Lecture 2 - Ortho 2025 PDF

UE Orthopedic Conditions and OT Interventions Glyn Murgatroyd, BScOT, BPE  Learning Objectives  Describe examples of frequently seen UE orthopedic conditions throughout the lifespan  Understand the functional impact of common orthopedic conditions of the UE  U...

UE Orthopedic Conditions and OT Interventions Glyn Murgatroyd, BScOT, BPE  Learning Objectives  Describe examples of frequently seen UE orthopedic conditions throughout the lifespan  Understand the functional impact of common orthopedic conditions of the UE  Understand the role of occupational therapists in the assessment and treatment of orthopedic conditions  Overview  OT role in orthopedics  Basics of OT and orthopedics (What do I do?)  Know the PRECAUTIONS, MOVEMENT RESTRICTIONS, ACTIVITY ORDERS  Know your PATIENT  Know the ENVIRONMENT  OT Role in Orthopedic Rehabilitation  “Help the patient achieve maximal function of body and limb to restore occupational functioning” (Radomski & Trombly , 2008, p.1107)  Help relieve pain and anxiety, decrease swelling and inflammation, assist in wound care, maintain joint and limb alignment, restore function at the injury site  Teach patient to safely perform tasks and activities while protecting the injury site for healing  Shoulder Considered the most challenging part of the body to rehabilitate  Unstable  Complex Shoulder complex  gelnohumeral joint  scapulothoracic joint  sternoclavicular joint  acromioclavicular joint Maher and Bear-Lehman, 2008 Shoulder Movement - Flexion Shoulder Movement - Abduction  Shoulder Complex Rotator Cuff Review  Supraspinatus = shoulder abduction  Infraspinatus and Teres Minor = external rotation  Subscapularis = internal rotation  Together they control the humeral head in the glenoid fossa and stabilize the shoulder complex Maher and Bear-Lehman, 2008  SUPRASPINATUS INFRASPINATUS TERES MINOR THE ROTATOR CUFF  THE ROTATOR CUFF SUBSCAPULARUS S I T Shoulder Mechanics  Rotator Cuff Tear Treatment Options  Conservative Management  Orthotherapy  Sub-acromial Corticosteroid Injections  Surgical Repair  RTC – Surgical Candidates  Patient physiologically younger than 60  Failure to improve with non-operative measures for a minimum of 6 weeks  Full passive ROM  Diagnosed full thickness tear using clinical assessment and/or diagnostic imaging  Needs to use shoulder functionally overhead  Poor Candidates for RTC Surgery  Over 60 y/o  Longstanding history of RTC tear (> 1 year)  No history of trauma  Smoker  Multiple steroid injections  Diffuse osteopenia or osteoperosis  Rotator Cuff Surgery  Can be open or arthroscopic or combination  Tendon → Tendon or Tendon → Bone Photo: UMass Memorial Health Care (2018) RTC Care Path Neer Classification of Shoulder Fractures Photo courtesy of American Family Physician  Shoulder Arthroplasty Goal:  A shoulder that has adequate amount of movement and strength to allow for functional independence in ADLs  Typically, more for pain control with some functional improvement Total or Hemi Arthroplasty Less common than hip/knee arthroplasty Reasons for arthroplasty:  Severe fractures  Avascular necrosis  Osteoarthritis/rheumatoid arthritis American Academy of Orthopedic Surgeons Shoulder X-Ray Hardware  Rehabilitation 0-6 weeks CONTRAINDICATION  No resisted or active INTERNAL ROTATION  No lifting anything heavier than a dinner plate Isometric shoulder exercises except for INTERNAL ROTATION Pendular exercises Alberta Health Services Protocol  Rehabilitation 0-6 weeks AROM for hand/elbow Active Assisted ROM (AAROM)  ex. Cane exercises  Flexion/extension/internal rotation/external rotation  Progress to AROM except for IR SLING: worn at night or for comfort Alberta Health Services Protocol  Rehabilitation: 6-12 weeks No lifting anything heavier than a dinner plate No movement restrictions  ROM progress limited by pain Internal Rotation  Gentle AROM can start Strength exercises  Resisted with theraband/tubing  Rehabilitation: 12+ weeks Passive ROM as indicated by the orthopedic surgeon Strength  Resisted internal rotation (theraband/tubing)  Case Study 45 year old woman, underwent