ptpm010 ptm of physical mobility impairment medical journal…

PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:010 Revision: 01 Page: 1 of 124

PHYSICAL THERAPY MANAGEMENT OF

PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS

NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time.

Medicine: It’s a noble profession, it serves humanity.

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KAL MERA HAATH PAKADNA, JAB MAIN BOODHA HO JAAOON

PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS

SPEC. BY: Abdulrehman S. Mulla DATE: 04/09/2009 REVISION HISTORY REV.

DESCRIPTION

CN No.

BY

DATE

01 Initial Release PT0009 ASM 05/24/2009






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TABLE OF CONTENTS PAGE

1.0 CEREBRAL PALSY: 7

1.1 FOR CEREBRAL PALSY: 8 1.2 EXERCISING WITH CEREBRAL PALSY: THE WORKOUT: 10

1.2.1 RANGE-OF-MOTION AND OTHER EXERCISES: 10 A. RANGE-OF-MOTION EXERCISES (ROM): 11

I. WARMING UP: 11 II. EXERCISES TO KEEP THE FULL MOTION OF JOINTS, TO AVOID CONTRACTURES: 11 III. STRETCHING: 12 IV. STRENGTHENING EXERCISES WITH MOTION: 12 V. STRENGTHENING EXERCISES WITHOUT MOTION: 12

B. SWIMMING: 13 C. WEIGHT RESISTANCE EXERCISES: 13 D. BREATHING AND MUSCLE STRENGTHENING EXERCISES: 14 E. AEROBIC EXERCISES: 14 F. INFLATABLE THERAPY BALLS: 15

2.0 SPINA BIFIDA: 16

2.1 PHYSIOTHERAPY FOR SPINA BIFIDA: 17 2.1.1 EXERCISE/FITNESS: 18

A. GENERAL GUIDELINES AND SAFETY: 18 I. BREATHING: 18 II. POSTURE: 18 III. BACK SUPPORT: 18 IV. REST: 18

B. SAMPLE PHYSICAL ACTIVITY PROGRAM: 18 C. USE AND CARE OF THE ELASTIC RESISTANCE BAND: 19

I. NECK STRETCH: 19 II. WRIST FLEXION / EXTENSION: 19 III. OVERHEAD STRETCH: 19 IV. UPPER TRUNK FLEXION: 19 V. TRICEPS STRETCH: 20 VI. BUTTERFLY STRETCH: 20 VII. TRUNK ROTATION: 20 VIII. HAMSTRING STRETCH: 20 IX. SEATED EXERCISES: 20 X. ELBOW FLEXION: 20 XI. FORWARD REACH: 21 XII. UPRIGHT ROW: 21 XIII. OVERHEAD REACH: 21 XIV. HIP FLEXION: 21 XV. HIP ABDUCTION: 21

3.0 MUSCULAR DYSTROPHY: 23

3.1 TYPES OF MUSCULAR DYSTROPHY AND NEUROMUSCULAR DISEASES: 24 3.1.1 OTHER NEUROMUSCULAR DISEASES: 25

3.2 PHYSIOTHERAPY FOR MUSCULAR DYSTROPHY: 26 3.2.1 PASSIVE STRETCHING: 26

A. HIPS: 26 B. KNEES: 27 C. FEET AND ANKLES: 27 D. ELBOWS, FOREARMS AND WRISTS: 27

3.2.2 ACTIVE AND ACTIVE ASSISTED EXERCISES: 27 A. ELBOW, WRIST & HAND EXERCISES ELBOW, WRIST & HAND EXERCISES: 27






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B. KNEE EXERCISE: 28 C. HEAD & TRUNK EXTENSION: 28

3.2.3 CHEST PHYSIOTHERAPY IN CHILDREN: 28 A. THE MAIN TECHNIQUES USED ARE 28

I. POSTURAL DRAINAGE: 28 II. PERCUSSIONS: 29 III. ASSISTING COUGH: 29

3.2.4 POSITIONING AND SEATING IN MUSCULAR DYSTROPHY: 29

4.0 HEART DEFECTS: 31

4.1 PHYSIOTHERAPY AFTER HEART SURGERY: 32

5.0 AMPUTATION: 35

5.1 CAUSES AND THE NEED FOR AMPUTATIONS: 36 5.2 REHABILITATION AFTER AMPUTATION: 36 5.3 PHYSICAL THERAPY MANAGEMENT OF AMPUTEES: 38

5.3.1 PHYSICAL THERAPY MANAGEMENT OF ADULT : 38 A. PRESURGICAL MANAGEMENT: 38

I. INITIAL PATIENT CONTACT: 38 B. POSTSURGICAL MANAGEMENT: 39

I. MENTAL STATUS: 39 II. RANGE OF MOTION: 39 III. STRENGTH: 39 IV. SENSATION: 39 VI. BED Mobility 40 V. BALANCE/COORDINATION: 40 VI. TRANSFERS: 40 VII. WHEELCHAIR PROPULSION: 40 VII. AMBULATION WITH ASSISTIVE DEVICES WITHOUT A PROSTHESIS: 40 VIII. CARDIAC PRECAUTIONS FOR AMPUTEES: 40

B. PATIENT EDUCATION: LIMB MANAGEMENT 41 I. LIMB CARE: 41 II. PROBLEM DETECTION/SKIN CARE: 41 III. PROSTHETIC MANAGEMENT: 41 IV. SOCK REGULATION 41 V. DONNING AND DOFFING OF THE PROSTHESIS: 41 VI. RESIDUAL-LIMB WRAPPING: 42

C. PREPROSTHETIC EXERCISE: 43 I. STRENGTHENING: 43 II. RANGE OF MOTION: 44 III. FUNCTIONAL ACTIVITIES: 45 IV. GENERAL CONDITIONING: 45 V. BED MOBILITY: 45 VI. WHEELCHAIR PROPULSION: 46 V. UNSUPPORTED STANDING BALANCE: 47

D. PREGAIT TRAINING: 48 I. BALANCE AND COORDINATION: 48 II. ORIENTATION TO THE CENTER OF GRAVITY AND BASE OF SUPPORT: 48 III. SINGLE-LIMB STANDING: 49

E. GAIT-TRAINING SKILLS: 50 I. SOUND LIMB AND PROSTHETIC LIMB TRAINING: 50 II. PELVIC MOTIONS: 50 III. VARIATIONS: 54

F. ADVANCED GAIT-TRAINING ACTIVITIES: 55 I. STAIRS: 55 II. STEP BY STEP: 55 III. STEP OVER STEP: 55






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IV. TRANSTIBIAL AMPUTEES: STEP OVER STEP 56 V. CRUTCHES: 56 VI. CURBS: 56 V. UNEVEN SURFACES: 56 VI. RAMPS AND HILLS: 56 VII. SIDESTEPPING: 57 VIII. BACKWARD WALKING: 57 IX. MULTIDIRECTIONAL TURNS: 57 X. TANDEM WALKING: 58 XI. BRAIDING: 58 XII. SINGLE-LIMB SQUATTING: 59 XIII. FALLING: 59 XIV. FLOOR TO STANDING: 59 XV. RUNNING SKILLS: 59 XVI.RECREATIONAL ACTIVITIES: 61

5.3.2 ADULT UPPER LIMB PROSTHETIC TRAINING: 62 A. POSTOPERATIVE THERAPY PROGRAM: 62

I. PROMOTE WOUND HEALING: 63 II. CONTROL INCISIONAL AND PHANTOM PAIN: 63 III. MAINTAIN JOINT RANGE OF MOTION: 63 IV. EXPLORE THE FEELINGS OF THE PATIENT AND FAMILY: 64 V. FINANCIAL SPONSORSHIP: 64

B. PREPROSTHETIC THERAPY PROGRAM: 64 I. RESIDUAL LIMB SHRINKAGE AND SHAPING: 65 II. RESIDUAL LIMB DESENSITIZATION: 65 III. MAINTENANCE OF JOINT RANGE OF MOTION: 65 IV. INCREASING MUSCLE STRENGTH: 66 V. INSTRUCTION IN PROPER HYGIENE OF THE LIMB: 66 VI. MAXIMIZING INDEPENDENCE: 66 VII. MYOELECTRIC SITE TESTING: 66

C. DETERMINING THE PROSTHETIC PRESCRIPTION: 67 I. FABRICATION AND TRAINING TIME: 67

D. ADULT UPPER-LIMB PROSTHETIC TRAINING: 68 I. INITIAL ASSESSMENT: 68 II. STATUS OF THE OPPOSITE UPPER LIMB: · 68 III. INITIAL VISIT: 69 IV. ORIENTATION TO PROSTHETIC COMPONENT TERMINOLOGY: 69 V. PROSTHETIC WEARING SCHEDULE: 69 VII. CARE OF THE RESIDUAL LIMB AND PROSTHESIS: 69 VIII. BODY CONTROL MOTIONS: 70 IX. PROSTHETIC EVALUATION: 71 X. PROSTHETIC CONTROLS TRAINING: 71 XI. CONTROLS PRACTICE: 72 XII. FUNCTIONAL USE TRAINING: 72 XIII. CUTTING FOOD: 73 XIV. USING SCISSORS: 73 XV. DRESSING: 73 XVI. OPENING A JAR OR BOTTLE: 74 XVI. WASHING DISHES: 74 XVII. HAMMERING A NAIL AND USING TOOLS: 74 XVIII. DRIVING A CAR: 74 XIX. VOCATIONAL ACTIVITIES: 75 XX. HOME INSTRUCTIONS: 75 XXI. FOLLOW-UP ISSUES: 76

6.0 ARTHRITIS: 78

6.1 OSTEOARTHRITIS: 79






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6.1.1 THOSE ODD PAINS: 80 A. STRESS: 80 B. AGE: 81 C. HEREDITY: 81 D. DIAGNOSIS: 81 E. IF IT HURTS, WHY DO DOCTORS WANT PATIENTS TO EXERCISE? 81

6.2 RHEUMATOID ARTHRITIS: 82 6.2.1. WHEN THE BODY TURNS ON ITSELF: 82

A. STIFFNESS IN THE MORNING: 83 1. DIAGNOSIS: 83 2. TREATMENT: 83

6.3 JUVENILE RHEUMATOID ARTHRITIS: 84 6.3.1 OTHER FORMS OF ARTHRITIS: 85

A. GOUT: 85 B. FIBROMYALGIA: 86 C. LUPUS: 87

1. TREATMENT: 87 a. Treating Mild Systemic Lupus Erythematosus: 87 b. Treating Severe Systemic Lupus Erythematosus: 87 c. Treating Specific Complications 88

B. DIET AND LUPUS: 88 D. LYME DISEASE: 90

6.4 LIVING WITH ARTHRITIS: 91

7.0 BACK DISORDERS: 92

7.1 RECOMMENDATIONS FOR TREATMENT OF LOWER BACK PAIN: 93






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PHYSICAL MOBILITY IMPAIRMENT: A physical impairment might be defined as a disabling condition or other health impairment

that requires adaptation. Persons with physical impairment disabilities often use assertive devices or mobility aids such as crutches, canes, wheelchairs and artificial limbs to obtain mobility. The physical disability the person experiences may be either congenital, or a result of injury, muscular dystrophy, cerebral palsy, amputation, multiple sclerosis, pulmonary disease, heart disease or other reasons. Some persons may experience non-visible disabilities that may include respiratory disorders, epilepsy, or other conditions.






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PHYSICAL MOBILITY IMPAIRMENT INCLUDES THE FOLLOWING CEREBRAL PALSY SPINA BIFIDA

o QUADRIPLEGIA o PARAPLEGIA

MUSCULAR DYSTROPHY HEART DEFECTS AMPUTATION ARTHRITIS BACK DISORDERS

1.0 CEREBRAL PALSY:

The term, 'Cerebral Palsy,' is used to describe a group of chronic conditions, which affect body movements and muscle coordination in persons affected with the disorder. Cerebral Palsy causes damage to one or more particular areas of the person's brain, and usually occurs during fetal development or before, during, or shortly after birth; although the damage may be done during infancy. Cerebral Palsy disorders are not caused by problems in the person's nerves or muscles. Faults in the development or damage to motor areas in the person's brain disrupt their brain's ability to control posture and movement. Cerebral Palsy is not progressive, although secondary conditions like muscle spasticity may develop that can worsen or improve over time, or may remain the same. Cerebral Palsy is not a communicable disease. Cerebral Palsy is not curable, but therapy and training may help to improve function.






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1.1 FOR CEREBRAL PALSY: Physical therapy for cerebral palsy patients consists of activities and education to improve flexibility, strength, mobility, and function. A physical therapist also designs, modifies, and orders adaptive equipment. Physical therapy can take place in clinics, hospitals, schools, and should carry on in the home through an exercise program. Physical therapy for cerebral palsy patients will not be successful without an ongoing daily home program. A physical therapy program should consist of a number of exercises that include stretching, strengthening, and positioning. To stretch the muscles, the arms and legs must be moved in ways that produce a slow, steady pull on the muscles to keep them loose. Because of the increased muscle tone of the cerebral palsy patient, they tend to have generally tight muscles. Therefore, it is extremely important to perform daily stretches to keep the arms and legs limber, allowing the child to continue to move and function. Strengthening exercises work specific muscle groups to enable them to support the body better and increase function. Positioning requires the body to be placed in a specific position to attain long stretches. Some positions help to minimize unwanted tone. Positioning can be done in a variety of ways.

Bracing, Abduction pillows, Knee immobilizers, Wheelchair inserts, Sitting recommendations, Handling techniques are all part of positioning techniques used in physical therapy for cerebral palsy

patients. New techniques of physical therapy for cerebral palsy patients have taken to the water.






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Aquatic-based rehabilitation uses the physical properties of water to resist or assist in the performance of exercises. Cerebral palsy patients experience muscle shortening in most of their involved extremities and it becomes a difficult task to lengthen the affected musculature with regular stretching while having to deal with the affects that gravity has on the spastic arm or leg. In the past, there was clinical prejudice against strengthening activities for this population. However, recent research findings are revealing that children with cerebral palsy can benefit from strengthening programs and that strength is directly related to motor function. Some of the documented benefits are optimization of neuromuscular responses, improved motor unit contraction synchrony and facilitation of maximal muscle contraction along a joint's available range of motion. Physical therapy for cerebral palsy patients does not cure spasticity but can improve impairments and limitations. Physical therapy for cerebral palsy patients is an important step towards an independent lifestyle. If these changes happen only in the therapy gym, the disability remains unchanged. Therapy must improve abilities to perform meaningful tasks in everyday life. Changing the level of disability is the ultimate goal of physical therapy for cerebral palsy






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1.2 EXERCISING WITH CEREBRAL PALSY: THE WORKOUT: Exercising with cerebral palsy is not only good for the patient but in most cases it is absolutely essential for the well-being of the patient and for loosening the muscles which can be very constricted at times. The exercises must be adapted to the particular patient's needs but general movement is agreeable as well. Playing outdoors, swimming, aerobic exercise, weight resistance training, all are acceptable forms of exercise for people suffering from cerebral palsy.

1.2.1 RANGE-OF-MOTION AND OTHER EXERCISES: All children need exercise to keep their bodies strong, flexible, and healthy. Most

village children get all the exercise they need through ordinary daily activity: crawling, walking, running, climbing, playing games, lifting things, carrying the baby, and helping with work in the house and farm.

Disabled children should get their exercise in ways that are useful and fun! As much as is possible, disabled children should get their exercise in these same

ways. However, sometimes a child's disability does not let him use or move his body, or parts of it, well enough to get the exercise he needs. Muscles that are not used regularly grow weak. Joints that are not moved through their full range of motion get stiff and can no longer be completely straightened or bent. So we need to make sure that the disabled child uses and keeps strong whatever muscles he has, and that he moves all the parts of his body through their full range of motion. Sometimes a child may need help with these exercises. But as much as possible, he should be encouraged to do them himself, in ways that are useful and fun.

No matter at what age you begin to exercise, or how long you may have been inactive, proper exercise will always improve your physical condition. People who have been inactive for some time can do the exercises in this booklet. Programs to improve flexibility, strength, and endurance are arranged in three levels of difficulty. It is important to begin any exercise program slowly and build up gradually. Remember, it may take several months to attain the minimal levels of physical fitness identified in Level I activities. Some people will take less time, others more.

Before beginning an exercise program, have a physical examination and discuss the program with your doctor. In addition, if your mobility is limited as a result of a chronic or disabling condition, be sure to review these exercises with your doctor. Keep in mind your level of ability and endurance so that you don't risk discomfort or injury. If you experience pain while exercising, stop that particular movement and ask your doctor about it on your next visit.

Stick with it, and you will see results! Different exercises for different needs Different kinds of exercises are needed to meet the special needs of different children. On the next

two pages we give an example of each kind of exercise. Then we look at some of the different exercises in more detail.






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PURPOSE OF EXERCISE KIND OF EXERCISE 1. Range-of-motion exercises (ROM) To maintain or increase joint

motion 2. Stretching exercises

3. Strengthening exercise with motion: exercises that work the muscles and move the joint against resistance To maintain or increase

strength 4. Strengthening exercises without motion: exercises that work the muscles without moving the joint

To improve position 5. Practice at holding things or doing things in good positions

To improve control 6. Practice doing certain movements and actions, to improve balance or control

A. RANGE-OF-MOTION EXERCISES (ROM):

I. WARMING UP: Preparing the body for exercise is important for people at any age and all fitness levels. A warm-up period should begin with slow, rhythmic activities such as walking or jogging in place. Gradually increase the intensity until your pulse rate, respiration rate and body temperature are elevated, which is usually about the time that you break a light sweat. It also is advisable to do some easy stretching exercises (such as the ones on page 6) before moving on to the strength and endurance activities.

II. EXERCISES TO KEEP THE FULL MOTION OF JOINTS, TO AVOID CONTRACTURES: PT slowly bends, straightens, and moves all the joints as far as they normally go. At least 2 times a day, these exercises must be carried out at home.






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III. STRETCHING: Stretch tightened muscles by working on the problem area for several minutes each day. For example, if the problem is tight calf muscles, the patient should exercise the legs by standing on his or her toes and slowly bouncing up and down. Also, flexing the calves in a sitting position, with the toes flexed and touching the toes, is a great stretching exercise. Stretching is a basic exercise for all cerebral palsy patients. Different kinds of exercises can promote stretching. Just standing as tall as the palsy will allow is strongly beneficial. Supports should be used where needed, in case the patient is not capable of standing alone.

IV. STRENGTHENING EXERCISES WITH MOTION: To strengthen the weak muscles in the thighs, raise and lower one at a time as shown below without added weight and later with a sandbag on the ankle. As the leg gets stronger the weight can be increased.

