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Assisting From Supine to Sitting Additional strategies: Fig. 10-2 and 18 Lateral Scooting in Sitting •Used for repositioning toward head of bed (HOB) before lying down •Good strengthening exercise in sitting, or trunk weight-shifting training •Good “pre-transfer” training – a component of lateral...

Assisting From Supine to Sitting Additional strategies: Fig. 10-2 and 18 Lateral Scooting in Sitting •Used for repositioning toward head of bed (HOB) before lying down •Good strengthening exercise in sitting, or trunk weight-shifting training •Good “pre-transfer” training – a component of lateral seated transfers 1. Position ipsilateral leg/foot laterally to prepare to receive weight 2. Abduct the arm with the hand (or fist) on bed (+space to shift hips). 3. Push down with both hands (or fist), lean head and trunk forward, lift hips up and shift laterally. Fig. 10-21 Clinical Pearl: Level of Assistance Application of Mobility Strategies: ▪Min Assist (75-25%) o the patient is able to initiate most of the movement o focus to guard the involved, weakened, and/or painful limb or site. ▪Mod Assist (50-50%) o Therapist will require to provide multi-point assistance or guarding to ensure patient safety and prevent falls or unsteadiness or worsening of pain ▪Max Assist (25-75%) o break down to assist one body part at a time ▪Always try to incorporate verbal, tactile, and visual cues to promote patient learning and subsequent independence Special Considerations IN THIS CLASS: IN FUTURE CLASSES: 1. (No particular precautions) 7. Sternal Precautions 2. Spine Precautions & Protection 8. Move-in-the-Tube 3. Abdominal Precautions 9. Hemiparesis 4. Total Hip Precautions 10. Spinal Cord Injury i. ii. iii. Posterior Approach Anterior Approach Minimal Invasive Approach 5. Hip Hemi-Arthroplasty Precautions 6. Total Hip Revision* Spine Precautions & Protection No “BLT” ◦ No bending (spinal flexion) ◦ No lifting (more than 5 lbs) ◦ No twisting (segmental rotation of the thoracolumbar spine) Clinical Applications: ◦ Spine Precautions - After Spine Surgery ◦ Spine Protection – Acute back injury or back pain ◦ Abdominal precautions & protection after abdominal surgeries, e.g., exploratory laparoscopy, and hernia repair. https://commons.wikimedia.org/wiki/Fil e:Exploratory_Laparotomy_Scar_(03).jpg Spine Surgeries https://youtu.be/itHlMoQ1iTA Anterior approach to cervical spine Spinal fusion. (2022, October 3). In Wikipedia. https://en.wikipedia.org/wiki/Spinal_fusion 1st: Supine to Sidelying using “Logrolling” • Flex hip and knee of both or one LE. • Cross the contralateral arm across the chest. • Roll into sidelying, moving the trunk as one unit. • No Twisting = Shoulder – Hip – Knee all face the same direction. nd 2 : Sidelying to Sitting Abduct the underside arm; place the other hand on the bed near the waist. Move legs off the bed, initially pressing down with the underside hand. Continue to push the torso upright by pushing with the underside arm. Keep shoulders facing straight ahead. (Placing the hand near the waist limits flexion and abduction of the uppermost arm which would create trunk rotation.) https://demo.staywellhealthlibrary.com/Content/healthsheets -v1/step-by-step-using-log-roll-to-get-out-of-bed-hip-care/ Special Considerations IN THIS CLASS: IN FUTURE CLASSES: 1. (No particular precautions) 7. Sternal Precautions 2. Spine Precautions & Protection 8. Move-in-the-Tube 3. Abdominal Precautions 9. Hemiparesis 4. Total Hip Precautions 10. Spinal Cord Injury i. ii. iii. Posterior Approach Anterior Approach Minimal Invasive Approach 5. Hip Hemi-Arthroplasty Precautions 6. Total Hip Revision* Total Hip Arthroplasty (THA) https://www.medscape.com/viewarticle/546103 (Top): https://www.sahortho.com/hip/approaches (Bottom:) Hip replacement. (2022, September 17). In Wikipedia. https://en.wikipedia.org/wiki/Hip_replacement Implant Components https://youtu.be/FIzxN2p0nEo (Left) A standard non-cemented femoral component. (Center) A close-up of this component showing the porous surface for bone ingrowth. (Right) The femoral component and the acetabular component working together. (Left) The acetabular component shows the plastic (polyethylene) liner inside the metal shell. (Right) The porous surface of this acetabular component allows for bone ingrowth. The holes around the cup are used if screws are needed to hold the cup in place. https://orthoinfo.aaos.org/en/treatment/total-hip-replacement/ Risk of Hip Dislocation POTENTIAL COMPLICATIONS: ▪Nerve injury – e.g., sciatic nerve injury ▪Osteonecrosis TREATMENT OPTIONS: ▪Closed Reduction ▪Surgery ▪Arthritis due to cartilage damage https://epos.myesr.org/poster/esr/ecr2020/C08100/findings%20and%20procedure%20details https://healthliteracyhub.com/pathology-101-blog/dislocation-of-hip-joint/ Posterior or Posterolateral Approach THA, Anterior Approach THA & Total Hip Revisions, Hip Hemi-arthroplasty No hip FLEXion beyond 90° No hip EXTension beyond 0° (neutral) • Limit forward bending of the trunk. • Do not bring the leg back past the neutral position. • Do not lift or position the knees higher than the hips. • If backing up, lead with non-surgical leg • Seat the patient with the foot of the affected leg forward and knee extended or on a raised seat to decrease sitting angle. No hip INternal rotation past 0° (neutral) No hip EXternal rotation past 0° (neutral) • Do not roll the leg (thigh and knee) in toward the non• Do not roll the leg (knee and foot) out; keep the surgical leg; keep the toes of the affected leg pointed up toes of the affected leg pointed up or in, not out. or out, not in. • Gait: When turning toward surgical side, turn leg outward first No hip adduction beyond 0° (neutral) • Do not cross legs (at knees or ankles) pass umbilical line. • Keep pillows between the knees (in supine/sitting). • Avoid sidelying (If needed: on unaffected side and with 3-4 pillows between knees). Minimally Invasive Hip Arthroplasty (Mini-Posterior) NO COMBINATION of hip flexion > 90 deg, with hip IR and hip ADDuction • Strictly follow surgeon’s guidelines • Aka “Hip protection,” “Pose avoidance,” etc. No hip adduction beyond 0° (neutral) • Do not cross legs (at the knees or the ankles) pass umbilical line. • Keep pillows between the knees (in supine/sitting). • Avoid sidelying. (If needed: on unaffected side and with 3-4 pillows between knees). THA (Posterior Approach) Same precautions also apply to Hip Hemi-Arthroplasty ◦ E.g., s/p hip fracture Restrict movement of post-op hip: ▪No hip FLEXion beyond 90° ▪No hip INternal rotation past 0° (neutral) ▪No hip adduction beyond 0° (neutral) Supine → sitting NOT through sidelying THA (Anterior Approach) https://youtu.be/MTJK9tdSsQY Restrict movement of post-op hip: ▪No hip EXTension beyond 0° (neutral) ▪No hip EXternal rotation past 0° (neutral) ▪No hip adduction beyond 0° (neutral) Goal - Independence https://www.physio-pedia.com/Total_Hip_Replacement Clinical Pearl: Initially train patient to get out on Stronger side. In preparation for discharge – when patient demonstrates improved motor control in surgical leg, train patient to get out of bed on either side to maximize function. E.g., Left THA – posterior approach 1. Provide patient education on pertinent hip precautions to prevent hip dislocation. Flatten the bed completely. Then remove hip abduction pillow. 