Physical Therapy Fundamentals Week 7- Notes

Center of Mass

• Center of mass is the central point where the gravity of a body or segment is acting on
• It is often called the center of gravity
• In a standing position, the center of gravity is located in the pelvic region, anterior to the S2 vertebra
• The center of mass shifts when the body segments change position, weight is added or removed, or both.

Base of Support

• Base of support is the contact area between an object and its supporting surface.
• A wider base of support increases stability because the center of mass is inside the base of support, decreasing stress on the clinician.
• A smaller base of support decreases stability because the center of mass is outside the base of support, increasing stress on the clinician.

Posture

• A plumb line is an imaginary line that represents the alignment of the body in an upright position
• Lateral view landmarks include:
  • External auditory meatus
  • Acromioclavicular joint
  • Mid-way through the trunk
  • Greater trochanter
  • Fibular head
  • Anterior to lateral malleoli

Stability and Mobility

• Stability refers to how well something stays put.
• Mobility refers to how easily something can move or be moved.
• Both stability & mobility are related to:
  • The center of mass of the object or system
  • The base of support of the clinician or patient

Promoting Stability and Mobility

• To promote stability:
  • Create a larger base of support
  • Make sure the line of gravity is acting on the object’s center of mass at or near the center of the base of support
  • Shorten the distance between the center of mass and the base of support and lower the center of mass closer to the base of support
• To promote mobility:
  • Create a smaller base of support
  • Allow the line of gravity to move beyond the center of the base of support.
  • Increase the distance between the center of mass and the base of support.

Body Mechanics

• Body mechanics are the way in which we position and move our bodies during tasks.
• It is a coordinated effort between the musculoskeletal and nervous systems to maintain:
  • Balance
  • Posture
  • Body alignment
• Correct posture and body alignment maintain the normal spinal curves.
• Body mechanics are important for:
  • Sitting
  • Standing
  • Reaching
  • Lifting and pushing

Value of Proper Body Mechanics

• Reduce stress and strain on the body structures.
• Promote efficient and safe movements for both patient and therapist.
• Maintain proper body control and balance.
• Conserve energy.
• Support effective respiratory and cardiopulmonary function.

In Summary:

• Center of mass and base of support are adjusted to promote either stability or mobility during a task.
• Body mechanics include maintaining balance, posture and alignment during tasks.
• Body mechanics are important for lifelong career success

Basics of Lifting Mechanics

Learning Objective

• Identify the key biomechanical principles related to lifting mechanics.
• Demonstrate proper lifting technique using the 5 L’s to lifting principle.

5 L’s to Lifting

• Load: Planning ahead by estimating the total load needed to be moved and clearing the path of travel with the load.
• Lever: Taking into consideration the distance of your center of gravity to the object being moved.
• Lordosis: Keeping proper posture and normal lumbar curvature while lifting.
• Legs: Using legs to lift to help prevent injury during lifting.
• Lungs: Ensuring breathing (exhaling) during lifting. Avoiding Valsalva maneuver while performing physical exertion, which can increase the risk of injury to the back.

Load: Plan Ahead

• Prepare mentally and physically.
• Ensure a safe environment.
• Assess the patient’s safety, including precautions and contraindications.
• Determine whether a team or individual lift is needed.
• Identify the space and equipment needed for the task.
• Communicate with the patient and team regarding the procedure, roles, and expectations.

Lever

• Position yourself close to the load.
• Stay close to the load throughout the lift.
• Keep the center of mass over the base of support for stability.
• This makes the task easier.
• Reduce muscle activity.
• Maintain a wide base of support.
• Stand with feet apart, one foot slightly in front of the other, and toes pointed slightly outward.

Lordosis

• Maintain normal spinal curvature.
• Maintain a slight inward curve of the low back.
• Look ahead instead of downward.
• Keep the chest facing forward.
• Avoid twisting at the trunk, especially when flexed.
• Pivot at the feet or take several small steps to rotate the body.

Legs

• Bend at the hips and knees (squat lift).
• This lowers the body’s center of mass for stability.
• Lift with an upright trunk and normal spinal curvature using the legs.
• Engage trunk muscles before lifting.
• Having a stabilized trunk makes the extremities more effective.
• Push instead of pull - Pushing offers a larger base of support and lower center of mass.
• Pushing utilizes larger muscles.

Legs variation

• Half kneel (tripod position): Begin directly behind the object in half kneeling position. Remain as upright as possible with eyes and chest facing forward. Place the object to rest on your knee. This brings the object closer to the base of support. Push through the forward leg.
• Golfer’s lift: Used for lighter objects. Stand on one leg and flex at the hip to reach forward towards the ground and lifts the back leg off the ground.