V. STRENGTHENING EXERCISES WITHOUT MOTION:

For a painful knee with weak thighs, that hurts when moved and standing is impaired. The muscles of the thighs need to be strengthened by following the muscle contracting and releasing exercise This strengthening exercise must be done without the movement of the knee. The leg must be held straight and the muscles thigh contracted and released for a certain amount of time. Repeatability of this exercise will add strength to the thigh.






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B. SWIMMING: Swimming is an excellent exercise for patients with cerebral palsy as the water

has a certain amount of resistance to it. The patient can float and his or her weight is much more buoyant than it is without water, so the person's movements are less restricted. Cold water is beneficial for increasing muscle tone while warm water tends to relax muscles. Whatever is needed for the muscle tone of the individual is what should be selected.

C. WEIGHT RESISTANCE EXERCISES: Assist the patient in performing weight resistance exercises, using only the amount of weight that the patient can safely handle. , Ankle bands and small dumbbells are ideal for this purpose.






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D. BREATHING AND MUSCLE STRENGTHENING EXERCISES: Work the arms and legs in a cycling motion, using stationary bikes or hand

machines. This can provide many positive effects for improving breathing and muscle strengthening.

E. AEROBIC EXERCISES: Try different types of aerobic exercises, such as jogging, walking and climbing the

stairs. These exercises work on improving circulation as well as muscle flexibility and strength. Many children enjoy dancing and it can be a great way to improve muscle tone and tightness as well as their breathing and circulation.






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F. INFLATABLE THERAPY BALLS: Using certain tools to help with stretching therapy is a good idea. Inflatable

therapy balls and therapy bolsters are useful for stretching the tight muscles of the cerebral palsy patient. Stretch the hamstrings with standers and floor sitters. Standers are comparable to wheelchairs that keep the child strapped into a standing position and floor sitters are padded chairs with chest brace straps so the child can sit on the floor upright like other children.

Pediatric Pressure Splints, are inflatable hand and ankle foot orthoses and wrist and forearm splints designed for therapy and proper limb positioning for infants, children, and adolescents with cerebral palsy. The transparent, durable PVC splints feature a softer inner layer which conforms to and equalizes pressure over the limb. The splints may be inflated orally or with a blower, and they may also be filled with water and refrigerated for use as a cold pack.






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2.0 SPINA BIFIDA: Spina Bifida is a form of neural tube defect. Neural tube defects involve incomplete development of the brain,

spinal cord, and/or their protective coverings, which are caused by the failure of the fetus' spine to close properly during the first month of pregnancy. Children who are born with Spina Bifida may have an open lesion on their spine where notable damage to their nerves and spinal cord has happened. The nerve damage is permanent, although the opening in the spine can be surgically repaired. The damage to the child's nerves may result in various degrees of paralysis in their lower limbs. In cases where there is no lesion present there is still the potential for the presence of improperly formed or missing vertebrae, as well as nerve damage. Persons with Spina Bifida often experience a form of learning disability in conjunction with physical and mobility disability. There is currently no cure for Spina Bifida; the nerve tissue can neither be repaired nor replaced. Treatment for Spina Bifida may involve surgery, physiotherapy, and medication. Many persons with Spina Bifida use assistive devices including braces, crutches, or wheelchairs. QUADRIPLEGIA is paralysis of the extremities and trunk caused by a neck injury. People with quadriplegia have

limited or no use of their arms and hands and often use electric wheelchairs. PARAPLEGIA is paralysis of the lower extremities and the lower trunk caused by an injury to the mid-back. People

often use a manual wheelchair and have full movement of arms and hands. Below are brief descriptions of other causes of mobility impairments.






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2.1 PHYSIOTHERAPY FOR SPINA BIFIDA: Management of spina bifida depends on its severity. Medical specialists, nurses, physiotherapists, speech and occupational therapists, social workers and neuropsychologists all contribute to manage the condition. As there is damage to the central nervous system, there is currently no cure. Generally, limitations in mobility can result in poor skin and muscle tone, and weight gain and declining mobility in adolescents. The child's normal social development may be hampered because of frequent hospital stays, outpatient appointments, and periods in plaster. The spinal cord: An operation is performed immediately after birth to close the lesion on the back. For the majority of children, no further treatment of the spinal cord is required. For a minority, further complications including spinal curvature and spinal cord adhesion will require additional surgery. Incontinence: Varying degrees of incontinence are a result of the nerve signals between the brain and bowel/bladder being impaired. Surgery of various types may be helpful in some cases. Bladder management usually involves Clean Intermittent Catheterisation. Initially parents, and then the individuals, learn to insert a catheter to empty the bladder a number of times daily. Social continence is thus achieved. Bowel management requires additional training and dietary considerations. However, by the time the child reaches the age of seven, incontinence problems are usually under control, although occasional 'accidents' will occur. Shunt complications: Once inserted, the modern shunt causes few problems. Sometimes,

however, a shunt may need to be replaced if it becomes blocked or infected. Symptoms of shunt malfunction are diverse and varying. Early signs can be detected in a gradual deterioration of the child's overall performance. Sometimes, symptoms are severe and include headaches and vomiting. A suspected shunt malfunction should be immediately communicated to parents and requires medical intervention.

Mobility: special braces help weakness and paralysis of the lower limbs (eg. Ankle Foot Orthosis: AFOs), crutches or wheelchairs. Surgery may be performed to enable functioning muscles to work more effectively. Some children will be involved in ongoing physiotherapy programs to maximize muscles and joint function.

Skin care: Children with spina bifida often have a lack of sensation due to nerve damage and poor circulation. They are prone to injury from prolonged pressure, friction, heat or cold. To prevent sores and burns, conscientious skin care, frequent position changes and careful monitoring of the child's environment is essential.

Testing: Professional neuropsychological assessment of the child to identify visual perception, auditory processing and cognitive differences is also essential in overall management. A range of specific interventions may be required from an early age.

It is important that the school does its best to manage the physical environment for students with SBH. Impaired mobility requires appropriate modifications to buildings and grounds. Incontinence requires access to toilet and washroom facilities that provide additional space, provision for support and privacy.






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2.1.1 EXERCISE/FITNESS: Make sure you are healthy enough to exercise. Inform your physician that you are

starting an exercise program. Choose the right program for YOU and make sure to keep activities that you choose

VARIED, FUN, and REWARDING. Exercise a minimum of five days a week, ideally performing strengthening exercises 3

to 4 days a week. Be active throughout the day - just keep moving. A. GENERAL GUIDELINES AND SAFETY:

Many people with spina bifida have latex allergy. If this is the case, always check beforehand to make sure that the exercise equipment is not made of latex. Equipment manufacturers such as Thera-band offer latex-free versions of their products.

I. BREATHING: Breathe normally while performing the exercises. Do not hold your breath at any time. To make sure that you are not overdoing the exercises, you should be able to maintain a normal conversation. If you are exercising alone, it is best to count out loud while doing the exercises. A useful technique is to slowly count 1-2 when performing the exercise action, and count 1-4 when going back returning to the starting position.

II. POSTURE: Sit up tall with both feet planted firmly on the floor.

III. BACK SUPPORT: To make sure that your lower back is supported, roll up a small towel and place it behind your back.

IV. REST: Give your muscles a day's rest between strength training sessions. Your muscles may feel sore a day or two after you've started a new exercise. IF you are sore, wait until soreness has diminished before going back to strength training. Consult with your doctor if the muscle soreness lasts longer than two days. In addition, if muscle soreness last 2-3 hours after exercise, you know you have done too much. During the next exercise session, decrease the number of repetitions, sets, or weight until you find the right settings for you.

B. SAMPLE PHYSICAL ACTIVITY PROGRAM:

Include as much variety as possible. M, W, F - walk 30 minutes, lift weights for 20 minutes, stretch for 10 minutes. Tuesday/Thursday: ride the stationary bike for 15 minutes and perform a dance video for 15 minutes. On the weekends, go hiking in a local park, swim during the summer months or ride a bike (three wheeled bicycles are becoming popular).






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C. USE AND CARE OF THE ELASTIC RESISTANCE BAND: Before starting, always check the band for damage. Make sure that the elastic band is wrapped firmly (but not too tight!) around your fists. Adjust the length of the band so that there is just enough slack/elastic resistance and you are able to go through the full or comfortable range of motion when exercising. Avoid pinching or pulling of body hair by covering area of skin. Control the band to avoid snapping back The resistance level of the band increases by decreasing the bands distance between your hands or by folding it over. As you increase strength, move to another color band for increased resistance. Store the band in a dark location. Keep away from pets and children.

I. NECK STRETCH:

Tilt your head to the side, moving your ear toward your shoulder Hold for 20 seconds. Return your head to an upright position. Repeat on the opposite side. This stretches the side of the neck.

II. WRIST FLEXION / EXTENSION:

Extend the arm and hand forward. Palm facing outward. Bend your wrist and assist the movement with your other hand. Hold. Then straighten your wrist and assist the movement with your other hand. Hold.

III. OVERHEAD STRETCH:

Sit on the chair with back and neck straight. Feet are planted firmly on the floor.

Raise arms up overhead. Interlock fingers if possible, for a stronger stretch. Extend your arms, straightening the elbows. This stretches the muscles of the shoulder.

IV. UPPER TRUNK FLEXION:

Sit with proper posture. Eyes looking forward, and feet planted firmly on the floor. Bring your chin to your chest and round the upper trunk keeping head, neck, and

shoulders relaxed. Keep your bottom firmly on the seat. Slowly straighten the back, and then bring head back to neutral/ starting position. Repeat.






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V. TRICEPS STRETCH: Stand or sit with proper posture. Bring one arm across your body. Using your other hand, gently pull your elbow farther across your body. Feel the stretch along the back of your shoulder. Hold for 20 seconds. Release the stretch briefly. Do the stretch 2 times with each arm.

VI. BUTTERFLY STRETCH:

Sit with proper posture and place your hands behind your neck. Slowly and gently bring your elbows backward, being careful not to pull on your neck. When your elbows are as far back as they will go, pause briefly. Feel the stretch in your shoulders and chest Relax and return to the starting position Repeat 10 times.

VII. TRUNK ROTATION:

Sit in chair and gently rotate you trunk and shoulders to one side Use your arms to help rotate Repeat in opposite direction. You should feel a stretch in your trunk.

VIII. HAMSTRING STRETCH:

Sit in chair and extend one leg forward Keep knee straight and gently lean toward your toes Repeat on the other leg You should feel a stretch in the hamstrings. Don't perform this exercise if it increases leg pain.

IX. SEATED EXERCISES:

For seated exercises, sit up tall with both feet planted firmly on the floor. You may want to use a rolled up towel to support your lower back. Begin with a few repetitions and progress to 12 as you increase your strength

X. ELBOW FLEXION:

Place the band crosswise on the seat of the chair. Adjust the length of the band so that there is enough slack.

Sit in chair or wheelchair arm free. Wrap the band around the hand with palm facing upwards. Tie the exerciser at knee level on the side of the chair or across legs Bend elbow Hold. Return to start position.






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XI. ELBOW EXTENSION: Place the half of the band crosswise on the seat of the chair. Adjust the length of the band

so that there is enough slack. Sit on the band, arm free. Make sure that the band crosses diagonally across the back. Wrap the band around your hand with elbow bent, and palm facing downward. Straighten elbow. Hold. Return to start position.

XII. FORWARD REACH:

Begin with band wrapped around your upper back. Grasp both ends of band with elbows bent and palms facing inward. Push band forward, extending your elbows to shoulder level. Slowly return to starting position.

XIII. UPRIGHT ROW:

Place center of band under both feet and grasp each end of the band with palms facing down

Pull band upward toward chin, lifting elbows outward. Slowly return to the starting position.

XIV.OVERHEAD REACH:

Place center of band under feet and grasp each end of the band with palms facing forward.

Lift arms forward and upward, extending your elbows with palms facing forward. Don't lift above your shoulders if it causes pain. Slowly return to the starting position.

XV. HIP FLEXION:

Sit on firm surface, the exerciser around thighs. Raise knee to chest, keeping opposite leg stationary. Hold. Return to start position.

XVI.HIP ABDUCTION:

Sit on firm surface, the exerciser around thighs, near knees. Lift one leg slightly and pull away from other leg. Hold. Return to start position.

LEG PRESS: Begin looping middle of band around foot with your knee bent. Hold both ends of the band at your waist. Keeping ends of band at your waist, extend knee to straighten leg. Slowly return to starting position Repeat on other leg.






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Tatyana McFadden, a young woman with spina bifida, was featured last week in the Washington Post for the inspiration she receives competing in wheelchair track events. Tatyana, who is 16, will be among the youngest of the 1,247 athletes competing at the European Wheelchair Championships in Espoo, Finland this month. "McFadden, 16, a sophomore at the Columbia school, will be among the youngest of the 1,247 athletes at the event; they will represent 47 countries. But she is considered a rising star on the U.S. Paralympic Team and one of the world's most talented wheelchair athletes, quite an accomplishment for a girl who wasn't expected to live more than a few weeks. McFadden was born in St. Petersburg, Russia, with spina bifida, a congenital defect in the spinal column that left her paralysed from the waist down. Abandoned by her mother, she lived in an orphanage until an American woman who worked for the U.S. Department of Health and Human Services providing humanitarian aid overseas spotted her. "She's already one of the top athletes in the world," said Joe Walsh, the managing director for U.S. Paralympics. "If she keeps improving the way she has, then three or four years from now she could be challenging to be the best ever at her sport."






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3.0 MUSCULAR DYSTROPHY: 'Muscular Dystrophy,' describes a group of genetic diseases, which are characterized by progressive weakness,

and degeneration of the person's skeletal or voluntary muscles used to control movement. Some forms of Muscular Dystrophy affect heart muscles, as well as some additional, involuntary muscles. Some forms of Muscular Dystrophy affect a person's organs as well. Duchene is the form of Muscular Dystrophy that affects children most commonly; Myotonic Muscular Dystrophy is the most common form of the disease affecting adult populations. There are some forms of Muscular Dystrophy that appear in infancy or childhood, while other forms may not appear until a person reaches middle age or older. Muscular Dystrophy has the potential to affect persons of any age group. There is no specific treatment for any form of Muscular Dystrophy. Both Physical therapy and corrective orthopedic surgery may improve a person's quality of life.






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3.1 TYPES OF MUSCULAR DYSTROPHY AND NEUROMUSCULAR DISEASES: Muscular dystrophy is a group of inherited diseases that are characterized by weakness and wasting

away of muscle tissue, with or without the breakdown of nerve tissue. There are nine types of muscular dystrophy, with each type involving an eventual loss of strength, increasing disability, and possible deformity.

The most well known of the muscular dystrophies is Duchenne muscular dystrophy (DMD), followed by Becker muscular dystrophy (BMD).

Listed below are the nine different types of muscular dystrophy. Each type differs in the muscles affected, the age of onset, and its rate of progression. Some types are named for the affected muscles, including the following:

TYPE AGE AT ONSET SYMPTOMS, RATE OF PROGRESSION, AND LIFE EXPECTANCY

Becker Adolescence to early adulthood

Symptoms are almost identical to Duchenne but less severe; progresses more slowly than Duchenne; survival into middle age.

Congenital birth Symptoms include general muscle weakness and possible joint deformities; disease progresses slowly; shortened life span.

Duchenne 2 to 6 years Symptoms include general muscle weakness and wasting; affects pelvis, upper arms, and upper legs; eventually involves all voluntary muscles; survival beyond 20s is rare.

Distal 40 to 60 years Symptoms include weakness and wasting of muscles of the hands, forearms, and lower legs; progression is slow; rarely leads to total incapacity.

Emery-Dreifuss Childhood to early teens Symptoms include weakness and wasting of shoulder, upper arm, and shin muscles; joint deformities are common; progression is slow; sudden death may occur from cardiac problems.

Facioscapulohumeral Childhood to early adults Symptoms include facial muscle weakness and weakness with some wasting of shoulders and upper arms; progression is slow, with periods of rapid deterioration; life span may be many decades after onset.

Limb-Girdle Late childhood to middle age

Symptoms include weakness and wasting, affecting shoulder girdle and pelvic girdle first; progression is slow; death is usually due to cardiopulmonary complications.

Myotonic 20 to 40 years Symptoms include weakness of all muscle groups accompanied by delayed relaxation of muscles after contraction; affects face, feet, hands, and neck first; progression is slow, sometimes spanning 50 to 60 years.

Oculopharyngeal 40 to 70 years Symptoms affect muscles of eyelids and throat causing weakening of throat muscles, which, in time, causes inability to swallow and emaciation from lack of food; progression is slow.






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3.1.1 OTHER NEUROMUSCULAR DISEASES:

Spinal Muscular Atrophies:

Amyotrophic Lateral Sclerosis (ALS), or Motor Neuron Disease

Infantile Progressive Spinal Muscular Atrophy

Intermediate Spinal Muscular Atrophy

Juvenile Spinal Muscular Atrophy

Adult Spinal Muscular Atrophy

Inflammatory Myopathies:

Dermatomyositis

Polymyositis

Diseases of Peripheral Nerve:

Charcot-Marie Tooth Disease

DeJerine-Sottas Disease

Friedreich's Ataxis

Diseases of the Neuromuscular Junction:

Myasthenia Gravis

Lambert-Eaton Syndrome

Metabolic Diseases of the Muscle:

Acid Maltase Deficiency

Carnitine Deficiency

Carnitine Palmityl Transferase Deficiency

Debrancher Enzyme Deficiency

Lactate Dehydrogenase Deficiency

Mitochondrial Myopathy

Myoadenylate Deaminase Deficiency

Phosphorylase Deficiency

Phosphofructokinase Deficiency

Phosphoglycerate Kinase Deficiency

Less Common Myopathies:

Central Core Disease

Hyperthyroid Myopathy

Myotonia Congenita

Myotubular Myopathy

Nemaline Myopathy

Paramyotonia Congenita

Periodic Paralysis - Hypokalemic - Hyperkalemic






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3.2 PHYSIOTHERAPY FOR MUSCULAR DYSTROPHY: Passive Stretching Active & Active Assisted Exercises Chest Physiotherapy Positioning & Seating As muscular dystrophy progresses and muscles weaken, contractures can develop in joints. This can affect the tendons that can become short, restricting the flexibility and mobility of the joints. The most important goal of physical therapy is to provide regular range of motions exercises to keep your joints as flexible as possible. The goal is also delaying the progression of contractures, and reducing or delaying curvature of the spine.

3.2.1 PASSIVE STRETCHING: Passive stretching is where you are doing all the work. Ideally it is performed daily to all

necessary joints through a full range. Use a firm surface such as a mat on the floor. It is also useful to do the exercises at the same time every day. Physiotherapy should start as soon as the child has been diagnosed, even with a very young baby.

