Musculoskeletal Disroders

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Musculoskeletal Disroders
2015-07-23 22:04:54
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  1. intrinsic muscles innervated by the median nerve
    • abductor pollicis brevis (palmar abduction)
    • opponens pollicis (opposition)
    • flexor pollicis brevis- superficial head (thumb MCP flexion)
    • lumbricals -radial side (MCP flexion and extension of IP joints)
  2. intrinsic muscles innervated by the median nerve
    • abductor digiti minimi (abduction of the 5th digit)
    • opponens digiti minimi (opposition of 5th digit)
    • flexor digiti minimi (flection of MCP joint and opposition of the 5th digit)
    • adductor (adducts CMC joint of the thumb)
    • lumbricals -ulnar side (MCP flexion and extension of the IP joints digits II-V)
    • Palmar interossei (adduction and assistance with MCP flexion and IP extension
    • Dorsal interossei (abduction and assistance with MCP flexion and IP extension)
  3. Extrinisic muscles inntervated by the median nerve
    • flexor digitorum superficialis (flexion of PIP joints)
    • flexor digitorum brevis profundus (flexion of DIP joints in digits II and III)
    • Flexor pollicis longus (flexion of the IP joint of the thumb)
  4. Extrinsic muscles of the hand innervated by the ulnar nerve
    flexor digitorum profundus (flexion of the DIP joints IV and V)
  5. Extrinsic muscles of the hand innervated by the radial nerve
    • Extensor digitorum communis (extension of the MCP joints and contributes to extension of the IP joints)
    • Extensor digiti minimi (Extension of the 5th digit and and contributes to extension of the IP joints)
    • Extensor Indicis proprius (extension of MCP joint of the 2nd digit and contributes to IP extension)
    • Extensor pollicis longus (extension of MCP and CMC joints of the thumb)
    • abductor pollicis brevis (abduction and extension of the CMC joint)
  6. wrist flexors innervated by the median nerve
    • Flexor carpi radialis (flexion of wrist and radial deviation)
    • Palmaris longus (flexion of the wrist)
  7. Wrist flexors innervated by ulnar nerve
    flexor carpi ulnaris (flexion of the wrist and ulnar deviation)
  8. wrist extensors innervated by the radial nerve
    • Extensor carpi radialis brevis (extension of the wrist and radial deviation)
    • extensor carpi radialis longus (extension of wrist and radial deviation)
    • extensor carpi ulnaris (extension of wrist and ulnar deviation)
  9. Volar forearm muscles innervated by the median nerve
    • pronator teres (forearm pronation)
    • pronator quadratus (forearm pronation)
  10. Doral forearm muscles innervated by the radial nerve
    supinator (forearm supination)
  11. Elbow flexion
    • biceps (elbow flexion with forearm supinated) innervated by musculocutaneous nerve
    • Brachilis (elbow flexion with forearm pronated) innervated by musculocutaneous nerve
    • brachioradialis (elbow flexion with forearm neutral) innervated by radial nerve
  12. Elbow extension innervated by radial nerve
    • triceps (elbow extension)
    • anconeus (elbow extension)
  13. Rotator Cuff Muscles
    • SITS
    • Supraspinatus- (abduction and flexion) innervated by suprascapular nerve
    • Infraspinatus (external rotation) innerveated by suprascapular nerve
    • Teres Minor (external rotation) innervated by the axillary nerve
    • Subscapularis (internal rotation) innervated by subscaular nerve
  14. shoulder flexion
    • Anterior deltoid innervated by axillary nerve
    • coracobrachialis innervated my musclocutaneous nerve
    • supraspinatus innervated by suprascapular nerve
  15. Shoulder abduction
    • Middle deltoid innervated by axillary nerve
    • supraspinatus innervated by suprascapular nerve
  16. Horizontal abduction
    Posterior deltoid innervated by axillary nerve
  17. Horizontal adduction
    Pectoralis major innervated by lateral pectoral nerve
  18. Shoulder extension
    • Latissimus doris innervated by thoracodorsal nerver
    • Teres major innervated by subscapular nerve
    • posterior deltoid innervated by axillary nerve
  19. Upward rotation of the scapula
