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Definition of Osteoarthritis (OA)

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• wear and tear = cartilage damage --Degenerative Joint Disease (DJD)

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Symptoms of OA

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• joints affected - symptoms at joints of all the body. - localized pain on joint - Carpal Metacarpal Osteoarthitis

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Definition of Rheumatoid Arthritis (RA)

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• chronic, systemic, autoimmune • synovitis

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Symptoms of Rheumatoid Arithritis

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Attack all the body • systemic symptoms • joints affected and symptoms at joints • nausea

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Clinical Presentation and Hand Deformities

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Bouchard's Nodes, Heberden's Nodes, swan neck deformity, ( finger bend like swan neck) boutonniere deformity,( like cailtilin's finger) trigger finger, ( like pulling a gun trigger) deQuervains tenosynovitis, carpal tunnel syndrome, ulnar drift, - deform bend toward pinky ( ulnar deviation splints) thumb deformities ( thumb affected)

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Prognosis, Course of RA

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• acute (exacerbation) and chronic (remission) phases. Gradual worsting pain

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Prognosis, Course of OA

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• progressive

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Medical Treatment for Arthritis

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• Drug Therapy: NSAIDs, DMARDs and BRMs, analgesics, steroids • Surgery: synovectomy, tenosynovectomy, tendon surgery, arthoplasty (repair), arthrodesis (fussion)

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1. OT EVALUATION

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-Pain assessment -Upper Extremity ROM -Hand placement test (Function ROM) -Observation grip strength -Functional ability (lateral pinch) -Endurance measurement (tolerance how many breaks they need to complete activity

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2. OT TREATMENT AND PRECAUTIONS

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a. Education b. Adaptive Equipment Training c. Splinting d. Therapeutic Exercise e. Physical Agent Modalities

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a. Education

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Joint Protection *Energy Conservation

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a. Education *Joint Protection:

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*Joint Protection: the damage joing -Respect pain- stop the pain before it starts -Use larger joints rather than smaller joints to accomplish a task; -Avoid positions of deformity -Avoid unnecessary loading of joints, especially towards positions of deformity e.g adapting the weight

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Energy Conservation

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-Pre-plan and organize- think a head -Rest- rest the body, the joint splinting -Use good postures and body mechanics -Avoid weather extremes-heat/cold attack systemic RA -Use diaphragmatic breathing

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b. Adaptive Equipment Training

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Select equipment based on patient needs. Some helpful devices may include: button hook, zipper pull, jar opener, enlarged handles, lever handles, long handled shoe horn, long handled bath sponge, reacher, dressing stick, tub seat, grab bars, raised toilet seat.

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c. Splinting

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-for rest, support during hand function, and/or prevention of deformity -provide hand function

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d. Therapeutic Exercise

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Move joints! -Avoid excessive movement and joint loading! Acute phase: ROM only, no resistance Chronic phase: ROM, gentle stretching, strengthening (isometric)

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e. Physical Agent Modalities

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- Heating modalities for stiffness -Cold modalities for swelling, inflammation,edema

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Energy Conservation and work simplification

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• Plan, set priorities, and balance your activities when planning your day. • Sit while you can. You are saving 25% more energy by sitting down. Tasks such as folding laundry, doing dishes, preparing food, bathing, and dressing can all be done while sitting. • Pace yourself during the activities. Take frequent breaks. • Avoid activities that involve exposure to warm weather----Remember, you always consume more energy if you have to work in less than optimal temperatures. • Slide objects instead of lifting or carrying them • Lay out work areas and storage areas within reach. Avoid all unnecessary bending, reaching, and stretching • Materials, utensils, and equipment should be arranged to allow the best sequence of motion

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PAINFUL CONDITIONS

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1. Acute Pain 2. Chronic Pain

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Acute Pain

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lasts 6 months or less

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Signs/Symptoms

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*signals tissue damage *identifiable cause *well localized *accompanies objective signs

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Chronic Pain -

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lasts more than 6 months

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Signs/Symptoms

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occurs after normal tissue damage and healing phases *lacks identifiable cause *poorly localized *lack of, or fluctuating, physical signs

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Also characteristic of chronic pain

