Dirette 27 Restoring Activities of Daily Living PDF

584 Midterm Dirette 27 Restoring Activities of Daily Living Importance of ADL Assessment ​ The assessment of Activities of Daily Living (ADLs) is a critical step in evaluating a client’s functional independence. ​ It allows occupational therapists to analyze performance, identify limi...

584 Midterm Dirette 27 Restoring Activities of Daily Living Importance of ADL Assessment ​ The assessment of Activities of Daily Living (ADLs) is a critical step in evaluating a client’s functional independence. ​ It allows occupational therapists to analyze performance, identify limitations, and develop intervention strategies to improve daily function. ​ ADL assessments help in tracking progress, determining if a client has met their therapy goals, and modifying interventions accordingly. Methods of ADL Performance Evaluation Therapists use two primary methods to evaluate ADLs: A. Self-Reported Assessments ​ The client provides a subjective report of their ability to perform ADLs. ​ Can be completed through questionnaires, interviews, or ADL checklists. ​ May be less accurate due to memory deficits, cognitive impairments, or personal bias. ​ Useful for initial screenings or when direct observation is not feasible. B. Performance-Based Assessments ​ Direct observation of ADL performance in real-life settings. ​ More objective and reliable compared to self-reports. ​ Allows therapists to analyze movement patterns, identify challenges, and determine the need for adaptive techniques. ​ Assessment should take place in a natural environment (e.g., home, hospital, rehab center) whenever possible. C. Factors to Assess Before ADL Performance ​ Range of Motion (ROM) – Can the client move joints effectively to complete tasks? ​ Strength – Does the client have adequate muscular power? ​ Sensation – Are there sensory deficits that may impact safety? ​ Balance – Can the client maintain stability when performing ADLs? ​ Cognition – Does the client have memory, attention, or executive function impairments that affect ADL performance? Standardized ADL Assessments Therapists may use various standardized tools to evaluate ADL performance. These assessments provide quantifiable data for goal setting and progress tracking. Common Standardized ADL Assessment Tools 1.​ Functional Independence Measure (FIM) ○​ Evaluates independence across self-care, mobility, and cognition. ○​ Scores range from complete dependence to full independence. 2.​ Klein-Bell Activities of Daily Living Scale ○​ Assesses 170 ADL tasks, including dressing, bathing, eating, and mobility. 3.​ Katz Index of Independence in ADLs ○​ Evaluates six basic ADLs: bathing, dressing, toileting, transferring, continence, and feeding. 4.​ Performance Assessment of Self-Care Skills (PASS) ○​ Measures functional mobility, ADLs, and instrumental ADLs (IADLs). ○​ Includes both clinical and home-based evaluations. 5.​ Disabilities of the Arm, Shoulder, and Hand (DASH) ○​ Assesses upper extremity function and ADL impact due to arm or hand impairments. 6.​ Barthel ADL Index ○​ Evaluates ADL performance in stroke and rehabilitation patients. Non-Standardized ADL Assessments ​ ADL Checklists – General assessments used in hospitals and rehabilitation centers to document basic functional abilities. ​ Observational Logs – Recorded by therapists over time to track progress and decline in ADL performance. Levels of Independence in ADLs When evaluating ADL performance, therapists classify clients based on the level of assistance needed. Categories of ADL Independence 1.​ Independent ○​ The client performs the activity without assistance, adaptive equipment, or modifications. ○​ Within a reasonable time and safely. 2.​ Modified Independence ○​ The client performs the activity independently but requires an assistive device (e.g., cane, walker, adaptive utensils).  ○​ May take more time or have minor safety concerns. 3.​ Supervision (Standby Assistance) ○​ The therapist does not physically assist but provides verbal cues or monitoring for safety. ○​ Needed for clients at risk of falling or making errors. 4.​ Contact Guard Assistance ○​ The therapist places hands on the client for balance but does not provide physical assistance. ○​ Used when there is a risk of instability. 5.​ Minimal Assistance ○​ The therapist provides up to 25% assistance. ○​ The client is able to perform at least 75% of the activity. 6.​ Moderate Assistance ○​ The therapist provides 50% assistance. ○​ The client completes 50% to 74% of the activity. 7.​ Maximal Assistance ○​ The therapist provides 75% assistance. ○​ The client completes only 25% to 49% of the activity. 8.​ Dependent ○​ The client requires more than 75% assistance. ○​ They perform less than 25% of the activity or cannot perform it at all. Additional Considerations ​ If multiple caregivers assist a client, note the number of people required. ​ A client may still be considered independent if they can direct their care, even if they rely on caregivers for physical assistance. Other Factors to Consider in ADL Evaluation A. Contextual and Environmental Factors ​ The physical environment impacts ADL performance. ○​ Examples: Clutter, accessibility barriers, poor lighting, steps/stairs, bathroom setup. ​ Adaptive changes may be required: ○​ Removing trip hazards (e.g., loose rugs). ○​ Installing grab bars, handrails, raised toilet seats. ○​ Organizing items for easier reach. B. Cultural and Social Considerations ​ ADL performance is influenced by cultural norms (e.g., hygiene practices, dressing styles, gender roles in caregiving). ​ Some clients prefer family involvement, while others may value privacy.  ​ Therapists must respect client preferences and ensure culturally appropriate interventions. C. Medical Complexity in Acute Care Settings ​ In hospitals, ICUs, or post-surgical settings, special precautions are needed: ○​ Monitor lab values, vital signs, and code status before ADL assessments. ○​ Consider precautions for cardiac, neurological, and orthopedic conditions. ○​ Be aware of medical devices (e.g., EKG monitors, ventilators, catheters, pacemakers). ​ Follow isolation protocols if the client has infectious disease precautions. D. Privacy & HIPAA Compliance ​ Ensure client confidentiality during assessments. ​ Obtain consent before involving family members or caregivers. ​ Comply with HIPAA regulations when documenting and sharing client information. Dirette 32 The Biomechanical Frame of Reference ​ Occupational therapy (OT) is built on theories that emphasize occupation as a means and an end for meaningful living. ​ Frame of Reference (FOR): A system of criteria used to evaluate and treat deficits in OT. ○​ A guide used in occupational therapy to assess and treat physical or functional problems. ​ The Biomechanical FOR applies physics and human movement principles to restore function in individuals with musculoskeletal, peripheral nervous, and cardiopulmonary conditions. Key Concepts & Terminology: ​ Edema: Swelling from excess fluid accumulation. ​ Endurance: Muscle’s ability to exert force over time. ​ Functional Range of Motion (ROM): Necessary movement at joints to complete tasks. ​ Impairment: Reduction in function or quality of body characteristics. ​ Kinematics: Study of movement without regard to forces. ​ Kinetics: Study of forces affecting motion. ​ Physical Agent Modalities (PAMs): Therapies using heat, cold, electrical stimulation, etc. ​ Strength: Muscle's capacity to exert force in a single contraction. ​ Therapeutic Activities: Functional tasks adapted for rehabilitation. ​ Therapeutic Exercise: Body movement to improve musculoskeletal function Biomechanical Frame of Reference: Theoretical Base ​ Biomechanics: Study of mechanical laws in living bodies. ​ Used for assessing motion limitations, strength deficits, and endurance issues. ​ Applied to individuals with movement restrictions due to musculoskeletal, neurological, cardiopulmonary disorders, injuries, or surgeries. Function/Dysfunction Continuum Three components required for functional movement: 1.​ Joint ROM: The potential movement at a joint. 2.​ Muscle Strength: Ability to exert force for movement or stability. 3.​ Endurance: Sustained effort capacity over time. Dysfunction occurs when there is a limitation in any of these components, impacting occupational performance. Key Factors Affecting ROM: ​ Joint structure and elasticity of surrounding tissues. ​ Common limitations: Arthritis, fractures, edema, contractures, muscle spasticity. Muscle Strength: ​ Muscles create movement and stability. ​ Primary weakness causes: Disease (e.g., ALS, muscular dystrophy), nerve injuries. ​ Secondary weakness causes: Disuse, immobilization, contractures. ​ Measurement tools: Dynamometers, pinch gauges, manual muscle testing. Endurance: ​ Influenced by muscle conditioning and cardiopulmonary function. ​ Measured by: Repetitions, time duration, or task completion. ​ Limitations arise from: Diseases, deconditioning, immobility. Evaluation: Indicators of Function and Dysfunction ​ OT evaluation determines the extent and cause of limitations. Assessment Methods: ​ ROM Measurement: Goniometer (degrees of movement). ​ Strength Testing: Manual muscle testing, grip strength (dynamometer), pinch strength (pinch gauge), BTE work simulator.  ​ Endurance Evaluation: Task repetition counts, duration before fatigue, distance covered. Intervention: Postulates Regarding Change Goal: Enable individuals to regain independence in occupational roles. Treatment Continuum: 1.​ Adjunctive Methods: Preparatory techniques (e.g., PAMs, exercises, splints). 2.​ Enabling Activities: Simulated purposeful tasks (e.g., work and driving simulators, tabletop activities). 3.​ Purposeful Activities: Real-life tasks that are part of daily routine and relevant/meaningful to client (e.g., dressing, eating, mobility). 4.​ Occupational Performance: Client resumes daily occupations. Final goal is always for the client to regain the ability to engage in occupation. Intervention Focus: ​ Remediation: Restore ROM, strength, endurance. ​ Compensation: Adapt tools/environments for function. ​ Prevention: Avoid complications like contractures, atrophy, or pain. Specific Interventions for Deficits 1. ROM Interventions Prevention (keep it mobile, prevent stiffness, deformities, and edema) ​ Active/passive ROM exercises. ​ Joint protection (e.g., ergonomic modifications). ​ Orthotics/Splinting to prevent contractures. Remediation (you need to determine what’s causing the limitation to apply appropriate interventions) ​ Stretching, mobilization, and PAMs (heat, cold, electrical stimulation). ​ Edema reduction: Compression, massage, elevation, PAMs. ​ Encouraging functional use Compensatory Techniques ​ Adaptive tools (e.g., long-handled reachers). ​ Environment modification 2. Strength Interventions Prevention ​ Daily activities/exercises to maintain strength. ​ Therapeutic exercise programs for chronic conditions Remediation (Lost strength due to illness, injury, or immobilization) ​ Graded therapeutic activities and exercises ​ Therapeutic exercises (start at the clients level and progress): Resistance bands, graded putty, weights, pulleys. ​ Therapeutic Activities: purposeful tasks are used in targeted ways to increase strength ​ BTE work simulator: simulation of tool use ​ Work hardening programs for return-to-work cases, specific job tasks in a work environment. Compensatory Techniques ​ Adaptive equipment for those with permanent weakness. 