    • trapezius (upper, middle, lower) innervated by spinal accessory nerve CNXI
    • Serratus anterior innervated by the long theracic nerve
  20. Scapula downward rotation
    • levator scapulae innervated by C3-C4 nerves
    • Rhomboids (major and minor) innervated by the dorsal scapular nerve
    • Serratus anterior
    • latissimus dorsi
  21. Scapula adduction
    • middle trapezius
    • rhomboid major
  22. scapular abduction
    serratus anterior
  23. scapular elevation
    • trapezius (upper)
    • levator scapulae
  24. scapular depression
    trapezius (lower)
  25. Refer to dermatome and myotome charts
  26. Dupuytrens Disease
    • disease of the fascia of the palm and digits
    • the fascia becomes thick and contracted and develops cords and bands that extend into the digits
    • results in flexion deformities of the involved digits
    • the etiology is unknown
    • conservative treatment has not been successful and surgical release is required
    • OT intervention can include wound care (dressing changes), edema control (elevation above the heart) extension splint (initially at all times except to remove for ROM and bathing), A/PROM and progress to strengthening when wounds heal, scar management (massage, scar pad, compression garment), purposeful and occupation-based tasks that emphasize flexion and extension
  27. Skier's Thumb (Gamekeepers thumb)
    • rupture of the ulnar collateral ligament of the MCP joint of the thumb
    • Etiology: most common cause is a fall while skiing with the thumb held in a ski pole
    • OT intervention includes conservative treatment including a thumb splint (4-6 weeks), AROM and pinch strengthening (at 6 weeks), focus on ADL that require opposition and pinch strength, Post-op treatment includes splint for 6 weeks followed by AROM, PROM can begin at 8 weeks and strengthening at 10 weeks
  28. Complex Regional Pain Syndrome (CRPS)
    • Type I formerly known as reflex sympathethic dystrophy
    • Type II formerly known as causalgia
    • Vasomotor dysfunction as a result of an abnormal reflex
    • can be localized to one specific are or spread to other parts of the extremity
    • Etiology: may follow trauma (e.g. Colles fracture) or surgery, but actual cause in unknown
    • Symptoms: severe pain, edema, discoloration, osteoporosis, sudomotor changes, temperature changes, trophic changes and vasomotor instability
    • OT intervention can include modalities to decrease pain, edema management (elevation, manual edema management, compression glove,) AROM of involved joints, ADL to encourage pain-free active uses, stress loading (weight bearing and joint distraction activities including scrub and carry activities), splinting to prevent contractures and enable ability to engage in occupation based activities, encourage self management, interventions to avoid or to proceed with caution include PROM, joint mobilization, dynamic splinting and casting)
  29. Types of fractures
    • intraarticular (fractures that involve a joint space) vs. extraarticular (fracture that does not extend into the joint)
    • closed (broken bone does not break the skin) vs open (broken bone breaks the skin)
    • dorsal displacement vs volar displacement
    • midshaft vs neck versus base
    • complete vs incomplete
    • transvers vs spiral vs olique
    • comminuted (shattered)
  30. Medical treatment
    • Closed reduction: Short arm cast, long arm cast, splint, sling, or fraction brace
    • Open Reduction Internal Fixation (ORIF): types include nails, screws, plates, or wire
    • Eternal fixation
    • Arthrodesis: fusion
    • Arthroplasty: joint replacement
  31. Most common UE fractures
    • Colles' fracture: fracture of the distal radius with dorsal displacement (wrist extended)
    • Smith's fracture: most common in scaphoid fracture (60% of carpal fractures). Proximal scaphoid has a poor blood supply and can become necrotic (flexed wrist-inward)
    • Metacarpal fractures: classified according to head, neck, shaft or base); common complication is rotational deformities; Boxer's fracture is a fracture of the 5th metacarpal and requires an ulnar gutter splint