A. HIPS:

The hip joint is controlled by some of the largest muscles in the body. The two groups that are most likely to become contracted are those that control the bending or forward lifting of the leg (the hip flexors) and those that move the leg out to the side (the hip abductors). There are three different ways in which these muscles can be stretched. When possible, all hip exercises should be repeated about 10 times on each side.

I. The child lies on one side with the top leg straight (the hip to be stretched) and the helper positioned behind. The bottom leg may be bent or straight. Place one hand firmly on top of the hipbone to steady it and slide the other hand under the thigh of the top leg, just above the knee. The leg is then drawn backwards towards you to stretch the hip flexors, which lie across the front of the hip joint.

If you choose this method you must be sure that the pelvis is steady. You can put your knee against the child’s lower back so that your thigh acts as a cushion. Repeat the stretch on the other side.

II. The child lies face down. One hand is placed firmly on the buttocks on the same side as the hip to be stretched and the other hand is slipped under the thigh just above the knee. The thigh is then lifted and thus extended, stretching the front muscles of the hip and thigh. Repeat with the other leg.

III. The child lies on his/her back and the opposite leg (the one not being stretched) is bent up towards the chest and held in that position by you or the child, if he/she can manage it. Your hand is then placed just above the knee of the leg to be stretched and a downward pressure is exerted. Repeat with the other leg.






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B. KNEES: Usually only minor contractures develop at the knees before the child has to start using a

wheelchair but it is essential to prevent these because it is difficult to stand or walk with bent knees. To stretch the knees the child lies on his/her back while the parent stands at the level of the feet, slightly to one side. Grasp the heel of the right foot with your left hand, your palm cupped and your fingers bent. With the other hand counter pressure is given on the thigh just above the knee–cap and the lower leg is brought up until the knee is straight. Be careful not to cause discomfort by over–straightening the knee. Repeat with the other leg.

C. FEET AND ANKLES:

The infant lies on his/her back while the parent stands at the level of the feet, slightly to one side. Grasp the heel of the left foot with your left hand, your palm cupped and your fingers bent. Extend your thumb up the side of the child’s lower leg. With the right hand grasp the foot and move it to a right angle. When doing this, check that the foot is straight i.e. that it is not turning in or out. The foot should be directly in line with the knee and the knee should be kept straight. Repeat with the other leg.

D. ELBOWS, FOREARMS AND WRISTS:

Most children with muscular dystrophy have floppy elbows and wrists but some can develop tightness as they get older. The main stretch is to straighten the elbows while turning the palm of the hand up. Stand beside the child on the side of the arm to be stretched. For the left arm, cup the elbow in your right palm and put your left hand on the palm surface of the wrist. Turn the forearm as far round as possible so that his/her hand faces upwards and pull the hand down to straighten the arm as much as you can (without overstretching), holding this position for a count of five. Repeat for the other arm.

3.2.2 ACTIVE AND ACTIVE ASSISTED EXERCISES: Active muscle work is where the child does the ‘Work’ himself/herself. This type of

exercise helps strengthen muscles and may or may not be against resistance. Active assisted exercises are where the child and the helper work together to achieve a particular movement.

A. ELBOW, WRIST & HAND EXERCISES ELBOW, WRIST & HAND EXERCISES:

No matter how much exercise your child does, you cannot expect the muscles to become as strong as the ‘Normal’ muscle. However, most of the muscles in the body have the potential for increased strength with exercises and this will lead to some improvement in function and ability. In the weakest children, it may be difficult to notice much increase in power with exercise. The exercises are directed at the weaker of the muscle pairs in the arms and legs. The opposite pairs of muscles in the neck and trunk are almost equally weak but it is thought more important to exercise the ‘Extensors’, those that lift the head up and pull the trunk up straight, rather than the ‘Flexors’ which are the muscles which bend them forward.






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B. KNEE EXERCISE: The child lies over a roll resting on the forearms with the head down. The object of

the exercise is to try to lift the head and push the arms straight.

C. HEAD & TRUNK EXTENSION:

The child rests on the tummy and attempts to raise the head and shoulders to look up. The helper may support the arms. Games such as pushing a ball can be incorporated into this exercise.

3.2.3 CHEST PHYSIOTHERAPY IN CHILDREN: In Muscular Dystrophy, the muscles are weak, along with the other trunk and spine

muscles. The children tend to use their diaphragm muscle more when breathing than we would normally, which is why they may develop a longer, thinner looking chest. When the children get a chest infection, the inability to take good deep breaths and cough forcefully may make the clearance of excess thick phlegm that occurs more difficult. This is when chest physiotherapy is useful to help clear the lungs and get the phlegm into the mouth where it can be spitted out. Chest physiotherapy works by helping to drain the secretions out of the lungs and get them to where they can be removed or swallowed.

A. THE MAIN TECHNIQUES USED ARE

I. POSTURAL DRAINAGE: Postural drainage involves laying the children in certain positions, dictated by the shape of the lungs to allow gravity to help drain the secretions towards the mouth. In some chest infections, only specific parts (lobes) of the lungs have excess secretions, while in other infections most or all of the lobes will be affected. The most commonly used positions involve the child lying tipped head down over pillows on his/her back, front and sides. The other position used, mostly with small children, is sitting.






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II. PERCUSSIONS: This is when the child’s chest is clapped gently with cupped hands to help shake the secretions loose. Most children find this quite soothing and effective, even though it may sound as though it hurts.

III. ASSISTING COUGH: Breathing exercises and ‘Forced expiration techniques’ (FET) Breathing exercises are used to help the child increase air entry into the lungs, as effective deep breaths also help to loosen the secretions that occur as a result of the infection. There are several different ways of teaching deep breathing and FET (which is sometimes called ‘Huffing’) This can be useful for very weak children who have a lot of difficulty getting the phlegm to the back of their throats to swallow it. It involves putting your hand under the diaphragm, on the child’s tummy and pushing firmly upwards to give more force to the cough. This technique is not difficult to do but needs practice to get the timing correct with the child’s attempt to cough.

3.2.4 POSITIONING AND SEATING IN MUSCULAR DYSTROPHY: The spine is a complicated series of bones joined together to allow bending forwards

and sideways and for rotation to be possible. Normally, the spine is held straight by the action of many spinal muscles and the abdominal (tummy) muscles working together. In babies, these muscles are weak but get stronger in due course of time as they grow up, allowing for rolling, then sitting and eventually standing, walking and more complicated movements.

In muscular dystrophy, these muscles remain weak and could affect the child’s ability to progress towards their expected milestones of development. The shape of the spine then becomes affected by gravity pushing down, by asymmetrical muscle power (i.e. one side being stronger than the other) and by joint contractures, particularly in the hips.

Some very weak children may need to wear a spinal jacket to help them to sit. Others may need to start wearing a jacket when they begin school because they spend a lot of time sitting down. Some of them may need to start wearing one for intermittent periods of time, as they grow taller and need extra support. Standing is strongly recommended as it helps to strengthen their spinal muscles. It is an easier position in which to control symmetrical movements, and in a ‘Lordotic’ posture, (one where the child appears to be leaning backwards) rotation of the spine is much more difficult. Besides, standing also stretches the hips.

Standing may be done in a standing frame, in a swivel walker or in calipers, but it is very crucial that whatever the child stands in, his/her spine is held straight. It is never possible to say that the child’s spine will or won’t remain straight and in most cases there will be some deterioration in posture as the child grows. The important thing to remember is that exercises, standing and wearing a spinal jacket when advised, will lessen problems in the long term.

In some cases, spinal surgery may be recommended for an older child but the decision to go ahead will have to be taken by you, the child himself/herself and doctor, all of you put together. If surgery is not a possibility, then it is imperative that the spine is






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supported to help prevent further deterioration. Seating becomes a higher priority and it really can help. Positioning and seating are very crucial for your child to enable him/her to perform any function in the best possible manner. Besides, it goes a long way in helping to prevent spinal and joint–related problems.

As a baby, it is good and advisable for your child to go through the normal experiences of lying on the back, sides and tummy, even though he/she may find lying on the tummy, a position from which he/she can do very little. A rolled towel placed under the chest will help your child to try and push down through the arms and try to lift the head and trunk. Just because your child finds certain things difficult, there’s no reason why he/she shouldn’t try, because that would provide the child with some good exercise.

A good supportive seat is essential all along. A cradle is often too soft and a firmer seat is better. Baby bouncers and baby walkers should be avoided as they do little to improve posture and trunk control. There are many good high chairs in the market that are convertible to floor chairs. In the case of very weak children, special seating would be necessary and your therapist would be able to arrange for this. Wheelchairs should also be supportive. Avoid those that have a bar at the front that cannot be removed. The back of the chair should be the type that could be brought up to almost the upright position for the child when he/she is awake, and only be reclined when he/she is particularly tired or sleeping. The footrest should be at the correct height to prevent the feet from dangling or the knees being pushed up. The depth of the seat should support almost the entire length of the child’s thighs without digging into the back of his/her legs.






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4.0 HEART DEFECTS: During early pregnancy, as the heart begins to form, a heart defect may develop as well. These defects might

affect the function and mechanics of a person's heart. Some of the children who develop heart defects show symptoms of them promptly after being born. Others do not show any symptoms until early childhood. Some heart defects prevent the person's heart from pumping adequate amounts of blood to their lungs or additional parts of their body, potentially leading to heart failure. Other heart defects may cause the person's skin to turn a pale gray or blue in color soon after they are born, or during their infancy; a condition referred to as, 'Cyanosis.' The cause of congenital heart defects is not clear.






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There are some environmental factors that are known to contribute to the formation of congenital heart defects, such as viral infections that are contracted by the mother during the early stages of pregnancy. Some medications, taken by the mother during pregnancy, may also cause congenital heart defects in children. Some of the medications that are associated with congenital heart defects in children include Acutane, certain anti-seizure medications, Lithium, Trimethoprim, and Folic Acid.

The characteristics of physical and mobility impairments involve many different things. Persons with physical and mobility impairments may experience deficits in motor and/or fine motor functioning, locomotor and non-locomotor functioning. There is the potential for deficits in cognitive, social, and adaptive behavior skills, as well as impairments in language, vision, hearing or other sensory areas. Persons with physical and mobility impairments may experience stiffness and/or spasticity, as well as loss of muscle strength. They may need help with learning, or activities of daily living.

Persons with physical and mobility impairments may need assistance with mobility, transfers, and ambulation. They may have a limited range of motion, and be reluctant to attempt movement, or experience a perceptual or cognitive impairment. They may experience pain, discomfort; depression or anxiety. Persons with these impairments may require prolonged bed rest, and have medical restrictions. They may have musculoskeletal or neuromuscular impairments as well.

Physical and mobility impairment is a limitation in independent, purposeful physical movement of the body or of one or more extremities. The alteration in the person's mobility may be either temporary, or more permanent. Most of the diseases and rehabilitative states involved in physical and mobility impairments do involve a degree of immobility. These are often associated with things such as leg fractures, strokes, morbid obesity, trauma, and Multiple Sclerosis, for example. Longer life expectancy will increase the incidence of disease and disability in the world. Shorter hospital stays are finding more people being transferred to rehabilitation facilities, or simply sent to their homes for physical therapy.

Mobility is related to changes in a person's body as they age as well. Loss in muscle strength and mass, less mobile and stiffer joints, as well as gait changes affect a person's balance and may significantly comprise their mobility. Mobility is crucial to the maintenance of independent living among Seniors. If a person's mobility is restricted, it may affect their activities of daily living.

4.1 PHYSIOTHERAPY AFTER HEART SURGERY:

After heart surgery, your child will need to do exercises. These exercises are: Deep breathing Splinted coughing Moving around These exercises help keep your child’s lungs well expanded and free of mucus. This will help your child get better so she can go home sooner. You and your child will learn how to do deep breathing before the operation Before the operation, a physiotherapist will meet with you and your child. A physiotherapist is a health care professional who is trained to prevent, identify, and correct movement problems. The physiotherapist will teach your child how to practice deep breathing: Young children will practice deep breathing by blowing bubbles. Older children will practice deep breathing using a device called an incentive spirometer. The physiotherapist will give you bubbles or an incentive spirometer to take home so your

child can practice.






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As soon as your child is awake and breathing on her own after the surgery, she can begin the breathing and coughing exercises. The nurse will help encourage your child to do these exercises.

The nurse will also help your child to start moving. First your child will sit at the edge of the bed. Later, she can start taking short walks. You can help your child as well.

Activity How long and how often Instructions

Start doing all activities when your child wakes up and is breathing on her own.

Bubbles (for young children)

2 to 3 minutes every hour (while awake) during hospital stay Take a deep breath in and blow the bubbles out slowly.

Ask your child to pop the bubbles. This will help your child move her arms.

Incentive spirometer (for older children)

10 breaths every hour (while awake) during hospital stay Sit up tall and hold the incentive spirometer in an upright position.

Place the mouthpiece in the mouth with lips tightly closed.

Slowly and steadily take in a deep breath. Keep the head and shoulders still.

De pending on the incentive spirometer, either:

Raise the ball(s) to the top and hold it for 2 to 3 seconds, or

Raise the plunger as high as possible, while keeping the flow indicator within the marked area.

Breathe out slowly and repeat.

Gradually get your child to work harder, as much as she can manage. Depending on the type of incentive spirometer, your child should either:

Increase 1 level at a time (marked 0 through 12) to make the exercise slightly harder, or

Raise the plunger even higher, which means that your child is taking a bigger breath.

Splinted cough Every hour after bubbles or incentive spirometer 2 to 3 times every hour if your child’s cough is congested

Cross arms across the chest, while hugging a pillow or stuffed toy. Take a deep breath and cough 2 or 3 times to clear any mucus.

At first, help your child to sit up in bed. Next, help your child to get up and sit in a chair.

Moving around 3 times a day until your child can move about on her own Finally, help your child to start walking around the room and ward.






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5.0 AMPUTATION:

Amputation is an acquired condition that results in the loss of a limb, usually from injury, disease, or surgery. Congenital (present at birth) limb deficiency occurs when an infant is born without part or all of a limb. In the US, 82 percent of amputations are due to vascular disease, 22 percent to trauma, 4 percent are congenital, and 4 percent are due to tumors. About 1.9 million individuals in the US are living with an amputation, with approximately 113,000 lower limb amputations performed each year according to the Agency for Healthcare Research and Quality (AHRQ).






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5.1 CAUSES AND THE NEED FOR AMPUTATIONS: The causes for amputation may include any of the following:

Diseases - such as blood vessel disease (called peripheral vascular disease or PVD), diabetes, blood clots, or osteomyelitis (an infection in the bones).

Injuries - especially of the arms. Seventy-five percent of upper extremity amputations are related to trauma.

Surgery - to remove tumors from bones and muscles. Acroosteolysis neurogenic Charcot-Marie-Tooth disease, Type 2B Compartment Syndrome Frostbite Gangrene Mycetoma Neuropathy, Hereditary Sensory, Type II Peripheral vascular disease

5.2 REHABILITATION AFTER AMPUTATION:

Loss of a limb produces a permanent disability that can impact a patient's self-image, self-care, and mobility (movement). Rehabilitation of the patient with an amputation begins after surgery during the acute treatment phase. As the patient's condition improves, a more extensive rehabilitation program is often begun.

The success of rehabilitation depends on many variables, including the following: Level and type of amputation Type and degree of any resulting impairments and disabilities Overall health of the patient Family support It is important to focus on maximizing the patient's capabilities at home and in the community. Positive reinforcement helps recovery by improving self-esteem and promoting independence. The rehabilitation program is designed to meet the needs of the individual patient. Active involvement of the patient and family is vital to the success of the program. The goal of rehabilitation after an amputation is to help the patient return to the highest level of function and independence possible, while improving the overall quality of life - physically, emotionally, and socially. In order to help reach these goals, amputation rehabilitation programs may include the following: Treatments to help improve wound healing and stump care Activities to help improve motor skills, restore activities of daily living (ADLs), and help the patient reach

maximum independence Exercises that promote muscle strength, endurance, and control Fitting and use of artificial limbs (prostheses) Pain management for both post-operative and phantom pain (a sensation of pain that occurs below the

level of the amputation)






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Emotional support to help during the grieving period and with readjustment to a new body image Use of assistive devices Nutritional counseling to promote healing and health Vocational counseling Adapting the home environment for ease of function, safety, accessibility, and mobility Patient and family education

The amputation rehabilitation team: Rehabilitation programs for patients with amputations can be conducted on an inpatient or outpatient basis. Many skilled professionals are part of the amputation rehabilitation team, including any/all of the following:

Orthopaedists/orthopaedic surgeons Prosthetics Physiatrist Social worker Internist Psychologist/psychiatrist Rehabilitation nurse Recreational therapist Physical therapist Case manager Occupational therapist Chaplain Orthotics Vocational counselor

Types of rehabilitation programs for amputations: There are a variety of treatment programs, including the following:

Acute rehabilitation programs Outpatient rehabilitation programs Day-treatment programs Vocational rehabilitation programs






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5.3 PHYSICAL THERAPY MANAGEMENT OF AMPUTEES:

5.3.1 PHYSICAL THERAPY MANAGEMENT OF ADULT : The prosthetist and the physical therapist, as members of the rehabilitation team, often

develop a very close relationship when working together with lower-limb amputees. The prosthetist is responsible for fabricating and modifying the specific socket design and providing prosthetic components that will best suit the life-style of a particular individual. The physical therapist's role is threefold. First, the amputee must be physically prepared for prosthetic gait training and educated about residual-limb care prior to being fitted with the prosthesis. Second, the amputee must learn how to use and care for the prosthesis. Prosthetic gait training can be the most frustrating, yet rewarding phase of rehabilitation for all involved. The amputee must be patiently educated in the biomechanics of prosthetic gait. Once success is achieved, the amputee may look forward to resuming a productive life. Third, the therapist should introduce the amputee to higher levels of activities beyond just learning to walk. Although the amputee may not be ready to participate in recreational activities immediately, providing the names of support groups and disabled recreational organizations can furnish the necessary information for the individual to seek involvement when ready.

A. PRESURGICAL MANAGEMENT:

I. INITIAL PATIENT CONTACT: This time provides an opportunity for the therapist to introduce himself to the patient and, in conjunction with other qualified members of the rehabilitation team, to prepare the patient for the events to come. Specifically, the therapist will attempt to develop a professional rapport with the patient and earn his trust and confidence. This period also offers the therapist an excellent opportunity to explain the time frame of the rehabilitation process. Fear of the unknown can be extremely frightening to many patients; therefore, having the comfort of knowing what the future holds as well as what will be expected of them can ease the process. A visit from another amputee who has been successfully rehabilitated can assist in this process. The visiting amputee should be carefully screened by appropriate personnel and should have a suitable personality for this task. Additional considerations should be given to similarities between level of amputation, age, gender, and outside interests. If available, any information on various prostheses or videos showing recreational activities may benefit the patient. The therapist must also keep in mind how much information the patient is psychologically prepared to hear. Many hospitals have affiliations with local support groups, where amputees visit other amputees to help them throughout the healing process. The pragmatic aspect of the therapist's responsibilities presurgically will include discussing the possibilities of phantom limb sensation and discomfort, joint contracture prevention, as well as overall functional assessment. If the patient so desires, a prosthesis may be introduced at this point to satisfy curiosity.