3. Endurance Interventions Prevention ​ Regular engagement in daily tasks. Prevents loss in strength which can also prevent loss in endurance. Remediation ​ Graded therapeutic exercises and activities: Increasing task duration, repetitions gradually. Compensatory Techniques ​ Rehabilitation FOR: Energy conservation strategies and adaptive devices for chronic conditions. Evidence-Based Practice (EBP) & Biomechanical FOR Evidence based practice is using the current best evidence in making decisions about client care. Goal is to eliminate unsound or risky practices ​ Challenges: ○​ Biomechanical gains don’t always translate to functional improvements. ○​ Insurance companies prioritize functional outcomes over ROM/strength gains. ​ Research supports the effectiveness of biomechanical interventions for the prevention and remediation of physical impairments, but there is a push for more evidence linking interventions to improved occupational performance.  ​ Third party payers or unlikely to pay for treatment that’s purely for biomechanical gain. Conclusion ​ Biomechanical FOR is effective for addressing ROM, strength, and endurance. ​ However, therapists should integrate occupation-based interventions to ensure functional outcomes. ​ Future research is needed to further validate biomechanical interventions in relation to occupational performance. Dirette 33 Rehabilitation Frame of Reference Overview of the Rehabilitation FoR ​ Therapists must decide between remediation, compensation, adaptation, or a combination of these. ​ Remedial approaches (e.g., biomechanical, motor learning) focus on restoring function by directly addressing impairments. ​ Compensatory/adaptive approaches (Rehabilitation FoR) focus on maximizing function when remediating impairments is not possible or not the immediate goal. ​ Rehabilitation FOR promotes the use of assistive technology, compensatory strategies, and environment modification. ​ Emphasizes strengths rather than limitations, helps client make the most of their strengths. ​ Aligns with the "Modify" approach in the Occupational Therapy Practice Framework (OTPF-3) which emphasizes compensation and adaptation. ​ Application beyond physical dysfunction: ○​ Cognitive & psychosocial conditions (e.g., dementia, mental illness, intellectual disabilities). ○​ Groups & populations (e.g., environmental adaptations in community settings). Background Characteristics of Clients Rehabilitation FoR is useful for: 1.​ Chronic, permanent, or progressive conditions: ○​ Examples: Arthritis, diabetes, CHF, COPD, amputations, TBI, spinal cord injuries, Parkinson’s, multiple sclerosis, dementia. ○​ Therapy focuses on assistive technology, compensatory strategies, environmental modifications. ○​ Jimmo vs. Sebelius (2013) clarified that Medicare covers therapy for maintenance and function, not just improvement. 2.​ Clients with residual impairments after remediation: ○​ Rehabilitation helps people adjust when full recovery isn't possible.  ○​ Example: A stroke patient may regain partial upper limb function but still need adaptive techniques. ○​ Remediation and compensation can be used together. 3.​ Clients preferring a compensatory approach: ○​ Clients may lack motivation or desire for remedial therapy. ○​ OT should balance clinical judgment with client choice. 4.​ Clients with limited access to remedial treatment: ○​ Due to financial constraints, lack of insurance, or rural settings. ○​ Compensation may be the most practical option. Settings and Situations ​ OT is provided across the continuum of care: ○​ Acute care & inpatient rehab: Focuses on remediation. ○​ Often most useful in later stages of care continuum (outpatient, home health, community rehab): Focus shifts to compensation/adaptation. ○​ Example: A TBI survivor might use assistive devices like smartphones for memory compensation. Theoretical Base and Related Models A frame of reference (FoR) connects theory with clinical practice. Key Models Related to Rehabilitation FoR 1.​ Medical Model: ○​ Focuses on diagnosis & treatment. ○​ OT historically used compensation strategies to improve function where medicine left off. 2.​ Rehabilitation Model: ○​ Developed post-WWII to maximize function in disabled veterans. ○​ Emphasizes task analysis, compensatory strategies, adaptive equipment. 3.​ International Classification of Functioning, Disability, and Health (ICF) Model: ○​ Views disability as influenced by environmental & personal factors. ○​ Aligns with Rehabilitation FoR by emphasizing function over impairment. 4.​ Client-Centered Model: ○​ Focuses on collaborating with clients to set meaningful goals. Key Assumptions of the Rehabilitation FoR (Dutton, 1995) 1.​ Independence can be achieved using compensation when remediation isn’t possible. 2.​ Motivation is critical and is influenced by values, roles, preferences, & sense of purpose. 3.​ Environmental context impacts motivation & function.  4.​ Psychosocial & cognitive skills are necessary for adapting to functional limitations. 5.​ A top-down approach is preferred in clinical reasoning. Evaluation: Function/Dysfunction Continua ​ Includes the development of an occupational profile, and analysis of occupational performance, observation of activities and environment, and assessment tools. ​ Top-down approach evaluates: 1.​ Environmental demands/resources. 2.​ Motivation, habits, and roles. 3.​ Determine functional abilities. 4.​ Identify impairments affecting function. Continua of Function & Dysfunction Function dysfunction continua in the rehabilitative FOR: 1.​ Activities of Daily Living (ADLs) 2.​ Instrumental ADLs (IADLs) 3.​ Work & education 4.​ Play & leisure 5.​ Social participation 6.​ Rest & sleep Indicators of Function ​ Ability to engage in meaningful activities. ​ Ability to complete activities with independence, safety, timeliness or efficiency, & accuracy. Dysfunction is considered to be present when these indicators are absent or limited. Intervention (Postulates Regarding Change) Principles of Change in the Rehabilitation FoR Postulates regarding change: 1.​ Compensatory & adaptive approaches can improve ability to participate in occupations with independence, safety efficiency, accuracy and satisfaction. 2.​ Compensatory & adaptive approaches are client-centered. It emphasizes individual strengths and teaches them how to maximize and utilize them. 3.