sub-acute case studies.docx

Case Study 1: LSF ================= Summary of case --------------- - 70 year old admitted for L1-L3 LSF - L1-L2 compression fracture with a retro pulsed fragment causing a 20% canal compromise - Chronic degenerative changes were noted - Previously independent - Stairs at home →...

Case Study 1: LSF ================= Summary of case --------------- - 70 year old admitted for L1-L3 LSF - L1-L2 compression fracture with a retro pulsed fragment causing a 20% canal compromise - Chronic degenerative changes were noted - Previously independent - Stairs at home → teach how to use crutches - Hip flexion and ABD ROM limited due to P1 - All hip movements present muscle weakness → limited by pain - Walking and transferring to chair reduced hip and trunk extension due to pain → forward lean - Anatomy of surgery ------------------ - L1-L2 compression fracture with a retro pulsed fragment causing a 20% canal compromise - L1-L3 are fused together Day 1 post-surgery precautions ------------------------------ - No lifting more than 2 kgs - No twisting of upper body - No overextending of back - Don't bend past your knees - No prolonged sitting for more than 30 minutes - Limit pushing and pulling - When sitting don't reach forward for things - Non slip shoes - Log roll out of bed - Sit down in shower Bed Mobility → log roll SOEOB ----------------------------- - 1x Mod assist - 4/10 pain performing bed mobility - BRP → bend roll and push - 1x Mod A → assist at hip and shoulder with log roll and SOEOB - Trouble remembering steps so provide video and info card as well as acronym WBAT → FASF ----------- - WBAT essentially means when mobilising you can put as much or as little weight through your lower limbs as you feel comfortable to do so - FASF →will hold you up using your upper limb strength - 1x A due to pain → hand on back and hand on FASF Sit to stand and transfer to chair ---------------------------------- - 1x SB A nil AID - Have them stand up off bed and place arms on FASF - Big sweeping turns to avoid twisting spine Fear Avoidance Behaviours → pain education ------------------------------------------ - Totally understand moving might be scary right now, but gentle movement is actually very important for your recovery. It helps with blood flow, reduces stiffness, and speeds up healing. We can start with some small gentle movements, and I'll be right here to guide you every step of the way. I want you to remember every little bit helps and we won't push you past where you are comfortable. I would never make you do something that would put you in harms way. - Acknowledge fear + reassure gentle movement is safe and beneficial - Helps reduce the risk of blood clots, and prevents stiffness and muscle loss which leads to quicker recovery - Clear instructions → demonstrate movements and give visuals - Gradual progression → SMART GOALS - Address misconceptions → clarify with evidence Exercises --------- - Hip flexion and abduction limited by P1 - All hip movements limited in strength by pain - Glute med and max and quad - Work on ROM and introduce resistance Bed Exercises → anatomy and rationale ------------------------------------- - Ankle pumps and knee bends - Ankle pumps for circulation - Knee bends → hamstrings and quad activation - Lying Hip abduction - Targeting glute med - 3 sets of 10, 3-4 times per day Week 1 post op exercises → anatomy and rationale ------------------------------------------------ - Standing knee raises - Quads, hamstrings and glute complex - Standing hip abduction - Glute med contracting - Adductors on stretch Case Study 2: THR ================= Summary of case --------------- - Previously independent - Does her own cooking, cleaning and shopping - Slightly underweight - WBAT - Resting pain 5/10 - Right sided hip flexion and extension limited by P1 - Hip flexion and extension strength limited due to pain on right side Anatomy of surgery ------------------ - Intracapsular neck of femur fracture - Fracture is on the neck of the femur between the base of the femoral head and above the greater trochanter - Posterior approach to surgery so glute max has been cut Lateral approach is glute med Anterior approach is VMO Day 1 post-surgery precautions ------------------------------ - Hips to 90 - No crossing legs in standing or sitting - Internal + External Rotation of the hip Bed Mobility → SOEOB -------------------- - 1 x Min A → stabilise upper body while going from lying to SOEOB WBAT → FASF ----------- Sit to stand → transfer to chair -------------------------------- - 1x mod A Walking ------- - 1 x mod assist with FASF x 10m Bed Exercises → anatomy and rationale ------------------------------------- - Glute squeezes → for circulation → posterior approach cut through glute muscles - Progression: glute bridge - Regression: lower sets and reps - Knee bends → hip flexion - Progression: standing march - Regression: quad squeeze Week 1 post op exercises → anatomy and rationale ------------------------------------------------ - Standing knee raises - Standing hip extension Case Study 3: RCR ================= Summary of case --------------- - FOOSH injury - 4 months of sick leave from work - Retraction of supraspinatus to the glenoid rim - Anatomy of surgery ------------------ - Full thickness RCT - Open repair surgery - Medium sized incision in the deltoid - Suprspinatus had retracted and was pulled back - Supraspinatus was fixed to the humeral tuberosity using a transosseus suture - Biceps tenodesis Post-surgery precautions ------------------------ - Sling must stay on 24/7 for 6 weeks even during sleep - When showering in first 6 weeks take sling off and arm must stay hanging by side - No pushing, pulling or lifting (no heavy lifting for 4-6/12) - No shoulder extension, horizontal adduction or IR - No overhead motions - No overstretching or sudden movements - No supporting BW through hands or leaning on elbows - Don't sleep on effected side - Keep wound clean and dry → Use shower sling - Use ice to help with swelling and reduce pain - Take prescribed pain medication from medical team - Operated arm into shirt first and operated arm out of shirt first Sling ----- - Abduction sling - 6/52 - Sling while sleeping, when riding in car - Can remove sling when resting or sitting with the arm by side - Remove arm from the sling 3-4 x/day to bend and straighten your elbow and move your wrist