Exam Flashcards
Physical Determinants hierarchy
person
- -> impairment: Diabetes, COPD, Mobility, wound, care sensation
- -> occupation: getting dressed, bathing, walking his dog, playing sports, gardening
Biomechanics:
Kinesiology:
Rehabilitation:
Anatomy:
Biomechanics: forces, mechanics
Kinesiology: movement
Rehabilitation: Enabling Function - Adaptation/compensation
Anatomy: underlying structures
Canadian Practice Process Framework (first four stages)
enter/initiate–> set the stage –> access and Evaluate
–> agree on Objectives, plan
Occupation-as-Means
the use of occupation as a treatment to improve clients impaired capacities and abilities to enable occupational functioning
Occupation-as-Ends
the client functional goal which is to be carried out within a given environment and within their own comprised goal
Activity –> steps –Activity Demands –> analysis for intervention
Explain in more detail
action verb, how the action takes place, objects, time amounts
“retrieve 1 shirt from the cupboard
Objects, environmental, social, contextual demands, timeing, safety. Biomechanical analysis
Grading and adaptation
Activity Analysis
Assessment:
Intervention:
Assessment: understand abilities, Analyze challenges
Intervention: grade activities to build capacity
compensate or adapt performance
Activity Analysis Steps ( 5 steps)
- Describe the activity
- Describe task demands
Identify primary therapeutic aspects of activity - Adapt activity demands to align with therapy goals
- Modify activity demands to adjust difficulty level
Performance Analysis steps (5 steps)
- Name the role
- List tasks the person identifies as important to the role
List the activities the person identifies as part of key task
-Describe environment and context in which person will be performing activity
-Observe person performing activity in environment
If person is able to perform activity, observe another activity
when unable to do activity an OT could then: (3 points)
- teach adaptive methods
- modify/simplify environment
- Remediate impaired abilities and capacities
Performance Analysis ( more points)
f remediating, analyze what ability limitations are interfering with performance
- after identifying ability limitations, measure abilities to confirm limitations, analyze what deficit capacities are causing limitations
- measure capacities and treat when verified
Bottom up
Biomechanical Approach
-person focused
Top Down
Rehabilitative approach
occupational focused
Biomechanical Approach
- remediation or prevention of limitations in ROM, strength and endurance to fully engage in purposeful and occupational based activities
- preventing or decreasing impairment through occupation
- meaning created by the ultimate goal of establishing occupations
- underlying pathology must be considered
Goals related to Biomechanical approach: (4)
- maintain or prevent limitations in ROM
- increase ROM
- increase Strength or prevent limitations in strength
- increase endurance or prevent limitation in endurance
Rehabilitation Approach ( 6 points)
achieve maximum function in the performance of his or her daily activities
-looks at overall client functioning and performance - al determinants considered
considers individual’s context - environment
-Emphasis on teaching individuals to compensate or adapt to optimize functioning when impairment cannot be remediated
-teaching and learning process
-collaboration with client
Goals related to Rehabilitative Approach:
- compensation and adaption
- teaching/education
- when remediation will not restore function OR goal is to optimize functional independence while restoring abilities
Modifying activity to: (3 points)
- enabling individuals to perform activities they would not otherwise be able to perform
- prevent injuries i.e cumulative trauma/repetitive stress injuries
- accomplish goal
Discuss Bullet round 1 case loads: COPD acute Upper Extremity BE amputation (rehab) Burn Dupytrens Disease Shoulder impingement
DISCUSS
Myocardial Infarct facts and risk factors
70000 heart attacks in Canada - heart attack every 7 minutes
16000 Canadians die annually a result of MI
Risk Factors include: obesity, smoking, physical inactivity, BP, high cholesterol and diabetes
Congestive Heart Failure States
500 000 Canadians live with heart failure and 50 000 are diagnosed each year
-up to 40-50% of people with congestive heart failure die within 5 years of diagnosis
Signs and symptoms of CHF
- Sudden Weight gain
- inability to sleep lying down
- dry hacking cough
- SOB (short of breath) with normal Activity
- swelling in ankles, feet or legs
- fatigue with activity
- lack of appetite
- difficulty concentrating/attending
Signs of cardiac distress
-Angina -chest pain dyspnea (shortness of breath) palpation fatigue presyncope/syncope (dizzy, confusion, fainting) -diaphoresis - cold clammy skin
Lifestyle Issues: (cardiac problems)