2. To get OOB on the stronger (R) side i. Bend strong (R) leg to a hook-lying position. ii.UEs: Use overhead trapeze if available; or use elbows to scoot laterally in bed iii.Assist pt to scoot or bridge close to (R) EOB using RLE and BUE (surgical leg can relax) iv.Patient fully scoots upper torso to L, and R leg toward EOB till R heel comes off the edge of bed. Therapist guards L leg to prevent hip adduction pass neutral. Left THA – posterior approach 3. To Long Sitting: i. Instruct pt to use elbows to prop upper torso up to sit up toward LEs till pt achieves modified long-sitting position. ii. Pt must keep UEs prop behind torso to avoid excessive hip flexion pass 90 deg. iii. Therapist: one hand support pt’s R scapula through axilla; another hand block patient’s L medial thigh from hip adduction or internal rotation pass neutral https://www.physio-pedia.com/Total_Hip_Replacement Left THA – posterior approach 4. Pt turns and pivots on gluts till sitting upright with BLE positioned in hip ER. • Pt keeps BUE behind torso while scooting to avoid excessive hip flexion. • Therapist: one hand support pt’s scapula through axilla; another hand block and gently scoot patient’s R medial thigh and assist to position in R external rotation. https://www.physio-pedia.com/Total_Hip_Replacement Orthostatic Hypotension  Also known as postural hypotension  Decrease in BP of at least 20 mm Hg systolic or 10 mm Hg diastolic within (2 to) 3 min of standing up  May also be evident when a person moves from supine to sitting  The pressure exerted in the arteries is not sufficient to move the blood against gravity to the brain and extremities  As the drop in BP occurs, the patient may experience lightheadedness, dizziness, fainting, and/or fall K. Sam Fall 2023 35 PT 704 Clinical Skills I: Foundations of Physical Therapy Practice Dr. Karen Sam, PT, DPT, GCS West Coast University K SAM 2023 1 Assisted Transfer Overview (Part A) ❑Sitting ◦ Balance, symmetry ◦ Posture ◦ Set-up ❑Sit-to-Stand ❑Stand-Step Transfer ❑Stand Pivot Transfer ❑Squat Pivot Transfer ❑Seated Transfer with Sliding Board K SAM 2023 2 Objectives: ❑12. Determine appropriate components of and complete a basic systems review to determine readiness for mobility and functional skills training including contraindications and precautions. (7D19 f, i, m, o, s) ❑18. Implement safe patient care interventions related to mobility and positioning for patients with common medical diagnoses and surgical procedures (including joint arthroplasties, CVA, fractures, etc.). (7D27b, d, e, g) ❑22. Use proper guarding, ergonomic, and body mechanic principles when performing any transfer, mobility, or positioning activity. Reference: Mobility in Context – Chapter 10 and more (see slides). K SAM 2023 3 Transfers Goals may include: 1. Improve patient to function in and access to different environments. 2. Teach use different pieces of equipment. 3. Patient to become independent in ADLs and participation in desired activities 4. Decrease level of assistance dependent to assisted to independent transfers K SAM 2023 4 Assisted Transfer Overview ❑Sitting ◦ Balance, symmetry ◦ Posture ◦ Set-up Corresponds to Week 3 Lab Handout ❑Sit-to-Stand ❑Bathroom Transfer ❑Stand-Step Transfer ❑Stand Pivot Transfer ❑Squat Pivot Transfer ❑Seated Transfer with Sliding Board K SAM 2023 5 Preparing the Patient ▪Universal precautions. Introduction. 2-patient identifiers. Ask permission, inform patient what is going to happen and why ▪Patient education & expectation: Explain the procedure and provide instructions via demonstration, verbal/tactile/visual cues; break down into individual steps if needed ▪Organize lines and equipment attached to patient. Watch jewelry (can get caught or scratch pt.) ▪Ensure proper footwear or non-skid socks if in hospital ▪ (NO regular socks – fall risk!) ▪Consider obtaining resting vital signs ▪If appropriate, can instruct bed level exercises as warm up K SAM 2023 https://www.caregiverproducts.com/posey-fall-management-non-slip-socks.html 6 Safety Consideration Evaluate before Assisted Transfer Training: ✓Strength at least 2+ to 3-/5 in LE extensors • Knee Extensors, Gluts ✓Cognitive • Able to follow 1-step motor commands, cooperative. • Demo Fair to Fair+ safety awareness ✓Dorsiflexion ROM in sitting (=wt-bearing) •If unavailable or unsure of safety → • Focus on Edge of Bed (EOB) level training, defer out-of-bed (OOB) transfer; • Demo Fair to Fair+ safety judgment • Check the level of nervousness vs retropulsive ✓Baseline Mobility ✓Trunk control • Fair static/dynamic sitting balance • Or, Sliding board transfer • Or, cardiac chair transfer, etc. •Proper body mechanics at all time (including set up and clean up) •Request assistance (2nd person) as needed K SAM 2023 7 Basic Environment Setup K SAM 2023 8 Direction of Transfer ▪In general, transfers are performed toward the “stronger” side ▪Increases patient confidence and safety ▪Eventually transfers to both sides may be necessary ▪Always comply with Restrictions and Precautions ▪Other Considerations: Therapeutic transfers ▪ E.g., s/p stroke (CVA), may want to transfer to involved side to provide weight bearing ▪ E.g., spinal cord injury (SCI) often leads with hips K SAM 2023 9 Basic Environment Setup 1. Which direction will you and the patient plan to move? 2. Sufficient lighting. 3. Clear and organize ALL equipment and lines (*gait belt); adjust to proper heights 4. Organize furniture 5. Make sure patient has a clear pathway + an alternative pathway ◦ E.g., a clear pathway to bathroom; bedside commode within reach on the other side; nurse can have a clear pathway to enter if assist is needed. 