FINAL Flashcards
Endurance
Muscles ability to sustain or perform repeated contractions over time.
Effort arm is able to overcome the resistance without expending as much force as the resistance.
CoG in anatomical position
S2
How can we increase/improve human stability
increase the size of the base of support such as widening leg stance or lowering center of gravity (ex. squatting)
CoG can be displaced in 3 ways:
- external movement of the support surface
- external force applied to the body
- during the performance of activities requiring self-initiated movement of the head, limbs, trunk
If client cannot move through AROM but can perform PROM
Potential issues: active excursion or muscle weakness. Do AROM measures, MMT
PROM deficits and AROM deficits
Potential issues: joint stiffness. Do A&P ROM measures. check succeeding joints
Protocol for testing grip strength using dynamomter
Elbow held against side, 90 degree angle. test at second position 3x and take average. compare to other hand
Protocol for Pinch testing
3 types: 2-point pinch, 3 point pinch, key pinch. do each 3x and take average. compare to other hand
What do abnormal results mean for grip/pinch strength:
- pain
- loss of muscle function
- loss of tendon glide
- lack of effort
- Pain: restricting max grip/pinch
- Loss of muscle function: inability to maximally contract
- Loss of tendon glide: inability to place fingers in position
- Lack of effort: fear or malingering
An easy way to quantify the physiological demand of a dynamic activity and effort
heart rate
ROM limits for elbow flexion
150
ROM limits for forearm and supination
80
ROM limits for wrist extension
80
ROM limits for wrist flexion
70
ROM limits for wrist ulnar deviation
30
ROM limits for wrist radial deviation
20
Sensory deficit patterns in SCI leisions
complete leision: total loss of sensation
incomplete leision: dependent on area damaged within specific spinal tracts
Anterior: loss of pain, temp
Posterior: loss of touch, vibration, proprioception
Wrinkle test
Immerse hand or affected area in water and wrinkling will occur in innervated areas and denervated areas will not have wrinkling.
Pain Descriptors
Dysesthesia: abnormal pain sensation (e.g. burning, sharp, stabbing) usually associated with touch
Allodynia: pain from a non-painful stimuli (ex. if someone touches someone’s hand and they say its painful)
Sensation descriptors
Anesthesia: absent
Paresthesia: an abnormal sensation (“asleep”, “pins & needles”)
Hyperesthesia or hypersensitivity: exaggerated sensation beyond expectation
Receptor types
Merkel’s/Ruffini’s/Meissner’s/Pacinian: sense mechanical information
Free nerve endings/thermal receptors: sense pain and temp
What are threshold evaluations?
They look at the level at which a stimulus can be detected
What are innervation density evaluations?
They look at the number of sensory units in a given area of skin
Indications for sensory evaluations
- known or suspected diagnosis (eg. SCI, peripheral nerve compression)
- Observed OP dysfunction (e.g. poor object handling, manipulation)
- Experience of odd/unpleasant sensations (aversion to certain materials, resistance to wearing splint)
Tinel’s sign
What happens if the test is positive?
A special evaluation of sensation where you tap over a nerve to see if it elicits a sensory response.
A positive test indicates there is nerve regeneration happening
Phalen’s test
Flexing the wrist 30-60 seconds to see if it elicits a sensory response (e.g. tingling, pain through median nerve)
Compression tests
Put pressure over the nerve in areas that tend to be a location for nerve compression
-eliciting the onset of symptoms
Moving 2 point discrimination test
Detects sensitivity to change. requires cortical integration. Useful as a measurement after nerve laceration and repair
Monofilmament test
Threshold test: mesure of threshold of light touch sensation
Useful as a measure if early nerve compression is suspected
Examples of compensatory techniques for continuous low pressure (e.g. seating with paraplegia)
- teach frequent position changes
- provide cushions/padding
- teach reliance on other senses
Examples of compensatory techniques for concentrated high pressure
- careful handling of sharp tools
- enlarged handles on suitcases, drawers, tools. etc.