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* multiple surgeries, medication/substance *psychological effects-depression, anxiety, cognitive effects *manipulative behavior- having been a patient *legal battle *Psychosomantic

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Common conditions associated with chronic pain:

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*fibromyalgia * Rheumatoid Arthritis *Cancer *Complex Regional Pain Syndrome (CRPS) Post-surgeries

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Pain Cycle

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Pain- muscle guarding- inactivity

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Etiology (cause of pain)

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1. Mechanisms of Normal Pain Responses 2. Gate Theory of Pain Modulation: 3. Theories About Mechanisms of Abnormal Pain Responses

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1. Mechanisms of Normal Pain Responses

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*Nociceptors- receptor *Thalamus - decide where to send *Somatosensory Cortex *Frontal Cortex- make decision (move, make rational decision) *Descending Analgesic Pathways- Pain suppressor)

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2. Gate Theory of Pain Modulation

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activation of nerves that do not transmit pain signals can interfere with signals from pain fibers and inhibit one's perception of pain

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3. Theories About Mechanisms of Abnormal Pain Responses

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* unknown *The nerve fibers behave abnormal. grow abnormal sprout *Centralized pain - it has become part of the body /brain

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Prognosis of a cute pain

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Acute pain resolves within normal tissue healing time frames, although factors such as age, infection, smoking, and diabetes will delay healing.

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Prognosis of a chronic pain

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Chronic pain has a poorer prognosis. Rates of successful resolution decrease as length of time in chronic pain increases.

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Precautions Adhere to all precautions related to the specific condition

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Acute Pain:- not making it to hurt more Chronic Pain- avoid that part of the body that stops activity

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Medical Management

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Medication, surgery, injection, nerve block

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OT Intervention

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1. Acute Pain: establish trust, splinting, PAMs, gentle ROM, soft tissue techniques, joint protection, compensatory techniques 2. Chronic Pain: a. Establish trust b. Offer choices and encourage ownership of intervention/goals "Helping patients adopt on internal locus of control over pain is essential for successful treatment." c. ADL Education!! *Posture and Body Mechanics *Joint Protection- using large joints *Adaptive Equipment- use reacher instead of bending *Energy Conservation and Pacing d. Therapeutic Exercise- stretches e. Other Interventions: Biofeedback, relaxation techniques, TENS, journaling/pain diary, Complementary and Alternative Medicine (CAM)

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Documentation of Pain in Occupational Therapy

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1. Location- where is the pain?lateral. posterior 2. Description- tingling, sharp cramp, ache, burning 3. Intensity- from 0--- to 10 no pain- to worst pain 4. Pain Aggravators- what cause the pain? walking, standing, twisting.... 5. Pain Relievers--what do you do to lower the pain? Relax, take pain medication, hot pack

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FRACTURES

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a break or crack in a bone

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Types of FRACTURES

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Closed---- the skin was not broken (skin intact) Open--- bone punctured skin

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Common types of fracture lines

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Transverse- across Oblique Spiral- like a triangle shape. sharp corner Comminuted- still in place but cracks- like a windshield crack Segmental- into small piece/ segment Avulsed- tip of the bone off Impacted - bone compress Torus- and Greenstick- mostly in children - flexible still can grow.

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Common Upper Extremity Fractures:

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Colles Fracture - fracture of distal radius Mallet Finger - avulsion fracture of distal phalanx Boxers Fracture - fracture of 5th metacarpal Scaphoid Fracture - fracture of a specific carpal bone

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Etiology

answer

trauma, disease, sports, cancer, oesteoporosis

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Signs and Symptoms: structural break in bone and...