​ Compensatory & adaptive approaches require collaboration between client & therapist that recognizes client context and motivation. Intervention Techniques  1.​ Assistive Technology (any piece of equipment that is use to maintain or improve function) ○​ Examples: Reachers, wheelchairs, adaptive communication devices. 2.​ Compensatory Techniques (intentional ways of performing an activity differently) ○​ Position of the activity ○​ Position or location of the person ○​ Materials and tools used to complete the activity ○​ Sequence of steps ○​ Time requirements ○​ Performance requirements i.​ Examples: Energy conservation strategies, one-handed dressing. 3.​ Environmental Modifications (changes to physical environment, but sometimes social environment as well) ○​ Examples: Improved lighting, removing clutter, limiting visitors, pet therapy. 4.​ Orthotics & Prosthetics (any external orthopaedic appliance, brace or splint, applied to the body) ○​ Are used to stabilize control limit or immobilize a body part to assist with function ○​ Can be both remedial and compensatory ○​ Used for stabilization, mobility support, & function. Evidence Supporting Rehabilitation FoR ​ Assistive technology & adaptive strategies improve independence. ​ Home modifications reduce falls & improve participation. ​ Mixed evidence for orthotics/splints in stroke rehabilitation. Key Takeaways ​ The Rehabilitation FoR focuses on compensating for impairments using adaptive techniques & assistive technology. ​ Can be used alone or with remedial approaches. ​ Highly client-centered, focusing on motivation, environment, and functional goals. ​ Widely applicable across physical, cognitive, psychosocial, & community-based rehabilitation. ​ Evidence supports its effectiveness, particularly for assistive technology & home modifications. ○​ Should be used with consideration of the client’s condition and prognosis. ○​ Be aware of psychosocial impacts ​ Some clients my view assistive technology as a sign of disability and fear the stigma Wounds Part One Role of Occupational Therapy in Wound Care ​ OT preserves and restores an individual's ability to participate in daily life occupations, including preventing and managing wounds. ○​ Prevention and amelioration of wounds ​ OTs identify causative factors for skin breakdown. ​ They recommend interventions that both protect the skin and promote wound healing. OT Wound Care Interventions 1.​ Restoring habits & routines to prevent further complications. 2.​ Preventing role loss by supporting independence in daily life. 3.​ Preventing wound occurrence through: ○​ Positioning ○​ Support surfaces ○​ Environmental modifications 4.​ Providing orthotic devices & pressure garments. 5.​ Educating patients and caregivers. 6.​ Managing wound sites to support healing. Burden of Chronic Wounds ​ 85% of amputations are preceded by ulcers. ​ A diabetic ulcer leads to an amputation every 30 seconds. ​ 40-70% mortality rate within 5 years of amputation. ​ Wounds affect independence in: ○​ Self-care ○​ Productivity ○​ Leisure Phases of Wound Healing 1.​ Hemostasis (Immediate response to stop blood loss) ○​ Stops bleeding via clot formation. ○​ Fibrinolysis breaks down the clot. 2.​ Inflammation (2-6 days post injury) ○​ Signs: Warmth, erythema (redness), edema, pain. 3.​ Proliferation ○​ New tissue growth & wound contraction. 4.​ Maturation/Remodeling ○​ Can take up to 2 years. ○​ Scar never achieves full strength (only up to 80% of original). Wound Terminology ​ Granulation: Healthy tissue growth. ​ Hypergranulation: Overgrowth of granulation tissue that rises above the level of the surrounding skin in a wound bed. Delays wound healing. ​ Callus: A thickened and hardened area of skin that develops due to repeated friction, pressure, or irritation. ​ Excoriation: A superficial skin abrasion or lesion caused by mechanical means, such as scratching, friction, or chemical irritation. ​ Slough: Yellow, dead tissue. ○​ A soft, moist, dead tissue that appears yellow, white, or tan and is often found in the wound bed. ​ Eschar: Black, necrotic tissue. ○​ A dry, thick, leathery, and necrotic tissue that appears black, brown, or dark tan in a wound bed. ​ Tunneling: Wound extending under healthy skin. ○​ A narrow, channel-like passage extending from the wound bed into deeper tissues or to another wound on tissue surface ​ Undermining: Wound edges are separated from healthy tissue. ○​ Results in a hollow space beneath the skin ​ Exudate: Fluid from wounds: ○​ Serous: Clear, pale yellow (normal). ○​ Sanguineous: Contains blood. ○​ Serosanguineous: Blood + clear fluid mix. ○​ Purulent: Pus, often indicating infection. ​ Erythema: Redness of the skin caused by increased blood flow to the capillaries in response to irritation, inflammation, infection, or pressure. ​ Rolled Edges: Edges of a wound become thickened and curl under, preventing proper healing. This occurs when epithelial cells migrate across the wound bed but fail to connect, leading to chronic wounds, such as pressure ulcers ​ Maceration: Softening and breakdown of the skin due to prolonged exposure to moisture Wound Assessment Criteria 1.​ History: How and when did it happen? 2.​ Surrounding tissue: Color, moisture level. 3.​ Location: Specific anatomical landmarks. 4.​ Wound base: Red (granulation), yellow (slough), black (eschar). 5.​ Edges & Undermining: Sloped, rolled edges. 6.​ Size: Length, width, depth (mm). 7.​ Drainage: Color and consistency of exudate. 8.​ Odor: Strong odor may suggest infection. Acute vs. Chronic Wounds  ​ Acute Wounds: ○​ Progress through healing phases smoothly. ○​ Examples: Surgical wounds, trauma. ​ Chronic Wounds: ○​ Fail to heal properly or recur. ○​ Pass through the repair process without restoring anatomic and functional results ○​ Examples: Diabetic ulcers, pressure injuries, venous ulcers. Can Chronic Wounds Heal? ​ Healable: If all healing factors are managed. ○​ All causes and co-factors that interfere with healing have been removed and healing is progressing in a timely manner. ​ Maintenance: Healing is slow due to adherence issues. ○​ Wound is healing but not in a timely fashion due to factors such as patient adherence. ​ Non-healing: Cannot heal due to irreversible causes. ○​ Cause of the wound can not be removed. Chronic Wound Types 1.