Examples of compensatory techniques for extreme hot or cold
- insulated coffee mugs
- insulate exposed hot water pipes
- mittens
- oven mitts
- utensils with wood or plastic handles as opposed to metal
Sensory training/re-education
- helps patient with sensory impairment learn to reinterpret sensation
- goal is to maintain or restore cortical hand representation
Passive sensory training: for patients without sensation. long term highly repetitive stimulation of the skin to preserve cortical representation
Active sensory training: for those beginning to have sensation return. combines attention, learning, repeated practice, etc. to regain functional use
Examples of tasks in sensory re-education program
- object recognition using distinct features to detect
- object prehension (Control while holding objects, maintenance of prehension during transport)
- object manipulation
- object identification (large to small, dissimilar to similar)
Example causes of hypersensitivity
nerve trauma
soft tissue injuries
burns
amputation
Intervention for hypersensitivity
Desensitization: repetitive stimulation with items that provide a variety of sensory experiences.
-it will allow progressive sensory tolerance
Desensitization techniques
- initially use a splint over affected area to allow use of limb without making contact on affected area
- create hierarchy of stimuli from least to most irritation
- weight-bearing pressure
- massage
- TENS
- vibration (e.g. electric toothbrush)
Interventions for Edema
- AROM
- Elevation
- Light retrograde massage
- compression (glove, sleeve)
- wrap
- residual limb shaping
Phases of environments to practice mobility skills
First phase: in accessible environment of hospital room
Second phase: takes into consideration the actual environments the client will be returning
Third phase: address community mobility
Non-weight bearing
0% of body weight on operated limb
-use crutches or wheelchair
Touchdown weight bearing
10-15% of body weight
-use walker or crutches
Partial weight bearing
30% of body weight
-use walker or crutches
50% weight bearing
50% of body weight
-use cane
full weight bearing
75-100%
-cane or no device
Potential issue when using axillary crutches
-may incur damage to brachial plexus
Measurements for crutches
- measure with shoes on
- measure from floor to axilla (then subtract 2 inches)
- adjust hand grips to height of waist
What side do you hold a cane on when compensating for a unilateral condition?
The cane is held on the unaffected side.
The cane is used in tandem with stride on the affected side
Measurement for cane/walker
- measure with shoes on
- with arm loose at side, measure from floor to wrist crease
- wrist should be flexed 20-30 degrees
Walking up stairs with cane
- push down on crutches through hands
- step on first step with unaffected leg
- put weight on unaffected leg, push down on cane and lift affected leg on step and cane on step
Walking down stairs with cane
- lower crutches/cane to step below
- lower affected leg onto step below
- push down through cane while lowering unaffected leg onto step
When are anterior walkers used?
- for those who need more support standing/walking
- make transfers easier with open back
When are posterior walkers/gait trainers used?
- Provides better posture alignment
- might help to increase walking speed
- requires less exertion from user
- preferred by users who want to access things easier in their daily enviro
Education on how to walk with a walker
- Move the walker ahead first
- step into the frame of the walker with your affected leg , then step in with your unaffected leg
*don’t hold onto walker when transferring from sit to stand
When would you use a stand-step stand-by/min assist transfer?
When client is able to weight bear, but is unsteady or weak
When would you use a stand-pivot/slide with min-mod assistance?
When client is able to weight bear through one leg only
-be ready to support affected leg by positioning your knees on each side of their affected leg’s knee.
When would you use a squat pivot transfer with mod-max assist?
When client is unable to completely weight bear and or stand up straight
-position your knees on either side of their knees to prevent buckling.
When would you use a transfer board to transfer?
When client is unable to weight bear
What does low tone indicate for wheelchair fitting?
They are not able to sit upright so they need a lot of support
Bony prominences to consider when assessing for a wheelchair
- PSIS
- ASIS
- Sacrum/coccyx
- Ischial tuberosity (ITs)
- Greater trochanter
Lordosis
Exaggerated inwards curvature in lumbar spine
Kyphosis
Exaggerated outwards curvature in thoracic spine
General rule for w/c seat width
Hip/GT width + 1 inch
General rule for w/c seat depth
Upper leg length - 1 inch
General rule for hand propellers
Finished seat height: lower leg length + 2 inches
lower leg length = cushion + footrest length
General rule for foot propellers
Finished seat height = lower leg length - 1 inch
Cushion materials most to least stability
- foam
- hybrid
- gels and fluids
Cushion materials most to least pressure distribution
- Air
- Gels & liquids
- hybrid
- foam
The higher the back length and contour of w/c:
the more support you get but less freedom of movement
“Chaining” task analysis
breaks down complex tasks into a series of steps or subtasks
-Forward: client is taught to complete the first action in the task sequence until mastered , then do steps 1,2 . etc,
-Backwards: client is taught in reverse order with the last step left incomplete, then last two steps left incomplete, etc.