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Pain, swelling, bruising, numbness, and loss of ROM

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Medical Treatment:

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1. Realign bony segments and immobilize for healing -closed reduction -open reduction internal fixation (ORIF) -external fixation Types of Abnormal Healing: a. Malunion------poor aligment of bone b. Delayed union----slow healing c. Nonunion------not connecting/healing 2. Relieve pain- use of medication 3. Minimize swelling- use cold modalities

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Prognosis:

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Upper Extremity Fractures typically heal in 6-12 weeks hand smaller bones 3-6wks Lower Extremitiy Fractures typically heal in 12-30 weeks Toes takes shorter than the femur

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Precautions:

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*Weight bearing is usually restricted *Universal Precautions- early mobility on how to progress after surgery *In therapy, one must balance progressing too quickly which risks re-injury with progressing too slowly which risks prolonged stiffness

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OT Intervention for Upper Extremity Fractures:

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1. Maintain integrity of non -immobilized joints 2. Splinting 3. Control pain, edema, scarring 4. Once fracture is stable , begin ROM exercises as prescribed by physician 5. Eventually progress to improving strength and control 6. Psychosocial adjustment to injury 7. Help patient achieve highest level of function/independent -ADL training, adaptive equipment training, compensatory techniques

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OT Intervention for Lower Extremity Fractures and Joint Replacement

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Hip Knee Femur, Fibula, Tibia Foot/Ankle

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*Precautions:

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Weight Bearing s/p Hip Arthroplasty Posterior - No hip flexion greater than 90 degrees -No internal rotation -No adduction (Crossing legs or feet) Anterior No external rotation No adduction (crossing legd/feet) No extension For lower extremity fractures

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*Special Medical Equipment:

answer

Hemovac/Drain Abductor Wedge CPM (Continuous Passive Motion) Machine Compression Devices and Stockings

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OT Goal:

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Achieve maximum level in ADL's, while maintaining safety -Self care -Transfers -Functional Mobility -IADL's, Work, Community

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Acronyms

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NWB- No Weight Bearing TTWB- 10% of body weight Toe Touch Weight Bearing PWB- Partial Weight Bearing WBAT- weight Bearing As Tolerated

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#2 ORTHOPEDIC SPINAL CONDITIONS

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1. Muscle Strain 2. Facet Joint Sprain 3. "Slipped Disc" 4. Spinal Stenosis 5. Spondylolesthesis

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Muscle Strain

answer

tearing, bruising, bleeding and/or irritation of individual muscle fibers

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Facet Joint Sprain

answer

tearing or inflammation of the ligament or joint capsule of a facet joint *To avoid injury or re-injury, avoid: twisting BLT

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"Slipped Disc

answer

bulging or herniated disc. Nerves, blood vessels, and ligaments are compressed *To avoid injury or re-injury, avoid: bending (forward from your spine)

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Spinal Stenosis

answer

narrowing of the spinal canal (age related)

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Spondylolesthesis

answer

superior vertebra slips over inferior vertebra *To avoid injury or re-injury, avoid: spinal Extension

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Signs and Symptoms

answer

localized pain, radiating pain, muscle guarding, muscle tenderness, weakness, numbness, tingling, mobility impairment

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Causes of Back Pain

answer

Macrotrauma - sudden injury from a major force Microtrauma - injury to tissue that occurs at a microscopic level; over time, cumulative effects of micro-trauma lead to a significant injury A majority of back injuries are due to cumulative factors, which include: 1. Poor posture 2. Poor body mechanics 3. Poor flexibility 4. Poor physical fittness

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Medical Treatment:

answer

medication to control pain, swelling, and muscle guarding; injection, surgery, bracing Physicians may also prescribe physical therapy which provides methods to alleviate symptoms, increase ROM and strength.

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Precautions of back condition

answer

No Contraindications No twisting, bending, extension Avoid poor posture, body mechanics, flexibility, physical fitness No bending, lifting tolerated

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OT intervention

answer

(1) Education- proper body mechanics, posture (2) ADls training- use of tools (3) Graded activities- pacing (4) Work rehab and services- job accommodations

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ORTHOPEDIC SOFT TISSUE CONDITIONS

answer

Strains, sprains, tears, myofascial syndromes, cumulative trauma disorders, dislocations, contusions, tendonitis, bursitis, lacerations, impingements....

question

OT Intervention for Soft Tissue Injuries:

answer

1. Pain Control - PAMs (Physical Agent Modalities), manual therapies, pacing, body mechanics training, compensatory strategies, splinting 2. Physical Rehabilitation - ROM, stretching, graded strengthening, coordination/dexterity, sensory re-education, desensitization 3. Splinting/Bracing for pain control, protection, rest, functional positioning, stretch 4. Training/Education a. ADL's - equipment and/or techniques b. Compensatory techniques - strategies to perform tasks in an alternate or enhanced way c. Prevention of re-injury and ergonomics - preventative stretches, pacing, work station modifications, job accommodation d. joint protection