    • Proximal phalanx fractures: most common with thumb and index finger; complication is loss of PIP A/PROM
    • Middle Phalanx fracture: not commonly fractured
    • Distal phalanx fracture: most common finger fracture; may result in mallet finger
    • Elbow fracture: involvement of the radial head may result in limited ROM of the forearm
    • Humerus fractures: nondisplaced vs displaced; Etiology: FOOSH (fall onto outstreched hand); fractures of the greater tuberosity may result in rotator cuff injuries; humeral shaft fractures may cause injury to the radial nerve resulting in wrist drop
  32. OT evaluation for fractures
    • history should include mechanism of injury and fracture management, results of special tests, edema, pain, AROM, sensation, roles, occupations, ADL and activities related to roles
    • Do not assess PROM or stength until ordered by physician (exceptions include humerus fractures which being with PROM or AAROM
  33. OT intervention for fractures
    • Immobilization phase: stablization and healing are the goals; AROM of the joints above and below the stablized part; Edema control (elevation, retrograde massage, compression); Light ADL and role activities with no resistance, progress as tolerated
    • Mobilization phase: consolidation is the goal; Edema control, AROM (progress to PROM when approved by physician (4-8 weeks); light purposeful or occupation based activities; pain management (positioning and physical agent modalities); strengthening (begin with isometrics when approved by physician)
  34. Cumulative Trauma Disorders (CTD)
    • AKA repetitive strain injuries, overuse syndromes, and/or musculoskeletal disorders
    • Risk factors: repetition, static position, awkward postures, forceful exertion, vibration
    • Non-work risk factors: acute trauma, pregnancy, diabetes, arthritis, and wrist size and shape
  35. Most common types of CTDs
    • De Quervains: stenosing tenosynovitis of the abductor pollicis longus and the extensor pollicis brevis; pain and swelling over the radial styloid, positive finkelsteins test
    • Conservative treatment: Thumb spica splint (IP joint free), activity/work modification, ice massage over radial wrist, gentle AROM of wrist and thumb
    • Post operative treatment: Thumb spica splint and gentle AROM (0-2wks); strengthening, ADL, and role activities (2-6 weeks); unrestricted activity (6 wks)
    • Lateral and medial epicondylitis: degeneration of the tendon origin as a result of repetitive microtrauma
    • Lateral epicondylitis (tennis elbow): overuse of wrist extensors (specifically extensor carpi radialis brevis)
    • Medial epicondylitis (golfers elbow): overuse of wrist extensors
    • Conservative treatment: elbow strap, wrist splint, ice and deep friction massage, stretching, activity/work modification; as pain decreases add strengthening (begin with isometric and then progress to isotonic and eccentric exercises)
    • Trigger finger: tenosynovitis of the finger flexors; most commonly is the A1 pulley
    • Caused by repetition and the use of tools that are placed too far apart
    • Conservative treatment: hand based trigger finger splint, scar massage, edema control, tendon gliding, activity/work modification (avoid repetitive gripping and using tools with handle too far apart)
    • Nerve compressions
  36. Tendon repairs
    • Rationale for early mobilization (prevents adhesion formation, facilitates wound/tendon healing)
    • OT goals: increase tendon excursion, improve strength at repair site, increase joint ROM, prevent adhesions, facilitate resumption of meaningful roles
  37. Early mobilization programs for flexor tendons
    • Kleinert: passive flexion using rubber band traction and active extension to the hood of the splint
    • Protocol:
    • 0-4 weeks Early phase- wrist 20-30 degrees flexion, MCP joints in 50-60 degrees flexion and IP joints extended; passive flexion and active extension within limits of splint
    • 4-7 weeks Intermediate phase continue dorsal block splint, adjust wrist to neutral. place/hold exercises and tendon gliding exercises
    • 6-8 weeks AROM, D/c splint
    • 8-12 weeks strengthening and work and leisure activities