When deficits impede participation, therapists must:
- select occupation as a means activities to remediate skills
- adapt or grade activity to promote engagement
- use compensatory strategies and devices that substitute for a patient’s deficient skills
Examples of graded dimensions
- ROM
- weight
- resistance
- speed
- repetition
- position
- surface height
- texture
- size
- duration
- complexity
- # of steps
- cognitive demand
- assistance level
Occupational adaptation
The process of modifying an activity to enable performance, prevent injury, or accomplish a therapeutic goal
Group of adaptations focusing on specific body functions that support the actions used to perform activities
- positioning the activity relative to the person
- arranging objects relative to each other (reduce energy required to perform a task)
- modifying lever arm length (can affect amount of resistance)
- modifying performance method & physical context (such adaptations allows performance of activity that would be otherwise impossible)
- modifying level of difficulty (cognitive or physical)
Group of adaptations: objects and their properties
- modifying materials and textures (ex. to change an activity’s level of resistance, material you cut with scissors)
- modifying tool and utensil handles
- modifying object size and shape
- modifying colour contrast between objects
- modify using supplemental tools and utensils
- adding weights
- add springs or rubber bands
Group of adaptations: Sequence and timing
- changing demands related to the steps involved in an activity
- modifying steps (increasing number of steps to completion)
- modifying time (changing the length of time needed to complete an activity)
Gradation: to increase range of motion
- activity must require that the body part being treated move to its limit repeatedly
- activity should be graded to demand greater amounts of movement
Gradation: to relearn skilled voluntary movement
- provide opportunities for vast amounts of varied practice
- practice may come through repetition of the whole action
Gradation: to decrease edema
- AROM of the muscles in the edematous part
- movement of the extremity into an elevated position
- can include activity in an elevated position OR avoid activity in a dependent position (below the level of the heart)
Gradation: to decrease hypersensitivity
- grading textures or interaction of objects
- lease noxious to tolerably noxious
- soft to hard to rough
- touching to rubbing to tapping to vibration
Gradation: to increase strength
- increasing the resistance needed to complete an activity
- increasing the number of repetitions
- increasing the amount of time an isometric contraction is held
Gradation: to increase muscular endurance
- gained through repetition over a controlled number of times
- resistance should be at least 50% or less of max strength
Gradation: to increase cardiopulmonary endurance
- increasing the duration of the task
- increasing the frequency of the task
- changing the muscles used in the activity to prevent over-fatiguing
- increasing the intensity of a task
Gradation: to increase coordination and dexterity
-slow gross movements to precise, fast movements
Gradation: to improve perceptual impairments
Activity should involve varied practice information processing or perceptual processing at the outside edge of the person’s capabilities
Gradation: to increase attention
- increasing the demand in one or more of the capacity domains
- noticing enviro cues
- sustaining attention over time
- attending to relevant stimuli
- alternating attention between different tasks
- keeping track of 2 or more items during an ongoing activity
Gradation: To retrain sensory awareness and/or discrimination
-Activity must provide components that offer a variety of textures, shapes and sizes graded from distinct to less distinct
Gradation: to increase memory
-should increasingly challenge the client to encode, store and retrieve information based on the type of memory needing remediation
Gradation: to improve problem-solving strategies
-practice may start with simple activities that present concrete problems involving objects that the patient can see and touch. then proceeds to more complex activities that require a higher level of abstraction
Long and short term goals should focus on:
- remediation of client skills
- modifying performance techniques
- altering the environment or
- using adaptive equipment
Facilitators to being receptive to education:
- motivation for independence
- support
- accepting accountability for recovery
- awareness & cognition
Barriers to being receptive to education:
- poor coping mechanisms
- lack of support
- not wanting to be seen as different by using devices
- psychologically defensive/angry
- lack of awareness/cognitive abilities
Weakness in limbs, trunk or overall body can result in:
- difficulty in dynamic and static balance
- posture
- transfers, functional mobility
- reaching, grasping
Bed mobility is the ability to:
- bridge in bed
- roll from supine to side-lying