a shoulder arthroplasty on her dominant side 1 week ago and it is your role to teach one- handed functional tasks Consider ADLs the patient will need OT intervention with  Dressing  Sleeping  Meal Preparation  Eating  Grooming  Bathing  Home safety  General (productivity/leisure)  Dressing Shirts with front closures best  dress operated arm first, undress it last Elastic waist pants Bra Buddy or Sports bra Slip-on shoes Button hook Keep ties knotted/zippers connected , loosen and slip over head What if your patient wears…  Sleeping Patient will sleep with sling on Sleep on back with pillow under arm for support Reclining chair may be a good option; consider which side the recline lever is on  Eating Rocker knife Dycem under the plate ® Easy to cut foods  Meal Preparation Choose meals that do not require food to be cut Pre-made frozen meals that can easily be reheated Dycem under cutting board ® Adapted Cutting Boards/Devices  Grooming Pre-strung flossers Low-maintenance hair style Hold toothbrush in mouth/place on counter to place toothpaste Pump toothpaste/flip lid Electric brush  Bathing May need a bath seat if weak post surgery d/t fall risk Shampoos/soaps with pumps May need assistance to wash non-operated arm  Home Safety Remove throw rugs and tripping hazards, little pets! May need to install handrails for non-operated arm to use  Other Considerations Computer use Emails/text on phone Leisure interests Driving  Orthopedic OT Basics Know your precautions, activity orders, and movement restrictions  FWB, WBAT, FeWB, NWB  Bed rest, bathroom privileges, AAT  Movement restrictions (ex. hip precautions, spinal precautions)  Will the bone be immobilized for healing? How? Wear and care?  Cast, braces, slings, TLSO, collar  Orthopedic OT Basics Get to know your patient  Your assessment  Occupational history what occupations does the pt engage in?  Social history what supports does the pt have at home?  Patient reliability cognition compliance  Orthopedic OT Basics Know your environment  Assess environmental needs/demands  Where will the patient be discharged to?  What equipment might be needed  What environments will the pt be in  School? Office? Seniors Centre? Reverse Total Shoulder Replacement Photo credit: OrthoInfo https://orthoinfo.aaos.org  Reverse Total Shoulder Replacement  Contraindications:  Nonfunctional deltoid muscle  Severe neurologic deficiencies (i.e. Parkinson’s Disease)  Refusal to modify postoperative physical activities  Indications:  Irreparable RTC tear associated with glenohumeral arthritis  Irreparable RTC tear associated with glenohumeral instability  Failed hemiarthroplasty or total shoulder replacement associated with rotator cuff deficiency Reverse Total Shoulder Replacement Matsen F, A, III, Warme, W. J. 2017  Elbow Injuries  Olecranon Fractures  Radial Head Fractures  Elbow Dislocations  Coranoid Fractures  Monteggia Fracture Olecranon Fractures Screw and Tension Band Wire Fixation Plate Fixation Wrist Fractures  Colles Fracture  Transverse fracture of the distal radius  Caused by extending the hand to decrease the impact from a fall  Tip of the ulna may also be fractured  Treatment: casting or ORIF  Scaphoid Fracture  Occurs due to a fall onto an outstretched hand - axial load across hyper-extended and radially deviated wrist  Symptoms: pain and tenderness in the area just below the base of the thumb  No visible deformity and no difficulty with motion, many people with this injury assume that it is a wrist “sprain.”  