SM - deviations and solutions Flashcards
what is the most common postural deviation seen and why
posterior pelvic tilt
if any impairment in motor control, pelvic typically slumps into post tilt bc that’s the direction of gravity’s pull in sitting
what overall posture results from a posterior pelvic tilt
- “sacral” sitting
- compensatory L & Tspine kyphosis
- inc cspine lordosis
- relative hip ext/IR
what patients will you see a worse posterior pelvic tilt in (2)
- sig loss of motor control
- lots of spasticity
how can a lack of prox motor control cause to a posterior pelvic tilt deviation
pts need to flex forward to bring COG over BOS to gain enough balance for UE mvmt (ie MWC propulsion in quads)
what are 4 physical causes of a posterior pelvic tilt
- limited strength (ie core)
- loss of ROM - esp tight HS
- prox hypotonia (related to core)
- ext hypertonia
how can extensor hypertonia cause a posterior pelvic tilt deviation
hip ext and ADD contract while thigh is fixed on the seat –> pelvis tilts
what spinal posture is consistent w a posterior pelvic tilt and why is this problematic
flexion (not ext)
pt uses ext at lumbar & tspine and hyper-ext of cspine to right their head/eyes in midline vertical
what are 3 equipment causes of a posterior pelvic tilt deviation
- seat depth too long
- seat belt on or above ASIS
- sling seat and back
squeeze vs dump
squeeze = back angle to seat to seat to squeeze pt
dump = angle of seat, interacts w gravity
flexible posterior pelvic tilt intervention
3 point pressure system:
* seat
* back
* ant strap below ASIS’s, shelf, or “squeeze”
additional pelvic support prn
firm, contoured back support
lumbo-sacral corset
fixed posterior pelvic tilt interventions
accommodate - open seat/back angle
correct/accommodate secondary deformity
* tilt back seat/back to inc trunk ext
* have to tilt further back if more severe, but sacrifice some of tilt for function so they can still propel
**maximize function **- compromise seated position as needed to mainatin or inc function
what is a pelvic rotation deviation
forward rotation of pelvis on one side
what are 3 physical causes of a pelvic rotation deviation
- lumbar scoliosis w rotational component
- LBP
- abnormal/asymmetrical tone
what are 2 equipment causes of a pelvic rotation deviation
- seat depth fitted to longer thigh in pt w thigh length discrepancy (shorter leg shifts forward)
- improper seat height for pt w hemiplegia -> rotates to functionally lengthen stronger LE for propulsion
what risks are associated with a pelvic rotation deviation
integ - skin breakdown
* inc pressure at IT and greater troch
MSK - progressive deformity and pain
flexible pelvic rotation interventions
3 point pressure correction
* seat
* back
* ant strap below ASIS, pelvic shelf, or “squeeze”
properlly fitting wc
* seat depth
* seat height
fixed pelvic rotation interventions
accommodate: asymmetrical seat depth to maximize support under “long side”
* split seat for full support under both long and short side
correct or accommodate secondary deformity
* medial thigh pad to block hip ADD
* lateral hip pads to block ABD
* if lot of tone, can use thigh pads to block tone from pulling pt forward
what is the second most common pelvic deviation
pelvic obliquity
what is a pelvic obliquity deviation
asymmetrical height of pelvic crests
what is the resulting posture of a pelvic obliquity with the R side lower
compensatory scoliosis
* R thoraco-lumbar “C” curve
* inc pressure at R IT and R greater troch
asymmetric position of LEs
* one side - hip flex, IR, ADD
* opposite side (R) - hip ext, ER, ABD
flexible pelvic obliquity interventions
3-point pressure for correction
- seat (firm/cushioned)
- back (firm/cushioned)
- ant strap below ASIS, shelf, squeeze
may build up under low side to neutralize (but check skin often!)
what determines the type of intervention in a fixed pelvic obliquity
position of head and upper trunk (midline or listing to lower side?)
fixed pelvic obliquity interventions if the head and upper turnk are listing to the lower side
- build up under high side to meet & support
- use accommodative materials to prevent breakdown
fixed pelvic obliquity interventions if head and upper trunk are near midline
- “build up” under high side to equalize Wbing
- protect soft tissues under IT on low side
- support thighs prn
- support spine prn
what are hip/thigh positioning strategies for maintaining optimal pelvic alignment
- adjust seat to back angle
- correct, block, or accommodate undesired hip positions
- seat cutouts/contours
hip and thigh positioning impacts what alignment
pelvic
knee positioning impacts what alignment
pelvic
thigh/hip
what do you use to determine the optimal position of the LE if the pelvis is properly positioned
HS length (it dictates the hanger angle)
why don’t we want to place HS on stretch when in position in wc
- not comfy
- won’t want to use wc
- pulls into posterior tilt
what support is needed for upper body positioning if pt has good trunk control w no asymmetries
chair height can be low, but at least tall enough to catch PSIS
need to have something that catches PSIS
what support is needed for upper body positioning if pt has fair trunk control w no asymmetries
chair height little higher - thoracic level support
* lower than inferior border of scap (esp if propelling)
* can have some contour
what support is needed for upper body positioning if pt has poor trunk control w no asymmetries
person not propelling or in PWC, full chair height
consider tilt - manual, power, static
lateral trunk supports
who is static tilt appropriate for and how does it work
people who can kinda shift their weight but over time need help, as they propel gravity helps them keep their pelvis in good position
how does lateral chair supports change between fixed and flexible scoliosis
in flexible - aren’t symmetrical, correcting off center
fixed - looking to hold pt there
what support is needed for flexible scoliosis
3 point pressure system:
* lateral: apex of C curve
* lateral: as high as 1/2’’ below axilla
* lap belt/pelvic pad
what is a consideration with lateral supports seen in the pressure system used in scoliosis
can get into axilla, but be careful of brachial plexus injury
what support is needed for fixed scoliosis
- 3 point system to prevent progression
- total contact if severe for skin protection
- consider spinal orthosis
- custom contour seating (foam in place, spinal orthoses) - severe scoliosis w rotational component
what support is needed for flexible kyphosis
- consider tilt for gravity assistance pending trunk control
- chest strap/ant support
- if good trunk control firm back at apex kyphosis
what support is needed for fixed kyphosis
- custom contoured back
- tilt or recline to accommodate and keep eyes in horizontal
what are functions of UE supports and what aren’t and what is a con
functions:
* prevent subluxation at shoulder
* assist w wt shifts
not a function: upper body support
con: impede access to wheels
when is a head rest indicated
- insufficient strength and endurance to hold head in neutral
- always when tilt/recline used
who reviews LMNs and why is this relevant to us
- don’t have background in DME prescription
- part of job is to keep outfloo of funds under control and save money
- following policy manual
- doesn’t know you or your pt
changes how we write the LMN so that we can maximize the coverage we get
what should be the general appearance of a LMN
- appropriate letterhead white paper
- date and signed
- neat and proofread
* impress upon reader it was written by professional who’s opinion should be valued
what are 5 key principes to writing LMNs
- prioritize info - state objective right off the bat so they know what you want
- stay focused on one issue at a time
- educate reader ab the pt and their needs
- strive for clarity - break into chunks w headings
- limit opinions to area of expertise
what are 6 commonly included/needed categories in a LMN
- med and social hx
- clinical and functional exams
- identified problems
- trials/simulation outcomes - tried this less expensive equipment to show it had to be r/o
- recs
- detailed medical justification of all recommended equipment