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B. POSTSURGICAL MANAGEMENT:

Evaluation Past Medical History

A complete medical history should be taken from the patient or obtained from the medical records to provide the therapist with information that may be pertinent to the rehabilitation program.

I. MENTAL STATUS:

An accurate assessment of the patient's mental status can lend insight into the likely comprehension level for future prosthetic care. The therapist should be concerned with assessing the patient's potential to cognitively perform activities such as donning and doffing the prosthesis, residual-limb sock regulation, bed positioning, skin care, safe ambulation, and other functional activities of the amputee. If the patient does not possess the necessary level of cognition, family members and/or friends should become involved in the rehabilitation process to help ensure a successful outcome.

II. RANGE OF MOTION: A functional assessment of gross upper-limb and sound lower-limb motions should be made. A measurement of the residual limb's range of motion (ROM) should be recorded for future reference. Joint contractures are complications that can greatly hinder the amputee's ability to ambulate efficiently with a prosthesis; thus extra care should be taken to avoid them. The most common contracture for the transfemoral amputee is hip flexion, external rotation, and abduction, while knee flexion is the most frequently seen contracture for the transtibial amputee. During the ROM assessment the therapist should determine whether the patient has a fixed contracture or just soft-tissue tightness from immobility that can be corrected within a short period of time. This may affect the manner in which the prosthesis is fabricated.

III. STRENGTH: Functional strength of the major muscle groups should be assessed by manual muscle testing of all limbs including the residual limb and the trunk. This will help determine the patient's potential skill level to perform activities such as transfers, wheelchair management, and ambulation with and without the prosthesis.

IV. SENSATION: Evaluation of the amputee's sensation is useful to both the patient and therapist alike. The therapist can gain insight into the possible insensitivity of the residual limb and/or sound limb. This may affect proprioceptive feedback for balance and single-limb stance, which in turn can lead to gait difficulties. The patient must be made aware that decreased pain, temperature, and light touch sensation can increase the potential for injury and tissue breakdown.






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VI. BED Mobility The importance of good bed mobility extends beyond simple positional adjustments for comfort or to get in and out of bed. The patient must acquire bed mobility skills to maintain correct bed positioning in order to prevent contractures or excessive friction of the sheets against the suture line or frail skin. If the patient is unable to perform the skills necessary to maintain proper positioning, assistance must be provided. As with most patients, adequate bed mobility is a basic requirement for higher-level skills such as bed-to-wheelchair transfers.

V. BALANCE/COORDINATION: Sitting and standing balance are of major concern when assessing the amputee's ability to maintain the center of gravity over the base of support. Coordination assists with ease of movement and the refinement of motor skills. Both balance and coordination are required for weight shifting from one limb to another, thus improving the potential for an optimal gait. After evaluating mental status, ROM, strength, sensation, balance, and coordination, the therapist will have a good indication of what would be the most appropriate choice of assistive device to use initially with the individual amputee.

VI. TRANSFERS:

Transfer skills are essential for early mobility. Additional functional transfers such as toilet, shower, and car transfers must also be assessed before discharge to more completely determine the patient's level of independence. For transtibial amputees who are not ambulatory candidates, a very basic prosthesis may be indicated for transfers only.

VII. WHEELCHAIR PROPULSION: The primary means of mobility for a large majority of amputees, either temporarily or permanently, will be the wheelchair. The energy conservation of the wheelchair over prosthetic ambulation is considerable with some levels of amputation. Therefore, wheelchair skills should be taught to all amputees during their rehabilitation program.

VII. AMBULATION WITH ASSISTIVE DEVICES WITHOUT A PROSTHESIS: A traditional evaluation of the amputee's potential for ambulation is performed, including strength of the sound lower limb and both upper limbs, single-limb balance, coordination, and mental status. The selection of an assistive device should meet with the amputee's level of skill, while keeping in mind that with time the assistive device may change. For example, initially an individual may require a walker, but with proper training, forearm crutches may prove more beneficial as a long-term assistive device. Some patients who have difficulty in ambulating on one limb secondary to obesity, blindness, or generalized weakness can still be successful prosthetic ambulators when the additional support of a prosthesis is provided (Fig 1a. and Fig 1b.).

VIII. CARDIAC PRECAUTIONS FOR AMPUTEES: During the initial chart review, the therapist should make note of any history of coronary artery disease, congestive heart failure, peripheral vascular disease, arteriosclerosis, hypertension, angina, arrhythmias, dyspnea, angioplasty, myocardial infarction, arterial bypass surgery, as well as prescribed cardiovascular medications that may affect the blood pressure and heart rate.






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The heart rate and blood pressure of every patient should be closely monitored during initial training and thereafter as the intensity of training increases. If the amputee experiences persistent symptoms such as shortness of breath, pallor, diaphoresis, chest pain, headache, or peripheral edema, further medical evaluation is strongly recommended.

B. PATIENT EDUCATION: LIMB MANAGEMENT I. LIMB CARE:

It is important that the patient understand the care of the residual limb and sound limb. For example, the dysvascular patient's prosthetic gait training could be delayed 3 to 4 weeks if an abrasion should occur. The patient must be taught the difference between weight-bearing areas and pressure-sensitive areas and also be oriented to the design of the socket and the functions of the prosthetic componentry.

II. PROBLEM DETECTION/SKIN CARE: Every patient should be instructed to visually inspect the residual limb on a daily basis or after any strenuous activity. More frequent inspection of the residual limb should be routine in the initial months of prosthetic training. A hand mirror may be used to view the posterior aspect of the residual limb. Reddened areas should be monitored very closely as potential sites for abrasions. If a skin abrasion occurs, the patient must understand that in most cases the prosthesis should not be worn until healing occurs.

III. PROSTHETIC MANAGEMENT:

The socket should be cleaned daily to promote good hygiene and prevent deterioration of prosthetic materials. As a rule, solid plastic materials are cleaned with a damp cloth and foam materials with rubbing alcohol. The patient should also be reminded that routine maintenance of the prosthesis should be performed by the prosthetist to ensure maximum life and safety of the prosthesis.

IV. SOCK REGULATION Sock regulation is of extreme importance to prevent pistoning from occurring. The patient should carry extra socks at all times in case of pistoning or extreme perspiration. A thin nylon sock (sheath) should cover the residual limb to assist in reducing friction at the residual-limb/socket interface. Stump socks are available in assorted plies or thickness that permit the patient to obtain the desired fit within the socket. Socks should be applied wrinkle free, with the seams horizontal and on the outside to prevent additional pressure on the skin.

V. DONNING AND DOFFING OF THE PROSTHESIS:

Today, there is a wide variety of suspension systems for all levels of amputation. To list just a few possibilities, the transtibial amputee has the option of a hard socket with or without a soft insert, which could include auxiliary suspension, a medial wedge, and suction or suction silicone sockets, while the transfemoral amputee has the choice of a nonsuction external suspension or a suction






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suspension socket that can be donned with an elastic bandage, pull sock, wet fit, or a silicone sleeve. The methods of donning each of these combinations are too numerous for the scope of this chapter; however, what is important is that the amputee become proficient in the method of donning and doffing his particular prosthesis.

VI. RESIDUAL-LIMB WRAPPING:

Early wrapping of the residual limb can have a number of positive effects: decrease edema and prevent venous stasis by ensuring a proper distal-to-proximal pressure gradient, Assist in shaping, help counteract contractures in the transfemoral amputee,

provide skin protection, Reduce redundant-tissue problems, Reduce phantom limb discomfort/sensation, Desensitise the residual limb with local pain. Controversy does exist concerning the use of traditional elastic bandaging vs. the use of residual-limb shrinkers. Currently, many institutions prefer commercial shrinkers for their ease and reproducibility of donning. Advocates of elastic bandaging state that more control over pressure gradients and tissue shaping is provided. Regardless of individual preference, application must be performed correctly to prevent circulation constriction, poor residual-limb shaping, and edema (Fig 2. and Fig 3.).

Fig 2. Fig 3






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C. PREPROSTHETIC EXERCISE: I. STRENGTHENING:

Eisert and Tester first described dynamic residual-limb exercises in 1954. Since then, their antigravity exercises have been the most favored method of strengthening the residual limb. These dynamic exercises require little in the way of equipment. A towel roll and step stool are all that is required. They also offer benefits aside from strengthening, such as desensiti-zation, bed mobility, and joint ROM. The exercises are relatively easy to learn and can be performed independently, thus permitting the therapist to spend patient contact time on other more advanced skills.

Incorporating isometric contractions at the peak of the isotonic movement will help to maximize strength increases. A period of a 10-second contraction followed by 10 seconds of relaxation for 10 repetitions gives the patient an easy mnemonic to remember, the "rule of ten." The rationale behind a 10-second contraction is that a maximal isometric contraction can be maintained for 6 seconds; however, there is a 2-second rise time and a 2-second fall time for a total of 10 seconds.

All amputees should consider performing abdominal and back extensor strengthening exercises to maintain trunk strength, decrease the possible risk of back pain, and assist in the reduction of gait deviations associated with the trunk.

The following illustrations demonstrate the basic dynamic strength training program for transfemoral and transtibial amputees (Fig 4.).

Amputees who have access to isotonic and isokinetic strengthening equipment can take advantage of the benefits derived from these forms of strengthening with few modifications in their positioning on the machines.

Fig 4






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II. RANGE OF MOTION: Prevention of decreased ROM and contractures is a major concern to all

involved. Limited ROM can often result in difficulties with prosthetic fit, gait deviations, or the inability to ambulate with a prosthesis altogether. The best way to prevent loss of ROM is to remain active and ensure full ROM of affected joints. Unfortunately, not all amputees have this option, and therefore, proper limb positioning becomes important. The transfemoral amputee should place a pillow laterally along the residual limb to maintain neutral rotation with no abduction when in a supine position. If the prone position is tolerable during the day or evening, a pillow is placed anteriorly under the residual limb for 20 to 30 minutes, two to three times daily, to maintain hip extension. Transtibial amputees should avoid knee flexion for prolonged periods of time. A stump board will help maintain knee extension when using a wheelchair. All amputees must be made aware that continual sitting in a wheelchair without any effort to promote hip extension may lead to limited motion during prosthetic ambulation (Fig 5.).

Amputees who have already developed a loss of ROM may benefit from many of the traditional therapy procedures such as passive ROM, contract-relax stretching, soft-tissue mobilization, myofascial techniques, joint mobilization, and other methods that promote increased ROM.

Fig 5






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III. FUNCTIONAL ACTIVITIES:

Encouraging activity as soon as possible after amputation surgery helps speed recovery in several ways. First, it will offset the negative affects of immobility by promoting movement through the joints, muscle activity, and increased circulation. Second, the patient will begin to re-establish personal independence, which may be perceived as threatened due to limb loss. Finally, the psychological advantage derived from activity and independence will continue to motivate the patient throughout the rehabilitation process.

IV. GENERAL CONDITIONING:

A decrease in general conditioning and endurance are contributory factors leading to difficulties in learning functional activities and prosthetic gait training. Regardless of age or present physical condition, a progressive general exercise program should be prescribed for every patient beginning immediately after surgery, continued throughout the preprosthetic period, and finally incorporated as part of the daily routine.

The list of possible general strengthening/endurance exercise activities is long: cuff weights in bed, wheelchair propulsion for a predetermined distance, dynamic residual-limb exercises, ambulation with an assistive device prior to prosthetic fitting, loweror upper-limb ergometer work, wheelchair aerobics, swimming, aquatic therapy, lowerand upper-body strengthening at the local fitness center, and any sport or recreational activity of interest. The amputee should select one or more of these, begin participation to tolerance, and progress to 1 hour or more a day.

The advantages of participation extend well beyond improving the chances of ambulating well with a prosthesis. The individual has the opportunity to experience and enjoy activities thought impossible for an amputee. If difficulties are experienced, the amputee is still within an environment where assistance may be readily obtained either from the therapist or from a fellow amputee who has mastered a particular activity.

V. BED MOBILITY:

The severely involved patient may be taught to utilize a trapeze, side rail, or human assistance when learning bed mobility. This practice, however, should not be employed for the general amputee population because, while easier initially, continued use of these methods will only hamper the future rehabilitation process. Regardless of age, each patient should be taught a safe and efficient manner in which to roll, come to sitting, or adjust his or her position. Logrolling, followed by side lying to sitting or supine lying on elbows to long sitting, are two acceptable methods that incorporate all the necessary skills for efficient bed mobility.

Once bed mobility is mastered, the patient must learn to transfer from the bed to a chair or wheelchair and then progress to more advanced transfer skills such as to the toilet, tub, and car. Unilateral amputees initially are taught single-limb transfers where the wheelchair is positioned on the sound-limb side and the patient pivots over the limb while maintaining contact with either the bed or chair. In most cases, it is advised that transfers to both the sound and involved side be taught since the patient will frequently be in situations where transferring to the sound si de will not be possible. As the patient's single-limb standing balance improves, more advanced transfers may be taught to improve the patient's independence. In cases where an immediate postoperative or preparatory prosthesis is






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utilized, weight bearing through the prosthesis can assist the patient in the transfer and provide additional safety.

Bilateral amputees who are not fitted with an initial prosthesis transfer in a "head-on" manner. The wheelchair approaches the mat or chair, with the front of the chair abutting the transferring surface. The patient then slides forward onto the desired surface by lifting the body and pushing forward with both hands. Until adequate strength of the latissimus dorsi and triceps is attained for this transfer, a lateral sliding-board transfer will be necessary to minimize friction and to cross the gap between the chair and desired surface (Fig 6.).

Fig 6.

VI. WHEELCHAIR PROPULSION: Wheelchair mobility is the first skill that will give the amputee independence in the world

outside of the hospital room. The degree of skill and mastery of the wheelchair varies depending on age, strength, and agility. Basic skills such as forward propulsion, turns, and preparation for transfers, i.e., parking and braking, should be taught immediately. Later, advanced wheelchair skills should be taught: ascending and descending inclines, wheelies, floor-to-wheelchair transfers, and curb jumping. The time dedicated to wheelchair skills is dependent on the degree to which the amputee may potentially require the wheelchair. Bilateral and older amputees may require greater use of the wheelchair, while unilateral and younger amputees will be more likely to utilize other assistive devices when not ambulating with their prosthesis. Because of the loss of body weight anteriorly the amputee will be prone to tipping backward while in the standard wheelchair. Amputee adapters set the wheels back approximately 5 cm, thus moving the amputee's center of gravity forward to prevent tipping, especially when ascending ramps or curbs.






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V. UNSUPPORTED STANDING BALANCE: In preparation for ambulation without prosthesis, all amputees must learn to

compensate for the loss of weight of the amputated limb by balancing the center of gravity over the sound limb. Although this habit must be broken when learning prosthetic ambulation, single-limb balance must be learned initially to provide confidence during stand pivot transfers, ambulation with assistive devices, and eventually hopping, depending on the amputee's level of skill. A patient should be able to balance for at least 0.5 seconds to allow for smooth and safe progression of an assistive device during ambulation.

One method of progressive ambulation starts with the amputee standing in the parallel bars while using both hands for support. Once confidence in standing with double arm support is attained, the hand on the same side as the amputated limb should be removed from the bars; subsequently both hands are removed as independent balance is achieved. In order to improve balance and righting skills, the patient should be challenged by gently tapping the shoulders in multiple directions or tossing a ball back and forth (Fig 7.). Allow enough time between taps or throws for the patient to regain a comfortable standing posture. Once confidence is gained within the parallel bars, the patient should practice these skills outside the parallel bars, eventually progressing to hopping activities.

Fig 7






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Ambulation With Assistive Devices

All amputees will need an assistive device for times when they choose not to wear their prosthesis or for occasions when they are unable to wear their prosthesis secondary to edema, skin irritation, or poor prosthetic fit. Other amputees will require an assistive device while ambulating with the prosthesis. There are a variety of assistive devices to choose from. While safety is a primary factor in selecting an appropriate assistive device, mobility is a secondary consideration that cannot be overlooked. The criteria for selection should include (1) unsupported standing balance, (2) upper-limb strength, (3) coordination and skill with the assistive device, and (4) cognition. A walker is chosen when a amputee has fair to poor balance, strength, and coordination. If balance and strength are good to normal, forearm crutches may be used for ambulation with or without a prosthesis. A quad or straight cane may be selected to ensure safety when balance is questionable while ambulating with a prosthesis.

D. PREGAIT TRAINING:

I. BALANCE AND COORDINATION: After the loss of a limb, the decrease in body weight will alter the body's center of gravity.

In order to maintain the single-limb balance necessary during stance without a prosthesis, ambulating with an assistive device, or single-limb hopping, the amputee must shift the center of gravity over the base of support, which in this case is the foot of the sound limb. As amputees become more secure in their single-limb support, there is greater difficulty in reorienting them to maintaining the center of gravity over both the sound and prosthetic limbs. Ultimately, amputees must learn to maintain the center of gravity and their entire body weight over the prosthesis. Once comfortable with weight bearing equally on both limbs, the amputee can begin to develop confidence with independent standing and eventually with ambulation.

II. ORIENTATION TO THE CENTER OF GRAVITY AND BASE OF SUPPORT:

Orientation of the center of gravity over the base of support in order to maintain balance requires that the amputee become familiar with these terms and aware of their relationship. The body's center of gravity is located just anterior to the second sacral vertebra. Average persons stand with their feet 5 to 10 cm (2 to 4 in.) apart, varying according to body height. Various methods of proprioceptive and visual feedback may be employed to promote the amputee's ability to maximize the displacement of the center of gravity over the base of support. The amputee must learn to displace the center of gravity forward and backward, as well as from side to side (Fig 8. and Fig 9.). These exercises vary little from traditional weight-shifting exercises, with the one exception that concentration is placed on the movement of the center of gravity over the base of support rather than weight bearing into the prosthesis. Increased weight bearing will be a direct result of improved center of gravity displacement and will establish a firm foundation for actual weight shifting during ambulation.

Fig 8

Fig 9






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III. SINGLE-LIMB STANDING: Weight acceptance in the prosthesis is one of the most difficult challenges facing both

therapist and amputee. Without the ability to maintain full single-limb weight bearing and balance for an adequate amount of time (0.5 seconds minimum) the amputee will exhibit a number of gait deviations, including (1) decreased stance time on the prosthetic side, (2) a shortened stride length on the sound side, or (3) lateral trunk bending over the prosthetic limb. Strength, balance, and coordination are the primary physical factors influencing single-limb stance on a prosthesis. Additionally, fear, pain, and lack of confidence in the prosthesis must be considered when an amputee is demonstrating extreme difficulty in overcoming weight bearing on the prosthesis. It is important to recognize the need to promote adequate weight bearing and balance on the prosthesis prior to and during ambulation.