-15% of adults acheive 150 min/week of moderate-vigorous physical activity
-52.5% of women (12 and over) are physically inactive
23% of Canadians report high degree of life stress
Medical interventions to consider ….. do we need to know this (cardiac)
- coronary artery bypass graft (CABG)
- percutaneous coronary intervention (angioplasty)
Why use the biomechanical model for cardiac stuff
Endurance:
ability to sustain an activity over time
cardiac, biomechanical and neuromuscular function
-compromised by inactivity, immobilization, cardioresp or muscular deconditioning
-related to intensity, duration or frequency of activity
-% max HR, # of reps, length a contraction is held
Functional Implications
Decreased endurance - impact on:
Psycho-emotional:
- ADL’s
- Leisure Activities
- work
Psycho-emotional:
high performance of depression and anxiety
-10-60% of depression; 11-45% anxiety
Top Down: Occupational-Participation
COPM
Barthel Index
Minnesota Living with heart failure Questionnaire
Health Promoting Activities
Bottom Up - Person -Impairment
-2 minute walk test
vital sign (BP, heart rate)
Borg Rate of Perceived Exertion
Barthel Index (4 points)
- Longstanding ADL assessment - primarily for acute or rehabilitation contexts (stroke, neuro)
- Used with older adults - fair- good inter-rater reliability
- Excellent internal consistency
- issues with ceiling effects in older adults
Minnesota Living with Heart Failure (3 points)
developed in 1984 - QOL measure
Validity
–> concurrent validity with a QOL measures function test (ie. 6 min walk test) and biological measures (O2 Consumption, chronic heart Failure score = 0.82)
Reliability - internal consistency
- -> chronbachs alpha = 0.86
- ->also reliable as telephone interview
Health Promoting Activity Scale (4 points)
-assesses participation in leisure that promote or maintain well-being
Developed to assess mothers of children with disabilities
-Psychometric properties - internal consistency, alpha .87, intra-rater =.9, minimal detectable change = 5 points, no ceiling or floor effect
-Recommended for use in broad populations
2 min Walk Test (6 points)
- individual walks without assistance for 2 min and the distance is measured
- start timing when the individual is instructed to “go”
- stop timing at 2 minute mark
- assistive devices can be used but should be kept consistent and documented from test to test
- if physical assistance is required to walk, this should not be performed
- should be performed at the fastest speed possible
Functional Movements of the shoulder (3 points)
- Foundation for u/e movement
- -> reach
- -> precision movement
- Wide ROM due to glenohumeral joint surfaces
- ROM further increased by movement of scapula
Muscles moving the pectoral girdle
-Scapula contributes to wide ROM
what terms do we use to describe movement of scapula
elevation/depression
- protraction/retraction
- upward rotation/downward rotation
What muscles move the GH joint through its wide ROM
- deltoid
- Pectoralis Major
- Latissimus Dorsi (teres major and coracobrachialis)
Anterior muscles of pectoral Girdle
subclavius
pectoralis minor
serratus anterior
Posterior muscles of pectoral Girdle
- Trapezius
- levator scapulae
- rhomboid minor and major
Muscles that stabilize GH joint
subscapularis
supraspinatus
infraspinatus
teres minor
Adhesive Capsulitis (5 points)
frozen shoulder -three phases: freezing, frozen and Thawing sudden or gradual onset 40-60 years olds at greatest risk --> stroke, diabetes, RA --> 2-5% of population --> External rotation
Assessment Top Down: (UE)
-COPM
-Self-report
–>DASH
Job site visit - activity analysis
–> observation at work
–> RULA
Assessment Bottom Up (UE)
-ROM
-active and passive
Strength -MMT
Pain - VAS
VAS
Visual Analogue scale
Numerical Pain Rating
(0-10) 0-no distress
10 unbearable distress
ROM
End feels
soft - Soft tissue (ie knee flexion)
-Firm -jt capsule (MCP ligament (sup, pron)
Hard - bone (elbow extension)
Strength
Manual muscle testing
MMT
Valid and reliable
grade 1-5
NOTE Grade 4 - against gravity
DASH
No difficulty - 1
Unable - 5
Example: open a tight or new jar
There is also a work module that is optional
Rula
-weird pictures
-shoulder is raised
select only one of these
Osteoarthritis (OA)
5 points
- most common form of arthritis
- can be multifocal
- leading cause of pain and disability worldwide
- involves all joint tissue (cartilage, bone, synovial membrane, capsule, ligaments, and muscle)
- Synovial membrane inflammation can occur due to irritation from osteophytes -bony formations (spurs) occur next to an OA joint causes pain and stiffness
Interventions of OA
self-management, condition education, muscle strengthening, exercise, ergonomic education
OA and occupation 3 points
-82% report difficulty with ADLs
–> shopping: 57%, housework: 43%, dressing 21 %