6. Arrange assistive device (usually within arm reach) ◦ Check all brakes, all equipment – Safety! ◦ If uses wheelchair: brakes on, caster wheels face forward – Safety! Arm rest and leg rest off K SAM 2023 10 Contraindications to the use of Gait Belt 1. Recent colostomy/ileostomy surgery 2. Severe respiratory problems or advanced cardiac disease 3. Fractured ribs 4. Recent mastectomy, abdominal, chest, or back surgery 5. Abdominal aneurysm 6. Phobia regarding belts 7. Patient refuses 8. NEVER use as a restraint K SAM 2023 11 Clinical Pearl: Level of Assistance Application of Mobility Strategies: ▪Min Assist (75-25%) o the patient is able to initiate most of the movement o focus to guard the involved, weakened, and/or painful limb or site. ▪Mod Assist (50-50%) o Therapist will require to provide multi-point assistance or guarding to ensure patient safety and prevent falls or unsteadiness or worsening of pain ▪Max Assist (25-75%) o break down to assist one body part at a time ▪Always try to incorporate verbal, tactile, and visual cues to promote patient learning and subsequent independence K SAM 2023 12 Assisted Transfer Overview ❑Sitting ◦ Balance, symmetry ◦ Posture ◦ Set-up ❑Sit-to-Stand ❑Stand-Step Transfer ❑Stand Pivot Transfer ❑Squat Pivot Transfer ❑Seated Transfer with Sliding Board K SAM 2023 13 Sitting (no precautions) ◦ Balance: A/P, lateral ◦ Symmetry. ◦ Posture. Foot support. Arm support. K SAM 2023 Ribeiro, Bruno et al. “Optimization of sitting posture classification based on user identification.” 2015 IEEE 4th Portuguese Meeting on Bioengineering 14 (ENBENG) (2015): 1-6. Sitting (no precautions) ◦ Set-up: ◦ To gain immediate static sitting balance in antero-posterior and lateral directions ◦ Take into consideration compliance of surface ◦ Maximize symmetry ◦ Assess how much foot and arm support are needed ◦ Unilateral, bilateral, foot flat ◦ Wide vs narrow BOS K SAM 2023 Nakamura, K., Nagami, S., Kurozumi, C. et al. Effect of Spinal Sagittal Alignment in Sitting Posture on Swallowing Function in Healthy Adult Women: A Cross-Sectional Study. Dysphagia (2022). 15 https://doi.org/10.1007/s00455-022-10476-8 Head-Hip Relationship E.g., SCI wheelchair transfer K SAM 2023 16 https://msktc.org/sci-topics/safe-transfer-techniques Lateral Scooting in Sitting •Used for repositioning toward head of bed (HOB) before lying down •Good strengthening exercise in sitting, or trunk weight-shifting training •Good “pre-transfer” training – a component of lateral seated transfers 1. Position ipsilateral leg/foot laterally to prepare to receive weight 2. Abduct the arm with the hand (or fist) on bed (+space to shift hips). 3. Push down with both hands (or fist), lean head and trunk forward, lift hips up and shift laterally. Fig. 10-21 17 Anterior-Posterior Scooting ▪Good “pre-transfer” training ▪Patient must move forward prior to transfer – assist patient to edge of surface safely ▪COG ▪Methods: ▪ Side to side weight shifting ▪ Pelvic slide A/P ▪ Sitting push up https://parivarthanforparkinsons.wordpress.com/category/hand-writing/ ▪Reverse to move back into seat/bed K SAM 2023 18 Guarding (without FWW) 1 SHOULDER + 1 KNEE BLOCK B/L PELVIS + B/L KNEE BLOCKS Video: Assistance/Guard Techniques for Seated Scooting (5’57”-7’49”) https://youtu.be/0EjZD9dwWwM?si=_M4VpZ2M0BBymjb5&t=357 K SAM 2023 19 Decision tree for blocking knees (Fig 11-18) K SAM 2023 20 Assisted Transfer Overview ❑Sitting ◦ Balance, symmetry ◦ Posture ◦ Set-up ❑Sit-to-Stand ❑Stand-Step Transfer ❑Stand Pivot Transfer ❑Squat Pivot Transfer ❑Seated Transfer with Sliding Board K SAM 2023 21 Sit-to-Stand – Movement Patterns 1) Flexion momentum Initiation – lift off Trunk flexion Ankle DF (Tib ant) 2) Momentum transfer Lift off – max ankle DF (largest GRF) Quads Tib ant \\ soleus 3) Extension Max ankle DF – (knee ext) – max hip ext Glut max Gastroc-soleus Tib ant (prevent excessive PF) 4) Stabilization Max hip ext – ankle strategy Gastroc-soleus (Top) https://www.alexandertechniquescience.com/biomechanics/the-physics-of-sit-to-stand/ (Bottom) https://youtu.be/UiICACfwKag 22 https://parivarthanforparkinsons.wordpress.com/category/hand-writing/ https://youtu.be/NP2fsqLYuSU K SAM 2023 23 Stand-Step Transfer •Example of Use with varying distance of stepping: • Edge of Bed (EOB) to Bedside Chair transfer • Edge of Bed (EOB) to Wheelchair (W/C) transfer • Edge of Bed (EOB) to Bedside Commode (BSC) transfers. •Used with pts. who have the necessary strength and balance to weight shift and step during the transfer •Guard and/or supervise •Patient takes a step to maneuver and position feet in preparation for lowering • Video: Edge of Bed → Wheelchair transfer with Moderate Assistance without assistive device (7’43”-13’30”) • If Maximal Assistance: Upper hands are placed at ischial tuberosities • https://youtu.be/0EjZD9dwWwM?si=KZIR0vL-2_yseXWp&t=463 K SAM 2023 24 PT 704 Lab Week 6 BED MOBILITY with Precautions (Station 1) Supine to Sit following Back Surgery (Spine / abdominal precautions) Video Reference: FA Davis Ch. 10 Bed Mobility Precautions: No BLT i. No bending forward and backward ii. No lifting > 5 pounds iii. No twisting/rotation of the spine b. Logrolling only = shoulders, hips, and knees face the same direction throughout c. E.g., To get OOB on R side at initial training 1. Lower HOB. Position pt in hook-lying to “shorten” the person. 2. Instruct patient to initiate logrolling to R by gently pushing L foot off the mattress while L arm reaches across for the bedrail or EOB. • Therapist: assists at L shoulder/scapula and L pelvis to maintain a neutral spine. 3. (Preparation:) Position R elbow forward and scoot b/l ankles forward toward EOB 4. Instruct pt to push off from R elbow (keep head tucked gently) while dropping both ankles off the bed to sit up. • Therapist: one hand assists at R scapula through R axilla; another hand provides leverage at the top pelvis and scoots the femur-knee forward off EOB. 5. Upon sitting, instruct pt to support oneself with hand, feet flat on the floor to avoid excessive lordosis and truncal loading. • Therapist’s hands remain on trunk/scapula and pelvis to assist in repositioning and ensure neutral spine and proper alignment (no BLT) • If an orthosis is ordered for OOB activity, don orthosis in a static sitting. K Sam 1 PT 704 Lab Week 6 BED MOBILITY with Precautions (Station 2) Supine to Sit following Total Hip Arthroplasty https://www.sahortho.com/hip/approaches Hip Positioning Precautions for Involved Extremity Following a Total Hip Arthroplasty Posterior or Posterolateral Approach THA Total Hip Revisions Hip Hemi-arthroplasty