Lungs

• Exhale during exertion.
• This prevents the Valsalva maneuver by minimizing intra-abdominal pressure.

No Skipping Leg Day

• Keep your movement equipment in good shape
• Promote strengthening
• Promote flexibility
• Promote aerobic conditioning
• Avoid prolonged sitting
• “Motion is lotion!”

Summary

• Utilize the 5 Ls to Lifting.
• Consider team lifts or mechanical devices when in doubt.

Draping

Learning Objectives

• Identify the key purposes of draping procedures in maintaining patient privacy and dignity in physical therapy settings.
• Describe the general procedures for draping in physical therapy sessions.

Draping Purposes

• Clinician: Necessary access to specific areas of the body for examination and intervention.
• Patient: Protection of privacy, modesty, and dignity.
  • Cultural safety
  • Warmth & comfort
  • Protection of vulnerable skin, including wounds, surgical sites and scars, neurologically impaired areas
  • Protection of clothes, perspiration, wound drainage, lubricants and lotions.

Maximize Comfort and Dignity

• Verbal communication: Clarity around plans and expectations. Obtain consent.
• Non-verbal communication: Facial expressions and body language demonstrate respect.
• Adequate coverage and warmth:
  • Provide coverage similar to normal manner of dress.
  • Only the treatment area should be exposed; cover the rest.
  • Use gowns, sheets, towels, and blankets.
• Providing privacy:
  • Use private secured doors, curtains, or room dividers.
  • If you need to leave the room, request permission before re-entering.
  • If the patient needs assistance, suggest it and ask for permission before helping.
• Covering: Provide clinical attire. Remove clothes and cover them with temporary clothing/linens
• Minimizing exposure:
  • Consider the amount of area exposed.
  • Consider the length of time exposed.
  • Layer the draping to limit exposure, provide modesty and protection.
• Secure the edges: Increases a sense of security. Tuck them along the sides of the body and clothes.

General Procedure

• Before treatment:
  • Plan ahead and cover the treatment area.
  • Provide specific instructions and obtain consent.
  • Provide temporary clothing/linens and instruction on use.
  • Provide privacy.
• During treatment:
  • Initially provide overall coverage.
  • Expose only the necessary area.
  • Secure edges.
  • Keep exposure time to the minimum.
• After treatment:
  • Provide specific instruction regarding dressing again.
  • Provide privacy.
  • Dispose of draping materials and sanitize your hands.

Key Considerations

• Approach with confidence and professionalism.
• Instill security and comfort.
• Pitch for optimal draping, settle for patient’s preferences.

Patient Positioning

• Supine: Examine anterior trunk and lower extremities.
  • Perceived as the most vulnerable position for patients.
  • Minimize patient exposure.
  • Secure edges of linens.
• Prone: Examine posterior neck, trunk, and lower body.
  • Psychologically vulnerable position.
  • Be attentive to verbal and non-verbal communication; avoid direct eye contact.
  • Alert the patient of areas to examine or treat.
• Sidelying:
  • Used with individuals unable to lie prone.
  • Minimize exposure.
  • Provide warmth and comfort.
• Sitting:
  • Linens are more likely to slide off.
  • Layer and tuck linens.
  • Adjust the positioning as needed.

Adjusting Positions

• Provide additional linens for coverage.
• Hold coverage in place during transitions.
• Once repositioned, adjust and re-secure the draping material.

In Summary:

• Draping is essential for a thorough exam and effective treatment.
• It ensures patient comfort, protection, modesty, and dignity.
• Draping should be purposeful, with effective verbal and non-verbal communication, adequate coverage and warmth, and respect for privacy.
• Draping requires confidence and professionalism.

Lines, Tubes, and Drains

Objectives

• Recognize common lines and tubes utilized for medical care.
• Understand the purpose of common lines and tubes utilized for medical care.

Why?

• Safe mobility.
• Be aware of various lines and tubes attached to the patient.
• Manage lines while moving the patient.
• Make sure not to kink, pull, stretch, or dislodge any line or drain.

Challenges

• Pain
• Neuromuscular impairments
• Sedation from medications
• Side effects from medications.