–> 1 in 5 have to leave work on retire early due to OA symptoms
4 out of 5 people report constant pain
Rheumatoid Arthritis (RA)
- inflammatory disease that can affect multiple joints in the body
- 1 out of every 100 Canadians have RA, affects women 2-3 x more
- Autoimmune disease where the body’s immune system mistakenly attacks the linings of the joints
- cause is unknown and no cure for RA but there are effective medications and treatments to control symptoms and inflammation
- thickening of synovial membrane and increased synovial fluid
(swelling) - prolonged swelling stretches and weakens ligaments and joint capsules resulting in joint instability and risk of deformity
symptoms of RA:
pain, fatigue, malaise, swelling
-inflammation can start to affect other organs, such as nerves, eyes, skin lungs or heart
Common Affected joints of RA
wrist 85% MCP 80% Elbow 70% PIP 65% Shoulder 60%
Management for RA
methotrexate, self-management, condition education, ergonomic education, exercise, fatigue management, ADLs
Occupation and RA
60% issues completing ADLS, 28-40%, stop work and will likely not return
Activity Analysis (summary)
-an analysis of the typical demands of an activity
-How is an activity completed
–> what are the steps
–> What are the body mechanics required
–> what are the cognitive components required
–> what tools are required?
–> how is the environment set up?
What are the barriers to accomplishing the activity
Performance Analysis
- An analysis of the level of physical effort, efficiency, safety, and independence a person demonstrates while doing an activity
- Focuses on quality of performance of an activity
- What are the barriers to accomplishing the activity
Function Repertoire of the hand Personal Constraints: Hand Roles: Hand Actions: Task Parameters:
Personal Constraints:
Physical and Psychological
Hand Roles:
Unimanual, bimanual
Hand Actions: reach, grasp, manipulation
Task Parameters: object, movement patterns, performance demands
Colles Fracture
A Colles’ fracture is a type of fracture of the distal forearm in which the broken end of the radius is bent backwards. Symptoms may include pain, swelling, deformity, and bruising.
WHAT WOULD IT IMPACT
Lateral Epicondylitis
Tennis elbow (lateral epicondylitis) is a painful condition that occurs when tendons in your elbow are overloaded, usually by repetitive motions of the wrist and arm. WHAT WOULD IT IMPACT
CMC (basal) joint arthritis
Carpometacarpal joint (trapezium and first metacarpal of the thumb)
De Quervain’s Tenosynovitis
affecting the tendons on the thumb side of your wrist. If you have de Quervain’s tenosynovitis, it will probably hurt when you turn your wrist, grasp anything or make a fist.
Although the exact cause of de Quervain’s tenosynovitis isn’t known, any activity that relies on repetitive hand or wrist movement — such as working in the garden, playing golf or racket sports, or lifting your baby — can make it worse.
Carpal Tunnel syndrome
carpal tunnel syndrome is a common condition that causes pain, numbness, and tingling in the hand and arm. The condition occurs when one of the major nerves to the hand — the median nerve — is squeezed or compressed as it travels through the wrist.
Colles Fracture
- Foosh injury -falling on outstretched hand
- Accounts for 14% of all fractures
- Women over 65 are 50% more likely to have clinically important functional decline
Fracture Healing process ( 4 steps)
fracture, (between 1-2 weeks) inflammatory Phase, (between 1-7 weeks), Reparative Phase (5 weeks -++ months), remodeling phase
-not scar tissue, but new bone
Mary –> colles fracture case
Rehabilitative FOR
observation -in kitchen -cup for ta -dressing shoe/socks and UE -bathing mobility: falls COMP: what were her issues
Mary –> colles fracture case
Biomechanical FOR
Edmena: circumferential measurement
Pain - visual analogue scale
Sensation - light touch
Volumeter assessment
- used for edema
- hand is placed in water –> water is displaced and measured
Figure 8 method
must also used observation
-pitting edema, warm shiny skin
Understand Lateral Epicondylitis
-muscles affected
Extensor carpi radialis longus Extensor carpi radialis brevis brachioradialis impacts extension and radial deviation extensor carpi ulnaris -extensor digitorum -extensor digiti minimi
understanding the Diagnosis: lateral Epicondylitis
- repetitive movements
- repetitive strain injury
- account for 43% of loss claims and cost in ON
- 50 % of individuals playing sports with frequent overhead arm movements will experience lateral epicondylitis
Assessment for Lateral Epicondylitis
Rehab FOR:
DASH
COPM
Assessment for Lateral Epicondylitis
Biomechanical FOR
- Grip strength
- MMT/ROM
- Pain
- Palpation/Observation
JAMAR Hydraulic Hand Dynamometer
Ideal for routine screening of grip strength and initial and ongoing evaluation of clients with hand trauma and dysfunction.