Anterior Approach THA No hip FLEXion beyond 90° • Limit forward bending of the trunk. • Do not lift or position the knees higher than the hips. • Seat the patient with the foot of the affected leg forward and knee extended or on a raised seat to decrease sitting angle. No hip EXTension beyond 0° (neutral) • Do not bring the leg back past the neutral position. • If backing up, lead with non-surgical leg No hip INternal rotation past 0° (neutral) • Do not roll the leg (thigh and knee) in toward the nonsurgical leg; keep the toes of the affected leg pointed up or out, not in. • Gait: When turning toward surgical side, turn leg outward first No hip EXternal rotation past 0° (neutral) • Do not roll the leg (knee and foot) out; keep the toes of the affected leg pointed up or in, not out. No hip adduction beyond 0° (neutral) • Do not cross legs (at knees or ankles) pass umbilical line. • Keep pillows between the knees (in supine/sitting). • Avoid sidelying (If needed: on unaffected side and with 3-4 pillows between knees). No hip adduction beyond 0° (neutral) • Do not cross legs (at the knees or the ankles) pass umbilical line. • Keep pillows between the knees (in supine/sitting). • Avoid sidelying. (If needed: on unaffected side and with 3-4 pillows between knees). Minimally Invasive Hip Arthroplasty (Mini-Posterior) NO COMBINATION of hip flexion > 90 deg, with hip IR and hip ADDuction • Strictly follow surgeon’s guidelines • Aka “Hip protection,” “Pose avoidance,” etc. K Sam 2 Supine to Sit Following Total Hip Arthroplasty (Posterior Approach): • May start training to get out of bed (OOB) toward stronger (L) side for pain control and initial decreased motor control in RLE → Prior to discharge, progress to getting OOB toward R side before discharge to maximize function, if needed 1. (Preparation:) Lower Head of Bed (HOB) to flat or slightly elevated. Bend L leg to a hook-lying position. UEs: Use overhead trapeze if available, or use elbows to scoot laterally in bed 2. Assist patient (pt) to scoot or bridge toward L side Edge of Bed (EOB) using LUE and BUE (RLE can relax) 3. In bed, pt scoots R shoulder to R side, then scoots L lower leg off the bed. Repeat until R heel is off the EOB and pt is at an angle. 4. Instruct pt to use elbows to prop upper torso up to sit up toward LEs till pt achieves modified long-sitting position. a. Pt must keep UEs prop behind the torso to avoid excessive hip flexion past 90 deg. b. Therapist: one hand supports pt’s L scapula through the axilla; another hand blocks the patient’s R medial thigh from RLE adduction or internal rotation until the patient achieves static sitting balance in a modified long-sitting position 5. Pt turns and pivots on glutes till sitting upright with BLE positioned in hip ER. Patient keeps BUE behind the torso while scooting to avoid excessive hip flexion. a. Therapist: one hand support pt’s L scapula through the axilla; another hand block and gently scoot the patient’s R medial thigh and assist in position in R external rotation. Tool Options to maximize independence at home: Video Reference: FA Davis Ch. 10 Bed Mobility K Sam 3 Don/Doff Hip abduction pillow: - Therapist may receive a patient in bed with a hip abduction pillow in place. Before mobility, the therapist will need to take the pillow off. Therapist may need to place the hip abduction pillow when the patient returns to bed. Supine to Sit Following Total Hip Arthroplasty (Anterior Approach): K Sam 4 PT 704 Lab Week 7 Mobility with Spine Precautions (Station 1) Activity 1: Supine to Sit following Back Surgery (Spine / abdominal precautions) Review: Spine Precautions: No BLT i. No bending forward and backward ii. No lifting > 5 pounds iii. No twisting/rotation of the spine Orthosis Donning and Fitting if MD order is present: • • • Some patients do not need orthosis after surgery. If the Orthosis is in place when receiving the patient supine, the Therapist must check positioning and proper fitting of the orthosis in place prior to any movement, ROM, or repositioning. If the MD Order states, “Orthotics/Orthosis at all times.” • Orthosis must be donned and properly fitted in supine, flatbed, in an anatomical position prior to any movement, ROM, or repositioning. Review: Supine to Sitting (referenced from Week 6 Lab handout) Logrolling only = shoulders, hips, and knees face the same direction throughout E.g., To get OOB on R side at initial training 1. Lower HOB. Position pt in hook-lying to “shorten” the person. 2. Instruct patient to initiate logrolling to R by gently pushing L foot off the mattress while L arm reaches across for the bedrail or EOB. • Therapist: assists at L shoulder/scapula and L pelvis to maintain a neutral spine. 3. (Preparation:) Position R elbow forward and scoot b/l ankles forward toward EOB 4. Instruct pt to push off from R elbow (keep head tucked gently) while dropping both ankles off the bed to sit up. • Therapist: one hand assists at R scapula through R axilla; another hand provides leverage at the top pelvis and scoots the femur-knee forward off EOB. 5. Upon sitting, instruct pt to support oneself with hand, feet flat on the floor to avoid excessive lordosis and truncal loading. • Therapist’s hands remain on trunk/scapula and pelvis to assist in repositioning and ensure neutral spine and proper alignment (no BLT) K Sam 1 Activity 2: Upon sitting: Positioning in Static Sitting: 1. Check to make sure the patient’s pelvis is level. 2. Patient scoots forward till feet are flat and even, the pelvis is flat and even to achieve proper spine alignment. a. typically, if the patient is in a hospital bed, it’s helpful to have the edge of the bed slightly elevated to reduce the need and workload the patient needs to exert to go from sitting to standing. b. Assistance and cues will be provided to ensure the patient's spine is straight and compliant with no BLT precautions. Orthosis Donning and Fitting if MD order is present: • • • Again, some patients do not need orthosis after surgery. If the Orthosis is in place when receiving the patient supine, the Therapist must check again to ensure proper fitting of the orthosis prior to any movement, ROM, or repositioning. If the MD order states, “Orthosis when Out-of-Bed.” o That means an orthosis is ordered for OOB activity, therapist will put on the orthosis for the patient in a static sitting at the first visit (and work toward patient's self-management). o Orthosis must be donned and properly fitted in upright sitting, feet flat on the floor, knees hip-width apart, upright posture, and