    • DURAN: passive flexion and extension of the digit
    • 0-4.5 weeks dorsal blocking splint, exericses in splint including passive flexion of PIP, DIP and DPC, 10 reps every hour
    • 4.5-6 weeks active flexion and extension within limits of splint
    • 6-8 weeks tendon gliding and differential tendon gliding, scar management and light purposeful and occupation-based activities
    • 8-12 weeks strengthening and work activities
  38. 7 zones for tendon injuries
    • higher the zone, the longer the recovery and higher risk for permanent damage
    • Zones V, VI and VII need splints and AROM
  39. Carpal Tunnel Syndrome
    • compression of the median nerve
    • etiology: repetition, awkward postures, vibration, anatomical anomalies, and pregnancy
    • Symptoms: numbness and tingling of the thumb, index, middle, and radial half of the ring finger; parasthesias usually ocur at night, person will complain of dropping things, Positive Tinels sign at wrist, Positive Phalen's sign, advanced stage of CTS can result in atrophy of the Thenar eminance
    • Conservative treatment:
    • wrist splint in neutral-should be worn at night and during the day if performing repetitive activity; median nerve gliding exercises and differential gliding exercises; activity modification (avoid activities with extreme positions of wrist flexion, wrist flexion with repetitive finger flexion, and wrist flexion with a static grip; egonomics (appropriate workstation design- CTS is the most common work related injury of the UE)
    • Post-operative treatment of CTS: Edema control, AROM, nerve and tendon gliding, sensory reeducation, strengthening of the thenar muscles (usually 6 weeks post op), work/activity modification
  40. Pronator Teres Syndrome (proximal volar forearm)
    • median nerve compression between the two heads of the pronator teres
    • etiology: repetitive pronation and supination and excessive pressure on the volar forearm
    • Symptoms: same as CTS and also aching pain in the proximal forearm; positive tine;'s sin at the forearm, no night symptoms
    • Conservative treatment: elbow splint at 90 degrees with forearm in neutral; avoid activities hat include repetitive forearm pronation and supination
    • Surgical intervention: decompression
    • Post operative treatment: AROM, Nerve gliding, strengthening (2 weeks post op), sensory reeducation, work/activity modification
  41. Guyons canal
    • Ulnar nerve compression at the wrist
    • Etiology: repetition, ganglion, pressure and fascia thickening
    • Symptoms: numbness and tingling in the ulnar nerve distribution of the hand; motor weakness of ulnar nerve-innervated musculature; positive Tinel's sign at Guyon's canal; advanced stages can lead to atrophy of ulnar nerve-innervated musculature in the hand
    • Conservative treatment: Wrist splint in neutral, work/activity modification
    • Surgical treatment: decompression
    • Post-operative intervention: Edema control, AROM, Nerve gliding, Strengthening (2-4 weeks) focusing on power grip, sensory reeducation
  42. Cubital tunnel syndrome
    • compression of the ulnar nerve at the elbow
    • Etiology: second most common compression pressure at the elbow (leaning on the elbow) and extreme elbow flexion
    • Symptoms: numbness and tingling along ulnar aspect of forearm and hand, pain at elbow with extreme position of elbow flexion, weakness of power grip, Positive Tinel's sign at elbow, advanced stages can lead to atrophy of the FCU, FDP to digits IV and V and ulnar nerve-innervated muscles
    • Conservative treatment: elbow splint to prevent positions of extreme flexion (especially at night), elbow pad to decrease compression of nerve when leaning on elbows, activity/work modification
    • Surgical intervention: decompression
    • Post-op treatment: Edema control, scar manageme, AROM and nerve gliding (2 weeks post), strengthening (4 weeks post), MCP flexion splint if clawing noted
  43. Radial nerve palsy
    • radial nerve compression
    • Etiology: saturday night palsy; sleeping in a position that places stress on the radial nerve; compression as a result of humeral shaft fracture
    • symptoms: weakness or paralysis of extensors to the wrist, MCPs and thumb; wrist drop