Arches of the hand (for the lols)
longitudinal arch
-distal transverse arch
proximal transverse arch
What is functional position of the wrist
wrist- extension 20 degrees ulnar deviation 10 degrees Fingers MCP = flexed 45 degrees PIP = flexed 30-45 degrees DIP flexed 10-20 degrees Thumb Partially abducted and opposed MCP =flexed 10 degrees IP flexed 5 degrees
What . are the main functions of the hand:
-most complex movements found in the body
-combined action of intrinsic and extrinsic muscles
Grasp
–> tool use
-Manual Dexterity
-Sensation
-Communication
What is the biggest key play in pouring (2 things)
the thumb
wrist stability and position
Grasp is dependent on:
- shape of the object
- what will you do with the object after grasping
- texture of the surface
- location, orientation of workplace
- No stereotypical pattern as seen in LE ie sit/stand
Type of Power grips
Cylinder
Ball
Hook
Type of Precision Grips
Plate Pinch Key Pincer Tripod (three-jaw chuck)
What is globally the most used Grasp Method
Pinch ,then cylinder or non P (non prehensile grasp)
RH only
Left Hand only
Both Simultaneously stats about hands
both is over 50 % just over a quarter for RH and left the remaining
Bilateral Activities
-playing the piano
cooking
In-hand Manipulation (4)
Translation: -->finger to palm -->palm to finger Rotation Shift Combination of movements
Understanding the Anatomy of DeQuervain’s:
Abductor Pollicis Longus (APL)
–>Abduction of carpometacarpal (joint 1)
–> slight extension
Extensor Pollicis Longus and Brevis (EPL and EPB)
F: Extension of CMC, MCP and IP joints of thumb (brevis does not extend IP joints
Flexor Pollicis Brevis
Adductor Pollicis Brevis
Opponens Pollicis
Anatomical “snuffbox”
between EPL and EPB and APL radial artery and radial nerve
Understand the Diagnosis
of De Quervain’s Tenosynovitis
-women 4X more likely than men
-pain weakness and swelling along the radial side of the wrist
29X increase in persons with highly repetitive or forceful jobs
–> opening jars, cutting with scissors, playing the piano, needlepoint
New Assessments for De Quervain’s Tenosynovitis
Grip strength, Pinch strength, Palpation/observation edema... volumeter Provocative tests --> Finklestein
Finklestein
put thumb in hand and and ulnar deviate
Pinch testing
pad to pinch
lateral key pinch
tripod pinch
New Tests added when we talked about arthritis Society Community OT
Bottom up and Top Down
TEMPA (top down )
Bottom-up
Dexterity - Purdue Pegboard
Minnesota Rate of Manipulation Test
UE assessment - Dexterity - Purdue Pegboard
instructions
get thirty seconds
do right , then left then both
Minnesota Rate of Manipulation Test/Minnesota Manual Dexterity Test
simple but rapid hand eye coordination muscle reaction time to visual stimuli -packing of components, filling containers, sorting cards instructions should be well understood and there should be a practice period placement test- hand movement turning test - finger manipulation only one handed
TEMPA (what the fuck is this) ??