- scoot up and down in bed
- move from supine to sitting and sitting to supine
- sit at the edge of the bed
Clients with weakness may have difficulty in the following areas of bathing:
- transferring into bath or shower
- standing or sitting in shower
- grasping and holding onto items
Clients with weakness may have difficulty in the following areas of toileting:
- don and doffing clothing
- sit on and rise from toilet
- reach and grasp toilet tissue and clean perianal areas
Clients with weakness may have difficulty with personal hygiene and grooming in the following areas:
What does therapy focus on in this area:
- grasping and holding onto grooming supplies such as combs, brushes, make-up and shampoo
- using counters for support, organizing frequently used items to be nearby, equipment to ease grip demands
Clients with weakness or paralysis may have difficulty with dressing in the following ways:
- obtaining clothing
- moving extremities into clothing
- manipulating zippers or buttons
- decreased balance in sitting
Clients with weakness may have difficulty with feeding in the following areas:
- difficulty grasping utensils
- cutting food
- bringing food from plate to mouth
Important areas of sexual activity to address
- scope of intimacy
- shift focus from function to pleasure
- consider impact of impairment on body image
- fears about resuming sex
Endurance
Ability to sustain physical activity over time
-a reflection of cardiopulmonary function and overall fitness
Energy conservation techniques
- rest: balance work and rest, including alternating heavy and light tasks
- examine and modify standards and priorities: eliminate unnecessary tasks, combine or delegate tasks to reduce work
- reduce task demands: use good body mechanics, sit to work when possible
- plan ahead and organize work
- use electrical appliances
- use lightweight utensils
- work with gravity assisting
Compensatory intervention approaches for limited or restricted ROM
- organize the task within functional limits
- follow activity steps designed to be within altered ROM patterns
Incoordination
- -loss of precise smooth movements and can result from CNS disorders.
- leads to poor dexterity loss of fine and dynamic manipulation and motor coordination skills
Clients may have problems stabilizing body parts and safely coordinating movements and objects
Interventions for incoordination
- stabilizing body as much as possible by sitting during ADL activities
- bearing weight on UE
- holding UEs close to body or
- using splints to stabilize selected joints to improve client’s extremity control
Adaptive equipment for incoordination & poor dexterity when eating
- weighted cuffs
- anti-slip mat, weighted utensils, covered lid with straw
- extended straw (for high lvl SCI)
Interventions for when a client has loss of use of one UE or one side of the body:
- teaching effective techniques that also protect less functional side of the body
- positioning items on unaffected side for max ease
- teaching specific sequences of techniques for alternative approaches to tasks
- adaptive equipment
Interventions for LE amputations:
- identifying the most stable and safe positions for activities
- teach sequencing for safe and efficient accomplishment
- particular attention focuses on when to don/doff prosthesis(es)
Interventions for low vision
- maximize visual functioning (identify and use remaining best vision for compensation)
- modify environment or task
- using adaptive equipment
Implications of obesity
- aggravate osteoarthritis, damage joint structures, destroy cartilage
- cause spinal and peripheral nerve compression
can lead to:
- difficulty moving and reaching
- decreased activity tolerance and mobility
- difficulty accessing environment
Interventions for memory deficits
- cueing strategies
- task simplification
- environmental simplification
- assistive technology reminders
Examples of devices/methods for feeding if decreased hand function
- universal cuff with/out wrist support
- weaving utensil handle through fingers
- using a spork to eliminate need to change utensils
- wrist/hand orthotics
- rocker or serrated knife
- attachable open bottom handle for cups
- sling
- enlarged or elongated handles made of lightweight material
- electric feeders
Examples of devices/methods for grooming if decreased hand function
- select products based on ease of opening and using
- universal cuff or splint to hold brush, toothbrush, lipstick, razor
- use friction material to provide added assistance
- enlarged or lengthened handles
- have a simple hairstyle to eliminate need for blow-drying, styling
Examples of devices/methods for toileting if decreased hand function
- teach alternative techniques for clothing mgmt when standing is not an option
- provide equipment or education regarding intermittent self-catheterization
- toilet paper dispenser in reach
- wiping tongs can be used to extend reach when using a toilet
- providing training in durable medical and adaptive equipment for bowel mgmt