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Body Mechanics Principles

answer

-Avoid twisting, quick movement -wide base -Test the weight before lifting -push don't pull

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Sensory Education

answer

numbness train them due to nerve injury (Stimulus)

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Desensitization

answer

-People who don't want to touch the area (Hypersensitive) local area of injury introduce touch slow/grading it to high level tolerate

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Spndylolysthesis

answer

anterior displacement of a vertebrae in relation to vertebra below it Contraindication: Spinal Extension

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Medical treatment

answer

Fracture Fixation Open Reduction Internal Fixation (ORIF) External Fixator

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Special Medical Equipment

answer

Hemovac/Drain Abductor Wedge CPM (Continuous Passive Motion) Machine Compression Devices and Stockings Suspension Reclining wheelchair Commode chair Patient controlled analgesia Antiembolism hose Incentive spirometer

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Spine

answer

Healthy disc bulging or herniated discs neutral spine spine flexion ( when you are gardening)

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Pain

answer

0-10 numerical pain rating scale no pain- moderate (5)--10 worst pain imaginable Pain diagram Wong- Baker Faces pain rating scale ( No hurt to hurt worst)

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FLACC PAIN SCALE

answer

used with infant and pediatric patients age 0-3 years , cognitively impaired patients, and those patients unable to use other scales.

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Over view of the skin

answer

Epidermis and dermis, Epidermal appendages

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Skin Functions

answer

-Protection -Keeps fluids in -Maintains body temperature -Protects against infection -Body image -Produces Vitamin D -Sensation -Immunologic Function -Allows motion and function

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Causes of Burn injuries

answer

Thermal Chemical Electrical Radiation Frostbite

question

Consequences of burn injury

answer

Infection Dehydration Lack of protection from the sun Strength and elasticity Altered sensation Loss of natural waterproofing Inhalation injury

question

How to classification of burn wounds

answer

Depth Total body surface Area (TBSA)

question

Factors Determining Severity of the Burn Injury

answer

Size Depth Location Age Other injuries Past medical history

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Classification According to Depth

answer

Superficial Thickness Partial Thickness Full Thickness Subdermal

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Superficial Burn 1 st degree

answer

1st Degree Epidermis only No blisters Injuries are painful, red, swelling Heals in 5-10 days Leaves no scar

question

Partial Thickness

answer

2nd degree burn Can be classified as superficial or deep

question

Superficial Partial Thickness

answer

Epidermis destroyed and damage down into upper third of dermis Results in red, serum filled blisters Healing in 7-14 days with zero to minimal scarring Painful

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Deep Partial Thickness ( Hand with Escharotomy)

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Damage well into dermis Usually blotchy pink, red and white Variable degree of reduced sensation Don't usually see blisters Coagulum (protein) Painful Usually requires Skin Grafting Risk of significant scarring increased

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Full Thickness Burns 3rd Degree

answer

3rd Degree Epidermis and dermis destroyed Burn appears white and waxy and does not blanch Down to subcutaneous tissue Little pain High risk for infection and contracture

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Subdermal Burns 4th degree burn

answer

4th degree burn Fat Muscle Bone Tendon, Ligament Muscle flaps for coverage Potential for amputation

question

Classification according to TBSA

answer

Rule of Nines -- body divided in to % not accurate in pediatric Lund-Browder-most accurate used from infant to adult uses patients hand to measure TBSA to be determined by the Resident and/or Attending Physician

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Infection Control

answer

Triceptin- use 1x/day Soap and water best Change gloves between limbs All patients are in isolation; additional mask and hat required during dressing change.

