputation.

  • Heterotopic ossification: Abnormal bone growth in soft tissue.

  • Phantom pain/sensation: Pain experienced in the absent limb.

Interventions for Amputation Care and Management

Medical Interventions

  • Surgical interventions: Amputation can occur as a planned (scheduled) or emergent surgical procedure, often to halt the spread of infection or in cases of non-salvageable limbs due to trauma or disease. Autoamputation can also happen when highly necrotic limbs detach from the body due to inadequate blood supply.

Occupational Therapy Interventions

  • Edema management: Involves wrapping the residual limb with elastic bandages to manage swelling and shape the tissue for optimal prosthetic fit.

  • Pain management: Addressing post-amputation pain is crucial; occupational therapy supports individuals in modifying and remediating daily occupations after limb loss.

  • Prosthetic training: OTs may assist with functional training in the use of prosthetics and management of associated challenges.

Pharmacological Interventions

  • Pain management may include non-steroidal anti-inflammatory drugs (NSAIDs) or opioids, especially for severe pain.

  • Gabapentin: Often prescribed for neuropathic pain, especially in cases of phantom limb pain.

  • Antibiotics: Important for preventing infection, particularly applicable in lower extremity amputations due to increased risk of reduced mobility post-surgery.

  • Anticoagulants: May be prescribed particularly for lower extremity amputees to prevent thrombosis given periods of immobility.

Safety and Health Management

  • Movement patterns and positioning: Guidance must be provided to enhance the individual's functional ability while using adaptive devices.

  • Functional safety: The therapy environment should be free of hazards that may pose risks during ambulation or device use.

Contraindications

  • Therapy should be deferred in cases of uncontrolled pain, active infection, or new bleeding from the incision. Generally, new amputees are instructed to avoid weight-bearing on the residual limb until healed completely.

Precautions

  • Attention must be given to the position of the residual limb to avoid complications like contractures. Avoid placing a below-knee amputation limb on a pillow as it may cause a bend at the knee joint and limit mobility.

Types of Therapy for Amputation Recovery

  • Preventing swelling: Individuals are advised against positions that may lead to swelling in the residual limb.

  • Elastic bandaging: Recommended shortly post-surgery to protect the tissue and shape for prosthesis adaptation.

Impact on Occupational Performance

Amputations considerably influence the occupational performance of affected individuals, necessitating tailored strategies in occupational therapy to accommodate their changing functional needs.

Fractures: Humerus, Elbow, and Lower Extremities

Overview of Fractures

Definition

Bone fractures are indicative of structural failure in the bone, occurring when the applied force exceeds the bone's capacity to withstand stress.

Severity of Fractures

The severity of fractures is determined by:

  1. Amount of force applied: High-energy forces (e.g., motor vehicle accidents) vs. low-energy forces (e.g., falls).

  2. Compromised bone integrity: Conditions like osteoarthritis or tumors can weaken bones, resulting in what are termed pathological fractures.

Types of Bone Fractures

Fractures can vary significantly in type depending on the nature of the break:

  • Stable fracture: The bone remains properly aligned.

  • Open (compound) fracture: The bone protrudes through the skin.

  • Transverse fracture: A horizontal fracture line.

  • Oblique fracture: An angled fracture line.

  • Comminuted fracture: The bone is shattered into multiple pieces.

  • Greenstick fracture: An incomplete fracture often seen in children.

Healing Processes of Fractures

The healing of fractures typically occurs in several stages:

  1. Inflammatory phase: Initial response to fracture with blood clot formation.

  2. Repair phase: Soft callus formation, leading into endochondral ossification (hard callus formation).

  3. Bone remodeling phase: Refinement and strengthening of the new bone.

Healing Timing

The estimated healing duration varies:

  • Upper limb fractures: 6 to 8 weeks.

  • Lower limb fractures: 12 to 16 weeks.

Specific Types of Fractures

  1. Humerus fractures: Common due to falls or blows; mid-shaft fractures can lead to radial nerve palsy.

  2. Elbow fractures: Common types include supracondylar and olecranon fractures, often requiring immobilization during the healing process.

  3. Hip fractures: Most prevalent in individuals over 50, primarily affecting the proximal femur. Treatment may involve closed reduction or surgical intervention.

Interventions for Fractures

Medical Interventions

  • Fractures diagnosed through physical exams and imaging (e.g., X-rays, MRIs).

  • Conservative management: Involves immobilization using casts or splints.

  • Surgical options: For unstable fractures, open reduction internal fixation (ORIF) techniques may be employed.

Occupational Therapy Interventions

  • Post-surgical therapy focuses on enhancing range of motion, pain management, and functional tasks related to ADLs.

  • OTs should adhere to weight-bearing statuses as prescribed by the physician, adjusting therapeutic activities accordingly.

Safety and Contraindications for Fractures

  • Knowledge of effective use of mobility aids is necessary for safety.

  • Contraindications include unstable fractures and signs of complex regional pain syndrome.

Weight-Bearing Status Guidelines

Weight-bearing status classifications include:

  • Non-weight bearing (NWB)

  • Toe-touch weight bearing (TTWB)

  • Partial weight bearing (PWB)

  • Weight bearing as tolerated (WBAT)

  • Full weight bearing (FWB)

  • Each classification specifies the percentage of body weight that can be supported by the affected limb.

Case Study: Fracture Management

Josh, a 16-year-old male, experiences a distal radial fracture from a snowboarding incident. After conservative management with casting, he undergoes occupational therapy to address range of motion and strength recovery in daily activities post-cast removal.

Impact on Occupational Performance

Fractures can severely affect an individual's ability to engage in occupational roles and daily routines, necessitating an adaptive approach in occupational therapy.

Musculoskeletal Pain

Overview of Pain

Pain is a primary concern that leads individuals to seek medical attention or therapy support. It is essential for establishing boundaries necessary for physical activities and rehabilitation.

Types of Pain

  1. Nociceptive pain: A result of potential tissue damage detected by nociceptors in soft tissues, typically perceived as pain differing in nature based on its origin.

  2. Neuropathic pain: Pain resulting from damage to the nervous system, often described as burning or shooting sensations.

Pain Pathway

  • Pain signals are transduced from nociceptors to the brain via specific nerve fibers, impacting how pain is experienced and managed.

Inflammation Process

The body's typical response to injury, inflammation, aims to heal damaged tissues. Effective therapeutic interventions depend on understanding inflammatory responses and associated healing factors.

Fibromyalgia

A chronic disorder characterized by widespread musculoskeletal pain and tenderness, fibromyalgia is often accompanied by fatigue and emotional disturbances (Gutman & Westover, 2022).

Interventions for Pain Management

  1. Medical: Topical analgesics, injections, and NSAIDs or opioids as required.

  2. Therapy Interventions: Non-pharmacological approaches include physical modalities, and mental health interventions aimed at coping and managing symptoms of chronic pain.

Safety and Health Management in Pain

Therapists must be aware of sudden worsening of pain symptoms and encourage strategies that emphasize body awareness and relaxation. Precautions include respecting patient limits and avoiding overstimulation or overexertion that could exacerbate pain.