chin tuck throughout the fitting procedure. Regardless, reinforce precautions in sitting through demonstration. Examples Resources: Cervical Aspen Collar in Supine and Sitting: https://youtu.be/94E3ZIH3wSE?si=IcJjf2RC6ird-WNB Spine brace in supine: https://youtu.be/uHSl2y1dIms?si=3J-x1jjuWATJKM1o K Sam 2 PT 704 Lab Week 7 Posterior Hip Precautions – Bed Mobility and Transfer (Station 2) https://www.sahortho.com/hip/approaches Hip Positioning Precautions for Involved Extremity Following a Total Hip Arthroplasty Posterior or Posterolateral Approach THA Total Hip Revisions Hip Hemi-arthroplasty Anterior Approach THA No hip FLEXion beyond 90° • Limit forward bending of the trunk. • Do not lift or position the knees higher than the hips. • Seat the patient with the foot of the affected leg forward and knee extended or on a raised seat to decrease sitting angle. No hip EXTension beyond 0° (neutral) • Do not bring the leg back past the neutral position. • If backing up, lead with non-surgical leg No hip INternal rotation past 0° (neutral) • Do not roll the leg (thigh and knee) in toward the nonsurgical leg; keep the toes of the affected leg pointed up or out, not in. • Gait: When turning toward surgical side, turn leg outward first No hip EXternal rotation past 0° (neutral) • Do not roll the leg (knee and foot) out; keep the toes of the affected leg pointed up or in, not out. No hip adduction beyond 0° (neutral) • Do not cross legs (at knees or ankles) pass umbilical line. • Keep pillows between the knees (in supine/sitting). • Avoid sidelying (If needed: on unaffected side and with 3-4 pillows between knees). No hip adduction beyond 0° (neutral) • Do not cross legs (at the knees or the ankles) pass umbilical line. • Keep pillows between the knees (in supine/sitting). • Avoid sidelying. (If needed: on unaffected side and with 3-4 pillows between knees). Minimally Invasive Hip Arthroplasty (Mini-Posterior) NO COMBINATION of hip flexion > 90 deg, with hip IR and hip ADDuction • Strictly follow surgeon’s guidelines • Aka “Hip protection,” “Pose avoidance,” etc. 1 Activity 1: Review Supine to Sit with Posterior Hip Precautions following Total Hip Arthroplasty Reference: Week 6 lab handout. Activity 2: Transfer with Posterior Hip Precautions following Total Hip Arthroplasty Equipment Preparation: o Fitting of Front wheel walker (FWW): handle at the level of patient’s wrist. Environmental Setup: o To Chair: The chair is angled at 90 degrees by the bedside with environmental objects as backup to avoid the chair slipping away during stand-to-sit transfer. o To Wheelchair (W/C): W/C is angled 45 degrees by the bedside with leg rests removed, brakes locked, and front wheels aligned with W/C. ▪ Extra thick cushion will be needed to keep the hip from flexing beyond 90-degree hip flexion. Be mindful of the risk of slipping out of seat as well. A lap belt and proper footrests will be needed. When turning with FWW: Be mindful to turn the involved leg out (into Ext rotation) before turning FWW. o E.g., R THA: Turning to R: 1. Patient steps to turn R foot out first (do not pivot on foot) 2. Turn FWW 3. Turn the other foot. 4. It may take 2-3 small turning steps to complete a turn to avoid hip internal rotation at all times. Add’l Notes and Details: Clinical Skills I Week 7 Gait (Part 1) KAREN W. SAM, PT, DPT, GCS WEST COAST UNIVERSITY Objectives for Week 7 ❑ 25. Describe the advantages and disadvantages of various types of ambulatory devices (7D27b, d, g). ❑ 26. Differentiate and perform the two-point, three-point, and four-point modified gait patterns and apply them to case scenarios on level, grades, curbs, and stairs (7D27b, d, g). ❑ 27. Choose and fit an appropriate assistive device(s) as related to weightbearing restrictions, fall risks, physical characteristics of the care recipient, and/or architectural barriers and apply them to patient scenarios (7D27b, d, g). Gait Cycle, Stride length, Step length  Step Length – the linear distance between the occurrence of one point in the gait cycle of one foot and the same point in the gait cycle accomplished by the opposite extremity (e.g., L heel strike to R heel strike).  Stride Length –the linear distance between the occurrence of one point in the gait cycle of one foot and the recurrence of that point by the same extremity (e.g., L heel strike to L heel strike).  Gait Cycle – the time period that begins with the initial contact of an extremity and lasts until that extremity strikes the ground again (contains a stance + swing phased of each LE) stance FIGURE 14-1 Gait cycle, stride length, and step length and width Gait Pattern – Phases https://youtu.be/DP5-um6SvQI?si=sZNMRI-a9pycRw4Z Other Gait-Related Terminology:  Stance Time -the period that an extremity is in contact with the ground  Single-limb support time - the period when only one extremity is in contact with the ground  Double-limb support time  Swing time - period that an extremity is off the ground during the swing phase of that extremity  Cadence  Speed - period when both feet are in contact with the ground the number of steps taken in a given unit of time (ex: steps/sec, or steps/min) - the rate at which an individual’s locomotion covers a specific distance (ex: m/s) Common Weight-Bearing Status for Lower & Upper Extremities:  “FWB RLE” = Full Weight Bearing    No restriction to weight bearing. “WBAT RLE” = Weight-Bearing As Tolerated  As tolerated, up to full body weight  Limited by weakness, pain, balance, apprehension, etc. “50% PWB RLE” = Partial Weight-Bearing  Commonly ranged from 30% to 50%. For example, “30% PWB RLE,” “40% PWB RLE.”  Need to have a defined percentage (%) in the Physician’s order  Need MD order to clarify % if not clearly stated in the order.  Depending on the facility and surgeons, PT may default to NWB if mobility needs to be initiated. Common Weight-Bearing Status for Lower & Upper Extremities (cont.)   “TTWB RLE” = Toe-Touch Weight-Bearing; or TDWB RLE = Touch-Down Weight-Bearing  Light enough to avoid crushing a potato chip (or a raw egg) underfoot.  Primarily for balance  Can promote normal gait pattern, especially if the patient will be on restricted weight bearing for weeks or longer. “NWB RLE” = Non-Weight-Bearing  Cannot put any weight through the affected limb.  