- equipment needs: bidet, dressing stick, raised toilet seat, toilet frame for balance and support
Examples of devices/methods for bathing if decreased hand function
- grab bars
- faucets with easy-to-control handles
- automatic faucets or dispensers
- teaching safety with water temperature
- mechanical bath lift
- shower wheelchair
- tub bench
- strategies to bathe the back, feet and perineal areas when bating on tub seat
Examples of devices/methods for dressing if decreased hand function
- adapted loops for clothing in absence of pinch
- loop attached to zippers
- button hook or zipper pull, dressing stick, reacher, sock aid, long shoehorn
- varying positions when putting clothes on
- elastic waist bands, avoid buttons
Examples of devices/methods for sexual activity if decreased hand function
- warm bath/magic bag/massage may reduce joint stiffness
- clients should explore options that do not cause pain
- education from stores that specialize in sexual accessibility
Examples of devices/methods for handling a book if decreased hand function
- book holders
- a rubber thimble to turn pages
- or a pencil with the eraser down can be used in a universal cuff or hand splint
- electric page turner
- mouth stick with friction tip end
- kobo other electronic device
Examples of devices/methods for writing if decreased hand function
- for excessive writing use a computer
- can use voice recognition software, voice recorder, typing sticks or mouth sticks for hitting keys
- splints that provide pinch to hold a writing instrument
- pencil holder
- pens with textured grips
- felt-tipped pends require little pressure and are easier to use
- mouthstick with pencil attached
Examples of devices/methods for opening containers if decreased hand function
- Jar openers: rubber sheets, clamp style, mounted style
- pliers
Examples of devices/methods for communication if decreased hand function
- bluetooth, headsets, speaker phones
- push buttons can be pressed using a stylus, mouth stick
- use speed dial
- voice-recognition, voice-text commands
- SMART Homes (voice activated)
Examples of devices/methods for shopping if decreased hand function
- shop at off hours so clerks are available to get out of reach items
- internet shopping
Examples of devices/methods for gardening if decreased hand function
- choose low maintenance perennial plants
- use tools with ergonomic grips
- sit while working
- use a sprinkler rather than a watering can
Strategies for ADLs when client has incoordination and poor dexterity
- teach use of the body in as stable a posture as possible
- sit when possible
- stabilize the upper extremities by bearing weight against a surface or by holding them close to the body
- friction surfaces, weighted utensils, weighted cuffs
- splints may be used to stabilize selected joints to reduce how much control a client must have to perform a task
Examples of devices/methods for feeding if incoordination and poor dexterity
- stabilize plate on friction surface
- weight utensils for stability
- a plate guard or scoop dish to prevent food from being pushed off plate
Examples of devices/methods for grooming if incoordination and poor dexterity
- standing in a corner enables patients to stabilize their trunk and head on the wall to the side
- stabilize the arms for brushing teeth or applying makeup
- using an electric razor to increase safety
- file the nails rather than clip to increase independence and safety
Examples of devices/methods for toileting if incoordination and poor dexterity
- self-catheterization may require adaptive equipment
- sanitary napkins are held in place better and easier to use compared to tampons
Examples of devices/methods for dressing if incoordination and poor dexterity
- choose front-opening, loosely fitting garments with large buttons, velcro closures or zippers
- shoe style should eliminate tying
- when wearing a tie slide it off without undoing the know
Examples of devices/methods for bathing if incoordination and poor dexterity
- teach strict safety precautions
- use safety grab bars and nonslip materials
- use a tub bench or seat to provide stable position
Examples of devices/methods for communication if incoordination and poor dexterity
- large button phones
- voice-controlled or speaker phone options
- voice activation
Examples of devices/methods for playing games if incoordination and poor dexterity
- weight board game pieces to increase dexterity
- enlarge squares
- use card holders
- computer games that use keyboards or switches
Examples of devices/methods for grooming if loss of one side of body
- suction cup brush fastened to the inside of the sink to brush dentures
- suction cup brush to clean nails
- fingernails can be trimmed either with a stabilized emery board or nail clipper
Examples of devices/methods for bathing if loss of one side of body
- unaffected arm is washed by rubbing across a washcloth placed on the thigh
- dry off as much as possible before transferring out of the tub
Examples of devices/methods for writing if loss of one arm
- secure paper with tape, a clipboard, a weight, etc.