​ Pressure Injuries (Ulcers) 2.​ Diabetic (Neuropathic) Foot Ulcers 3.​ Venous Leg Ulcers 4.​ Arterial Ulcers 5.​ Surgical Wound Dehiscence 6.​ Fistulas Pressure Injuries ​ Can present as intact skin or on open ulcer ​ Caused by prolonged and/or intense pressure, or pressure in combination with shear and/or friction ​ Often occurs over bony prominences (sacrum, heels, elbows). ○​ Or related to a medical or other device 75% of the sitting dependent population will develop a pressure ulcer. 60% of spinal cord injury patients 70% of pressure ulcers are preventable 75% reoccur Pressure Injury Staging 1.​ Stage 1: Non-blanchable (redness on the skin that does not turn white (blanch) when pressed.) erythema (redness), skin intact.  2.​ Stage 2: Partial-thickness skin loss, with exposed dermis. a.​ outermost layer of skin (epidermis) is gone, revealing the pink or red underlying dermis 3.​ Stage 3: Full-thickness skin loss. a.​ both the epidermis (outer layer) and dermis (middle layer) are completely destroyed, exposing deeper structures such as fat, muscle, tendon, or bone. 4.​ Stage 4: Full-thickness skin and tissue loss. a.​ the epidermis, dermis, and underlying tissue layers (such as fat, muscle, tendon, or bone) are completely destroyed. 5.​ Unstageable: Covered by slough or eschar. a.​ a full-thickness skin and tissue loss wound where the depth cannot be determined because it is covered by slough (yellow, tan, green tissue) or eschar (black, necrotic tissue). 6.​ Deep Tissue Injury: Non-blanchable, purple/maroon skin. a.​ occurs beneath intact or discolored skin, affecting deep tissues like muscle, fat, or bone, even though the outer skin may initially appear intact. Prevention & Treatment of Pressure Injuries Risk Factors ​ Medical Conditions: Diabetes, obesity, immobility, etc. ​ Inadequate Nutrition: Deficiencies in protein, Vitamin C, Zinc. ​ Moisture: Incontinence & sweating weaken skin making it more fragile, and can also introduce bacteria. ​ External Forces: ○​ Pressure: From body weight or medical devices, force exerted over a unit of an area. ○​ Friction: force resisting the relative motion of solid surfaces ​ Skin rubs on a surface. ○​ Shear: Layers of tissue move in opposite directions, leading to stretching, distortion. ​ Skin stays in place while deeper tissues move. Assessment Tools: Braden Scale ​ Evaluates risk based on: ○​ Sensory perception ○​ Moisture ○​ Activity ○​ Mobility ○​ Nutrition ○​ Friction & Shear ​ Lower scores = higher risk for pressure ulcers. ​ Ranked 1-4 except friction and shear which is ranked 1-3 Pressure Redistribution & Support Surfaces ​ Pressure Management Formula: Pressure = Force/Area ​ Increase surface area to reduce peak pressure. ○​ by spreading pressure over a larger surface area, you can reduce the amount of force applied to any one specific point on the bod ​ Support Surfaces: ○​ Reactive: Changes load distribution in response to patients weight. ​ (e.g., air, foam, gel mattresses, cushions, overlays). ○​ Active: Changes load distribution without a patient on it ​ (e.g., alternating pressure mattresses). Key features of support surfaces: Pressure redistribution, immersion, durability. Preventing Friction & Shear ​ Proper transfer techniques: ○​ Slider/transfer boards, move sheet not the skin, protect high risk areas ○​ ​ Protective devices: ○​ Sheepskin to reduce shear. ○​ Heel boots to offload pressure. Final Thoughts ​ OT plays a crucial role in wound prevention & management. ​ Early intervention prevents complications. ​ Holistic care approach includes nutrition, mobility, environment modifications. Part Two Wound Bed Preparation Paradigm Key Considerations for Chronic Wounds ​ Treat the Cause (underlying conditions) ​ Patient-Centered Concerns (pain, lifestyle) ​ Local Wound Care: ○​ Debridement ○​ Infection Control ○​ Moisture Balance ○​ Managing Non-Healing Wounds Venous Leg Disease What is Venous Leg Disease?  ​ Chronic Venous Insufficiency (CVI) → Poor venous drainage leading to venous hypertension. ​ Common causes: Congestive heart failure, obesity, advanced age, trauma. Etiology of Chronic Venous Insufficiency (CVI) 1.​ Vascular Incompetence (Venous Reflux) 2.​ Obstructed Veins (e.g., Deep Vein Thrombosis - DVT) 3.​ Failure of the Calf Muscle Pump (ineffective circulation) Consequences of Venous Hypertension ​ Fluid leakage into tissues → Edema ​ Hemosiderin Staining: ○​ RBCs leak out and break down, leaving red, purple, or black skin discoloration. Edema Classifications ​ C0 – No visible or palpable signs. ​ C1 – Telangiectasia or reticular veins. ​ C2 – Varicose veins. ​ C3 – Edema. ​ C4 – Skin changes (eczema, pigmentation, lipodermatosclerosis). ​ C5 – Healed venous ulcer. ​ C6 – Active venous disease. CVI Statistics ​ 10-25% of adults exhibit symptoms. ​ 1-5% of adults will develop venous ulcers. ​ CVI wounds account for 80-90% of lower extremity wounds. ​ Recurrence rate: 60-70%. Common Characteristics of Venous Leg Disease ​ Lipidermatosclerosis (hardened, inflamed skin) ​ Hemosiderin Staining ​ Edema ​ Gaiter area ulcers (around ankles) Venous Leg Ulcers ​ Located in the "gaiter" area (lower leg). ​ Often multiple wounds.  ​ Shallow, irregularly shaped wounds. ​ Moderate to heavy exudate. ​ Yellow fibrin or ruddy granulation tissue at the base. Lymphedema What is Lymphedema? ​ Disruption of the lymphatic system, leading to abnormal fluid accumulation. ​ Lymph vessels transport protein, water, waste, and fatty acids through the lymph nodes for filtering. ​ Can be a result of cancer treatments or chronic venous disease. Arterial Insufficiency What is Arterial Insufficiency? ​ Inadequate blood supply due to atherosclerosis or trauma. ​ Leads to reduced oxygen delivery to tissues. Common Symptoms ​ Intermittent Claudication: ○​ Pain during activity, relieved by rest. ○​ Can progress to constant pain. ​ Rest Pain: ○​ Relieved by dependent positioning (legs hanging down). ​ Cool to touch extremities. ​ Pale, shiny, thin skin with minimal hair growth. ​ Dependent Rubor (redness when legs are down). Arterial Ulcers ​ Located over bony prominences (e.g., toes, ankles). ​ "Punched-out" appearance. ​ Little to no exudate. ​ Very painful. Diabetic Foot Ulcers Diabetic Neuropathy ​ Chronic high blood sugar damages nerves and blood vessels. ​ Types: 1.​ Sensory Neuropathy: Loss of sensation. 2.​ Autonomic Neuropathy: Dry skin, calluses, fungal infections.  3.​ Motor Neuropathy: Muscle atrophy, foot deformities (e.g., hammer toes, pes planus). Diabetic (Neuropathic) Ulcers ​ Occur on pressure points (e.g., soles of feet). ​ Surrounded by callus. ​ Deep wounds, may probe to bone. ​ Pain-free due to neuropathy. ​ Minimal exudate. Charcot Foot ​ Midfoot collapse ("rocker-bottom" foot deformity). ​ Severe complication of diabetes due to inflammation and bone destruction. Comprehensive Lower Extremity Assessment 1.​ Medical History (DVT, diabetes, heart failure, obesity, smoking). 2.​ Social History (mobility, falls, orthotics, compression therapy use). 3.​ Vascular Exam: ○​ Circulation (Ankle Brachial Index, Toe Brachial Index, Capillary refill). ○​ Edema (pitting vs. non-pitting). ○​ Venous Abnormalities (varicose/spider veins). ○​ Nail Condition (thickness, dryness, discoloration). ○​ Skin Condition (hair loss, dryness, texture). 4.​ Foot Architecture (deformities like Charcot, hammer toes). 5.​ Sensation Testing (Monofilament testing for loss of protective sensation). 6.​ Wound Assessment (Size, base, exudate, infection signs). Local Wound Care – D.I.M.E. Model 1.​ Debridement (removal of dead tissue) ○​ Mechanical (scrubbing, wet-to-dry dressings) ○​ Autolytic (moisture-retentive dressings) ○​ Enzymatic (enzymes to break down tissue) ○​ Biological (maggot therapy) ○​ Sharp/Surgical (scalpel, scissors) 2.​ Infection Control ○​ NERDS: Non-healing, Exudate, Redness, Debris, Smell. ○​ STONES: Size increase, Temperature rise, Bone exposure, Breakdown, Erythema, Smell. 3.​ Moisture Balance ○​ "Not too wet, not too dry". ○​ Promotes re-epithelialization and reduces pain.  4.​ Edge Advancement ○​ Assess rolling edges, undermining, non-healing signs. Compression Therapy ​ First-line treatment for venous insufficiency & edema. ​ Types: ○​ TED stockings (8-10 mmHg) ○​ Wraps (Coban, Profore, Tubigrip) ○​ Custom Pressure Gradient Stockings (18-60 mmHg). ​ Compression Contraindications: ○​ Uncontrolled CHF. ​ Congestive Heart Failure ○​ Severe arterial disease (ABI 90°. ○​ Avoid internal rotation (posterolateral approach) or external rotation (anterolateral approach). ○​ No crossing legs or hip adduction. ADL Modifications Post-Hip Surgery ​ Dressing: Use long-handled reachers and elastic laces. ​ Bathing: Shower standing or use a bath bench. ​ Seating: Use a raised toilet seat, reclined seating with wedge cushion. Conclusion ​ Occupational therapy plays a crucial role in orthopedic rehabilitation, from acute injury management to functional restoration. ​ Early mobilization prevents complications such as stiffness and atrophy. ​ Adaptive equipment and activity modifications are key in managing both acute and chronic orthopedic conditions. ​ Patient education and home programs significantly enhance recovery outcomes. Orthopedics Part One Bone Anatomy & Growth Bone Structure: ​ Periosteum: Outer membrane, attachment for muscles, tendons, and nerves. ​ Compact Bone: Mineralized layer, provides strength. ​ Spongy Bone: Contains bone marrow, blood vessels, and fat deposits. Bone Growth (Osteogenesis/Ossification) ​ Begins at 8 weeks post-conception and continues dynamically. ​ Bone Cells: ○​ Osteoblasts – Build new bone.  ○​ Osteocytes – Mature bone cells. ○​ Osteoclasts – Break down and reabsorb bone. Common Orthopedic Disorders ​ Congenital disorders. ​ Arthritis (Osteoarthritis, Rheumatoid). ​ Soft tissue injuries (bursitis, nerve damage). ​ Bone diseases (Paget’s, scoliosis, tumors). ​ Autoimmune conditions (leukemia). ​ Osteoporosis (common in older adults). ​ Fractures – Trauma-related injuries. Fracture Classifications Long Bone Fractures ​ Various types based on location and displacement. Hip Fractures ​ Classified based on fracture pattern and location. Fracture Healing Phases 1.​ Reactive Phase – Inflammatory response, formation of granulation tissue. 2.​ Reparative Phase – Periosteum generates osteoblasts, new bone forms. 3.​ Remodeling Phase – Can take 3–5 years, depending on age and health. Factors Affecting Healing ​ Negative factors: Displacement, infection, bone loss, diabetes, steroid use, poor health, and non-compliance with weight-bearing restrictions. Fracture Treatment Non-Surgical Fracture Management ​ Undisplaced fractures: ○​ Stable: May need protection only (e.g., minor spinal fractures). ○​ Unstable: Require immobilization (e.g., casting a radius fracture). Surgical Treatment ​ Goal: Precise stabilization for optimal recovery. ​ Surgical Methods:  ○​ Open Reduction Internal Fixation (ORIF) – Uses pins, screws, plates, wires. ○​ External Fixation – Cage-like structure attached to bone with screws/wires. Ilizarov Procedure (Limb Lengthening) ​ Bone is surgically cut, wires inserted through bone, skin, and muscle. ​ Bone is lengthened by 1mm/day. ​ Requires weight-bearing for bone formation. OT Role in Ilizarov: ​ Fabricating foot plates. ​ Wound care and pin-site assessment. ​ Edema management. ​ ADL practice and home modifications. Arthroplasty (Joint Replacement) ​ Required when conservative treatment fails due to pain, stiffness, functional impairment. ​ Indications: ○​ Osteoarthritis. ○​ Rheumatoid arthritis. ○​ Trauma. ○​ Avascular necrosis. Types of Arthroplasty 1.