    • Conservative treatment: dynamic extension splint; work/activity modification, strengthening wrist and finger extensors when motor function returns
    • Surgical intervention: decompression
    • Post-op treatment: ROM, nerve gliding, strengthening (6-8 weeks), ADL and meaningful role activities
    • DEFORMITY: flattening of thenar eminance (ape hand), clawing of index and middle fingers for a low lesion, benediction sign for a high lesion
    • Loss of thumb opposition, weakness of pinch
    • Dorsal protection splint with wrist positioned in 30 degrees flexioni a low lesion, include elbow 90 degrees flexion if a high lesion; begin A/PROM of digits with wrist in flexed position at two weeks post op; scar management, AROM of wrist 4 weeks; strengthening starts at 9 weeks
    • SPLINT CONSIDERATION: C Bar to prevent thumb adduction contracture
    • Sesnroy reeducation: begin when idividual demonstrates a level of diminished protective sensations on Semmes-Weistein
  44. Median nerve laceration
    • sensory loss:
    • Central palm (thumb to radial half of ring finger)
    • palmar surfacce of thumb, index, midle and radial 1/2 of ring finger
    • dorsal surface of index, middle and radial 1/2 of ring fingers (middle and distal phalanges)
    • MOTOR LOSS for a low lesion at wrist
    • lumbricals I and II (MCP Flexion of digits II and III)
    • opponens pollicis (opposition)
    • abductor pollicis brevis (abduction)
    • flexor pollicis brevis (flexion of thumb MCP)
    • MOTOR LOSS FOR HIGH LESION at or proximal to the elbow
    • All above
    • FDP to index and middle fingers and FDL
    • FCR (inablity to flex to radial aspect of wrist)
  45. Ulnar nerve laceration
    • Sensory loss:
    • Ulnar aspects of the palmar and dorsal surfaces, ulnar 1/2 of ring finger and little fingers on palmar and dorsal surfaces
    • Motor loss:
    • palmar and dorsal interossei (adduction and abduction of the MCP joints)
    • lumbricals III and IV (MCP flexion of digits IV and V
    • Flexor pollicis brevis and adductor pollicis (flexion and adduction of the thumb)
    • ADM, ODM, FDM (abduction, opposition, and flexion of the fifth digit)
    • Same as above and Flexor carpi ulnaris (flexion toward ulnar wrist)
    • Flexor digitorum profundus IV and V (flexion of the DIPs of ring and pinky)
    • Claw hand, flattened metacarpal arch, positive Froment's sign (assessment of thumb adductor while laterally pinching paper)
    • loss of power grip, decreased pinch strength
    • same as median nerve repair
    • MCP flexion block splint
    • SENSORY REEDUCATION: same as median nerve
  46. Radial Nerve Laceration
    • high lesions at the level of the humerus
    • medial aspect of dorsal forearm; radial aspect of dorsal palm, thumb, and index, middle and radial 1/2 of ring phalanges
    • MOTOR LOSS low lesion at the level of the forearm
    • loss of wrist extension due to abset of impaired innervation to ECU; MCP extension; EPB, EPL, APL (thumb extension)
    • MOTOR LOSS high lesion at the level of the humerus
    • All of the above, and ECRB, ECRL, and brachioradialis; if level of axilla, loss of triceps (elbow extension)
    • inability to extend digits to release objects, difficulty manipulating objects
    • Wrist drop
    • Dynamic extension splint, ROM, Sensory reeducation (if needed), instruct HEP, activity modification
  47. Rotator Cuff Anatomy
    • SITS
    • Supraspinatus- shoulder flexion and abduction
    • Infraspinatus - external rotation
    • Teres minor- external rotation
    • subscapularis- internal rotation

    Rotator cuff functions together to control the head of the humerus in the glenoid fossa

    site of impingement (acromion, coracoacromial ligament, and coracoid process)
  48. Rotator Cuff Tendonitis
    • Etiology: repetitive use, curved or hook acromion, weakness of rotator cuff, weakness of scapula musculature, ligament and capsule tightness, trauma
    • Conservative treatment: activity modification (avoid above level shoulder activities until pain subsides); educate in sleeping posture (avoid sleeping with arm above head or combined adduction and IR; decrease pain (positioning, modalities, and rest); restore pain free ROM; strengthening (below shoulder level); occupation and role specific training