- encourage practicing writing if dominant hand is affected
Suggestions for blindness/low vision clients
- teach organization and consistency in placement of objects
- objects can be enlarged or magnified, use of better lighting or contrasting colours, reducing glare
- teach use of auditory and tactile information
Examples of devices/methods for feeding if limited vision
- food should be set in a consistent pattern using a clock method of description
- when pouring liquid, insert a clean finger over rim of glass to feel when liquid is near the top
- for low vision: plate, glass and utensils should be a colour that contrasts the table covering and food
Examples of devices/methods for dressing if limited vision
- create a system to coordinate colours of clothes and compatibility of style
- tactile or high contrast identification tags can be placed on hangers to denote the colour of clothing
Examples of devices/methods for reading/writing if limited vision
- talking books or magazines in place of written materials
- optical devices can enlarge print
- some reading materials come in large print
- some apps can scan and inform person of products especially medications and their dosage schedule
Examples of devices/methods for medication mgmt if limited vision
- use magnifiers
- mark bottles with large, high-contrast labels
- apply tactile identifiers
Examples of devices/methods for bathing if decreased sensation
- cold water should be turned on first and then hot water is added gradually to prevent scalding
- educate client to use area of hand that has intact sensation to test water temp
Examples of devices/methods for dressing if decreased sensation
- select clothes that avoid excessive pressure (ex. low elastic socks)
- in cold weather, dress warmly to avoid frostbite
Fatigue
A subjective experience of feeling tired or exhausted (not simply low endurance)
How many METs do most self-care activities require?
-less than 3 METs.
What is energy conservation?
and what is it a primary intervention for?
- breaking up physically active periods with rest periods, resulting in increased amounts of physical activity.
- Primary intervention for low endurance/fatigue
Pacing
Alternating higher paced/higher resistance tasks with lower paced/lower resistance tasks
Sleep suggestions for those with low endurance and fatigue
- develop a bedtime routine and schedule
- avoid consumption of alcohol, tobacco, and caffeine within 4 hours of bedtime
- avoid upsetting, important or stimulating activities before bedtime
- have a comfortable environment in which to sleep
- quality mattress, correct size and type of pillow
Orthotics can be viewed as…
- an intervention strategy (e.g. protection, mobilization)
- an environmental adaptation (a component of the individual’s environment. ex, w/c break extender)
- an interface between the individual & the environment (e.g. binoculars holder)
4 types of orthoses
- static
- serial static
- static dynamic
- dynamic
Static orthoses
no moving parts–used to support, stabilize, protect, immobilize
- to decrease pain and inflammation
- prevent undesired movement
- provide positive pressure over scar
- maintain gains in ROM following exercise/surgery
Serial static orthoses
- to lengthen tissues and regain pROM by placing tissues in an elongated position for prolonged periods
- resolve muscle-tendon tightness
- to stretch skin and soft tissue scar
Static progressive
use nondynamic components such as velcro, hinges, screws to create mobilizing force to ROM
- resolve muscle-tendon tightness
- to stretch skin and soft tissue scar
Dynamic splints
uses moving parts to permit, control, or restore movement. used to apply intermittent gentle force with goal of lengthening tissues to restore ROM
- mobilize stiff joints
- resolve muscle-tendon tightness
- to stretch skin and soft tissue scar
Diagnosis may direct the purpose of orthosis to…
- immobilize
- lengthen soft tissue
- substitute for nerve loss (protect areas with nerve loss)
Effects of orthotics that immobilize
-minimal repetitive use is needed to maintain normal viscoelasticity
•Immobilize→connective tissue will contract, and then reorganize, making it become more dense →leading to mvt restricted
Effects of orthotics that mobilize
support, and connect other tissues, prevent abnormal or excessive motion
Viscosity
the resistance of a substance during loading; required to achieve “plasticity”
Plasticity
The deformation of the tissue after load is applied
Elasticity
Temporary elongation of tissues (precursor to plasticity)
Stress-strain curve
You want to achieve the right amount of strain and stress to reach the plastic region where permanent changes will occur.
Ultimate strain and ultimate stress will lead to failure point which may lead to ruptures or inflammation/pain in the body
Too little stress/strain will only reach the elastic region where only temporary change will occur.
When does optimal deformation (changes) occur?
When there is an application of low-load prolonged stress over a long period of time
The longer a joint is positioned at its end range, the greater ___
The gain in PROM
What are the optimal gains in ROM per week?