This includes not resting the foot on the ground during standing or ambulation., Clinical Skills I Gait (Part 3) KAREN W. SAM, PT, DPT, GCS WEST COAST UNIVERSITY To Prepare for Gait: Sit to Stand with Assistive Device MOBILITY IN CONTEXT CHAPTERS 14 AND 15 Sit-to-Stand with Walker * Front casters facing forward Sit-to-Stand with Axillary Crutches • Both crutches on one side (holding on inside) • Crutches are best held opposite the “involved” side • Push down on armrest and crutch grips • Stand and balance; transfer a crutch under each arm • Reverse to sit Sit-to-Stand with Forearm Crutches Sit-to-Stand With Cane • Move into ready position • Lay cane to the side, holding the handle in the same hand with the armrest • Push to standing and place cane upright • OR if the cane can stand on its own: • Place cane next to chair • Push to standing on both armrests • Grasp cane Fitting an Assistive Device •You can estimate with the patient seated •Most devices have a weight limit ~260-300 lbs. – check for bariatric options as needed *Always confirm fit in Standing (and functional walking position, if needed): • Have the patient in good posture and wearing typical footwear when fitting the device • Guard appropriately during fitting • Two fingers should fit between the axilla and the axillary pad. • Device handle is typically at the level of the greater trochanter or ulnar styloid process • Patient should have approximately 20-30 degrees of elbow flexion to allow triceps activation Navigating Curbs & Ramps Up and Down Curbs with Walker Ascending a curb: ◦ Walker first, followed by STRONG Leg Descending a curb: • Walker first, Weaker Leg, STRONG Leg. Up and Down Curbs with Crutches (no rail) Ascending Curb with Crutches: If patient is steady: 1. 2. Up with STRONG Leg Weaker Leg + B/L Crutches If patient is Less steady: 1. 2. 3. Up with STRONG leg Weaker leg Crutches Descending Curb with Crutches If patient is steady: 1. 2. 3. Down with B/L Crutches Weaker Leg STRONG leg If patient is Less steady: 1. 2. 3. 4. Down with 1 Crutch from the Strong Leg side Down the other Crutch Weaker Leg STRONG leg Up and Down Curbs with Cane (no rail) Ascending Curb with Cane: If patient is steady: 1. 2. Up with STRONG Leg Weaker Leg + Cane If patient is Less steady: 1. 2. 3. Up with STRONG leg Weaker leg Cane Descending Curb with Crutches 1. 2. 3. Down with Cane Weaker Leg STRONG leg Guarding – Ascending Curb Ascending: Typically, behind and slightly to the weaker side: o Therapist’s starting position: • 1 foot on the same step as the patient. • Other foot: 1 step behind the patient. • Hand Placement: anterior shoulder + pelvis/low back/hips and on gait belt. Guarding – Descending Curb Descending: Typically, Guard on the weaker side: o Therapist’s starting position: • 1 foot on 1 step down – ready to receive walker. • Other foot: 1 step behind the patient. • Hand Placement: anterior shoulder + pelvis/low back/hips and on gait belt. Walking on Ramp/Inclines With Assistive Devices • Lean forward when ascending. • Take slightly longer steps when ascending. • Take slightly shorter steps when descending. • Follow zigzag path if necessary to reduce steepness of path. Navigating Stairs Stairs With Assistive Devices (cont.) Stairs with Axillary Crutches • “Up with the good, down with the bad.” • Move crutches with the involved or weaker LE (requires more coordination and trunk control) • If more stability is needed, then GAS up and SAG down Stairs with Axillary Crutches Using Rails Stairs with Forearm Crutches Can perform as with axillary crutches Stairs with Cane • “Up with the good, down with the bad.” • May move cane to other hand in order to use handrail • May need to turn quad cane sideways for secure placement • Step-to-step or step-over-step Stairs with Walker…? Debatable….. risk of loss of balance considering the unsteadiness and challenge to place FWW on an even surfaces to support patient’s body weight. Guarding – Ascending Stairs Ascending: o Therapist’s Starting Position: • behind and slightly to the weaker side • Hand Placement: anterior shoulder + pelvis/low back/hips on gait belt. • 1 foot on the same step as the patient. • Other foot: 1 step below and behind the patient. • Patient and Therapist take turns to step (Avoid taking step at the same time) Guarding – Descending Stairs Descending: o Therapist’s Starting Position: • Face patient (therapist will descend backward) • Hand Placement: anterior shoulder + anterior part of gait belt. • 1 foot 1 step lower than the patient. • Other foot: 2 steps lower than the patient. Bottom Scooting Up Stairs May be needed for emergencies (teach it!) Safest option if you have limited strength to complete the task: 1. Position yourself in front of the stairs so that they are behind you. 2. Pushing through the unaffected leg and both hands, raise yourself up the stairs one at a time. HTTPS://WWW.PAT.NHS.UK/DOWNLOADS/NEW%20NCA%20LEAFLETS/PHYSIOTHERAPY/483%20%20GOING%20UP%20AND%20DOWN%20STAIRS%20ON%20YOUR%20BOTTOM.PDF Clinical Skills I PT 704 Intro to Basic Support Equipment / Lines Precautions & Contraindications Fall Semester 2023 Karen W. Sam, PT, DPT, GCS K. Sam 2023 1 ❑ Implement safe patient care interventions related to mobility and positioning for patients with common medical diagnoses and surgical procedures (including joint arthroplasties, CVA, fractures, etc.). Objectives for Week 9 ❑ Demonstrate safe and appropriate management of equipment (e.g. IV lines, urinary catheter, post-op drains) while facilitating physical activity such as transfer and gait training. Reference: Mobility in Context Chapter 3 K. Sam 2023 2 K. Sam 2023 3 K. Sam 2023 4 Home Environment K. Sam 2023 5 Basic Line Management Watch F.A. Davis video https://www.fadavis.com/product/physical-therapy-mobility-in-context-patient-care-skillsjohansson-chinworth-2 (2:28)K. Sam 2023 6 Basic Line Management - Why?  Essential to best patient outcomes  Safety  Appropriateness - Who?  Interprofessional Team Communication  Physicians, PA’s and NP’s  Nursing  PT, OT, SLP, RT  Patient – patient education is very important  Supportive personnel K. Sam 2023 7 Basic Line Management - What?  What?  Types of Lines  Thorough chart review  Check MD orders  Current and discontinued orders  Purposes and Indications for lines and equipment  Insights into patient’s status and acuity  Identify precautions and contraindications  Check parameters relevant to mobility, as needed - Where?  Where?  Location / Site  Attachment or device, if any K. Sam 2023 8 Basic Line Management - How?  Before mobility  Communicate with nursing for patient status, recent vitals, and order clarification as needed  Coordinate time and supportive personnel  Systematic approach in equipment and line handling  Observe environment systematically  E.g., Top to bottom, L to R  Equipment on the wall, on the floor, and on the bed  Physically trace all lines and tubes  From the point of insertion or attachment to the patient to the monitoring equipment (or vice versa, choose the safest option).  