Single-limb balance over the prosthetic limb while advancing the sound limb should be practiced in a controlled manner so that when required to do so in a dynamic situation such as walking, this skill can be employed with relatively little difficulty. The stool-stepping exercise is an excellent method by which this skill may be learned. Have the amputee stand in the parallel bars with the sound limb in front of a 10- to 20-cm (4- to 8-in.) stool (or block), its height depending on the patients level of ability. Then ask the amputee to step slowly onto the stool with the sound limb while using bilateral upper-limb support on the parallel bars. To further increase this weight-bearing skill ask the patient to remove the sound-side hand from the parallel bars and eventually the other hand. Initially, the speed of the sound leg will increase when upper-limb support is removed, but with practice the speed will become slower and more controlled, thus promoting increased weight bearing on the prosthesis (Fig 10.).

The amputee's ability to control sound-limb advancement is directly related to the ability to control prosthetic limb stance. The following are three contributing factors that may help the amputee achieve adequate balance over the prosthetic limb. First, control of the musculature of the residual limb is necessary to maintain balance over the prosthesis. Second, the patient must learn to utilize the available proprioceptive sensation at the residual-limb/socket interface to control the prosthesis. Third, the amputee must visualize the prosthetic foot and its relationship to the ground. New amputees will find it difficult to understand this concept at first but will gain a greater appreciation as time goes on.

Fig 10






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E. GAIT-TRAINING SKILLS: I. SOUND LIMB AND PROSTHETIC LIMB TRAINING:

Another component in adjusting to the amputation of a limb is restoration of the gait biomechanics that were unique to a particular person prior to the amputation. That is to say, not everyone has the same gait pattern. Prosthetic developments in the last decade have provided limbs that more closely replicate the mechanics of the human leg. Therefore, the goal of gait training should be the restoration of function to the remaining joints of the amputated limb. Prosthetic gait training should not alter the amputee's gait mechanics for the prosthesis, but instead, the mechanics of the prosthesis should be designed around the amputee's individual gait.

II. PELVIC MOTIONS:

The pelvis, with the body's center of gravity, moves as a unit in four directions: it displaces vertically, shifts laterally, tilts horizontally, and rotates transversely. Each of these motions can directly affect the amputee's gait and result in gait deviations or increased energy consumption during ambulation. If restoration of function to the remaining joints of the amputated limb is a goal of gait training, then the pelvic motions play a decisive role in determining the final outcome of an individual's gait pattern. 1. Vertical displacement is simply the rhythmic upward and downward motion of the body's

center of gravity. The knee must flex 10 to 15 degrees during foot flat, and full extension must be obtained during midstance. The transtibial amputee has the ability to flex and extend the knee during the stance phase of gait. The transfemoral amputee is at a disadvantage because the knee must remain in extension throughout the entire stance phase to avoid buckling of the knee (Fig 11.).

Fig 11






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2. Lateral shift occurs when the pelvis shifts from side to side approximately 5 cm (2 in.). The

amount of lateral shift is determined by the width of the base of support, which is 5 to 10 cm (2 to 4 in.), depending on the height of the individual. Amputees have to spend an inordinate amount of time in single-limb standing on the sound limb when they are on crutches and hopping without the prosthesis or during relaxed standing. Because of this, they become adept at maintaining their center of gravity over the sound limb and therefore have a habit of crossing midline with the sound foot, which leaves inadequate space for the prosthetic limb to follow a natural line of progression. The result is an abducted or circumducted gait with greater-than-normal lateral displacement of the pelvis toward the prosthetic side. While more frequently observed in transfemoral amputees, this altered base of support may also be seen with transtibial amputees (Fig 12.).

Fig 12 3. Horizontal dip of the pelvis is normal up to 5 degrees; anything greater is considered a

gluteus me-dius gait. Usually, this is directly related to weak hip abductor musculature, more specifically, the gluteus medius. Maintenance of the residual femur in adduction via the socket theoretically places the gluteus medius at the optimal length-tension ratio. However, if the limb is abducted, the muscle is placed in a compromised position and is unable to function properly. The result is a gluteus medius gait where the trunk leans laterally over the side of the weak limb in an attempt to maintain the pelvis in a horizontal position (Fig 12.).

4. Transverse rotation of the pelvis occurs around the longitudinal axis approximately 5 to 10 degrees to either side. This transverse rotation assists in shifting the body's center of gravity from one side to the other. In addition, it also helps to initiate the 30 degrees of knee flexion during toe-off that is necessary to achieve 60 degrees of knee flexion during the acceleration phase of swing. Knee flexion during toe-off is created by other influences as well, including plantar flexion of the foot, horizontal dip of the pelvis, and gravity. No prosthetic foot permits active plantar flexion, and horizontal dip greater than 5 degrees is






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abnormal; therefore restoration of transverse rotation of the pelvis becomes of great importance in order to obtain sufficient knee flexion (Fig 13.). Normalization of trunk, pelvic, and limb biomechanics can be taught to the amputee in a systematic way. First, independent movements of the various joint and muscle groups are developed. Second, the independent movements are incorporated into functional movement patterns of the gait cycle. Finally, all component movement patterns are integrated to produce a smooth normalized gait.

Fig 13 One suggested method of training is as follows:

1. Strengthening of all available musculature by dynamic residual-limb exercises (see "Preprosthetic Exercise").

2. Proprioceptive neuromuscular facilitation (PNF), Feldenkrais, or any other movement awareness techniques may be performed for trunk, pelvic, and limb re-education patterns. These exercises encourage rotational motions and promote independent movements of the trunk, pelvic girdle, and limbs.

3. Pregait training exercises (see "Pregait Training"). 4. Sound-limb stepping within the parallel bars is performed with the amputee stepping

forward and backward, heel rise to heel strike, with both hands on the bars. The purpose of this activity is for the amputee and therapist to become familiar with the gait mechanics of the sound limb without having to be concerned about weight bearing and balance on the prosthetic limb. This also affords the therapist an opportunity to palpate the anterior superior iliac spines (ASIS) in order to gain a feeling for the patient's pelvic motion, which in most cases is close to normal for that individual (Fig 14.).

Fig 14






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5. Prosthetic-limb stepping in the parallel bars is similar to the activity described above except that the amputee uses the prosthetic limb. As the therapist palpates the ASIS, in many cases a posterior rotation of the pelvis will be observed. This is often the result of the amputee's attempt to kick the prosthesis forward with the residual limb. The pelvis rotates posteriorly, just as it would if someone were kicking a football.It is important that the amputee feel the difference between the pelvic motion on the prosthetic side and the sound side.

6. To restore the correct pelvic motion, the amputee places the prosthetic limb behind the sound limb while holding on to the parallel bars with both hands. The therapist blocks the prosthetic foot to prevent forward movement of the prosthesis. Rhythmic initiation is employed to give the amputee the feeling of rotating the pelvis forward as passive flexion of the prosthetic knee occurs. As the amputee becomes comfortable with the motion, he can begin to move the pelvis actively, eventually progressing to resistive movements when the therapist deems them appropriate (Fig 15.).

7. Once the amputee and therapist are satisfied with the pelvic motions, the swing phase of gait can be taught. The amputee is now ready to step forward and backward with the prosthetic limb. Attention must be given to the pelvic motions, that the line of progression of the prosthesis remains constant without circumducting, and that heel contact occurs within boundaries of the base of support (Fig 16.). As the amputee improves, release the sound-side hand from the parallel bars and eventually both hands. There should be little if any losses of efficiency with the motion, but if there is, revert to the previous splinter skill.

8. Return to sound-limb stepping with both hands on the parallel bars. Observe that the mechanics are correct and that the sound foot is not crossing midline as heel strike occurs. When ready, have the amputee remove the sound-side hand from the bars. At this time, there may be an increase in the speed of the step, a decrease in step length, and/or lateral leaning of the trunk. This is a direct result of the inability to bear weight or balance over the prosthesis. Cue the amputee in remembering the skills learned while performing the stool-stepping exercise (see "Pregait Training"). After adequate skill is perfected, sound-limb stepping without any hand support may be practiced until sufficient mastery of single-limb balance over the prosthetic leg is acquired (Fig 17.).

9. When each of the skills described above is developed to an acceptable level, the amputee is ready to combine the individual skills and actually begin walking with the prosthesis. Initially, begin in the parallel bars with the therapist and amputee facing each other, the therapist's hands on the amputee's ASISs, and the amputee holding onto the bars. As the amputee ambulates within the bars, the therapist applies slight resistance through the hips to provide proprioceptive feedback for the pelvis and musculature of the involved lower limb.

10. When both the therapist and the amputee are comfortable with the gait demonstrated in the parallel bars, the same procedure as described above is practiced out of the bars, with the amputee initially using the therapist's shoulders as support and progressing to both hands free when appropriate. The therapist may or may not continue to provide proprioceptive input to the pelvis (Fig 18.). As the amputee begins to ambulate independently, verbal cueing may be necessary as a reminder to keep the sound foot away from midline in order that the proper base of support can be maintained. Maintenance of equal stride length may not be immediately forthcoming because many amputees have a tendency to take a longer step with the prosthetic limb than the sound

Fig 15

Fig 16

Fig 17

Fig 18






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limb. When adequate weight bearing through the prosthetic limb has been achieved, have the amputee begin to take longer steps with the sound limb and slightly shorter steps with the prosthetic limb. This principle also applies when increasing the cadence. When an amputee increases his speed of ambulation, the prosthetic limb often compensates by taking a longer step, thus increasing the asymmetry. By simply having the amputee take a longer step with the sound limb and a moderate step with the prosthetic limb, increased speed of gait is accomplished without increased asymmetry.

11. Trunk rotation and arm swing are the final missing components in restoring the biomechanics of gait. During human locomotion, the trunk and upper limbs rotate opposite the pelvic girdle and lower limbs. Trunk rotation is necessary for balance, momentum, and symmetry of gait. Many amputees have a decreased trunk rotation and arm swing, especially on the prosthetic side. This may be the result of fear of displacing their center of gravity too far forward or backward over the prosthesis (Fig 19.). Normal cadence is considered to be 90 to 120 steps per minute, or 2.5 mph. Arm swing provides balance, momentum, and symmetry of gait and is directly influenced by the speed of ambulation. With acceleration of gait, arm swing excursion becomes greater, thus permitting a more efficient gait due to increased forward momentum. Similarly, amputees who walk at slower speeds will demonstrate a diminished swing excursion and hence less gait efficiency. Restoring trunk rotation and arm swing is easily accomplished by utilizing rhythmic initiation or passively cueing the trunk as the amputee walks. The therapist stands behind the amputee with one hand on either shoulder. As the amputee walks, the therapist gently rotates the trunk. When the left leg steps forward, the right shoulder is rotated forward and vice versa. Once the amputee feels comfortable with the motion, he can actively take over the motion. Amputees who will be independent ambulators as well as those who will require an assistive device can benefit to varying degrees from the above systematic rehabilitation program. Most patients can be progressed to the point of ambulating out of the parallel bars. At that time, the amputee must practice ambulating with the chosen assistive device and maintaining pelvic rotation, an adequate base of support, equal stance time, and equal stride length, all of which can have a direct influence on the energy cost of walking. Trunk rotation will be absent in amputees utilizing a walker, but those ambulating with crutches or a cane should be able to incorporate trunk rotation into their gait.

III. VARIATIONS: Naturally, the time and degree of prosthetic training required is individual to each

amputee, depending on many factors such as age and motivation, as well as the cause and level of amputation.

Syme ankle disarticulates have a major advantage over transtibial amputees due to the ability to bear weight distally. This allows them to have better kinesthetic feedback for placement of the prosthetic foot. Because of this kinesthetic capability and the increased length of the lever arm, minimal prosthetic gait training is required. Although Syme ankle disarticulates are able to progress rapidly with weight shifting and other basic gait skills, they may require practice to attain equal stride length and stance time.

Knee disarticulates have several advantages over transfemoral amputees, including a longer lever arm, enhanced muscular control, improved kinesthetic feedback, and greater distal-end weight bearing. Although these advantages do provide an opportunity for decreased

Fig 19






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rehabilitation time, the knee disarticulate must learn all the same skills as a transfemoral amputee.

Hip disarticulates and transpelvic (hemipelvectomy) amputees have the additional responsibility of learning to master the skills of a mechanical hip joint as well as the knee joint and foot/ankle assembly. The gait-training procedures are essentially the same as for transfemoral amputees. In some cases the mechanical hip joint may dictate that a slight vaulting action is necessary in order to clear the ground.

Amputees of all levels should be educated in residual-limb sock regulation, knowledge of pressure and relief areas, care of the prosthesis, and residual-limb donning and doffing techniques.

F. ADVANCED GAIT-TRAINING ACTIVITIES:

I. STAIRS: Ascending and descending stairs is most safely and comfortably performed one step at a

time (step by step). A few exceptional transfemoral amputees can descend stairs step over step, with or without a railing, or by the "jackknifing" method. Even fewer, very strong transfemoral amputees can ascend stairs step over step. Most transtibial amputees have the option of either method, while hip disarticulates and transpelvic amputees are limited to the step-by-step method.

II. STEP BY STEP:

This method is essentially the same for all levels of amputees. When ascending stairs, the body weight is shifted to the prosthetic limb as the sound limb firmly places the foot on the stair. The trunk is slightly flexed over the sound limb as the knee extends and raises the prosthetic limb to the same step. The same process is repeated for each step. When descending stairs, the body weight is shifted to the sound limb, which lowers the prosthetic limb to the step below primarily by eccentric contraction of the quadriceps muscle. Once the prosthetic limb is securely in place, body weight is transferred to the prosthetic limb, and the sound limb is lowered to the same step.

III. STEP OVER STEP:

Timing and coordination become critical factors in executing stair-climbing step over step. As the transfemoral amputee approaches the stairs, the prosthetic limb is the first to ascend the stairs by rapid acceleration of hip flexion with slight abduction in order to achieve sufficient knee flexion to clear the step. Some transfemoral amputees will actually hit the approaching step with the toe of the prosthetic foot to achieve adequate knee flexion. With the prosthetic foot firmly on the step, usually with the toe against the step riser, the residual limb must exert a great enough force to fully extend the hip so that the sound foot may advance to the step above. As the sound-side hip extends, the prosthetic-side hip must flex at an accelerated speed to achieve sufficient knee flexion to place the prosthetic foot on the next step above.

Placing only the heel of the prosthetic foot on the stair below and then shifting the body weight over the prosthetic limb, thus passively flexing the knee, achieve descending stairs. The sound limb must quickly reach the step below in time to catch the body's weight. The process is repeated at a rapid rate until a rhythm is achieved. Most transfemoral amputees who have mastered this skill descend stairs at an extremely fast pace, much faster than would be considered safe for the average amputee. In fact, both ascending and descending stairs






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step over step for transfemoral amputees is so difficult and energy demanding that the majority who master these skills still prefer the step-by-step method.

IV. TRANSTIBIAL AMPUTEES: STEP OVER STEP

When ascending stairs, the transtibial amputee who does not have the ability to dorsiflex his foot/ankle assembly must generate a stronger concentric contraction of the knee and hip extensors in order to successfully transfer body weight over the prosthetic limb.

Descending stairs is very similar to normal descent with one exception: only the prosthetic heel is placed on the stair. This compensates for the lack of dorsiflex-ion within the foot/ankle assembly.

V. CRUTCHES:

When using crutches with stairs, hold both crutches in the hand opposite the handrail, or use both crutches in the traditional manner.

VI. CURBS:

The methods described for stairs are identical for curbs. Depending on the level of skill, the amputee can step up or down curbs with either leg.

V. UNEVEN SURFACES:

A good practice with gait training is to have the amputee ambulate over a variety of surfaces, including concrete, grass, gravel, uneven terrain, and varied carpet heights. Initially, the new amputee will have difficulty in recognizing the different surfaces secondary to the loss of proprioception. To promote an increased awareness, spending time on different surfaces and becoming visually aware of the changes help to initiate this learning process. Additionally, the amputee must realize that it is important to observe the terrain ahead to avoid any slippery surfaces or potholes that might result in a fall.

VI. RAMPS AND HILLS:

Ascending inclines presents a problem for all amputees because of the lack of dorsiflexion present within most prosthetic foot/ankle assemblies. For most amputees, descending inclines is even more difficult than ascending, primarily because of the lack of plantar flexion in the foot/ankle assembly. Prosthesis wearers with knee joints have the added dilemma of the weight line falling posterior to the knee joint, resulting in a flexion moment.

When ascending an incline, the body weight should be slightly more forward than normal to obtain maximal dosiflexion with articulating foot/ankle assemblies or to keep the knee in extension. Depending on the grade of the incline, pelvic rotation with additional acceleration may be required in order to achieve maximal knee flexion during swing.

Descent of an incline usually occurs at a more rapid pace than normal because of the lack of plantar flexion resulting in decreased stance time on the prosthetic limb. Amputees with prosthetic knees must exert a greater-than-normal force on the posterior wall of the socket to maintain knee extension.

Most amputees find it easier to ascend and descend inclines with short but equal strides. They prefer this method since it simulates a more normal appearance as opposed to the sidestepping or zigzag method.






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When ascending and descending hills, the amputee will find sidestepping to be the most efficient means. The sound limb should lead and provide the power to lift the body to the next level, while the prosthetic limb remains slightly posterior to keep the weight line anterior to the knee and act as a firm base.

During descent the prosthetic limb leads but remains slightly posterior to the sound limb. The prosthetic knee remains in extension, again acting as a form of support so that the sound limb may lower the body.

For hip disarticulates or transpelvic amputees, sidestepping is the most common alternative regardless of the grade of the incline.

VII. SIDESTEPPING:

Sidestepping, or walking sideways, can be introduced to the amputee at various times throughout the rehabilitation program. He can begin with simple weight shifting in the parallel bars and later perform higher-level activities such as unassisted sidestepping around tables or a small obstacle course that requires many small turns. During early rehabilitation this skill provides the amputee with a functional exercise for strengthening the hip abductors and, later in the rehabilitation process, with an opportunity to progress into multidirectional movements.

VIII. BACKWARD WALKING:

Walking backward is not difficult for transtibial amputees but poses a problem for amputees requiring a prosthetic knee since there is no means of actively flexing the knee for adequate ground clearance. In addition, the weight line falls posterior to the knee, and this causes a flexion moment with possible buckling of the knee.