​ Total Arthroplasty – Both joint surfaces replaced. 2.​ Hemi-Arthroplasty – Only one joint surface replaced. Hip Replacement Approaches Posterolateral Approach (Most Common) ​ Advantages: ○​ Simple technique. ○​ Preserves hip abductors. ​ Disadvantages: ○​ High risk of posterior dislocation (9.5% cases). Precautions Post-Hip Replacement: ​ No hip flexion >90° (avoid reaching down). ​ No internal rotation (keep toes aligned with the body). ​ No hip adduction (avoid crossing legs). Weight-Bearing Classifications 1.​ Non-Weight Bearing (NWB) – No weight on the limb. 2.​ Toe-Touch Weight Bearing (TTWB/FeWB) – Only for balance. 3.​ Partial Weight Bearing (PWB) – Up to 50% of body weight. 4.​ Weight Bearing As Tolerated (WBAT) – Full weight if tolerated. Occupational Therapy in Hip/Knee Surgery ​ Pre-op education: Mobility precautions, home setup, assistive devices. ​ Day 0: Early mobilization, sitting at the edge of bed within 4 hours. ​ Day 1: ADL practice, transfer training (bed, chair, toilet). ​ Day 3: Discharge when independent in self-care. Equipment Recommendations ​ Dressing aids: Long-handled shoehorn, sock aid. ​ Bathing: Shower stool, tub grab bar. ​ Toileting: Raised toilet seat, grab bars. Special Conditions Slipped Capital Femoral Epiphysis (SCFE) ​ Growth plate slips due to weakening + obesity. ​ Occurs in boys (10–16 years). ​ Requires surgical pinning. Knee Arthroplasty ​ Knee replacement process: ○​ Cartilage removed. ○​ Metal components attached. ○​ Plastic spacer inserted. ​ Precautions: ○​ No twisting/kneeling. ○​ Sleep with pillow between knees. Ankle Injuries Fracture Classification (Weber System) ​ Weber A – Below syndesmosis; stable. ​ Weber B – At syndesmosis; variable stability. ​ Weber C – Above syndesmosis; unstable, requires ORIF. Other Ankle Injuries ​ Pilon Fracture – Fracture of distal tibia from high-impact trauma. ​ Maisonneuve Fracture – Fibular fracture + medial malleolus damage. ​ Tillaux Fracture – Adolescent growth plate injury. Ankle Arthrodesis (Fusion) ​ Indicated for severe pain or deformity. ​ Requires 6-12 weeks NWB. Assistive Devices for Ankle Injuries ​ Walking casts. ​ Rigid sole shoes. ​ Air casts. Part Two OT Role in Orthopedic Rehabilitation ​ Restore maximal body and limb function to aid occupational functioning. ​ Reduce pain, anxiety, swelling, and inflammation. ​ Assist with wound care, joint alignment, and functional recovery. ​ Teach patients safe task performance while protecting the injury site. Shoulder Complex & Rotator Cuff Challenges in Rehabilitation ​ The shoulder is unstable and complex due to its multi-joint structure: ○​ Glenohumeral Joint ○​ Scapulothoracic Joint ○​ Sternoclavicular Joint ○​ Acromioclavicular Joint Rotator Cuff Function ​ Supraspinatus: Abduction ​ Infraspinatus & Teres Minor: External Rotation ​ Subscapularis: Internal Rotation ​ Overall Function: Stabilizes humeral head within the glenoid fossa. Rotator Cuff Tear (RTC) Treatment Options  1.​ Conservative Management – Orthotherapy, corticosteroid injections. 2.​ Surgical Repair – Open, arthroscopic, tendon-to-tendon, or tendon-to-bone. Surgical Candidates ​ 1 year). ​ No trauma history, smoker, multiple steroid injections, osteoporosis. Shoulder Arthroplasty (Replacement) ​ Goal: Restore pain-free movement for ADLs. ​ Indications: ○​ Severe fractures, avascular necrosis, arthritis (OA/RA). ​ Rehabilitation Protocol: ○​ 0–6 weeks: No resisted/active internal rotation, avoid lifting. ○​ 6–12 weeks: Strengthening with therabands. ○​ 12+ weeks: Passive ROM, strength training. Reverse Total Shoulder Replacement ​ Indications: Irreparable RTC tear, GH arthritis, instability, failed replacements. ​ Contraindications: Nonfunctional deltoid, neurological impairments (e.g., Parkinson’s). Elbow & Wrist Injuries Common Fractures 1.​ Olecranon Fractures (elbow). ○​ Fixed with screws & tension bands or plate fixation. 2.​ Colles’ Fracture (distal radius, wrist). ○​ Caused by FOOSH (Fall on Outstretched Hand). ○​ Treated with casting or ORIF (Open Reduction Internal Fixation). 3.​ Scaphoid Fracture: ○​ Can mimic a sprain. ○​ Poor healing due to limited blood supply. ○​ Requires thumb spica cast (6-8 weeks) or surgery (if displaced >1mm). Back Conditions Common Disorders 1.​ Degenerative Disc Disease (DDD) ○​ Aging process → discs dehydrate, lose flexibility. ○​ Symptoms: Pain, stiffness, limited mobility. ○​ Treatment: Physical therapy, surgery (if severe). 2.​ Herniated Disc ○​ Disc bulge compresses spinal nerves. ○​ Symptoms: Pain, numbness, weakness. ○​ Treatment: Non-surgical (exercise, body mechanics) or surgery (laminectomy, discectomy). 3.​ Spinal Stenosis ○​ Narrowing of the spinal canal, compressing nerves. ○​ Symptoms: Back pain, sciatica, leg weakness. ○​ Treatment: Physical therapy, cortisone, NSAIDs, or surgery. 4.​ Scoliosis/Kyphosis/Lordosis ○​ Abnormal spinal curvature. ○​ Can cause respiratory issues, heart compression. ○​ Treatment: Bracing, surgery (grow rods, spinal instrumentation). Low Back Pain & OT Role Common Causes ​ Poor posture, prolonged sitting, lifting mechanics. ​ 90% recover within 6 weeks, 1% develop chronic pain. OT Treatment Approaches ​ Acute: Encourage activity, early return to work. ​ Chronic: Graded exercise (yoga, aquatic therapy), ADL resumption, CBT, body mechanics education. Body Mechanics & Safety ​ Prolonged standing: Place one foot on a stool. ​ Bending: Bring body closer to task. ​ Sitting: Use armrests, avoid deep seats. ​ Lifting: Knees bent, spine straight, hold objects close. ​ Carrying loads: Keep balanced, use strollers for children. Spinal Fractures ​ Causes: Trauma, osteoporosis, tumors.  ​ Treatment: ○​ Non-Surgical: TLSO brace, cervical collar. ○​ Surgical: ORIF (plates, wires, screws). Post-Surgical Precautions ​ No lifting >5-10 lbs. ​ No twisting/bending: Use log rolling, adapted tools. ​ No prolonged sitting: Take breaks. ​ No high-impact activities. Osteoporosis & OT Role ​ 2 million Canadians affected. ​ Risk factors: Aging, estrogen loss, poor diet, inactivity. ​ OT Interventions: ○​ Fall prevention (home safety, footwear, grab bars). ○​ Weight-bearing exercises to strengthen bones. ○​ Education on proper posture & risk identification. Falls & OT Prevention Strategies ​ 1/3 adults (65+) fall yearly. ​ Falls are NOT a normal aging process. ​ 90% of hip fractures in seniors caused by falls → 20% die within a year. ​ Preventative Measures: ○​ Environmental: Remove rugs, improve lighting. ○​ Activity-based: Encourage balance training. ○​ Personal: Wear non-slip shoes, proper assistive devices. Osteogenesis Imperfecta (OI) ​ “Brittle Bone Disease” → Collagen synthesis disorder. ​ Symptoms: Frequent fractures, short stature, blue sclera, respiratory issues. ​ Types: 1.​ Type I: Most common, mild, fractures before puberty. 2.​ Type II: Fatal, severe skeletal deformities. 3.​ Type III: Fractures at birth, short stature. 4.​ Type IV: Moderate, fractures before puberty. OT Role in OI ​ Prevent fractures via activity modifications. ​ Surgical treatment: IM rods for bone stability. Key Takeaways for OT in Orthopedics  1.​ Know precautions, activity orders, and movement restrictions. 2.​ Understand your patient's condition, lifestyle, and needs. 3.​ Assess and adapt the environment for safety and function. 4.​ Guide patients through a day-in-the-life approach to restore independence. Amputation Lower Extremity Primary Causes of Amputations ​ Vascular Disease (leading cause) ​ Burns ​ Trauma ​ Frostbite ​ Cancer ​ Congenital abnormalities ​ Infections Specific Causes Buerger’s Disease ​ Thromboangiitis obliterans: Intermittent vascular inflammation. ​ Onset typically in the 3rd-5th decade of life. ​ Starts distally in UE and/or LE. ​ Smoking cessation halts disease progression. Diabetes Mellitus & Amputations ​ Diabetics often develop foot disease: ○​ Diabetic Peripheral Neuropathy (DPN) ○​ Atherosclerotic Peripheral Artery Disease (PAD) ○​ Cellulitis ○​ Osteomyelitis ​ Diabetes contributes to 70% of non-traumatic amputations. ​ 15-25% of people with diabetes will have foot ulcers. ​ Diabetic foot ulcers caused by: ○​ Impaired sensation ○​ Structural abnormalities ○​ Poor blood flow to injured areas Statistics on Amputations ​ Most common cause: Dysvascular disease (97 per 100,000 hospital discharges). ​ Trauma-related amputations: 31 per 100,000. ​ Cancer-related amputations: 3 per 100,000. Levels of Lower Extremity (LE) Amputations 1.​ Hemipelvectomy – removal of half the pelvis and entire leg. 2.​ Hip Disarticulation – removal at the hip joint. 3.​ Transfemoral (Above Knee) Amputation. 4.​ Van Ness Rotationplasty (rotation of lower leg). 5.​ Knee Disarticulation/Through Knee Amputation. 6.​ Transtibial (Below Knee) Amputation. 7.​ Syme’s (Ankle Disarticulation). 8.​ Partial Foot Amputation: ○​ Ray Resection (Toe). Functional Impact by Level ​ Ray Resection: Affects balance, endurance, righting reactions. ​ Syme’s Amputation: ○​ Initially non-weight-bearing. ○​ Uses prosthesis for longer distances. ​ Below Knee Amputation (BKA): ○​ Most common LE amputation. ○​ Post-op: Non-weight bearing, requires walking aid. ○​ May or may not need a long-term walking aid. ​ Above Knee Amputation (AKA): ○​ Requires walking aid. ○​ May suspend work for 3-6 months. ○​ Wheelchair needed for mobility. Post-Surgical & Pre-Prosthetic Considerations Edema Management ​ Rigid Dressings ​ Residual Limb Wrapping (Tensor Bandages) ​ Elastic Tubular Bandages ​ Shrinker Socks ​ Alpha Liners Postoperative Therapy Goals ​ Promote wound healing. ​ Manage phantom pain. ​ Maintain joint ROM. ​ Adjust body image perception. ​ Educate on edema management. Pre-Prosthetic Therapy Goals ​ Shape residual limb. ​ Desensitize residual limb. ​ Maintain joint ROM. ​ Educate on hygiene. ​ Maximize functional independence. Prosthetics Below Knee Prosthesis ​ Standard socket, liner, pylon, and foot components. Above Knee Prosthesis ​ Types of Knee Prostheses: 1.​ Single Axis - Locked Knee: Best for stability, locks in extension. 2.​ Single Axis – Free Knee: Lightweight, no automatic locking. 3.​ Polycentric Knee: Multiple axes, shortens during swing phase. 4.​ Hydraulic Knee: Allows for variable gait speeds. 5.​ Microprocessor Knee: Uses sensors for natural gait pattern. Osseointegration ​ Direct prosthesis attachment to the bone. ​ No need for sockets. ​ Improves mobility. Mobility & Wheelchair Considerations ​ Bilateral Below Knee Amputations: ○​ Transfers are primary focus. ○​ Prosthesis takes more energy. ​ Manual Wheelchair Considerations: ○​ Seat-to-floor height and hanger angle impact comfort. ○​ Anti-tipper rollers prevent backward falls. ○​ Amputee board prevents knee contractures. Impact on Daily Life Driving Considerations ​ Right Below Knee Amputees: Require modifications: ○​ Left-foot accelerator. ○​ Driving with left foot.  ○​ Driving with a prosthesis (if safe). ​ Right Above Knee Amputees: ○​ Cannot drive using prosthesis. ○​ Must use left-foot accelerator. ​ Legal Requirement: Notify Alberta Transportation and take a road test. Activities of Daily Living (IADLs) ​ Struggle with housekeeping, meal prep, snow removal. ​ May need temporary supports. Body Image & Sexuality ​ Common emotional challenges. ​ Some avoid looking at their amputated leg. ​ Pillows help with residual limb comfort during intimacy. Return to Work ​ Sedentary jobs allow for easier transition. ​ Job modifications may be necessary. Leisure & Sports ​ Running, swimming, skiing, and skating prosthetics available. ​ Staying active is encouraged. Travel Considerations ​ Extra planning required. ​ Longer time at airport security. ​ Request more legroom on flights. Key Takeaways ​ Vascular disease is the primary cause of LE amputations. ​ Higher amputation levels have greater functional impacts. ​ Pre-existing medical conditions affect rehabilitation outcomes. ​ Prosthetic advancements are improving mobility and independence. Amputation Upper Extremity