Scaphoid Fracture  Challenging to heel due to limited blood supply and fracture often disrupts the blood flow  Treatment options:  Non-operative  thumb spica cast immobilization – 6-8 weeks +  Operative  if displacement is > 1mm  ORIF  Bone Grafting  Proximal Row Carpectomy  Scaphoid Fractures Singh et al. 2012 Classification of Finger Fractures Photo courtesy of Curso ENARM 2017  Back Conditions Back pain  One of the most common chronic diagnosis  4/5 adults will experience back pain at one point in their lives (WHO, 2003)  Higher risk 30 to 50 years old  Male = Female  Acute pain > chronic pain Treatment  Medication; pain and muscle relaxant  Ice vs heat  Mobilize http://www.statcan.gc.ca/  Degenerative Disc Disease Disc  Allow spine to flex  Shock absorption Not a disease Normal changes in the spinal discs with age  Discs dehydrate and become stiff and rigid  Lose their shock absorbing qualities  Restrict movement Most commonly found in people who do heavy lifting or misuse their backs repetitively Highsmith, Walker & Hawkinson  Degenerative Disc Disease Herniated Disc  Part of the disc pushes through towards the spinal canal, compressing the spinal nerves  Pain, numbness, weakness  Non-surgical  Gentle physical activity  Education: body mechanics  Surgical  Laminectomy and Discectomy  Lamina is removed then the herniated disc fragment is removed  Back Conditions Spinal Stenosis  Narrowing of spinal canal Causes  Degeneration  Bone growth (wear and tear)  Herniation  ligament thickening  Tumors  spinal injuries  Spinal Stenosis Symptoms d/t compression on cortico-spinal tract  Back pain  Sciatica  Leg weakness and foot drop  Numbness/tingling down the legs  Non-surgical interventions  Stretching and strengthening, cortisone, NSAIDS, acupuncture, chiropractic  Surgical Interventions  Laminectomy/decompression  Spinal fusion American Association of Orthopedic Surgeons  Scoliosis/Kyphosis/Lordosis Abnormal spine curvature creating an unlevel shoulder and pelvic position  Congenital  Improper formation of the vertebrae (misshapen)  Adolescent Idiopathic  Spine begins to twist in adolescence  Acquired If uncorrected, curve increases  Back pain  Decreased lung volume  pneumonia  Heart compression Scoliosis Research Society  Scoliosis: Surgical Treatment 3 phases  Observation  Assess the curve as the pt grows  Bracing (TLSO)  Prevents the curve from progressing  Surgery  Bracing ineffective  Grow Rods/VEPTRs  Spinal Instrumentation Scoliosis Research Society  Low Back Pain 80% of adult population (WHO, 2003) Most common cause : postural stress  Poor sleeping posture  Poor sitting posture  Lifting/reaching with rounded back  Prolonged standing/sitting 90% of pts return to work (RTW) within 6 weeks 1% develop chronic back pain  6 months to RTW McKenzie, R. (2005) Hu et al (2003)  OT Role in Low Back Pain Proven Treatments (Acute)  Advise patient to stay active  Advise early RTW Proven Treatments (Chronic)  Graded exercise program (yoga, aquatic)  Graded resumption of ADL and IADLs  Cognitive Behavioral Therapy  Progressive muscle relaxation  Education re: body mechanics Guideline for the Evidence-Informed Primary Care Management of Low Back Pain (2011)  Low Back Pain: Body Mechanics Good body mechanics  reduces the loads and stressors on the spine in various positions or when moving objects.  avoid compressing and twisting of the spine  avoid exert force in positions that poorly support the spine.”  Low Back Pain: Body Mechanics Prolonged Standing Activities such as brushing teeth, washing dishes, cooking)  Place one foot on a shelf under the sink or stool to create posterior pelvic tilt Mayer & Bear-Lehman (2008)  Low Back Pain: Body Mechanics Bending/Reaching tasks Activities such as sweeping, vacuuming  Teach pt to move body closer and reach less  Walk with the broom rather than reaching with it  For vacuum cleaning put the hose around your waist Mayer & Bear-Lehman (2008)  Low Back Pain: Body Mechanics To sit  Teach pt to flex at the knees and hips, not the spine  Reach back towards armrests for transitional support  Raised seat may be helpful  requires less muscle power than sitting on a low surface, which stresses the back  Slightly reclined posture helpful for prolonged sitting  Ergonomic modifications to seated workspace Mayer & Bear-Lehman (2008)  Low Back Pain: Body Mechanics Lifting objects from floor  Light object  Pt squats to floor while keeping back straight and maintaining posterior pelvic tilt  Heavy object  Half-kneeling to the body is close to and facing object, knee pushes body up, both knees extend  Keep object’s mass close to pts centre of gravity  Lift to a height, put object down to rest, pick up again to carry Mayer & Bear-Lehman (2008)  Low Back Pain: Body Mechanics Carrying loads  Light loads  Balanced loads  Close to the pts centre of gravity  Place children in strollers  Front/back baby carrier Mayer & Bear-Lehman (2008)  Spinal Fractures Caused by  Trauma  Osteoporosis  Tumor Flexion, extension, rotation, burst fracture pattern If unstable, could cause spinal cord injury American Association of Orthopedic Surgeons  Spinal Fractures  Non surgical  Flat bed rest  TLSO  Philadelphia Collar  Surgical  ORIF: Plates, wires, screws  Back Restrictions and Precautions No lifting, pushing or pulling objects over 5-10 lbs  Keep frequently used items on counter tops  Slide heavy items along counter tops  Unload unnecessary objects from backpacks, purses  Take multiple trips to carry in groceries  Assistance with laundry (Back Guide, Alberta Health Services)  Back Restrictions and Precautions No Twisting  Toileting  Adapted devices or tongs for wiping  Bed mobility  Log rolling  No Driving  Unable to shoulder check  Bathing  Step into tub, then sit on stool  Back Restrictions and Precautions No spinal forward flexion, side flexion, extension  Dressing  Sit and cross ankle over knee for LE dressing  Long handled reacher, sock aid, long handled shoe horn, elastic shoe laces  Toileting  Bath seat, toilet arm rests, raised toilet seat  Caution with overhead work  Light house work  Allow more time for completion of ADLs  Back Restrictions and Precautions Avoid straight leg lifts  Places excessive strain on the back  Back Restrictions and Precautions Avoid activities that will jar the back  No contact sports  Avoid crowded areas where may be jostled  Modify sexual activity  Back Restrictions and Precautions Avoid staying in one position for too long  Graded return to work/school  Take movement breaks  Avoid long car rides Back Restrictions and Precautions  General Safety Remove clutter/ throw rugs in the home Use handrails when ascending/descending stairs Ensure shoes on securely  Osteoporosis ~2 million Canadians have osteoporosis  Loss of bone mass  1/3 women 1/5 men  Start at any age  Asymptomatic – silent thief Menopausal women  Estrogen no longer produced  Osteoporosis Occurs when bone is being broken down faster than it can be replaced  2 types  Primary  Post-menopausal women  Secondary  Young and middle aged people  Medications (corticosteroids)  Anorexia Nervosa (malnutrition)  Too much exercise amenorrhea  Osteoporosis Risk increases  Drop in estrogen after menopause  Family history  Body type  small, thin-boned  Lifestyle factors  Smoking  Excessive drinking  Lack of exercise  Weight bearing encourages osteogenesis  Lack of calcium and vitamin D  Important components of bone  Osteoporosis: OT role Education  Falls prevention  Personal  Environmental  Activity based  Safety precautions  Teach patients to identify risk and problem solve  Encourage exercise  Weight bearing  Muscle strengthening Randles, N., Randolph, E., Schell, B., Grant, S. (2004) Opp Hofmann (2009)  Falls Statistics in Canada 90% of all hip fractures in seniors o 20% die within a year of the fracture Can cause a loss in confidence  Resulting in a decrease of activities  which can lead to a decline in health and function  contribute to future falls with more serious outcomes A 20% reduction in falls - > ~ 7,500 fewer hospitalizations and 1,800 fewer permanently disabled seniors.  The overall national savings could amount to $138 million annually Public Health Agency of Canada (2005)  Falls 1/3 adults over the age of 65 falls each year Falls are not part of the natural aging process Most fall are preventable Falls and osteoporosis -> high risk of fractures Opp Hofmann (2009)  Osteogenesis Imperfecta “Imperfectly formed bone” Body is unable to make strong bones  Disorder of collagen synthesis  Type 1 collagen not formed properly Hereditary or genetic defect is a spontaneous mutation Type 1 collagen also present in ligaments, teeth, sclera of the eyes (all fragile!)  