The most comfortable method of backward walking is by the amputee vaulting upward (plantar-flexing) on the sound foot to obtain sufficient height so that the prosthetic limb that is moving posteriorly can clear the ground. The prosthetic foot is placed well behind the sound limb, with the majority of the body's weight being born on the prosthetic toe, thus keeping the weight line anterior to the knee. The sound limb is then brought back, usually at a slightly faster speed and a somewhat shorter distance. The trunk is also maintained in some flexion in order to maintain the weight forward on the prosthetic toe. With a little practice most amputees become quite proficient in backward walking.

IX. MULTIDIRECTIONAL TURNS:

Changing direction during walking or maneuvering within confined areas often magnifies an amputee's difficulty in controlling the prosthesis. “hip-hiking” the prosthesis and pivoting around the sound limb often overcome situations such as crowded restaurants, elevators, or just simply turning around. This method is effective but hardly the most aesthetic means of maneuvering.

When turning to the sound side, two key factors for a smooth transition should be remembered: first, maintain pelvic rotation in the transverse plane, and second, perform the turn in two steps. Simply move the prosthetic limb over the sound limb 45 degrees, rotate the sound limb 180 degrees, and complete the turn by stepping in the desired direction with the prosthetic limb and leading with the pelvis to ensure adequate knee flexion (Fig 20.).

Turning to the prosthetic side is performed almost exactly the same way as turning to the sound side with one exception: slightly more weight is maintained on the prosthetic toe in order to keep the weight line anterior to the knee, thus preventing knee flexion. For example,

Fig 20






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by crossing the sound limb 45 degrees over the prosthetic limb, the weight line is automatically thrown forward. The prosthetic limb is rotated as close to 180 degrees as possible without losing balance (135 degrees is usually comfortable), and the turn is completed by stepping in the desired direction with the sound limb. If necessary, remind the amputee to maintain knee extension by applying a force with the residual limb against the posterior wall of the socket (Fig 21.).

One exercise that will reinforce turning skills is follow the leader, where the amputee follows the therapist who is making a series of turns in all directions and with various speeds and degrees of difficulty.

The level of skill in turning will vary among amputees. All functional ambulators should be taught to turn in both directions regardless of the prosthetic side. Those with poor balance may be limited to unidirectional turns and require a series of small steps to complete the turn.

X. TANDEM WALKING:

Walking with a normal base of support is of prime importance. However, tandem walking can assist with balance and coordination and improve prosthetic awareness for the amputee. Place a 5- to 10-cm (2- to 4-in.)-wide strip on the floor. The amputee is asked to walk in three different ways: first, with one foot to either side of the line; second, heel to toe with one foot in front of the other; and third, with one foot crossing over in front of the other so that neither foot touches the line and yet the left foot is always on the right side and vice versa.

XI. BRAIDING:

Braiding (cariocas) may be taught either in the parallel bars or in an open area depending upon the person's ability. Simple braiding is one leg crossing in front of the other. As the amputee's skill improves, the prosthetic limb can alternate, first in front of and then behind the sound limb, and vice versa. As ability improves, the speed of movement should increase. With increased speed the arms will be required to assist with balance, and likewise, trunk rotation will increase, further emphasizing the need for independent movement between the trunk and pelvis (Fig 22.).

Fig 21

Fig 22






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XII. SINGLE-LIMB SQUATTING: Single-limb balance is taught during the early stages of rehabilitation for crutch walking,

hopping, and other skills. Single-limb squatting is considerably more difficult but can help improve balance and strength. When first attempting this skill, half squats with a chair underneath the individual are recommended in case balance is lost.

XIII. FALLING:

Falling or lowering oneself to the floor is an important skill to learn not only for safety reasons but also as a means to perform floor-level activities.

During falling, amputees must first discard any assistive device to avoid injury. They should land on their hands with the elbows slightly flexed to dampen the force and decrease the possibility of injury. As the elbows flex, they should roll to one side, further decreasing the impact of the fall.

Lowering the body to the floor in a controlled manner is initiated by squatting with the sound limb followed by gently leaning forward onto the slightly flexed upper limbs. From this position the amputee has the choice of remaining quadruped or assuming a sitting posture.

XIV.FLOOR TO STANDING:

Many techniques exist for teaching the amputee how to rise from the floor to a standing position. The fundamental principle is to have the amputee use the assistive device for balance and the sound limb for power as the body begins to rise. Depending on the type of amputation and the level of skill, the amputee and therapist must work closely together to determine the most efficient and safe manner to successfully master this task.

XV. RUNNING SKILLS:

For most amputees, the inability to run is the single most common factor limiting participation in recreational activities, and yet it is the most desired skill. Many amputees who do not have a strong desire to run for sport or leisure do have an interest in learning how to run for the simple peace of mind of knowing that they could move quickly to avoid a threatening situation. Rarely, if ever, is running taught in the rehabilitation setting. Running, as with all gait-training and advanced skills, takes time and practice to master. If the amputee is exposed to the basic skills of running during rehabilitation, then the individual may make the decision to pursue running at a later date.

Syme ankle disarticulates and transtibial amputees do have the ability to achieve the same running biomechanics as able-bodied runners if emphasis is placed on the following principles. At ground contact, the hip on the amputated side should be flexed and moving toward extension with the knee flexed and the prosthetic foot passively dorsiflexing. The knee flexion not only per mits greater shock absorption but in addition creates a backward force between the ground and the foot to provide additional forward momentum. As the center of gravity passes over the prosthesis during the stance phase, the ipsilateral arm should be fully forward (shoulder flexed to 60 to 90 degrees), while the contralateral arm is simultaneously extended. Extreme arm movement can initially be difficult for the amputee concerned with maintaining balance. During late mid-stance to toe-off, the hip should be forcefully driven downward and backward through the prosthesis as the knee extends. If the prosthetic foot is of the dynamic-response type, the force produced by hip extension should deflect the keel so that the prosthetic foot will provide additional push-off. Forward swing and the float phase are






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periods when the hip should be rapidly flexing and elevating the thigh. The arms should again be opposing the advancing lower limb, with the ipsilateral arm backward and the contralateral arm forward. During foot descent, the hip should be flexed and then begin to extend as the knee is rapidly extending and reaching forward for a full stride (Fig 23.).

Transfemoral amputees and knee disarticulates traditionally run with a period of double

support on the sound limb during the running cycle, commonly referred to as the "hop-skip" running gait pattern. The typical running gait cycle begins with a long stride by the prosthetic leg, followed by a shorter stride with the sound leg. In order to give the prosthetic leg sufficient time to advance, the sound leg takes a small hop as the prosthetic limb clears the ground and moves forward to complete the stride. The speed that a transfemoral amputee runner may achieve will be hampered because every time either foot makes contact with the ground, the foot's forces are traveling forward and the reaction force of the ground must therefore be in a backward or opposite direction (Newton's third law). The result is that each time the foot contacts the ground, forward momentum is decelerated. In other words, with every stride the amputee is slowing down when running with the "hop-skip" gait.

The ability to run "leg over leg" has been achieved by a number of transfemoral amputees who have developed this technique through training and working with knowledgeable coaches. The transfemoral amputee takes a full stride with the prosthetic leg, followed by a typically shorter stride with the sound leg. With training, equal stride length and stance time may be achieved. This running pattern is a more natural gait where the double-support phase of the sound limb is eliminated and forward momentum maintained by both legs. Initially, problems that may occur include excessive vaulting off the sound limb to ensure ground clearance of the prosthetic limb, decreased pelvic and trunk rotation, decreased and asymmetrical arm swing, and excessive trunk extension. Again with training, many of these deviations will decrease and possibly be eliminated (Fig 24.).

Fig 24






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The transfemoral amputee has an additional consideration when learning to run. To date,

no knee system permits flexion during the prosthetic support phase, and this results in the residual limb having to absorb the ground reaction force during initial ground contact. Another problem with present knee units that transfemoral amputees must contend with is maintaining the appropriate cadence during swing. Hydraulic knee units offer the ability to adjust the hydraulic resistance during knee flexion and extension. During running, less resistance in extension permits faster knee extension, while increased resistance in flexion decreases the amount of heel rise with beginning runners. Seasoned runners often reduce knee flexion resistance to permit the prosthetic shank to bounce off the socket and thus return to the extended position at an accelerated rate. Collectively, these adjustments decrease the amount of time required for the prosthetic swing phase.

The "leg-over-leg" running style does permit the transfemoral amputee to run faster for short distances but at a greater metabolic cost. While the "leg-overleg" style is preferred, the hop-skip method is often more easily taught and less demanding physically on the amputee. If the sole purpose of instructing running is to permit the individual to move quickly in a safe and sure manner, the hop-skip method is most frequently suggested.

XVI.RECREATIONAL ACTIVITIES:

By definition, recreation is any play or amusement used for the refreshment of the body or mind. That is to say, the term recreational activities need not exclusively mean athletics such as running or team sports. In fact, many people enjoy recreational activities such as gardening, shuffleboard, or playing cards as a means of socializing or relaxing. A comprehensive rehabilitation program should include educating the amputee on how to return to those activities that are found pleasurable. For example, the therapist can teach physical splinter skills such as weight shifting, necessary to help the amputee participate in shuffleboard, or various methods of kneeling for gardening. In addition, there are many national and local recreational organizations and support groups that provide clinics, coaching, or another amputee who can teach from experience how to perform various higher-level recreational skills. Providing the amputee with information on how to contact these groups is the first step to mainstreaming the patient back into a life-style complete with recreational skills as well as activities of daily living.

In summary, the physical therapist must work closely with the rehabilitation team to provide comprehensive care for the amputee. An individualized program must be constructed according to the level of ability and skill of each patient. The primary skills of preprosthetic training help build the foundation necessary for successful prosthetic ambulation. The degree of success the amputee experiences with ambulation may directly influence how much the prosthesis will be used and how active a life-style is chosen. Therefore, the primary goal of the rehabilitation team should be to make this transitional period as smooth and successful as possible.






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5.3.2 ADULT UPPER LIMB PROSTHETIC TRAINING: The impact of the sudden loss of a hand or arm upon a person cannot be overstated.

The loss of fine, coordinated movements of the hand, tactile sensation, proprioceptive feedback, and aesthetic appearance can only be compensated for to a limited extent by three types of prostheses that are currently available.

As outlined in previous chapters, the three prosthetic options include (1) a passive cosmetic arm and hand; (2) a cable-controlled, body-powered prosthesis; and (3) an electrically powered prosthesis controlled by myoelectric sensors or specialized switches. In reality there are no perfect or ideal replacements that take the place of the exquisite mechanisms and function of the human hand.

An unusually high rejection rate of upper-limb prostheses can often be attributed to the following reasons: development of one-handedness, which removes the functional need for the prosthesis; lack of sufficient training or skill in using the prosthesis; poor comfort of the prosthesis; a poorly made prosthesis; the unnatural look or profile of the prosthesis; and the reactions that the wearer gets from other people.

It is felt that successful outcomes in rehabilitation for the unilateral and bilateral amputee can be attributed to the following reasons: Early post-traumatic intervention Experienced team approach Patient-directed prosthetic training Patient education Patient monitoring and follow-up

The focus of this chapter is to stress the importance of postoperative, preprosthetic, and prosthetic training principles. Listening to and acknowledging the patient's psychological and functional needs will be critically important in determining the success or lack of success with prosthetic acceptance and function.

A. POSTOPERATIVE THERAPY PROGRAM:

Awareness of postoperative and subsequent preprosthetic principles of care is crucial to successful management of an individual who has just sustained traumatic limb loss. This phase of care is one where the patient has little control over what is happening and must depend upon the health care team to provide the best treatment possible. Any member of the rehabilitation team, which may include the physician, nurse, and occupational or physical therapist, can address treatment goals of postoperative care. The goals are as follows: I. Promote wound healing. II. Control incisional and phantom pain. III. Maintain joint range of motion. IV. Explore the patient's and family's feelings about a change in body image. V. Obtain adequate financial sponsorship for the prosthesis and training.






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I. PROMOTE WOUND HEALING: Wound healing is generally monitored by the surgeon who performed the amputation and

by the nurse. The role of the nurse cannot be overemphasized since she is the member of the team having continuous contact with the patient during this stage of healing. The nurse will need to be active in the patient's rehabilitation program so that those activities taught to the patient by the occupational and physical therapists may be carried over successfully to the nursing unit situation.

II. CONTROL INCISIONAL AND PHANTOM PAIN:

Narcotic agents given intravenously or intramuscularly generally manage acute incisional pain. This is necessary for the first 3 to 4 postoperative days. Transcutaneous electrical nerve stimulation (TENS) has also been used to decrease incisional and phantom pain in the amputated limb. This modality can be used alone or in conjunction with oral analgesics.

The difference between a phantom limb and phantom pain should be clearly explained to the amputee. A phantom limb is the feeling or sensation that the limb is still present, and phantom pain is differentiated by the sensation of pain in the phantom limb. Significant success in decreasing phantom pain has been achieved by using amitriptyline (Elavil) at doses of 50 to 150 mg daily at bedtime. Elavil is involved in serotonin production and is believed to modify pain perception.

Phantom limb pain may also be controlled by isometric exercise. These exercises can be started within 5 to 7 days following surgery. Residual wrist extensors and flexors as well as residual biceps and triceps are the muscles of choice to use in isometric exercise in transradial and transhumeral amputees, respectively. These exercises should be performed every other hour for 10 to 20 repetitions.

III. MAINTAIN JOINT RANGE OF MOTION:

Maintaining adequate range of motion in all joints of the upper limb is critical. This is particularly true in the burn patient. Full range of motion is frequently lost at the glenohumeral and elbow joints. Additionally, scapulohumeral mobility must be maintained and strengthened. Full flexion and extension at the elbow combined with maintaining maximum pronation and supination of the forearm cannot be overemphasized. These motions are crucial for terminal device placement and subsequent function.

An active exercise program should be initiated by the physical or occupational therapist. This can begin as early as the second postoperative day. The program should be closely supervised and include active and ac-tive-assistive joint range of motion. Gentle isometric contractions can begin on the fifth postoperative day, and isotonic contractions can be encouraged 7 to 10 days postoperatively. Active exercise practiced several times daily can begin shortly thereafter and should be thoroughly reviewed with the patient.






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IV. EXPLORE THE FEELINGS OF THE PATIENT AND FAMILY: The emotional impact of limb loss on the patient and his family is overwhelming. Often there is a period of depersonalization that may occur during this time when other limbs and body systems may be involved following severe traumatic injury. Reassurance and support are vitally necessary not only at this time but throughout the rehabilitation process. All members of the team should respect the individual's dignity, support the patient and family throughout the grief process, as well as offer encouragement and realistic optimism with respect to his future generally. It is premature to discuss prosthetic component options at this time. Often the patient and his family are not ready to hear about or see prostheses until the acute postoperative phase has passed.

V. FINANCIAL SPONSORSHIP:

It is important to identify and explore third-party sponsorship at this time. Specialized prostheses are often costly. Sponsorship must be sought early, and these devices must be adequately described to the payer so that a comprehensive rehabilitation program can be realistically pursued.

B. PREPROSTHETIC THERAPY PROGRAM:

From the time the sutures are removed to the time the prosthetic prescription is being discussed there are many goals that are important to address. The occupational therapist is the primary person who will be managing and monitoring this program for the upper-limb amputee. Nursing is an important adjunct, however, and all shifts of the nursing staff should be thoroughly familiar with each of these areas.

The goals of the preprosthetic program are as follows:

Residual limb shrinkage and shaping Maximizing independence

Residual limb desensitisation Myoelectric site testing (if myoelectric components are prescribed)

Maintenance of normal joint range of motion Orientation to prosthetic options

Increasing muscle strength Exploration of patient goals regarding the future Instruction in proper hygiene of the limb

This phase generally occurs 2 to 3 weeks after surgery. Healing has essentially occurred by the 21st postoperative day and should allow a vigorous program for prosthetic preparation.






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I. RESIDUAL LIMB SHRINKAGE AND SHAPING: Shrinking and shaping of the residual limb is usually accomplished by

compression from an elastic bandage, intermittent positive-pressure compression, or a tubular elastic bandage. If an elastic bandage is used, it is important that the proper technique be taught to the patient, family, and nursing staff. A figure-of-8 wrap is one that applies more pressure distally than proximally; elastic bandaging should never be done in a circumferential manner.

The wrapping process begins with the end of the bandage placed diagonally at the distal end of the residual limb. The wrap should encircle the limb from behind and wrap diagonally upward to cross over the end of the bandage. This figure-of-8 process should continue, with each pattern overlapping the previous one by approximately two thirds the width of the bandage (.Fig 1). The bandage is then secured with tape or special clasps.

No elastic bandage should be used for more than 48 hours without being washed with mild soap and lukewarm water and thoroughly rinsed with clean water. Bandages should not be twisted, but laid flat to dry. Washers and dryers decrease their longevity and ruin their elasticity.

The wrap should be reapplied every few hours or more frequently if it slips or bunches. The elastic bandage should be worn all day and all night except when bathing. A preparatory prosthesis might also be applied early in the shaping process; however, a compression bandage is generally preferred because it affords better monitoring of skin healing and points of pressure.

II. RESIDUAL LIMB DESENSITIZATION:

An equally important yet often overlooked factor is desensitization of the residual limb. It can be accomplished with gentle massage and tapping techniques (Fig 2.). Desensitization can also be accomplished by vibration, constant touch pressure, or the input of various textures applied to the sensitive areas of the limb. The patient should be encouraged to do these techniques himself. He is aware of his tolerance and can become more "in touch" with his body by practicing this regularly. When healing has occurred, aggressive massage will prevent adhesions from occurring and provide additional sensory input. It should be explained that this will improve the patient's tolerance to the pressure that will be placed on the residual limb by the prosthetic socket.

III. MAINTENANCE OF JOINT RANGE OF MOTION: When establishing an effective treatment program, the maintenance of joint range of

motion is essential. As stated earlier, scapular, glenohumeral, elbow, and forearm range of motions are crucial to maintain in order to aid in the prosthetic control motions and to maximize the functional potential of the prosthesis.

Fig 1

Fig 2






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IV. INCREASING MUSCLE STRENGTH:

Increasing upper-limb muscle strength can be accomplished in conjunction with the range-of-motion program. Active resistance applied by the therapist or cuff weights attached to the limb can be utilized.

V. INSTRUCTION IN PROPER HYGIENE OF THE LIMB: Education in proper hygiene and care of the residual limb is equally important at this time.

The limb should be washed daily with mild soap and warm water. It should be rinsed thoroughly and patted dry with a towel. This provides additional sensory input into the residual limb as well as allows the patient to become more familiar with the changes in his body.