and hand Exercises: ---------- +-----------------------------------+-----------------------------------+ | 0-4 Weeks | - Pendulum swings 60s x 3/day | | | | | | - Scapular depression (should | | | feel pinch in rhomboids) → | | | only group to teach this | | | | | | - Scoop and bring shoulder | | | blades down and back | +===================================+===================================+ | 5-8 Weeks | - Using dowel or clasp hands | | | together | | | | | | - AAROM SH Flexion to 90° | | | | | | - AAROM ER to 55° | | | | | | - AAROM ABD 90° | | | | | | Progress with ROM → P1/R1 as main | | | determinant | | | | | | ROM exercise 3-4 x /day | +-----------------------------------+-----------------------------------+ | 6-8 Weeks | - Can come out of sling | | | | | | - Can do active movements | | | onwards | | | | | | - AAROM IR (passing ball around | | | back) | | | | | | - AROM SH flexion 0-90deg | | | | | | - Looking for hikinh, | | | compensatory side | | | flexion, excessive upward | | | rotation of the scapula | | | | | | - AROM SH abduction 0-90 | | | | | | - Or can do hand crawls up | | | the wall to 90° | +-----------------------------------+-----------------------------------+ | 9 Weeks | - Can do some resisted | | | exercises | | | | | | - Can still do physio PROM | | | | | | - Can still do AAROM | | | | | | - Exercises -- isometric | | | | | | - ER 45s | | | | | | - Flexion 45s (punching | | | wall) | | | | | | - Abduction (lead with | | | elbow out towards wall) | | | | | | - Extension (facing away | | | from wall with elbow bend | | | at 90° and elbow pushing | | | againt wall) | +-----------------------------------+-----------------------------------+ | 10 Weeks | - Low rows → therapband row or | | | abducted at 45° row | | | | | | - Keep doing till 12 weeks | +-----------------------------------+-----------------------------------+ | 12 Weeks -- 16 | - Resisted exercise in all | | | directions | | | | | | - Continue with theraband in | | | ER, ABD (straight arm or bent | | | elbow), Flexion (yellow band | | | only with long lever arm -- | | | if increasing theraband | | | strength shorten lever arm) | | | | | | - Day to recover, 3x per week | | | | | | - Strength exercise prescribed | | | 2 sets once | +-----------------------------------+-----------------------------------+ | 16+ | - Elevated push up | +-----------------------------------+-----------------------------------+ - Retraction of supraspinatus to the glenoid rim Case Study 4: ACL Reco ====================== Summary of case --------------- - 17 year old with ACL - In year 12 - Bus to school → 5 minute walk to bus stop and then a 10 minute walk to school - Parents will drive him for the first 2 weeks - Return to AFL in 8 months Anatomy of surgery ------------------ - Patella tendon graft - Meniscus horizontal tear debrided → damaged part of meniscus was removed - Bone bruising on the tibial plateau and medial femoral condyle Day 1 post-surgery precautions ------------------------------ - Keep incision sites clean and dry - Reduce pain → ice packs and cryotherapy → 2-3 times per day for 20 minute and after exercises - Rest → only 1-2 coffee walks per day → try not to overload it in initial phase - Regain knee extension and flexion asap - Reduce swelling → mobility of joint Quadricep activation - Elevating leg - ROM - extension is a priority → quicker extension is regained the quicker gait pattern will return to normal as ext is reduced in standing up, static standing and walking stance phase - aiming to get to 70-90° of knee flexion in 5 days → knee flexion reduced in swing phase of walking Bed Mobility → SOEOB -------------------- - 1 x Mod A → cannot straight leg raise or abduct leg - Sit up - Bend good leg with operated leg closest to edge of bed - Instruct patient to push through foot of good leg and hands to shuffle to the edge of the bed - Support the patients leg above and below the knee - Ask the patient to pivot around using their hands and good leg while you support their operated leg STS --- - 1x SB assist with e/c - Sit on edge of bed and place your good leg back towards to bed with your op leg out in front - With both crutches in one hand push off the bed with your other hand and the crutches - Then balance yourself and put the crutches one in each hand WBAT → e/c ---------- - Weight bearing as tolerated essential means you we want you to put as much weight through your operated leg as you feel comfortable doing - Step too - Place crutches about a shoe length distance in front of you - Step forward with your operated leg and then bring your good leg to meet it - and continue those steps - to progress place crutches forward and step with operated leg at the same time and then meet with good leg - Step through - Place crutches out in front of you at the same time as your operated leg - Think of your crutches as magnitised to your opterated leg. where ever you put your operated leg the crutches follow - Then with your good leg instead of meeting your operated leg take a normal step through the crutches. Stairs e/c → hasn't been assesses --------------------------------- - Good leg to heaven bad leg to hell - The easiest way to remember is by using above saying and think of your crutches as magnetic to your operated leg. where every your operated leg goes so do your crutches Bed Exercises → anatomy and rationale ------------------------------------- - Quad contraction → towel under knee and push down into towel - Progression: inner range quad exercise → towel under knee, push down into towel aiming to lift ankle off the bed hold for a few seconds then relax and repeat - Regression: - Knee slides → - Progression: resisted knee flexion in prone - Regression: ankle pumps - Calf raise Week 1 post op exercises → anatomy and rationale ------------------------------------------------ Patella tendon graft -------------------- - Strength program - Bone bruising → will heal by itself Return to AFL advice -------------------- - I understand you want to return to AFL by the start of next season which is 8 months away. - We will do everything we can to get you ready for return to play but you need to understand that it is recommended post ACL reconstruction to take 9 months before returning to play. You should be able to return to sports specific exercises and tailered training by the start of the season but we will reassess closer to that