    • Surgical interventions: Arthroscopic surgery; open repair (small, medium, large and massive tears)
    • PROM (0-6 weeks) Progress to AA/AROM; decrease pain (begin with ice progress to heat); strengthening (6 weeks post op) begin with isometric (muscle contracts but does not shorten), progress to isotonic (muslce contracts and shortens) below shoulder level; activity modification; lesiure and work activities (8-12 weeks post op)
  49. Adhesive Capsilitus
    • AKA Frozen Shoulder
    • Restricted passive should ROM
    • greatest limitation is ER, then abduction, IR, and flexion
    • Anatomy: glenohumeral ligaments and joint capsule
    • Etioloy: inflammation and immobilitiy; linked to diabetes mellitus and Parkinson's disease
    • OT intervention:
    • Encourage active use through ADL and role activities; PROM; Modalities
    • Surgical interventions: manipulation and arthroscopic surgery
    • OT Post Op:
    • PROM following surgery
    • Pain relief (modalities)
    • Encourage use of UE for all ADL and role activities
  50. Shoulder dislocations
    • anterior dislocation is the most common
    • Etiology: trauma, repetitive overuse
    • OT intervention
    • regain ROM, avoid combined abduction and external rotation with anterior dislocation, pain free ADL and role activities, strengthen rotator cuff
  51. Arthritis
    an inflammation of a joint or joints
  52. rheumatoid arthritis
    • systemic, symmetrical, and affects many joints
    • most commonly attacks the small joints of the hands
    • characterized by remissions and exacerbations
    • begins in the acute phase as an inflammatory process of the synnovial lining
    • Etiology: unknown but there are two main theories (infection theory and autoimmune theory)
    • pain, stiffness, limited ROM, fatigue, weight loss, limited ADL status, swelling, deformities
    • ulnar deviation and subluxation of the wrists and MCP joints; boutonniere deformity (flexion of the PIP joint and hyperextension of the DIP joint; swan neck deformity (hyperextension of PIP joint and flexion of DIP joint)
  53. Osteoarthritis (OA)
    • Degenerative joint disease
    • not systemic, but wear and tear
    • commonly affects large weight bearing joints
    • attacks hyaline cartilage
    • ETIOLOGY: genetic, trauma, inflammation, cumulative trauma, endocrine and metabolic diseases
    • Symptoms: pain, stiffness, limited ROM, bone spurs
    • Types of bone spurs: herberdens nodes (DIP joints) bouchard's (PIP)
  54. Occupational Therapy Evaluation for Arthritis
    • ROM- focus on AROM, PROM should be avoided, especially in the inflammatory stage- note deformities and nodules
    • muscle strength (avoid muscle testing unless requested by physician); document strength in relation to function
    • GRip strength: use sphygomomanometer
    • ADL and role activities: note if ADL and role activity deficits are related to pain, limitation in motion, deformity, weakness, or fatigue
    • Pain: use pain scales
    • Edema: Volumeter or tape measure
  55. OT Intervention for Arthritis
    • splinting
    • resting hand splint in the acute phase
    • wrist splint only if arthritis specific to wrist
    • ulnar drift splint to prevent deformity
    • silver ring splints to prevent boutonneire and swan neck deformities
    • hand base thumb splint for CMC arthritis
    • Joint protection techniques; energy conservation; ROM (AROM)- pain free;
    • heat modalities- hot packs can be used before exercise but avoid during the inflammatory stage; parrafin is recommended for the hands
    • Strengthening-avoid during inflammatory stage; gentle strengthening while avoiding positions of deformity; purposeful and occupation based activities; adaptive equipment should be provided to prevent deformity, decrease stress on small joints and extend reach
  56. osteogenesis imperfecta
    • Etiology: disorder caused by the dysfunSnherited from one or both of the parents); in some cases the collagen can begin to malfunction after the child is concieved.