VI. MAXIMIZING INDEPENDENCE:

Another important element in the preprosthetic phase of care is maximizing functional independence. Instruction in change of dominance and teaching one-handed activities are often indicated when working with the unilateral amputee. The bilateral acquired upper-limb amputation presents a unique challenge to the amputee team. Before receiving his prostheses, this amputee is essentially dependent in all activities of daily living, and this results in very real anxiety and frustration. It is important to express reassurance, support, and realistic optimism to these individuals during this time. Independence can be significantly enhanced by a simple device such as a universal cuff utilized with an adapted utensil, toothbrush, pen, or pencil.

VII. MYOELECTRIC SITE TESTING:

If a myoelectric prosthesis is being considered, this is an appropriate time to utilize a myotester to gauge the electric potential generated by various muscles. The myotester results should be discussed with a prosthe-tist, particularly for the proximal levels of amputation. The occupational therapist, physician, and prosthetist should jointly determine the best positioning for the electrodes and discuss the issues of prosthetic socket design.

Orientation to Prosthetic Options

This is an important time to orient the amputee patient and his family to prosthetic options available to him. The unique differences between body-powered and electric components should be comprehensively described, and examples of each should be shown and demonstrated if possible. Photographs or slides may be reasonable substitutions, but being able to touch the device and understand how it operates is extremely helpful and informative for the amputee. An overview of the advantages and disadvantages of body-powered and electric components should be clearly explained.

A careful inventory of the patient's life-style, support system, educational background, and future goals should be explored and discussed. The amputee patient is an integral part of the decision-making process of this prosthetic prescription. Involving the patient in decisions that affect his own health care will help to restore a sense of control over his life.






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C. DETERMINING THE PROSTHETIC PRESCRIPTION:

The discussion of the prosthetic prescription is ideally accomplished in the presence of the patient, physician, therapist, prosthetist, family, and third-party payer. Many amputees who have sustained work-related injuries have the unique advantage of having a rehabilitation insurance nurse or case manager assigned to their care. This individual is a valuable liaison between the patient, insurance carrier, and medical providers. It is important to include these insurance representatives in the discussion of the prosthetic prescription because they have a direct influence on the financial approval of the prosthesis and the rehabilitation treatment plan.

The prosthetic prescription is based on a number of criteria that should be comprehensively addressed and recorded. These criteria frequently include the following:

1 Length of the residual limb 9 Desire for function 2 Amount of soft-tissue coverage 10 Desire for cosmesis

3 Presence of an adherent scar 11 Patient attitude and motivation

4 Movement of proximal joints 12 Vocational interests

5 Muscle strength in the residual limb 13 Avocational interests

6 Muscle strength in the opposite limb 14 Third-party payer considerations

7 Adequate ability to learn and retain new informatio15 Family preferences

8 Adequate sensation in the residual limb

I. FABRICATION AND TRAINING TIME: The steps involved in fabricating the prosthesis should also be explained at this time.

Several steps are required from the time the prosthesis is prescribed to the time it is delivered to the patient. This process should be thoroughly explained to the patient and third-party payer, particularly if the patient lives out of town so that transportation can be arranged for prosthetic fitting and training.

This is also an appropriate time to discuss the options of outpatient vs. inpatient hospitalizations. Generally, all unilateral upper-limb amputee patients can be managed on an outpatient basis. It is strongly recommended that all bilateral upper-limb amputees be trained on an inpatient basis. The bilateral upper-limb amputee has not only issues of functional independence to address but emotional issues as well. These can be more closely monitored on an inpatient basis, with the family and patient becoming involved with the social worker or psychologist on the amputee team. Recommended and approximate training time schedules are as follows:

Transradial, 5 hours Transhumeral/shoulder disarticulation, 10 hours Bilateral transradial, 12 hours Bilateral transhumeral, 20 hours Ideally this training should be managed on a daily basis for 1 to 2 hours a day. This is also an appropriate opportunity for the new amputee to meet others with similar

levels of limb loss who have worn a prosthesis for a period of time. Common reactions, frustrations, and anxieties can be shared. Positive achievements should be stressed, however.






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It must be remembered that one amputee's experience does not directly parallel another's. These encounters should be followed by an opportunity for the amputee to discuss his feelings and reactions with an experienced psychosocial professional in amputee rehabilitation.

D. ADULT UPPER-LIMB PROSTHETIC TRAINING:

Before initiating a program of upper-limb prosthetic training, one must realistically orient the patient to what the prosthesis can and cannot do. If the individual has an unrealistic expectation about the usefulness of the prosthesis as a replacement arm, he will be dissatisfied with the ultimate functioning of the prosthesis and may reject it altogether. On the other hand, if the expectations of the amputee are more realistic at the beginning of training, then the ultimate acceptance will be based upon the ability of the prosthesis to improve the individual's performance. It is imperative, then, that the therapist be honest and positive about the function of the prosthesis. If he "believes in" and understands the functional potential of the prosthesis, success can be more realistically achieved.

I. INITIAL ASSESSMENT:

During the therapist's first encounter with the amputee patient in therapy, the following issues need to be discussed and documented if they have not already been accomplished. Etiology and onset Phantom pain or residual limb pain

Age Previous rehabilitation experience

Dominance Revisions

Other medical problems Viable muscle sites (for myoelectric control)

Level of independence Previous information regarding prostheses

Range of motion of all joints of the residual limb Background education and vocational goals

Muscle strength of the remaining musculature Goals and expectations regarding the prosthesis

Shape and skin integrity of the residual limb II. STATUS OF THE OPPOSITE UPPER LIMB: ·

Although this list may appear unreasonably long and too lengthy to document, the assessment will make a significant difference in the therapist's awareness of the individual with whom he is working. The nature of patient-therapist rapport and subsequent success of therapy will be greatly enhanced if this information is gathered before therapy actually begins.

The period of time from casting until final fitting of the prosthesis is characterized by eager anticipation and hope that the artificial arm will enable the individual to function as before the amputation. Unfortunately, the finished prosthesis is often a disappointment for the patient. It is perceived as "artificial looking," heavy, uncomfortable, and awkward to operate. If the patient is appropriately oriented to the realities of the prosthesis, how it looks and operates, acceptance of the limitations of the prosthesis are more readily achieved following delivery.






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III. INITIAL VISIT:

When the upper-limb amputee visits the occupational therapist for the first time, he will probably be carrying the prosthesis in a bag or sack. It is important to understand this awkwardness and reluctance in putting it on with others "watching." A quiet, nondistract-ing room with a mirror plus an atmosphere of acceptance and understanding is preferable.

During the first couple of visits the following goals should be addressed: orientation to prosthetic component terminology, independence in donning and doffing the prosthesis, orientation to a wearing schedule, and care of the residual limb and prosthesis.

IV. ORIENTATION TO PROSTHETIC COMPONENT TERMINOLOGY:

In view of the fact that the prosthesis has not become the patient's "arm," it is important that the patient learn to identify the major components of the prosthesis appropriately. Any orientation to identifying such basic aspects as the figure-of-8 harness, cable, elbow unit or elbow hinge, wrist unit, terminal device, and hook or hand will suffice at this time.

Independence in Donning and Doffing the Prosthesis It is important that independence be established early in donning and doffing

the prosthesis by the "pullover sweater" method. As an alternative, the "coat" method may also be used (Fig 3.). Bilateral amputees most often use the "sweater" method.

V. PROSTHETIC WEARING SCHEDULE:

Development of a wearing schedule is an extremely important aspect of this first visit. Initial wearing periods should be no longer than 15 to 30 minutes, with frequent examination of the skin for excess pressure or poor socket fit. This is particularly important for the amputee with insensate areas and adherent scar tissue. If redness persists for more than 20 minutes after the prosthesis is removed, the patient should return to the prosthetist for socket modifications. If no skin problems are present, wearing periods may be increased in 30-minute increments three times a day. By the end of a week, the upper-limb amputee should be wearing his prosthesis all day.

VII. CARE OF THE RESIDUAL LIMB AND PROSTHESIS:

Following amputation, the skin of the residual limb is subject to irritation and sometimes to further injury and infection. Appropriate care of the skin is therefore a vital part of rehabilitation. The residual limb should be bathed daily, preferably in the evening. It is advisable to not wash the residual limb in the morning unless a stump sock is worn. Damp skin may swell and stick to the prosthesis and may be irritated by rubbing. The limb should be washed with mild soap and lukewarm water. It should be rinsed thoroughly with clean water. If soap is left to dry on the skin, it may be irritating. After rinsing, the skin should be dried thoroughly by using patting motions. Avoid brisk rubbing, which may irritate the skin. Lotions, creams,

Fig 3






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and moisturizers should not be applied to the limb unless the physician or therapist gives specific orders.

The socket should be cleaned often, particularly if the individual perspires heavily. In warm weather the socket may require cleaning at least once or twice daily. The socket should be washed with warm water and mild soap. It should be thoroughly wiped out inside with a cloth dampened in clean warm water. The socket can be left to dry through the night or dried thoroughly with a towel inside if one plans to continue to wear the prosthesis immediately.

If stump socks are worn, several changes may be necessary during warm weather owing to perspiration. If possible, the sock should be washed as soon as it is taken off, before the perspiration dries on it. This will prolong the life of the stump socks. Mild soap and warm water should be used, followed by the sock being thoroughly rinsed. Allow the sock to dry slowly to avoid shrinkage.

The amputee should be encouraged to inspect his skin daily. If skin disorders develop, the physician should be called promptly. A minor disorder may become disabling if incorrect treatment is used. It will probably be necessary to adjust the prosthesis, and therefore the prosthetist is generally involved at this time as well. Strong disinfectants such as iodine should never be used on the skin of the stump.

VIII. BODY CONTROL MOTIONS:

Prior to allowing the upper-limb amputee to practice prosthetic controls training, several motions need to be reviewed. This is best done before the prosthesis is actually applied. 1. Scapular abduction.-Spreading the shoulder blades apart in combination with

humeral flexion, or alone, will provide tension on the figure-of-8 harness in order to open the terminal device.

2. Chest expansion.-This motion should be practiced by deeply inhaling, expanding the chest as much as possible, and then relaxing slowly. Chest expansion may be utilized in a variety of ways for the transhum-eral, shoulder disarticulation, or forequarter amputee. Harnessing this motion with a cross-chest strap is determined by the prosthetic design; in some instances of extensive axillary scarring, it may be preferred to the figure-of-8 harness.

3. Shoulder depression, extension, and abduction.- This is the combined movement necessary to operate the body-powered, internal-locking elbow of the trans-humeral prosthesis. It is advisable to have the amputee practice this motion by cupping one's hand under the residual limb and instructing the patient to press down into the palm. This will simulate the motion required to lock and unlock the elbow in the individual with transhum-eral amputation.

4. Humeral flexion.-The amputee is instructed to raise his residual limb forward to shoulder level and to push his arm forward while sliding the shoulder blades apart as far as possible. This motion applies pressure on the cable and allows the terminal device to open. Scapular abduction and humeral flexion are the basic motions to review with the transradial amputee.

5. Elbow flexion/extension.-It is critical to instruct the transradial amputee to maintain full elbow range of motion. This range will enable him to reach many






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areas of his body without undue strain or special modifications to the prosthesis.

6. Forearm pronation/supination.-In the long transradial amputee, it is equally important to maintain as much forearm pronation and supination as possible. This will enable the amputee to position the terminal device where he chooses without manually preposition-ing the wrist unit. If the amputee has retained more than 50% of his forearm, some degree of forearm pronation and supination is maintained.

IX. PROSTHETIC EVALUATION:

Before beginning functional training, it is important to ensure that the prosthesis fits comfortably and that the components function in a satisfactory manner. Ideally this is accomplished with the occupational therapist and prosthetist together. A formal prosthetic checkout form for this purpose is available from Northwestern University.

The therapist is encouraged to communicate openly with the prosthetist on a frequent basis not only initially but whenever concerns regarding fit or operation arise.

X. PROSTHETIC CONTROLS TRAINING:

Manual controls are important to review after the prosthesis is applied. One control should be taught at a time and then combined with others: 1. Positioning the terminal device in the wrist unit is accomplished by manual rotation with

the sound hand. In the bilateral upper-limb amputee, a force against an object in the environment or between the individual's knees is necessary to accomplish this positioning.

2. Rotation at the elbow turntable is manually adjusted or controlled by leaning the prosthesis against an object.

3. The friction shoulder joint is manually adjusted with the sound hand or by applying pressure against an object or the arm of a chair.

4. If the prosthesis has a wrist flexion unit, this can be manually controlled by applying pressure on the button or, for the bilateral amputee, by applying pressure against a stationary object.

Active controls are equally important to review prior to functional training. The upper-limb amputee incorporates the body-control motions he learned previously while wearing the prosthesis. It is essential that the harness be adjusted properly before initiating these exercises: 1. In all proximal levels of upper-limb loss, body-powered elbow flexion is facilitated by a

forearm lift assist that counterbalances the weight of the forearm. Elbow extension is accomplished by gravity if the elbow unit is unlocked.

2. Elbow lock/unlock is perhaps one of the most difficult tasks to learn in the operation of a transhumeral prosthesis. The pattern of "down, back, and out" is often stated to the amputee in an effort for him to repeat the shoulder depression, extension, and abduction pattern. This pattern not only locks but unlocks the elbow in an audible "two-click cycle." Practicing this task should occur in a quiet, nondistracting room where one can hear the

Fig 4






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clicks without difficulty. This pattern may need to be exaggerated at first, but soon it will be barely observable.

3. Before approaching terminal device operations, it is important for the amputee to practice locking and unlocking the elbow in several positions.

4. In the shoulder disarticulation and forequarter amputee, the mechanism to lock and unlock the elbow is often a nudge control "button" attached to the thoracic shell. By depressing this button with the chin, one is able to position and lock the elbow where desired.

5. It is important to clearly explain that the elbow must be locked first, in the proper position, before one is able to operate the terminal device. As described previously, biscapular abduction and/or humeral flexion causes the conventional terminal device to open, while relaxing allows it to close (Fig 4.).

XI. CONTROLS PRACTICE:

A form board is frequently utilized to perfect prepositioning as well as tension control of the terminal device (Fig 5.). Prepositioning involves both manual and active controls to place the prosthesis in the most optimal position for a specific activity. Close attention must be paid to the individual's awkward or compensatory body motions when he approaches an object. Often the amputee will "adjust" his body rather than repositioning the elbow and wrist unit positions. A mirror can be effective in assisting the amputee to see the way his body is positioned. It is helpful to instruct the patient to "think" how his own arm would have been positioned to approach the object. It is often necessary to remind him to maintain an upright posture and to avoid extraneous body movements.

The five motion elements that are primarily used in hand manipulation are reach, grasp, move, position, and release. A form board can be used in training to orient the individual to approach, grasp, and release objects differing in shape, weight, density, and size. Prehension control can be practiced with a sponge or paper cup. The amputee is instructed to maintain constant tension of the terminal device control cable so as not to crush the object being held. Approach to an object should be such that the stationary hook finger makes contact with the object and the movable finger actually "grasps" it. Flat objects can be moved to the edge of the table and then grasped with the terminal device in a horizontal position. Prehension force is generally controlled by rubber bands, which can be added as tolerated. Springs may be used as an alternative.

Controls training for the bilateral upper-limb amputee are an aspect of therapy that may require a period of time to perfect. To learn to separate the controls motion of two prostheses is a complex and coordinated motor process that may need to be practiced frequently. Passing an object back and forth, such as a rule, may help in reinforcing this pattern.

XII. FUNCTIONAL USE TRAINING:

Functional use training is the most difficult and prolonged stage of the prosthetic training process. The individua'ls acceptance and usage of the prosthesis is dependent upon (1) the motivation of the patient, (2) the comprehensiveness and quality of the tasks and activities practiced, and (3), of critical importance, the experience and enthusiasm of the occupational therapist.

Fig 5






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The training experience is most effective if the same therapist remains with the patient throughout the entire process.

It is extremely important to reinforce to the unilateral amputee that his prosthesis will play a nondomi-nant functional role. The prosthetic terminal device is most useful for gross prehension activities and to hold and stabilize objects, while the sound limb performs fine motor prehension activities. It is unreasonable to expect the prosthesis to assume any more than 30% of the total function of the task in unilateral upper-limb activities. The sound hand will always be dominant for all activities performed. The therapist must be realistic and convince the patient to view the prosthesis as a "helper."

Unilateral patterns of independence occur quickly in the amputee who has lost an arm or hand. It is therefore essential, if possible, to fit the unilateral amputee within 1 to 2 months of the amputation. These individuals definitely show a greater propensity for wearing and successfully using their prostheses. This applies to all amputees fitted with body-powered or electric components.

It is appropriate to practice activities of daily living that are useful and purposeful. Realistic situations should be pursued so that the individual will automatically use the prosthesis when he encounters the same activity in his daily routine. Examples include the following:

1. Cutting food 5. Washing dishes 2. Using scissors 6. Hammering a nail and using tools 3. Dressing 7. Driving a car 4. Opening a jar or bottle

The importance of pre-positioning, prior to approaching these tasks, cannot be overemphasized. The amputee should be instructed to orient the components of the prosthesis in space to a position that resembles that of a normal limb engaged in the same task. As a rule, most difficulties in use are a result of improper positioning.

XIII. CUTTING FOOD:

It is easiest to cut food by holding the fork in the hook, with the hook fingers grasping the flat surface of the fork handle and the upper handle of the fork resting on the dorsal surface of the thumb of the hook. The sound hand holds the knife.

XIV.USING SCISSORS: When using scissors, the material to be cut should be placed in the terminal device. The scissors are held by the sound hand. To avoid "flopping," the area to be cut should be as close to the area grasped as possible. The material should be repositioned as cutting angles are changed (Fig 6.).

XV. DRESSING:

Dressing activities such as fastening trousers are accomplished by the terminal device holding the waistband or belt loop while the sound hand tucks in the shirt and fastens the waist hook, snap, or button. The terminal device can "pinch" the fabric at the bottom of the zipper to facilitate zipping with the sound hand. A buttonhook may be used to assist in buttoning cuffs on the sound side (Fig 7.).






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With the proper preposi-tioning, the cuff can be buttoned rapidly and reliably. Buttonhooks are particularly helpful for the transhum-eral and shoulder disarticulation amputee.

XVI.OPENING A JAR OR BOTTLE:

When opening a jar or bottle, the middle of the container is grasped by the terminal device, and the sound hand unscrews the lid. All tension should be removed from the cable to ensure maximum grasp on the container.

XVI.WASHING DISHES:

To achieve the greatest security of grasp while washing dishes, the dish should be held in the sound hand. Depending on the individuals preference, a dishcloth or sponge is held and manipulated by the terminal device. Submerging the hook in water should be avoided because detergents dissolve the lubricating oils in the hook and wrist units. Periodic cleaning and oiling of the stud threads and bearings may be necessary for the amputee who engages in frequent dishwashing activities. When drying dishes, the sound hand holds the dish while the terminal device grasps the towel.