Osteogenesis Imperfecta Clinical presentation can include short stature, frequent fractures, respiratory problems, may or may not have blue sclera Fractures heal but with abnormal bone  Osteogenesis Imperfecta 4 types, based on onset of fractures  Type 1  Most common and most mild – Type 1 collagen present but in small quantities. fractures occur before puberty. Blue Sclera.  Type 2  Fatal– abnormal collagen structure. Do not survive beyond birth.  Type 3  Fractures are usually present at birth. Short stature. Born with multiple fractures, even skull fractures.  Type 4  Fractures occur before puberty. Incidence of fractures decreases as child ages but bones may weaken again with menopause or old age  Treatment OTs main role is to prevent fractures  Activity analysis to identify safety risks, reduce potential for injury  Provide activity modifications Frequent surgical interventions  IM rods for bone stability  OT treats post operatively for environmental modifications, task modifications, positioning  Summary There are an unlimited number of orthopedic conditions, surgical procedures As the OT:  Know your precautions, activity orders, movement restrictions  Know your patient  Know your patient’s environment As OTs, your role is to problem solve through a day in the life of your patient to restore occupational functioning  References Alberta Health Services. Back Guide. Guideline for the Evidence-Informed Primary Care Management of Low Back Pain (2nd ed) (2011). Institute of Health Economics, Alberta, Canada. Retrieved Feb 7, 2013 from http://nationalpaincentre.mcmaster.ca/documents/LowerBackPainGuideli neNov2011.pdf Highsmith, J.M., Walker, K.A., Hawkinson, N.V. Degenerative Disc Disease Centre. Retreived Feb 9, 2013 from http://www.spineuniverse.com/conditions/degenerative-disc-disease. Hu, S.S., Tribu, C.B., Tay, B.K., & Carlson, G.D. (2003). Disorders, injuries, and diseases of the spine. In H.B.Skinner (Ed.) Current diagnosis and treatmtment in orthopedics (3rd ed, pp. 228-231). New York: Lange Medical Books/McGraw-Hill. McKenzie, R. (2005). Treat your own back (7th ed). New Zealand: Spinal Publication  References Matsen F.A. III, Warme W. J. (2017) Reverse Total Shoulder or Delta Shoulder for Shoulder Arthritis Combined with Massive Rotator Cuff Tear and for Failed Conventional Total Shoulder Replacement. Shoulder & Elbow Service, University of Washington Department of Orthopaedics and Sports Medicine. Singh. H.P., Dias J. J. (2011) Focus on Scaphoid Fractures. British Editorial Society of Bone and Joint Surgery. Shoulder Replacement Guidebook, Dartmouth-Hitchcock Medical Centre. Retrieved Feb 7, 2013 from http://patients.dartmouth- hitchcock.org/documents/shoulder_replacement_guide.pdf. Tan, V., Leggin, B.J., & Williams, G.R. (2002). Surgical and post-operative management of the rheumatoid shoulder. In Rehabilitation of the hand and upper extremity (5th ed., pp. 1608-1623). St Louis, Mosby.  References Ogiela, D., Zieve, D. (2012) Spinal Stenosis. A.D.A.M Medical Encyclopedia. Retrieved Feb 9, 2013 from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001477/. Opp Hofmann, A. (2009) Preventing falls with occupational therapy. AOTA. Retrieved Feb 11/13 fromhttp://www.aota.org/Consumers/Professionals/WhatIsOT/PA/Article s/41100.aspx. Public Health Agency of Canada (2005). Report on Seniors Falls in Canada. Retrieved on Feb 11, 2013 from http://publications.gc.ca/collections/Collection/HP25-1-2005E.pdf Radomski, M.V., Trombly Latham, C.A. (Eds.). (2008). Occupational Therapy for Physical Dysfunction (Sixth Ed.). Baltimore, MD: Lippincott, Williams & Wilkins.  References Randles, N., Randolph, E., Schell, B., Grant, S. (2004).The impact of occupational therapy intervention on adults with osteoporosis. Physical and Occupational Therapy in Geriatrics. 22(2), pp. 43-56. Scoliosis Research Society. www.srs.org. Retrieved Feb 9, 2013. Tetreault, P., Ouelette, H. (2009). Orthopedics Made Ridiculously Simple. Miami, FL: Medmaster Inc. Weleschuk, C (2014). Orthopedic Conditions and OT Interventions power point presentation. World Health Organization (2003). WHO Technical Report Series. The burden of musculoskeletal conditions at the start of the new millennium. Geneva: World Health Organization.