    • Signs and Symptoms:
    • malformed bones- short, small body; triangular face; barrel-shaped rib cage; brittle bones that fracture easily; multiple fractures as the child grows, developmental growth problems
    • loose joints, sclera of the whites of the eyes look blue or pipe, brittle teeth, hearing loss (starting in 20s or 30s), respiratory problems, insuffiecient collagen
    • Classification: eight main types classified by the genes that are involved- type 1 (mild symptoms); types 2, 3, 7, and 8 (severe symptoms); types 4,5,6 (moderate symptoms)
    • OT Evaluation:
    • Activity interests that can be safely performed, environmental risk factors, evalaution for fractures and pain assessment
    • Activity adaptation and AT prescription; environmental adaptations; preventative positioning and protective splinting/padding; activities to increase strength; weightbearing activities to facilitate bone growth; health education to promote a healthy lifestyle; family, caregiver, and teacher education about proper handling, positioning, activity adaptations, environmental modifications, and need to observe all safety precautions
  57. Hip fractures
    • Etiology: trauma, osteoarthritis, pathological fracture (cancer)
    • Types: femoral neck, intertrochanteric, subtrochanteric fractures
    • management: ORIF, Closed reduction, Joint replacement
    • OT EVAL
    • review precautions and weight bearing status; ADL (focus on dressing, bathing, and transfers); ROM and strength of UEs; conduct other assessments as needed
    • OT Intervention
    • bed mobility and bedside ADL; UE strengthening; functional ambulation; instruct and practice use of AT (reacher, shower chair, dressing stick, sock aid, shoe horn; practice occupation based activities
  58. Total hip replacement/arthroplasty
    • Total hip joint implant- replaces acetabulum and femoral head
    • Austin Moore: partial hip replacement; replaces femoral head
    • Same eval as before
    • anterolateral vs posterolateral (more common)
    • precautions for posterolateral:
    • 1. do not flex beyond 90 degrees, 2. do not adduct or cross legs (no IR), 3. do not pivot at hip, 4. sit only on a raised chair and toilet seat, 5. transfer from sit to stand by keeping affected hip in slight abduction and extended out in front
    • precautions for anterolateral:
    • 1. no ER, 2. no hip extension. precautions vary
  59. Amputations
    • etiology: congenital, peripheral vascular disease, trauma, cancer and infection
    • classification:
    • UE level
    • shoulder disarticulation - loss of entire UE
    • Above elbow (AE)
    • Elbow disarticulation- distal to elbow joint
    • below-elbow (BE)- any where below elbow joint
    • Wrist disarticulation- distal to wrist, loss of entire hand
    • finger ampuation- amputation of digit at any level
    • Lower extremity
    • hemipelvectomy- half of the pelvis and entire lower extremity
    • hip disarticulation- amputation at the hip joint
    • above-knee amputation- any level on thigh
    • knee disarticulation- amputation at the knee
    • below-knee (BKA)- any level of the calf
    • complete tarsal - ampuation at the ankle
    • partial tasal- ampuation of metarsals or phalanges
    • complete phalange- amputation of toes
  60. Terminal devices
    • function to grasp and maintain hold on an object
    • to main types are the hook and the hand
    • Voluntary opening- hook remains closed until tension is placed on cable and then it opens
    • voluntary closing- hook remains opened until tension is placed on cable and then it closes
    • cosmetic device- minimal function
    • determination of the appropriate TD is based upon the persons interests, roles and preferences, TDs can be interchangable
  61. Complications with TDs
    • neuromas- nerve endings adhered to scar tissue
    • skin breakdown
    • phantom limb syndrome
    • phantom limb pain
    • infection
    • knee flexion contractures in transtibial amputation
    • psychological impairments due to shock/grief