4 unilateral and 5 bilateral tests examiner sits beside they test grip strength at end of test scoring : functional rating (independence 0 to -3 point scale) 0 is the best , task analysis (active range of motion, strength and precision (all also on a 4 point scale) , time to complete task -instructions and manual for scoring
Understand the Diagnosis:
Carpal Tunnel Syndrome
- Compression Injury
- loss of light touch or vibration – initially mild, but may lead to loss of protective sensation
- Electronic assembly work was found to be one of the top jobs at risk of CTS
- -> other include meat and fish processing, forestry work with chain saws
- -> Associated with hand force > 4 kg, repetition >50% of cycle time performing same movements
Assessments for carpal tunnel new
Sensory evaluation --> two point discrimination (moving and static) Touch threshold --> semesweinstien monofilaments --> mobera pick-up Palpation/observation Provacative tests --> tinnels --> Phalens
Phalens Test
out your two palms together for 30-60 secs put hands together on dorsal surface
for 30 to 60 seconds
Tinels test
Tapping on carpal tunnel produces positive sign (tingling/numbness in lateral 2.5 fingers)
what are the 5 senses
touch (somatic) sight (vison) smell auditory taste the sixth sense --> proprioception
Cutaneous Sensory
-Pain, light touch, pressure, temperature
Dermis and epidermis
Proprioceptors sensory system
-position, movement, vibration
joints, muscles, bones, tendons, ligaments
Corical Sensations the sensory System
-stereognosis, graphesthesia, 2-pt. discrimination
Combined superficial and deep sensation
Sense organs in the skin
thermo-receptor senses heat or cold
Meissner’s corpuscle –> sense touch
nociceptor –> sense pain
Pacinian corpuscle senses pressure
three layers of the skin
epidermis
dermis
hypodermis
RECAL LAB ONE FUUUCK \
ROOTS GANGLION GREY MATTER WHITE MATTER
in the dor(sal) out the Ven(tral)
sensory info in the dorsal
motor out ventral roots
Purpose of sensory evaluation
Extent and type of loss
- intact, impaired, absent
- exteroception; proprioception, cortical sensation
Purpose of sensory evaluation
Document recovery
-Nerve regeneration
Purpose of sensory evaluation
direction of intervention
- sensory retraining
- Compensation/ safety
- Desensitization
Sensory Evaluation: general Principles (4 points)
- Client seated and comfortable in no-distracting
- -> support body part being tested
- -> occlude vision during testing
- ->eliminate auditory cues - Explain Procedure
- Test on unaffected side first
- Apply stimulus distal to proximal:
in random order, at irregular intervals, maintaining stimulus
Sensation
light touch
pain
temperature
vibration
Two point discrimination
measures innervation denisty
Stereognosis:
Graphesthesia:
Proprioreception:
Kinesthesia:
Stereognosis: the mental perception of depth or three-dimensionality by the senses, usually in reference to the ability to perceive the form of solid objects by touch.
Graphesthesia: Graphesthesia is the ability to recognize writing on the skin purely by the sensation of touch. Its name derives from Greek graphē (“writing”) and aisthēsis (“perception”).
Proprioreception
Kinesthesia:
Proprioception (or kinesthesia) is the sense though which we perceive the position and movement of our body, including our sense of equilibrium and balance, senses that depend on the notion of force
Pattern of Sensory Recovery ( 3 points)
-crush injuries have a faster recovery than lacerations injuries
-sensation of temperature and pain recover first, followed by touch sensation
-moving touch recovers before light touch
–> pain fibre regrowth 1.08mmm/day
touch fibre regrowth .78 mm/day
Sensation: touch threshold
Monofilaments-semmes-weinstein
-start with 2.83 smallest
-begin distally
-apply filament perpendicular to the skin
-record on a hand map
Location of light touch (protective sensation)
-smallest filament felt by client in previous test
-provide stimulus to an area
-record on hand map (differentiate location felt from location stimulated)
Sensation: innervation Density
-two point discrimination
static: start with 5 mm
perpendicular to fingertip
-longitudinal or transverse direction
Moving ( always returns earlier)
- start with 5mm to 8 mm
- Perpendicular to fingertip
- stimulate in a longitudinal direction
- proximal to distal
Why is it important to conduct functional tests
- understand disability associated with sensory impairment (sterogenosis)
- -> is the client sensibility sufficient to manipulate small objects