Important to understand the effects of mobility can have on each line and on the patient’s systems being monitored  Mentally rehearse mobility activity and organize lines strategically  Examine cardiac monitor; check baseline vitals, especially with cardiopulmonary or neurological devices K. Sam 2023 9 Basic Line Management - How? (cont.)  During mobility  Be cautious, safe, and vigilant in line monitoring  Integrity of all line insertions and attachments  Lines are not impeded and not pulled taut  Communication  Monitoring patient response  HR, rhythm, BP, O2 sat, RPE, pallor, diaphoresis  After mobility     K. Sam 2023 Check patient’s vitals and response to mobility Inspect all lines, sites and equipment Positioning for comfort and pressure relief Notify RN if any lines need to be re-connected, releveled, or re-start after mobility 10 Systems I. Cardiovascular System II. Respiratory System III. Neurological System IV. Nutrition V. Suction Devices – Nasal/Oral VI. Suction Devices – Wound VII. Drainage Devices VIII. Skeletal System K. Sam 2023 11 Cardiovascular System BP cuff  Purpose/Indication:   Location:    Provides indirect measure of BP Typically, not used on arm with IV In ICU, cuff usually remains on patient’s arm and is inflated automatically Clinical Implications:  Record blood pressure before, during and after therapy K. Sam 2023 12 Cardiovascular System Pulse oximeter  Purpose:   Location:   Indirectly measures O2 saturation External device applied to fingertip, toes, forehead, bridge of nose, or earlobe Clinical Implications:  Activity may be contraindicated when O2 saturation falls below a certain level. K. Sam 2023 13 Cardiovascular System  Purposes: EKG leads  Indications:  Diagnostic, screening, continuous monitoring of electrical conduction through the heart  Reveal basic anatomy of the heart     Chest pain, palpitation, dizziness, syncope, cyanosis To detect myocardial injury, ischemia, previous infarction Heart conditions and associated symptoms+ To detect pacemaker or defibrillator device malfunction&  Locations:  Surface electrodes. Standard 12-leads for full cardiac assessment, monitoring may be done with fewer leads  Clinical Implications:     Notify RN before mobility if patient is on telemetry Monitor hemodynamic response & exercise tolerance Identify pathological rate and rhythms & adjust/stop PT Identify Red Flags on EKG and declining cardiac status K. Sam 2023 14 Cardiovascular System Sequential Compression Device (SCD)  Purposes/Indications: • To promote venous return • To prevent the risk of DVT in LE due to prolonged bedrest, venous insufficiency, or limited ambulation capacity  Location: LEs  Clinical implications • Compression is graduated, distal to proximal, to return venous blood to heart. • Contraindicated on limb with DVT • Turn off machine and unwrap SCD sleeves for mobilization; Place back and turn on after therapy session K. Sam 2023 15 Cardiovascular System  Purpose/Indication:  Peripheral Intravenous (IV) line  Location:   For administering liquid medications, fluids, electrolytes or blood product transfusions Vein (forearm, back of hand, neck, leg, or foot) Clinical Implications:       Avoid BP cuff on limb with IV Nurse can often disconnect IV for therapy, but some meds must be continuous Do not kink, occlude or place tension on IV Drip bag above insertion site. Notify nursing staff if insertion site is swollen or red If IV becomes displaced during therapy session put pressure on the site to control bleeding and notify nursing staff immediately K. Sam 2023 https://www.icumed.com/products/critical-care/triox-venous-oximetry-catheters/triox-picc 16 Cardiovascular System Venous Line & Catheter  Purpose/Indications:  Allows long term IV administration of medications,+ fluids, blood products directly into the heart  PICC and Port-A-Cath: chemotherapy administration  Hickman/Broviac and Port-A-Cath: multiple blood draw without repeated needle sticks. • Location: Terminating in superior vena cava typically  Clinical Implications: • Keep insertion site dry • Nurse can disconnect IV if medication is not continuous • No mobility / exercise / UE ROM restrictions • Types: • • • • PICC: peripheral, commonly at basilic vein Hickman: internal jugular or subclavian vein Broviac: subclavian vein Port-A-Cath: subclavian vein K. Sam 2023 17 Cardiovascular System Venous Line & Catheter - PICC line Peripherally inserted central venous (PICC) line • Location: • Basilic vein is the most common placement • May also be placed in the cephalic or median cubital vein, terminating in superior vena cava or right atrium • Single, double, triple lumens  Additional Clinical Implications: • Wait for X-ray confirmation of proper placement before mobilization or exercise • Avoid BP on the extremity with PICC line • No mobility / exercise / UE ROM restrictions • No axillary crutches - can occlude the line and can cause thrombus formation (Top) https://www.icumed.com/products/criticalcare/triox-venous-oximetry-catheters/triox-picc (Bottom) https://www.lhsc.on.ca/thoracicsurgery/picc-line-insertion K. Sam 2023 18 Cardiovascular System Venous Line & Catheter Hickman/Broviac    -Hickman/Broviac - Port-A-Cath, MediPort Location: Tunneled central venous catheter typically inserted into internal jugular or subclavian vein May have multiple lumens Cuff helps prevent slippage and the entrance of bacteria Port-A-Cath, MediPort   Location: Port implanted under the skin, typically subclavian, attached to thin catheter  Port is accessed with a special needle Additional Clinical Implication:  (Top 4) https://nursekey.com/central-venous-access-catheter/ (Bottom Right): https://www.shutterstock.com/search/port+a+cath Usually compatible with bathing or swimming K. Sam 2023 19 • Purposes: • Directly measures arterial BP directly and in real-time Cardiovascular System • Indications: Arterial Line (A-line) • Locations: • Obtain blood sample for arterial blood gas (ABG) analysis • Labile BP, hemodynamic instability, titration of vasoactive drugs, frequent arterial blood sampling (e.g. hypoxia), etc • Commonly in radial and femoral arteries, also seen in brachial or dorsalis pedis arteries • Thin catheter inserted into artery and connected via pressure tubing to pressure transducer • Clinical Implications: • Invasive – ICU, peri-op for high-risk