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Treatment for burns

answer

Daily dressing changes Surgical Interventions Debridement Allograft placement Autograft placement

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Burn Team

answer

Physician Nurse Physical Therapist Occupational Therapist Certified Occupational Therapy Assistant (COTA) Social Worker Chaplin Pharmacy Child Life Pharmacist Dietician Speech Therapist

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The role of OT with burn patients

answer

Positioning Splinting ADLs Functional mobility Education Scar management Assist with d/c recommendations

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Positioning to prevent contracture

answer

Hand/wrist - extension, thumb abd Elbow - extension Shoulder - abduction 90* Neck - extension, no pillows Hip - abduction, neutral rotation Knee - extension Ankle - neutral

question

Scar Formation and Types

answer

Hypertrophic - stay within boundaries of original wound. Keloid - grow outside boundaries of original wound.

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Eschar

answer

a dry, dark scab or falling away of dead skin

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Debridement

answer

removal of dead, damaged or infected tissues

question

Scar Management Techniques

answer

Ace Wrap Tubigrip Isotoner Gloves Custom Fit Compression Garments Silicone Products Scar Massage Passive Elongation Stretch and Massage

question

Heterotrophic Ossification

answer

Usually happens with pts who have greater then 30% TBSA burns Joint locks in place Very painful Comes on quickly Often doesn't show up on X-rays

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OT initial eval

answer

Home set-up Area/degree of burns Stretching exercises Positioning goals Splinting Functional mobility ADL's Staff/Caregiver goals- stretching program

question

OT Treatment

answer

Stretching/ROM Splinting/positioning Balance Functional transfers, safety ADLs Adaptive ADL techniques Patient and family education

question

ROM and stretching

answer

Hold stretch for 30 seconds 10 repetitions Complete at least 4 times a day Can range multiple joints at a time

question

Role of COTA

answer

Provide daily treatment to address patients plan of care Monitor progress with ROM Identify splinting needs Continually assessing for d/c recommendations and needs

question

Considerations with Therapy

answer

-Coordinate with pain meds -See during dressing change if pt able to tolerate and is appropriate -Holding ROM and activity after autograft placement -Exposed tendons- extra caution Psychosocial adjustment with the injury- encourage, cheer up the patient

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Pediatric Patients

answer

-Try not to see pt in room- use room as "safe place" -Walk, stand, and take patients outside- especially pts who have been burned on soles of feet. -Involve child-life (use play, diversion, etc.) when it is tolerable

question

Amputations

answer

Traumatic/Acquired Congenital

question

Traumatic/Acquired

answer

trauma, electrical, burns, disease, circulatory, industrial, MVA, cancer, meningococcemia, flesh eating virus, frostbie

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Congenital

answer

embryonic period: 1st 7 wks of pregnancy: differentiation occurs; fetal period: 7th week+: growth occurs

question

Congenital Limb Differences

answer

---Failure of a part to develop: ongoing research w/ genetic "switches" -Spontaneous mutation -Genetic link/ inherited -Exposure to external factors: cocaine, ethanol (fetal vascular disruption) ----Intrauterine amputation: constriction band

question

Phases of Recovery

answer

1. Enduring- surviving amputation surgery and pain that follows 2. Suffering-- Questioning: why me? emotional 3. Reckoning-- becoming aware of the new reality 4. Reconciling--putting the loss in perspective- regaining control 5. Normalizing- doing things that matters in life, advocating for self 6. Thriving- confident and living life to the fullest *used by the Amputee Coalition of America

question

Body Image

answer

(the attitudes we have about our body) Focus on the future, not what's missing

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Postoperative ; Pre-prosthetic Objectives

answer

-Promote residual limb shrinkage ; shaping -Promote residual limb desensitization -Maintain normal joint range of motion -Maintain skin mobility -Increase muscle strength -Provide instruction in the proper limb hygiene -Maximize functional independence -Myoelectric site testing -Educate about prosthetic options -Explore patient's goals for the future

question

Skin Preparation for Prosthetic Training

answer

1. Massage and Tapping 2. Desensitization (circular movement using cotton ball or terry cloth) 3. Scar Mobilization before scar healed (not massaging the scar) and healed ( touch on the scar) 4. Skin inspection with dressing change, later on daily

question

Exercise and Conditioning

answer

-Remember the whole person, not just the involved limb -Work bilaterally for optimal body alignment AROM -Strength: thera-band, cuff wts., specific muscle exercise preparing for prosthetic use -Balance and core strength -Aerobic

question

Types of Prostheses

answer

1. Passive or cosmetic: does not have active grasp/release 2. Body powered: cable controls movement with body motion 3.External powered: has outside power source: example is myoelectric 4. Hybrid: combination of types

question

Passive

answer

passive hand

question

Body powered

answer

Voluntary opening (V.O.) Split Hook Voluntary closing (V.C)

question

Recommended Hours Needed to Complete Upper Extremity Amputee Training

answer

Wrist Disarticulation, standard below elbow level: 1-10 hrs. ( less time for cosmetic fit) Short below elbow, standard above elbow level: 1-13 hrs. (less time for cosmetic fit) Shoulder disarticulation level: 2-19 hrs.