- can the client use the hand for fine coordination without relying on visual feedback
Moberg’s: pick up test
pick up small objects (safety pin, key, coin) and place them in a box
Score: total time client take with and without vision
Stereognosis
a number of known objects
-identify objects without vision
ZONE of FLEXOR LOL
zone 1 distal end zone 2 rest of phalanges zone 3 metacarpals zone 4 carpals zone 5 radial and ulnar thumb has its own 1, 2, 3 (three is the same as other zone 3 called T111
What are the different types of mobility
- bed mobility
- mat/we/bed transfers
- functional ambulation for ADL
- toilet and tub transfer
- car transfer
- functional ambulation for community
- community mobility and driving
Functional Mobility
how a person walks a while achieving a goal
-adapting to their environment and task demands
community mobility (4 factors )
- distance
- speed
- navigation
- fall safety
Assessments for Hip replacement
FIM (functional independence measure)
-observation of task (formal/informal)
Ambulation Self-Confidence Measure
FIM (functional Independence Measure)
no helper 7
minimal assistance 4
total assitance 1
Functional mobility
Postural control
ambulation in home and community
transfers-bed mobility
sit to stand
stairs
Key concepts of Balance
base of support and centre of gravity
Types of Postural Control:
Anticipatory
postural adjustments required for reaching, leaning, lifting
Static Posture control
-maintaining safe, idependentent sitting or standing
Reactive
-balance response: recovery from loss of balance
Postural Control Strategies
stepping stiffening/fixation shifting weight visual regard extra input from environment mobility aids (changing BOS -avoiding activity
Assessments for
Bernadette – Aging, Balance
Frequent falls – in bedroom, bathroom and garden. Difficulty walking in home and community due to balance issues
Gait balance balance confidence/falls efficacy -ROM/strength testing Sensory testing -proprioception and sensory
Balance Test
- timed up and GO
- berg balance test
- functional reach test
- activities balance confidence scale (ABC)
Task/activity assessment
-observation
–> sit to stand, transfers, transitional movements, functional mobility -walking in the community/home, taking a bath, climbing stairs
self-Report -Ambulation confidence
-ambulation Aids
-ENVIRONMENT
Gait what are the two phases what are the percent
double and single support
stance phase (60%) and swing (40%) double (20%) and single support (80%)
The Gluteal Region:
adductors of the hip
gluteus minimus
–> medial rotation and abduction
gluteus medius
–> abduction
Gluteus Maximus
Tensor Fascia Lata
Function: extends thigh at hip
adducts and medially rotates the thigh at the hip stabilizes pelvis while standing tenses IT band.
The knee (gait) Muscles that flex the hip and extend the knee
Quadriceps femoris
special: rectus femoris
action Hip flexion and knee extension
Biceps Femoris
composed of long and short heads hip extension (long head only) and knee flexion
Pes Anserinus
SGT
common insertion located on anteromedial tibia (proximal)
The ankle (gait) muscles that dorsiflex the foot
tibialis anterior
extensor Hallucis Longus
Extensor Digitorum longus
Muscles that plantar flex the foot
gastrocnemius
popliteus
plantaris
soleus
What to observe during gait
step and stride length
BOS
toe angle
Speed
Common Acute weight bearing care restrictions
NWB no weight bearing TDWB: Toe Down or toe touch weight bearing PWB partial weight bearing WBAT: weight bearing as tolerated FWB : full weight bearing
what side do you use
what foot do you lead with
Torque = force * distance
15 degree angle
affected foot
Sit to Stand
move from large to small BOS
Lower limb flex and extend over a fixed pt
trunk muscles stabilize
hip/knee extensor and tibialis anterior
Hip Replacement facts
55981 hip replacements in 2016-2017 up to 17.8% from five years ago
2 of every 3 individuals were aged 65 and older
almost all surgeries were performed in an inpatient setting
most common reason was OA and acute fracture
Hip precautions
hip flexion
internal rotation
adduction
Hip Fracture Stats
almost 30 000 people across Canada experience a hip fracture each year
- direct health care systems costs approx 27 000 per patient
- falls are leading cause of hip fracture
- 20 % will die within a year of the fracture
- 15% of total hip replacements are due to hip#’s - predominantly women (69%) and older mean age 82 vs 71
Hip fractures
intertrochanteric Fracture
Femoral Neck