patients, critically ill patients • Pressure bag (saline) must remain above level of A-line site • Pressure transducer is placed at the level of right atrium+ • Changes in bed height will alter arterial BP readings • Femoral insertion requires hip flexion ROM up to 60° to 80° • check MD order and facility protocol • Arterial blood carries higher pressure than venous blood • Displacement of an arterial line is a life-threatening emergency because of significant rapid blood loss. • Apply pressure to the insertion site and immediately call for help. K. Sam 2023 http://www.nu2icu.com/nu2icu-haemodynamics/nu2icu-haemodynamic-monitoring-in-icu-arterial-lines-map/ 20 Cardiovascular System Pulmonary artery catheter (= PA line, Swan-Ganz catheter)  Purposes:  Directly measures pressures in R-side of the heart and pulmonary artery; Indirectly measure cardiac output • Indications: • Heart failure, shock, post-MI, pulmonary hypertension, pulmonary edema, after open heart surgery or drug therapy, heart valve disease, cardiomyopathy • Location: • Multi-lumen catheter inserted through internal jugular or subclavian vein, terminating in the pulmonary artery • Clinical Implications: • Physical activity very restricted • Avoid ROM that may disturb the insertion site • Internal jugular insertion: limit head and neck movement • Subclavian insertion: Limit ipsi. shoulder flexion to 90 deg and contra. shoulder minimal functional movement • For femoral insertion: Limit flexion to 70 deg • Dislodging a PA line is a life-threatening emergency! Apply pressure to the insertion site and call for help. K. Sam 2023 (Top) https://quizlet.com/98485028/pa-catheter-monitoring-flash-cards/21 (Bottom) https://slidetodoc.com/pulmonary-hypertension-invasive-monitoring-by-kimberly-napper-pulmonary/ Systems I. Cardiovascular System II. Respiratory System III. Neurological System IV. Nutrition V. Suction Devices – Nasal/Oral VI. Suction Devices – Wound VII. Drainage Devices VIII. Skeletal System K. Sam 2023 22 Respiratory System Supplemental Oxygen  Purpose:  O2 is considered a drug when breathed in concentrations greater than atmospheric air  Regulated by FDA - Needs MD prescription  Indications: Hypoxemia, anemia, pulmonary edema, CO poisoning  Clinical Implication: Inflammable; risk of overdose  O2 delivery Devices: 1. 2. 3. 4. 5. 6. Nasal cannula Closed/simple face mask Tracheostomy mask/collar Partial non-rebreather mask Non-rebreather face mask Air entrainment system – Venturi mask  Nebulizer:  Handheld or attached to respiratory tubing  Used to administer pulm medications  Patient responses vary  Some patient may demo improved activity tolerance. Others may become very agitated, making activities more difficult. K. Sam 2023 23 Respiratory System Supplemental Oxygen - Oxygen Delivery Devices 1. Nasal cannula (NC) 2. Closed/simple face mask 3. Tracheostomy mask/collar 4. Non-rebreather face mask 5. Partial non-rebreather mask 6. Air entrainment system – Venturi mask • 2-prong device – most common - deliver low flow O2 (1-2L)  Like a NC in a mask form; mouth breather; Hard to talk / eat  Placed over a tracheostomy – through which O2, humidification or nebulizer is given  Has a reservoir bag & a 1-way valve – the reservoir bag is filled with 100% supplemental O2 – so patient will breathe in 100% O2  For short term help when patient is less stable.  Allow some room air or exhaled air which contains CO2 back to the reservoir bag and allow rebreathing. So O2 concentration is below 100%.  Allow greater O2 flow  Has adaptor or dial - diff adaptor deliver different level and very precise FiO2  Great for COPD patients – not to knock out the hypoxic drive K. Sam 2023 24 Respiratory System Supplemental Oxygen - Home Oxygen Systems  O2 tanks – high pressure  Liquid oxygen – low pressure  Lightweight canister  Some can last for 8 hours  Oxygen concentrators      Separates out oxygen from ambient air Flow generally 2-3 liters/min Can deliver continuous vs pulsed O2 Requires electricity or battery Can be stationary for home use or portable K. Sam 2023 25 https://www.istockphoto.com/photo/oxygen-flow-meter-plugged-in-thegreen-outlet-on-hospital-wall-medical-equipment-gm1195282355-340656933 Respiratory System Non-invasive positive pressure ventilation (NIPPV) - CPAP - BiPAP  Purpose: To decrease work of breathing  Location:  Uses a mask instead of artificial airway - use supplemental O2  provides Positive Airway Pressure (PAP) to help to keep alveoli open and support ventilation  Indications:  To avoid intubation & mechanical ventilation  Often used for obstructive sleep apnea  Type:  CPAP: continuous pressure  BiPAP: Bi-level or 2 level – lower pressure on exhalation K. Sam 2023 26 PT 704 Lab Week 9 Gait Training 2-, 3-, 4-Point Gait Patterns and Applications (Station 1) Part 1 Indications: Full Weight-Bearing (FWB) Weight Bearing as Tolerated (WBAT) 1. One (1) Lower Extremity Affected with Bilateral Axillary Crutches or Loftstrand Crutches (4-Point Gait) – Step Through Pattern PhysioU Link (Axillary crutches): https://app.clinicalpattern.com/acute_care/2641/2167/2167-2/p5849/ PhysioU Link (loftstrand crutches): https://app.clinicalpattern.com/acute_care/2641/2167/2167-2/p5851/ 1 2. One (1) Lower Extremity Affected with One (1) Axillary Crutch, or One (1) loftstrand Crutch, or Quad Cane (Modified 4-Point Gait) • • Showing Step-To Pattern Can progress the patient to a Step-Through pattern when patient is stable and feels stronger. PhysioU Link (1 axillary crutch): https://app.clinicalpattern.com/acute_care/2641/2167/2167-3/p5859/ PhysioU Link (Loftstrand Crutches): https://app.clinicalpattern.com/acute_care/2641/2167/2167-3/p5861/ 3. One (1) Lower Extremity Affected with Cane (Modified 4-Point Gait) (E.g., Spine surgery and Total Hip Arthroplasties – Cane if the patient has minimal pain or has good balance or as a progression from FWW when the patient is ready) • • Often start with Step-To Pattern Can progress the patient to a Step-Through pattern when the patient is stable and stronger. PhysioU Link: https://app.clinicalpattern.com/acute_care/2641/2167/2167-3/p5860/ 2 PT 704 Lab Week 9 Hip Precautions – Gait Training (Station 2) 1. Front Wheel Walker – Lower Extremity Affected (Modified 3-point Gait) -To incorporate with Sit to Stand, Turn, and Stand to Sit following precautions: • Posterior Precautions o Min Assist o Mod Assist • Anterior Precautions o Min Assist o Mod Assist PhysioU link: https://app.clinicalpattern.com/view/acute_care/b85e26bb6d7061249a5c0a0adfbd0d9dfd776bb7257 25688/?ctx=pt&lng=en 1