Vital Signs Monitoring

• Electrocardiogram (ECG or EKG): Can be 3-7 leads. Monitors heart rhythm and heart rate. Be aware of ECG leads to minimize snagging or pulling.
• Blood pressure cuff
• Pulse oximeter
• Temperature monitor
• Respiratory rate

Lines and Tubes; Head and Neck

• Nasogastric feeding tube: Feeding tubes attached to an electrical pump contain liquid nutrition. It is inserted through the nasal passages through the esophagus into the stomach.
  • Nasoduodenal tube: If the tube ends further in the GI system.
• Use: Administer oral medication or empty the stomach.
• Placement: Held in place and the nose by tape. Can be pinned to the patient’s gown for extra protection to prevent dislodgement or pulling.
• Considerations: Can be disconnected for therapeutic activities. Pumps must be stopped before any activity.
• Discuss with the nurse before touching any pump.
• Positioning: Patients need to be upright or semi-reclined for at least 30 minutes (1 hour for pediatric patients). This ensures the pumped liquid is absorbed and prevents reflux through the esophagus, nose, and mouth.
• Nasal cannula: Flexible tube that goes around the ears and back of the head. The endpoint is attached to supplemental oxygen (from an oxygen tank).
  • High flow or low flow.
  • Use: Any condition that requires additional oxygen.
• Tracheostomy: Alternative way of breathing (through the tube instead of the nose or mouth).
  • Common reasons: blockage in the upper airway; inability to clear mucus from lungs and airway.
  • May need long-term help with breathing.

Lines and Tubes; Upper Extremity

• PICC Line (Peripherally inserted central catheter): A central venous catheter that is longer and thicker than a peripheral IV.
  • Peripheral IV (Intravenous device): Placed peripherally on an extremity (hand or arm). Can be placed on the foot or lower leg. Sometimes called peripheral lines. Used to draw blood or give treatment fluids (electrolytes, medications, blood fusions, liquid nutrition for infants). Easiest place to insert is at the scalp.
• Insertion: Inserted with a needle and advanced into the vein with a catheter.

Lines and Tubes; Torso

• Percutaneous endoscopic gastrostomy (PEG) tube / G-tube: Feeding tube inserted using radiological imaging into the stomach or duodenum of the GI system.
  • Direct line into the GI tract.
  • Positioning: Patients should not be lying flat during feeding. Proper positioning promotes absorption and prevents backflow through the mouth and nose.
• Chest tube: Flexible plastic tube inserted through the chest wall and into the pleural space (sometimes inserted into the middle section of the thoracic cavity between the left and right pleural cavities).
  • Use: Removes air or fluid.
  • Conditions: Pneumothorax, pleural effusion with blood or pus, after open heart surgery or major surgery to the thorax.
• Ostomy bag:
  • Ostomy: Surgically created opening in the abdomen that allows waste or urine to leave the body.
  • Stoma: Actual opening created by the ostomy surgery.
  • Use: Bodily waste is rerouted from its usual path due to malfunctioning parts of the urinary or digestive system.
  • Types: Temporary or permanent.
  • Placement: Usually has a bag placed over it to collect waste or urine.
  • Important note: Gait belts cannot be used over chest tubes or ostomy bags due to potential constriction.

Drains: Post Surgery

• Jackson Pratt: Thin flexible tube connected to a bulb that collects fluids that drain off a wound after surgery (lymphatic or blood) due to negative pressure.
• Hemovac drain: Collects fluids after surgery. Larger than a Jackson Pratt drain.
  • Must discuss with the nurse before using.
  • Pin or tape to the patient’s gown, walker, or assistive device.
• Wound vac: Can be placed anywhere on the body where there is a need for closure.
  • Use: Vacuum assisted closure to decrease air pressure around the wound to encourage healing.
  • Conditions: Burns, trauma or surgical wounds, pressure ulcers
  • Appearance: Covered with black foam and sealed on top.
• Foley catheter: Tube inserted into the bladder to provide drainage.
  • Collection bag: Hung nearby. Position below bladder level, and move with the patient if mobile.

Movement Precautions and Contraindications

Objectives

• Demonstrate awareness of contraindications and typical precautions utilized in a healthcare setting.

Contraindications vs Precautions

• Contraindication: Patient conditions that make therapy inappropriate or inadvisable.
• Precautions: Recognizing potential harm to prevent injury, re-injury, or stress.
  • Protective measures that are taken in advance to minimize the chance of injury.