  62. treatment
    • ROM
    • preparing limb (wrapping to shape, desensitization)
    • donnin and doffing prosthetic,
    • trensfer training, ADL training, UE strengthening ( for LE amputation), psychological support
  63. Burns classification
    Superficial- first degree, involves epidermis only, minimal pain and edema, no blisters, healing time is 3-7 days

    Superficial partial thickness burns- second degree, involves epidermis and upper portion of dermis (i.e. sunburn), appears red, blistering and wet; painful no grafting, heals on its own, healing time 7-21 days

    Deep Partial Thickness burns - deep second degree (involves epidermis, and deep portion of dermis, hair follicles and sweat glands, appears red, white, and elastic; sensation may be impaired; infection could convert it to full thickness burn; healing time 21-35 days

    full thickness burn- third degree, involves epidermis and dermis: hair follicles, sweat glands, and nerve endings; appears white, waxy, leathery, and non-elastic; sensation is absent; requires graft; hypertrophic scar; healing can take months

    fourth degree burn:  involves, fat, muscles and bone; elctircal burn-destruction of nerve along pathway

    Rule of nines is a method of assessing burn wound size- 9% head, 9% each arm, 36% trunk, 1 % peri area, 18% each LE
  64. OT burn eval and interventions
    • superfical partial thickness burns
    • Occupational profile; ROM 72 hours post-op; sensation when wounds are healed; strength when wounds are healed; ADL and meaningful role activities
    • intervention- wound debridement, gentle AROM and PROM to tolerance, edema control splinting if necessary, ADL
    • DEep partial thickness burns - same as partial thickness and then add strengthening when wounds are healed
    • Full thickness- same interventions; be aware of grafts
  65. Avoid positions of comfort to prevent contractures
  66. hand splints for burns
    position of anti-deformity- slight extension of the wrist with MCP joints flexed and IP joints extended, thumb abducted and extended

    if burns to volar surface of the hand, flexion contractures-- use palmar extension splint, slight wrist extension with MCP joints in neutral/slight extension, IP and thumb the same

    web-space burn- c-splint
  67. hypertropic scar
    • most common with deep second and third degree burns
    • appear 6-8 weeks after wound closure
    • one to two years to matures
    • compression garment should be worn 24 hours daily- applied when wounds are healed.
    • ROM , skin care, ADL, role activities, and patient/family education
  68. pain
    personal sensation of hurt that can significantly affect an individuals quality of life

    Acute- has a recent onset and usually lasts for a short duration

    chronic- pain is of a long duration and can lead to depression
  69. myofascial pain syndrome
    persistent deep aching pains in muscle, non articular in origin; trigger points
  70. fibromyalgia syndrome
    • pain and fatigue
    • widespread pain accompanied by tenderness of muscles and adgacent soft tissues
    • nonarticular rheumatic disease of unknown origin
  71. low back pain
    • most common work related injury
    • lumbar lordosis location
    • etiology- poor posture, repetitive bending, heavy lifting, sleeping with poor posture
    • stmptoms- pain, diffictuly with self-care activities and other role actiities, difficulty sleeping
  72. Assessment of pain
    • location- localized vs diffuse
    • intensity of pain - NRS 0-10 pain, time of day more pain
    • onset and duration- gradual vs sudden
    • description of the pain, sharp throbbing, burning shooting
  73. Intervention
    • pysical agent modalities and massage in prep for functional activities
    • teach proper positioning techniques
    • splint in resting position
    • Gentle ROM
    • teach relaxation exercises
    • correct standing and seating posture
    • modify activities and provide AT
    • provide alternative exercise programs
    • pain management