3 degrees a week (range from 1-10)
Temperature benefits for changing muscle length
heating→load→deformation
cooling→load maintained→enhances deformation
Low temperature thermoplastics properties
- type of orthotic material
- plastic is malleable for molding at a low temp
- most commonly used now
High temperature thermoplastics properties
- temp is too high to be molded directly on skin, may require liner
- less commonly used
- often found a pre-fabricated orthotics
Neoprene properties
- type of orthotic material
- light/supportive, allows some movement
- used when rigidity is not tolerated or excessive padding is required
Leather properties for orthotics
- requires plaster molds
- time consuming
- durable
Plaster properties for orthotics
- used for serial static purposes
- often with neurological issues
- messy
- extensive pad
Thermoplastic property: resistance to stretch
- amount that a material resists pulling or stretching
- Max resistance: more control of the material, holds its shape and thickness while warm, can tolerate more aggressive handling
- Min resistance: more likely to become thin and lose its shape during the molding process, requires delicate handling, conforms to the shape of the bony part with less handling
Thermoplastic property: Conformability or drape
- works with gravity
- material will easily conform to body part with minimal handling
Thermoplastic property: Memory
- ability of the material to return to its original shape with re-heating
- high memory: good for less experienced, more forgiving, inherent strength of material maintained
- low memory: modifications are more difficult, more thinning of material, less strength with each re-heating
Thermoplastic property: Rigidity vs. flexibilty
-amount of resistance a cold material has when force is applied to it
high rigidity: very resistive to forces, not easily broken
high flexibility: bends easily, but may break over time, usually minimum resistance to stretch, often more comfortable, thinner materials
*perforations impact rigidity
Edge finishing
-smooth or rounding to remove sharp edges/improve cosmesis (the look)
Self-sealing edges
a material’s ability to seal its edges as it is cut when warm
Solid vs. Perforated orthotic material
solid: maximum support
perforated: for ventilation, added comfort
What is the temperature you should heat most thermoplastics at?
150-160 degrees F
What are the purpose of smooth edges on a splint?
To prevent pressure points
Orthosis used for remediation vs. compensation
remediation: allows patient to restore ROM, strength, endurance
Compensation: allows patient to return to function despite limitations. it can substitute for motor loss or lack of stability
Considerations for patient adherence
- incorporate patient’s preferences in design
- educate family members about orthosis
- educate patient on benefits
- educate about wear, care & hygiene
- make sure orthosis is good fit and is comfortable
- incorporate aesthetics
- offer options when possible
- create orthosis for easy put on and take off
- collaborate with patient on wearing schedule
Principles of splinting: Mechanical principles
-increase the total area of force application to reduce/disperse pressure and increase comfort
wider, longer splints are more comfortable
- rounded internal corners increase splint durability by decreasing the effects of force on the thermoplastic
- smooth edges distribute forces, strengthening the material
- Ensure at least 3 points of fixation. middle force frequently placed over a joint, proximal and distal force straps are typically at proximal and distal edges of splint
- provide contour to increase thermoplastic material strength
Principles of splinting: Biomechanical principles
- eliminate friction (friction usually indicates poor fit, improper joint alignment, or inefficient fastening devices).
- consider ligamentous stress (unequal forces on a joint can cause damage). Awareness of the desired alignment is critical (always aim for 90 degree pull)
Principles of splinting: Anatomical principles
- accommodate bony prominences (soft tissue is at a minimum ->vulnerable to skin breakdown)
- creases of the hand provide landmarks for splint fabrication
- Ensure distal and proximal ends of splint allow desired freedom of movement by using the skin creases as a guide e.g. ½-1 cm proximal or distal to the crease with a corresponding underlying joint in the wrist and hands
- Arches: clinically important since they combine stability and flexibility to adapt to various shapes during grasp
-functional position of hand:
•Ideal for all wrist/hand joints
–Wrist ~20 ext; MCP’s ~ 60 flex; IPs 10 flex; thumb ~mid-opp
Normal biomechanics of digit flexion result in convergence toward what bone
scaphoid bone
Dual obliquity in hand
•Two oblique angles can be seen through the hand
Metacarpal length: shorter on the ulnar side than the radial (dorsal view–look down onto the top of your hand)
Distal transverse arch formed by the higher mobility of the ulnar metacarpals (D4/D5) vs. the relative immobility of the D2/D3 metacarpals (fist to the mouth view) creates another angle we need to incorporate into a splint
**Implications for splints involving the 2nd-5th metacarpals
Dynamic splint components
- base splint
- outrigger attachments
- cuff with tension
- line guides (creates the angle of pull 90)
- fixation for tension
outrigger attachments:
- tension for dynamic splint (rubber bands, coil springs, etc.)
- attachments for tension (velcro tabs, hooks, knobs, etc)
Splints that use articulations or hinges must have exact alignment with ___
-Anatomical joints
What happens if there is poor alignment of splint axis and anatomical axis?