Contraindications for Exercise and Physical Activity

• Medically unstable
• Unstable vital signs
• Unstable angina
• Unstable aortic aneurysm
• Uncontrolled arrhythmias
• Uncompensated congestive heart failure
• Uncontrolled or unstable blood glucose
• Severe dehydration or heat stroke
• Severe anemia
• Low oxygen saturation

Activity Precautions

• Nasogastric tube
• Sternal precautions
• Abdominal precautions
• Spinal precautions
• Hip precautions
• Weight-bearing precautions

Nasogastric Tube (NGT) Precautions

• Risk of liquid nutrition traveling from the stomach to the esophagus and into the lungs causing aspiration pneumonia.
• Positioning:
  • Head of bed (HOB) at least 30-45 degrees.
  • Avoid supine or prone during active feeding.
  • Avoid supine or prone for at least 30-60 minutes after feeding is complete.

Traditional Sternal Precautions

• No lifting more than 5-10 pounds
• No pushing or pulling with arms
• No driving
• No reaching overhead
• Splint the chest when coughing.

Modified Sternal Precautions (“Move in the Tube”)

• Biomechanical principles to reduce stress on the sternum (more functional and allows patients to reach independence sooner).
• Instructions: Keep upper arms close to the body (“inside the tube”) during rolling, pushing up to stand, and lifting.
• The “in the tube” position decreases the lever arm created by the arm and hand, which lessens stress on the sternum.

Sternal Precautions - Splinting

• Hold a cushion/pillow against the chest when coughing.
• Cross the arms in a “self-hug”.

Abdominal Precautions

• Minimal trunk extension and rotation.
• No lifting greater than 5-10 lbs.
• Log rolling for bed mobility.
• Use of abdominal binders, self-splinting.

Spinal Precautions

• Typically: no BLT (bending, lifting, twisting).
• No lifting greater than 5-10 lbs.
• Teach log rolling for bed mobility.
• Safe sit to supine transfers.

Hip Precautions

• Total hip arthroplasty (THA - Posterior approach): Prevent dislocation of the new femoral head from the acetabulum.
  • Risk of dislocation is greatest the first couple of months after surgery.
  • Positioning:
    • No hip flexion beyond 90 degrees (or a more conservative 70 degrees).
    • No hip internal rotation beyond neutral (0 degrees).
    • No hip adduction beyond neutral (0 degrees).
• THA, Anterior approach: Exercise caution with excessive hip extension and external rotation.

Introduction to Functional Movement and Functional Levels

Learning Objective

• Explain functional movement and its relative importance within physical therapy practice.
• Describe the characteristics of different patient function levels and recall the key differences between them.

Functional Movement

• Movement patterns essential for daily life and physical activities.
• Different ways to assess functional movement.
• Functional is specific to the individual.

Examination of Functional Movement

• Establish baseline status.
• Set function-oriented goals.
• Track outcomes of intervention.
• Assess initial abilities and progression toward more complex functional levels.
  • Used to make placement decisions (e.g., inpatient rehab, extended care, etc.)
  • Used to determine an individual’s level of safety.
  • Used to assess the effectiveness of an intervention.
  • Used for documentation to support payer requirements.

Activities of Daily Living

• Basic Activities of Daily Living (ADLs): Routine activities done every day.
  • Feeding
  • Ambulating/transferring/walking.
  • Toileting
  • Bathing/personal hygiene.
  • Continence management
  • Dressing (upper/lower body)
• Instrumental Activities of Daily Living (IADLs): Necessary to collaborate and live independently within the community.
  • Companionship and mental support.
  • Transportation and shopping.
  • Preparing meals.
  • Housekeeping and maintenance.
  • Managing medications and finances.
  • Communicating with others.

Functional Levels

• Independent (I): Functions safely and efficiently alone. No cueing, assistance, or supervision.
• Modified Independent (Mod I): Functions safely alone. Requires an assistive device or more time. No cueing, assistance, or supervision.
• Supervision (S): Functions safely with an individual monitoring for safety. May or may not require a device or more time. May require verbal cueing or set-up assistance.
• Minimal Assistance (Min A) and Contact Guard Assistance (CGA): Patient completes the majority of the task (>75%). Requires physical assistance (e.g., light touch) to complete the task, but otherwise can perform the task safely.
• Moderate Assistance (Mod A): Patient completes less than 75% of the task, requiring physical assistance.
• Maximum Assistance (Max A): Patient completes less than 50% of the task, requiring physical assistance.
• Total Assistance/Dependent (Total A): Patient requires one or more people to complete the task.

Test your knowledge on the basic principles of physical therapy, including body mechanics, patient mobility, and therapeutic activities. This quiz covers essential concepts that are vital for maintaining safety and effectiveness in a clinical setting.