wheel chair mobility
participation and engagement in meaningful occupations
Wheelchair/seating Evaluation
–> person, technology/equipment, environment
Seating Intervention
-postural control, pressure management, comfort function
Seating intervention (4 points)
- seat for postural control and prevention of deformity
- seat for pressure management
- seat for comfort and postural accommodation
- seat to optimize occupational performance and interaction with the environment
Basic guide to seating
Keep it simple and individualized (KISS)
-work proximal to distal (pelvis first )
promote function
-monitor impact of changes in components on comfort and function
Re-Assess seating - needs will change over time
i.e changes in physical status or function
why use a wheelchair
fatigues when walking longer distances; difficulty with walking independently
needing full postural management and support; unable to sit independently
Wheel chair assessment the person
seating goals occupations –> interview
Postural assessment –> MAT assessment
Skin –> pressure Risk assessment
Use –> wheelchair skill assessment
Mechanical Assessment Tool (MAT)
in supine and sitting (plinth is ideal) -posture/balance -tone -endurance -skin integrity -strength -ROM --> flexible -->tight --> Fixed e.g contracture ALWAYS START WITH THE PELVIS
pelvis
key point of control -stable base - U/E freedom and movement
-iliac crests aligned
Check for: (in the pelvis)
- Pelvis obliquity
- pelvis rotation
- posterior tilt
- windswept legs
What can you palpate on the pelvis
Ischial tuberosity -ASIS anterior superior iliac spine -PSIS posterior superior iliac spine
Pelvic rotation
one ASIS in front of the other
Pelvic Obliquity
PSIS one in higher than other causes curving of the spine
can cause windswept deformity
Pelvic Tilt
ASIS higher than PSIS bone titled back
-causes tilt of spine
windswept Deformity
legs to one side
Vertebral Column curvature
Cervical convex 2 degrees
Thoracic concave 1
lumbar convex 2
sacral concave 1
Spine develop
primary: concave anteriorly
Secondary: convex anteriorly
secondary curves mature through early-life growth and development
-new born some convex lumbar
4 years -some convex lumbar and cervical
adult all four sections clearly defined
Kyphosis
Kyphosis is a spinal disorder in which an excessive outward curve of the spine results in an abnormal rounding of the upper back. The condition is sometimes known as “roundback” or—in the case of a severe curve—as “hunchback.”
Lordosis
Lordosis is the normal inward lordotic curvature of the lumbar and cervical regions of the human spine. The normal outward (convex) curvature in the thoracic and sacral regions is termed kyphosis or kyphotic
Scoliosis
Scoliosis is a sideways curvature of the spine that occurs most often during the growth spurt just before puberty. While scoliosis can be caused by conditions such as cerebral palsy and muscular dystrophy, the cause of most scoliosis is unknown.
Movements of the Vertebral Column
Flexion, extension (cervical and lumbar spine )
Lateral flexion –> lateral extension (cervical and lumbar spine )
Rotation of head and neck, rotation of upper truck
Cervical and thoracic spine
Comfort and FIT Size measurements for a wheel chair
Seat width: measure across hips or thighs which ever is wider (add 2 inches)
Seat depth: measure from behind the cafe to back (subtract 2 inches)
Leg length Measure from heel to under thigh
Seat height: add 2 inches to leg length measurement
Arm height: measure from seat platform to just under the elbow Add 1 inch
Back height: measure from the seat platform to under the axilla, hihc the arms fully extended parallel to the ground
Pressure Ulcers Stats
prevalence declining
- significant impact on quality of life
- -> pressure ulcers cause endless pain–> produce a restricted life–> coping with a pressure ucler
Pressure Ulcers deff
-localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction
Intrinsic and extrinsic risk factors
Sensation Moisture Activity Mobility Nutrition Friction and shear Grade 1 pressure ulcer Cognitive level Age Other health conditions affecting circulation (ie diabetes) Smoking Incontinence Spasticity
Risk Assessment for pressure Ulcers
- Braden scale for predicting pressure sore scale
- waterlow pressure ulcer risk management
Pressure equation
F/A
-the amount of force applied perpendicular to a surface per unit area of application
Pressure in terms of wheelchairs
tissue damage = duration of application and (intensity) amount of pressure applied.