-risk of ineffective attempts to improve mobility, limitations of mobility and/or shear forces (skin breakdown, damage to structures involved)
Rotational and translational components of force in dynamic splints
Rotational force: optimally achieved by a 90 degree rotational angle of pull
Translational force: as the angle of pull moves away from 90 degrees greater translational forces are exerted as compression or distraction
Torque
= the amount of force x the length of the lever on which it acts (T= FxFA)
-As the distance between the joint axis and the point of attachment of the dynamic assist increases, the amount of torque on the joint increases
Functional capacity evaluations
-meant to measure a person’s ability/capacity to perform tasks; primarily work related.
Compares a person’s health status, body functions and body structures with demands of a job
-most helpful at the end of remediation (e.g. if questionable ability to RTW)
Ergonomics help to:
- reduce muscle fatigue and injury risk
- simplify work and energy conservation interventions
Job Analysis
a systematic procedure to quantify and evaluate the physical, cognitive, social, environmental and psychological requirements of the essential and non-essential tasks of a job
- observe workers performing tasks
- measure equipment and equipment placement
- interview those who perform the job and their supervisors
Job (site) analysis vs. Job Demands Analysis
Job site analysis:
- often tailored to an individual’s needs,
- knowledge of their capacities/abilities vs limitations/restrictions
- some aspects of job targeted in evaluation due to specific challenges identified by worker
Job Demands analysis:
- often based on what the requirements are of a job
- how much lifting/carrying
- frequency of tasks
- executive functions that are critical
- work pace
Physical Demand Characteristics of Work
Limited- work activities involved handling loads up to 11 lbs
Light- between 11 and 22 lbs
medium- between 22-44 lbs
heavy- more than 44 lbs
Frequency of Demand Characteristics of Work
minimal: 0-1 hour
occasional: 1-2.5 hours
frequent: 2.5-5.5 hours
continuous: > 5.5 hours
Work simplification & energy conservation
- interventions used when occupation is too demanding. includes:
- limited amount of work
- sitting at work
- using efficient methods
- using correct equipment and techniques
- balancing physical tasks with rest break
Work Conditioning
Typically follows or is concurrent with acute care
- generally 1-2 hours
- focuses on remediation of physical or cognitive abilities
- focused on functional requirements of job or employment setting
- preceded work hardening
- provides realistic feedback regarding client’s capabilities
Work Hardening
- not always necessary
- inter-professional treatment program designed to maximize client’s ability to return to employment
- uses work simulation, generally building up to typical hours of regular work
- considers performance in the following:
- productivity
- safety
- physical tolerance for tasks
- cognitive functioning
METs
Metabolic equivalents- units of measure to describe the amount of O2 the body needs for a given activity. The higher the MET the more demanding the activity
Personal barriers to RTW
- high level of perceived disability
- psychological/physical/cognitive functional limitations
- substance use issues
- lack of motivation to RTW
- medication issues
- pain
Social/Cultural Environment barriers to RTW
- limited social supports
- social stressors
- cultural beliefs
- pending medical investigations or procedures
Vocational barriers to RTW
- no job attachment
- limited gradual RTW options
- limited transferable skills
- workplace issues
Physical environment barriers to RTW
- accessibility issues
- ergonomic issues
Key elements for best practice in transitional RTW for OTs
- communication between individuals involved (Especially availability of modified/alternate work)
- determine readiness for RTW
- develop RTW plans (transitional duties? hours?)
- initiate RTW
- monitor RTW
- Evaluate outcomes
Denial -> Anger -> Depression -> Dissappointment -> Acceptance
Anger: patient expels pent up energy and avoid initial depression
Depression: patients exhausted from rehab efforts, social supports, and caregivers are emotionally depleted and potentially not as supportive.
Disappointment: lack of swift progress is experienced by patient and echoed by significant others, no “quick fix”, impact of health care systems processes
Acceptance: coming to terms with limitations, willing to use strengths to accomplish meaningful goals and roles
Interventions for role loss
- plans for future require reorganization
- life satisfaction and dignity are recognized as valuable measures of rehabilitation
Most frequently experienced psychological result of stroke:
Depression
Questions therapists ask patients about substance use
- is patient functioning in work or school? maintaining relationships?
- and family members likely helpful to describe patient’s hx?
- any evidence that substance abuse was a primary cause of condition
- any predisposing factors?
Evaluations/Interventions for substance use
Motivational strategies: used to identify patient’s stage of change and then foster their motivation to change
Motivational interviewing: client-centered strategy that increases intrinsic motivation using non confrontational communication that reflects empathy. An effective strategy for client’s who verbalize resistance to change