question

Considerations for Adjusting Hours Needed for Prosthetic Training

answer

Elderly patients or with complications: 1 x to double above Bilateral amputees: 1x above plus 50% again for opposite extremity Additional therapy may be needed to gain skill with higher level functional tasks

question

i-Limb™ Hand Training Protocol for Therapists

answer

Pre-prosthetic visits: 2 Includes education, peer support, evaluation, home exercise program (wrist extension/flexion 3-5x daily for 10 reps. each, hold for 3-5 sec.

question

i-Limb™ Hand Training Protocol for Therapists

answer

Prosthetic Training visits: 6 Includes: Donning/doffing prosthesis Orientation to wearing schedule Care of residual limb & prosthesis Orientation to grasp & release activities Unilateral ADL task training Bilateral ADL task training Advanced ADL task training ( as work specific )

question

Progression of Prosthetic Skills Training

answer

* Education for prosthetic terminology * Independence to don/doff prosthesis * Increase wearing time: 15-30 min. 3x daily first day -and frequent skin checks. Increase each period by 30 min. 3x daily each day. * Independence in controls: TD and elbow * Grasp/release at table top, floor & mouth * Prepositioning prior to reach/during reach

question

Progression of Prosthetic Skills Training

answer

***Functional independence: ------bimanual activities for the unilateral amputee ----ADL skills for the bilateral amputee: Eating Dressing Hygiene Toileting Bathing Writing ***Functional Cosmestic e.g swinging hands or marching to look like part of the body

question

Prehension Training (action Training)

answer

* Grasp/Release: solid block in pronation at table top, to floor, to mouth repeating until smooth * Grasp/Release: sponge in neutral at table top, to floor, to mouth repeating until smooth * Grasp/Release: paper cup in supination at table top, to floor, to mouth repeating until smooth

question

Activities of Daily Living

answer

Adaptive equipment: buttonhook, elastic laces, dressing stick , cutting board with nails, wall hook Modified techniques: one handed shoe tying, securing jar between knees to open, foot function Modified environment: rearranging kitchen pantry for easier reach, open shelves in closet for clothes instead of chest w/ drawers Work closely with the prosthetist especially with the bilateral amputee for: 1. Modifications to the harness or suspension to maximize independence to don/doff prosthesis 2. Length adjustments for optimal reach to mouth and perineal area 3. Need for wrist flexion for midline work

question

Terminal Devices

answer

***Hooks & Hands Voluntary Opening VO Voluntary Closing VC Hands VO VC Passive Hands- restore body image Specialty ***Components Wrist Units Friction- rubber washer Locking / Disconnect Flexion ***Harnessing

question

Flexion Wrists

answer

Allows for wrist flexion APRL Fits b/t TD and Wrist 3 friction positions Pediatric / sizing Locking Flexion Wrist Locking Positions @ 0*,30* &* 50 Cannot be used in conjunction with a VO / VC hand

question

Trans Radial Suspension

answer

Harness Suspension Self Suspending Capturing of anatomical features Locking Liners

question

Elbow Hinges

answer

Flexible Allows for pronation / supination Single Pivot Does not allow for pronation / supination Extension Stop / Heavy Duty Useage

question

UE Harnessing

answer

Figure 9 Self Suspending Socket Design TD function only Figure 8 Primary Suspension TD function Adjustability Sewn Back More cosmetic / Non adjustable Saddle Heavy Duty / Lifting

question

Time of Fitting

answer

Acquired: immediate post operative fit to 6 wks unless skin or wound issues Congenital: unilateral 4-6 months old for passive 18-24 months old to activate

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