when pressure is applied over a bony prominence the internal stresses are at highest in the soft tissues closest to the boney prominence
-patient at highest risk from pressure are those who are unable to move themselves or to ask to be moved
–> focus on removing or reducing pressure
Sources of pressure
-bed
-wheelchair
-recliners and hard chairs
toilets
splints
Friction
- 2 surfaces moving across one another
- involved in the development of shear stresses
- consider skin moisture, surface wetness and humidity -all increase coefficient of friction
shear
mechanical force that acts on an area of skin in a direction parallel to the body surface
Stage 1
skin in not broken but read or discoloured
redness change in colour does not fade within 30 min
Stage 2
thickness loss of dermis
skin is broken creating a shallow open sore
-drainage may or may not be present
Stage 3
break in the skin extend through dermis (second skin layer
into subcutaneous and fat tissue
-tendon/bone not visible
-depth depends on location
stage 4
- ful thickness. breakdown extends into the muscle and can extend as the bone/muscle
- usually lots of dead tissue and drainage are present
Unstageable wound
- ulcer covered by necrotic tissue or eschar and depth obscured
- unable to accurately stage ulcer - but either stage 3 or 4
- eschar should not be removed
Suspected
- Purple or maroon localized of discoloured, but intact skin
- skin may feel firm, mushy, warmer or cooler than adjacent tissue
types of seating
Manual
Independent
Power
dependent (attendant propelled) --> manual --> transport --> other Broda Power -power add-on Power Scooter
Standard Manual category 1
- user is not consistently independently mobile
- requires minimal adjustment for posture and mobility
- limited options
- tend to be more institutional type of chair
Lightweight Manual -category II
- user is independently mobile
- requires some adjustments for posture and mobility
- great number of options
- frame height
- wheel size
- front hangers
- rear axle adjustments
- -> up/down
Lightweight manual - Category iii
-user is very active
-requires altered wheel placement for optimal posture and mobility
-Adjustable axles
–>up/down, forward/backward
quick release
-key features
–>frame height
–>wheel size
–> front hangers
Ultra lightweight Manual iV
- ultra lightweight, rigid frame and optimal maneuverability user requires postural support and altered wheel placement
- ->high performance
Category V
manual Dynamic Tilt
- user cannot maintain upright posture though use of seating components alone
- tilt and recline
Stability vs Maneuverability
Casters
rear wheel positions
camber
-squeeze
Camber
decrease height increase base
increase lateral stability decrease turning radius
squeeze
angle from back front to back
-decrease trunk-hip angle
real wheel position
typically 60% of weight over rear wheels 40% over front
can change to up to 75%/25%
Cushion Type
-planar
-contour
-custom
Foam and air
Assistive Devices Program
Eligibility criteria
Ontario resident with valid health card
Physical disability with duration of 6 months or longer
Basic and essential
Individual not covered by WSIB or DVA Group A benefits
Accessing – certified authorizer / certified vendor
Chronic Pain
pain only starts when signal reaches our brain
Gait control
pain signal two arrows a-dulta nerve fiber C-fibers
laminae –>a-beta nerve fiber (inhibitory neuron not active during danger active ) spinal cord –> brain
Classification of burns
superficial (epidermal)
partial thickness (affects deep layers)
Full thickness
-affects all layer of skin
skin graphs
autographs are graphs that remove skin from unburnt parts of the body
skin from left thigh was used over the fulthickness burns on dorsal of hands
special considerations of burns
psychosocial side effects
-newly grafted skin is incredibly sensitive
Phantom Limb pain
Phantom limb pain (PLP) refers to ongoing painful sensations that seem to be coming from the part of the limb that is no longer there. The limb is gone, but the pain is real. The onset of this pain most often occurs soon after surgery. … The length of time this pain lasts differs from person to person
Residual limb pain
Residual limb pain is defined as a painful sensation or feeling from the remaining part of the leg. Aggressive bone edge, bone spur formation, neuroma, abscess or bursitis are common causes of residual limb pain. … The non-amputated limb was used as a control for the amputated side.
Acute VS Chronic Pain
acute pain serves to alert after an injury or malfunction of the body
chronic pain begins as as acute but it continues beyond the usual time expected for resolution of the problem or persists or recurs for other reasons
chronic pain
Pain without apparent biological value that has persisted beyond the normal tissue healing time (usually taken to be 3 months)
-multidimensional in nature
-subjective
Subjective nature of pain does NOT mean that pain is not real
what is the impact of chronic pain
-fear and anxiety
sensitivity
-anticipation of future event
Impact of chronic pain
triggers emotional distress
- reveals strength or weakness of relationships
- pain and occupation are reciprocally related forces
- elicits innovative adaptive responses
Pain related to disability
dependent on many psycho-social variables
- fear of movement
- perceived disability
- depression -anxiety
Pain assessment PQRST
provoking factors quality region severity time Accept description as accurate Ensure clients use their own words Actively listen .. . Pain diagram Pain scales Manage pain ASAP
Occupational Therapy Lens
-empowerment is in an important concept
–> pain is all encompassing
-Takes over all aspects of daily life
OT help clients regain control by teaching the use of specific tools to enable occupational performance despite pain
Important concepts to pain
therapeutic listening
- compassion
- innovativeness of individual with chronic pain
- potential of occupation to invoke change