XVII. HAMMERING A NAIL AND USING TOOLS: Hammering nails is accomplished by holding the nail in the hook fingers,

rubber band guard, or special attachment of the no. 3 or no. 7 Hosmer-Dorrance work hook. The hook should be pronated to 90 degrees so that the nail is perpendicular to the wood. When correctly positioned, the tip of the nail should just contact the wood.

As demonstrated (Fig 8.), the head of a large bolt may be secured in the hook terminal device while the wrench is held in the sound hand to tighten or loosen the bolt. Again, the amputee may need to be reminded that the prosthesis and terminal device are merely "functional assists" to aid in stabilization. The sound limb always becomes the dominant and active limb (Fig 9.).

An alternative design in terminal devices is illustrated by the voluntary-closing Grip II (Fig 10.). This device is specifically designed by Therapeutic Recreation Systems, Inc. (TRS, 2860 Pennsylvania Ave, Boulder, CO 80803), to hold and manipulate objects by using body power to close rather than to open the hook.

XVIII. DRIVING A CAR:

Driving a car is an important goal for the individual who has lost an arm. The actual turning of the steering wheel should be done by the sound limb. If the prosthesis has sufficient function, performance can be improved by using the prosthesis to assist the sound arm. A driving ring is available from most prosthetic suppliers. The fingers of the hook are secure in the ring for turning but can easily slip out in emergencies.

A list of activities and a rating guide designed by Northwestern University are helpful adjuncts to the therapy plan in determining which activities are important for the unilateral amputee to accomplish (Fig 11.).

Fig 7

Fig 8

Fig 10






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XIX.VOCATIONAL ACTIVITIES:

Discussing vocational needs and expectations with the amputee is very important. Unfortunately, this is an area that is often overlooked or given only brief attention during the rehabilitation process. This discussion should occur later in the training continuum when the individual begins to acknowledge and accept his disability. Although not everyone can return to the exact job held prior to the injury, a review of job responsibilities and expectations can be explored with the therapist. It may be possible to break down the tasks of a job into a step-by-step process that can be practiced and reinforced in therapy. An example of how effective prosthetic hooks can be for drafting is illustrated in Fig 12.. If the therapist can do an on-the-job site evaluation, it would be a valuable addition to the amputee's comprehensive rehabilitation.

XX. HOME INSTRUCTIONS:

At the conclusion of training, a home program of wearing, functional use, and care instructions should be reviewed with the amputee and his family. Specific instructions regarding which team member to contact when a problem arises should also be provided. A follow-up appointment should be arranged, and an

Fig 12

Fig 11






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explanation of what to expect during this visit is helpful in making the transition from the rehabilitation center to the home environment.

The following points are important to review with the amputee who has been fitted with a body-powered upper-limb prosthesis. 1. The harness should be washed when soiled because perspiration stains permanently

mark the straps. A household cleaner with ammonia works well. 2. Do not iron the Velcro closures on straps. 3. The elbow lock should be cleaned frequently and kept free from abrasive materials. 4. The cable should be examined frequently for cut or worn areas. 5. The neoprene lining of the hook may need to be periodically relined for a firmer grip. The

neoprene is resistant to gasoline, oil, and other petroleum products. It should, however, be protected from hot objects.

6. When a rubber band wears out from use, grease, or injury, cut it off with scissors, and replace it with a new band. Rubber band applicators are obtained from the prosthetist. Each rubber band is equivalent to approximately 1 lb of pinch force.

7. Take the prosthesis to the prosthetist as soon as damage occurs. 8. Never use the terminal device as a hammer, wedge, or lever. 9. The prosthesis should be hung up by the harness rather than by the cable or cable strap. 10. Detergents should be avoided since they tend to dissolve the lubricating oils in the hook

and wrist unit mechanism. When an amputee washes dishes frequently, the stud threads and bearings of the hook should be cleaned and oiled regularly.

11. Never reach for a moving object with the hook. 12. The cosmetic glove of a mechanical or myoelectric hand is easily stained. The following

substances cannot be removed unless immediately washed with water or alcohol: ball point ink, shoe polish, egg yolk, carbon paper, colored lacquers, brightly dyed fabric, fresh newsprint, tobacco tar, mustard/ketchup, and lipstick.

XXI.FOLLOW-UP ISSUES:

Following discharge from the therapy program, the amputee is regularly monitored and reviewed in an outpatient clinic by the rehabilitation team. This is an appropriate time to discuss the amputee's present status and successes as well as problems that may have been encountered. The services of the prosthetist are available for consultation as well as for any repairs and modifications to the prosthesis that may be required. This is a crucial time for the upper-limb amputee, and patterns of prosthetic use and emotional well-being must be carefully re-evaluated at each visit. In an attempt to define prosthetic function in a quantitative manner, the author has designed the following use rating scale. 100%-Wearing all day, using well in bilateral tasks, incorporating well in the body scheme. 75%-Wearing all day, using in grossand fine-motor tasks. 50%-Wearing all day (primarily for cosmetic reasons), incorporating in gross activities

(used as a leaning surface, i.e., desk/paper tasks). 0%-Not wearing or using the prosthesis. This individual is choosing to be essentially

unilaterally independent.






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Wearing patterns have been quantified as follows: Full-12 hours or more per day Moderate-6 to 12 hours per day Minimal-0 to 6 hours per day None-0 hours per day. In addition to quantifying prosthetic function and wearing patterns, the following goals are equally important to address during the follow-up visit. 1. Maximize prosthetic function. 2. Maintain prosthetic components. 3. Decrease assistive devices. 4. Resume previous vocation or explore new vocational options. 5. Resume avocational interests. 6. Re-enter the family and community environment. 7. Maintain a regular periodic follow-up with rehabilitation professionals.

The first follow-up visit is scheduled approximately 4 weeks after discharge from training. Follow-up visits are then scheduled at wider intervals, e.g., 3 months, 6 months, and eventually an annual visit. For the more complex amputee with specific skin, bone, or pain problems, more frequent return visits may be necessary.

The complete rehabilitation process for an amputee is, indeed, a long one. Early fitting is crucial to encourage successful functional outcomes for all upper-limb amputees. Rehabilitation should not be considered complete until a stable, independent life-style has been achieved and the individual's social and occupational niches have been re-established.

The amputee's potential is limitless. It is not solely dependent upon the quality of the prosthesis, of medical care, or of therapy. All these areas ideally work in close harmony with one another. Motivation and the desire of the patient to be independent are perhaps the most important ingredients to cultivate and reinforce. It is the responsibility of all rehabilitation professionals involved to create a conducive environment that will not only encourage this process to occur but enhance it as well.






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6.0 ARTHRITIS:

Arthritis is a common problem for many older people, but it can affect anyone, from toddlers to centenarians.

Although people use the term as if it were only one disease, arthritis actually refers to a condition found in a large group of disorders. The major symptoms of arthritis affect the areas in and around joints, making them stiff, swollen, and often painful. In addition to the joints, certain types of arthritic diseases may affect other parts of the body, including the heart and lungs.






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As a group, the various forms of arthritis are among the most common medical conditions. About 1 of every 6 people, have it. Arthritis usually is chronic, which means the problem can last to some degree for months, years, or the rest of people's lives. Centenarians are people who are at least 100 years old. Rheumatoid arthritis (ROO-matoid ar-THRY-tis) is a chronic autoimmune disease characterized by pain, swelling,

stiffness, and deformation of the joints. Arthritis affects millions of people. Although there are many types, the most common are: Osteoarthritis Rheumatoid arthritis Juvenile rheumatoid arthritis

o Gout o Fibromyalgia o Lupus o Lyme disease

These conditions develop for a variety of reasons, but they are not contagious. Some forms of arthritis, however, can develop from contagious infections, like sexually transmitted diseases or viruses that cause mumps and rubella (German measles). One form of arthritis, Lyme disease, develops from the bite of an infected tick. Sometimes arthritis occurs as one of the symptoms seen in conditions that primarily affect other organs. For example, inflammatory bowel disease may have arthritis as one of its symptoms. Gout occurs when deposits of uric acid in the joints cause inflammation and pain. Fibromyalgia (fi-bro-my-AL-ja) is a group of disorders that are characterized by achy, tender, and stiff muscles. Contagious means transmitted from one person to another.

6.1 OSTEOARTHRITIS:

Arthritis may affect many different parts of the body, including shoulders, elbows, hands, hips, and knees (left). In healthy joints (top right), a flexible cushion of cartilage allows bones to slide past each other smoothly. But in arthritis (bottom right), cartilage loss forces the bones to touch without their usual cushioning, which creates pain and inflammation.

Arthritis may affect many different parts of the body, including shoulders, elbows, hands, hips, and knees (left). In healthy joints (top right), a flexible cushion of cartilage allows bones to slide past each other smoothly. But in arthritis (bottom right), cartilage loss forces the bones to touch without their usual cushioning, which creates pain and inflammation.

That is because the pain, stiffness, and swelling often result from the wearing down of the protective tissues within and around joints.

Osteoarthritis is sometimes called "wear and tear arthritis" and often affects the knee joints, making them stiff, swollen, and painful.

Osteoarthritis is sometimes called "wear and tear arthritis" and often affects the knee joints, making them stiff, swollen, and painful.

The human body contains more than 150 joints that connect more than 200 bones. There are small joints in toes and fingers; larger ones in the spine, elbows, and knees; and even bigger ones like the hips and shoulders. The bones do not touch directly. Instead, a tough, smooth, rubbery layer of tissue called cartilage covers the ends of the bones. When a knee, elbow, or other joint moves, the cartilage allows the bones to slide past each other smoothly. Cartilage also is flexible and absorbs some of the weight placed upon certain joints, such as the knee.






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People with osteoarthritis, however, have lost some of the smooth cartilage in their joints. Eventually, the cartilage can wear away so much that the ends of the bones touch without any cushioning. The bones also can grow small spurs or bumps, which is why some people with osteoarthritis have lumps in their joints. These lumps often are most noticeable in the hands.

6.1.1 THOSE ODD PAINS: Osteoarthritis usually is felt first in the knees, hips, feet, spine, or fingers. These are

joints that bear much of the body's weight or are used often for everyday activities. The pain increases as the cartilage between the bones is worn down. People often start to avoid using the joint. For example, people might exercise less if pain is in the knees. This only makes the problem worse. It leads to increased stiffness, because muscles around the joints begin to weaken from disuse.

A. STRESS:

No one is exactly sure why osteoarthritis happens, but often it results from stresses placed on the joint. In the example of Jenny's father, his years of running on hard surfaces caused damage to his knee cartilage. The pounding on pavement was too much stress for the cartilage to absorb.

Other types of stress or injury also can lead to osteoarthritis. People whose jobs involve hard physical labor (like construction workers) or repetitive tasks (like assembly line workers) can develop osteoarthritis. An injury to a knee or elbow also can increase the risk of osteoarthritis. Certain activities like football or ballet can put a person at greater risk for developing osteoarthritis. Even the stress of too much body weight contributes to the disease. People who are significantly overweight are more prone to osteoarthritis because their weight places extra stress on joints, especially knees and hips.






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B. AGE: Many older people also develop osteoarthritis, even if they never put extra stress

on their joints. That is because as people age, the rubbery cartilage tissue loses some of its ability to stretch and can become thinner. This places people at greater risk for osteoarthritis as they age.

C. HEREDITY:

Not all older people develop osteoarthritis, just as not all runners or laborers do. This is one reason doctors believe heredity may play a role in determining who is at greatest risk for this type of arthritis.

D. DIAGNOSIS:

It is important to understand what type of arthritis people have, because treatments vary. Doctors diagnose osteoarthritis based on the symptoms they see. They might look for loss of cartilage and bone spurs with x-rays. Doctors also look for other causes of the pain. For example, blood tests can show if the problem is rheumatoid arthritis instead.

E. IF IT HURTS, WHY DO DOCTORS WANT PATIENTS TO EXERCISE?

Once doctors have determined the problem is osteoarthritis, they tell patients something that might seem to make little sense. They want them to exercise the joint. This does not mean Jenny's father should return to running. It does mean he and others with the disease need to work with their doctors to find the best way to exercise.

Appropriate exercise can strengthen the muscles around the joint and help lessen the stiffness. Often, the exercises are different from those done in the past. Some give up running for swimming or water aerobics. Others walk or ride stationary bikes. If the pain is severe, a physical therapist who specializes in helping patients learn appropriate exercises might get involved. If people are overweight, doctors advise them to take off the pounds.

The pain of arthritis is often treated with aspirin or other over-the counter drugs that reduce swelling. There also are prescription drugs that are stronger and can help if the pain is extreme.

Often the pain of osteoarthritis decreases with treatment. For some people, however, surgery is performed to remove stray pieces of damaged cartilage, to smooth bone spurs, or in severe cases to replace damaged joints with mechanical ones. Hips and knees are the most likely candidates for replacement.






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6.2 RHEUMATOID ARTHRITIS: The ancient Greeks believed the body was filled with various substances they called "humors." Sometimes they said the humors got out of balance and caused illnesses, such as-the aches and pains of swollen joints. The humors, they believed, could get back in balance, and the pain would subside. But the problems also could return. One disease the Greeks observed is what we now call rheumatoid (ROO-ma-toid) arthritis. "Rheuma" derives from a Greek word that means, "flux" or "discharge." The Greeks believed the humors were fluxing, or flowing, through the body to cause the bouts of pain.

6.2.1. WHEN THE BODY TURNS ON ITSELF: In a way, rheumatoid arthritis is a disease in which substances in the body are out of

balance. The body fights infections with chemicals known as antibodies. But in rheumatoid arthritis, the antibodies turn against healthy areas of the body and cause the thin covering around joints to become inflamed.

The pain usually starts in the hands or feet, but rheumatoid arthritis can affect many different joints as well as other parts of the body, like the heart and lungs. The disease's cause is unknown. Some researchers believe that the immune system's attack on healthy tissues may be caused by the body's overreaction to viral infection.

Doctors use x-rays to diagnose rheumatoid arthritis, which often affects the hands. People with rheumatoid arthritis may feel stiffness when they wake up in the morning, and their joints may feel warm to the touch. © 1998 Michael English, M.D., Custom Medical Stock Photo.

Doctors use x-rays to diagnose rheumatoid arthritis, which often affects the hands. People with rheumatoid arthritis may feel stiffness when they wake up in the morning, and their joints may feel warm to the touch.

It is known as the most disabling of the various diseases that cause arthritis. Rheumatoid arthritis can lead to deformed joints, extreme pain, and loss of the ability to do common tasks like walking.






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A. STIFFNESS IN THE MORNING: The symptoms of the disease can develop in a few days, months or years. For most

people, a joint in the hands, feet, arms, or legs feels stiff, as it does in osteoarthritis and other forms of arthritis. Rheumatoid arthritis, however, has a few distinctive features. People tend to feel worse in the morning after awakening. They also can get a fever, and their joints can seem warm to the touch.

At first, the antibodies damage only the thin covering around joints. This covering contains cells that produce fluid that keeps joints lubricated and working properly. As the covering is damaged, it becomes thicker. Soon, damaging cells appear and eat away cartilage, bone, and other tissue. Swelling and pain result, and the joints become deformed. People with rheumatoid arthritis also can develop small bumps around joints, especially hands and elbows. Often, the disease flares up and then subsides on its own. Some people, however, receive no relief without treatment.

1. DIAGNOSIS:

Doctors diagnose rheumatoid arthritis with special blood tests. They also look for other causes of the joint problems and use x-rays to look at the spaces between bones to see if they are narrowing.

2. TREATMENT:

Over-the-counter medications like aspirin can ease the pain. Stronger prescription pain relievers and anti-inflammatory drugs also are available. Weight loss is urged for people who are too heavy. Some people need surgery to replace badly damaged joints in the arms, legs, or hips.

Many people, however, learn to live with the disease through a combination of rest and exercise. When the symptoms are at their worst, patients with rheumatoid arthritis try to avoid putting stress on the joint to help reduce damage to the joint. But when the symptoms are less severe, doctors want the patients to exercise to maintain flexibility in the joints and strength in the muscles around them.

Patients with rheumatoid arthritis often learn relaxation techniques, because the disease is known to flare up in times of emotional stress.






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6.3 JUVENILE RHEUMATOID ARTHRITIS:

Juvenile rheumatoid arthritis is one of several common forms of juvenile arthritis that cause swelling and pain in the joints. There are a great variety of symptoms among children with arthritis. The causes are unknown, although heredity is believed to play a role. Juvenile rheumatoid arthritis affects children under age 16. Although very similar to the adult form of rheumatoid arthritis, 50 to 75 percent of young patients will "outgrow" the disease. Children are treated the same way that adults are: with pain medication, exercise, and careful treatment to prevent joints from becoming deformed.






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6.3.1 OTHER FORMS OF ARTHRITIS: Osteoarthritis is the most common form of arthritis, and rheumatoid arthritis is the

most disabling. But there are more than 100 diseases that are accompanied by the symptoms of arthritis. Here are a few of the other major ones, as well as a couple of unusual types:

A. GOUT:

Gout causes extreme pain that develops suddenly, often in the big toe. The pain, swelling, and redness develop because uric acid crystals build up in the joint. Uric acid is a natural substance found in the body that usually is passed out through the kidneys and urine. When uric acid is not removed from the body, crystals form and settle in the joints. Gout often is associated in people's minds with excessive eating and drinking. Although those activities, as well as obesity, increase the risk for gout, it can develop for no apparent reason. About 2.1 million Americans have gout, and about 90 percent of them are men.






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B. FIBROMYALGIA:

Fibromyalgia causes pain in the muscles and in the ligaments and tendons that are attached to bones around joints. Often, people with fibromyalgia are excessively tired and have trouble sleeping. The causes are unknown, although people with the disease often experience psychological stress. This does not mean the disease or its pain are not real. Unlike other forms of arthritis, fibromyalgia affects muscles and tissues around joints, not the joints themselves. It also does not lead to permanent damage.






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C. LUPUS:

Lupus is a disease that affects joints as well as other body parts, like the kidneys, nervous system, heart and skin. There are many symptoms of lupus, including fatigue, rashes, chest pain, fever, and sensitivity to sunlight. Like rheumatoid arthritis, lupus is an autoimmune disease with no known cause. In autoimmune diseases, the cells in the body that usually fight infections attack healthy cells and tissue instead. The disease mostly strikes women in their childbearing years. Women of African ancestry are almost three times as likely to develop lupus as women of European ancestry are. Overall, it affects as many as 500,000 people in the United States.

About 355 million people worldwide have arthritis, according to the Arthritis Foundation. Some forms, like rheumatoid arthritis, appear to be increasing in the developing nations of Africa, while their incidence appears to be decreasing in the United States and Western Europe.

1. TREATMENT: No treatment cures systemic lupus erythematosus, but many therapies can

suppress symptoms and relieve discomfort. Treatment of SLE varies depending on the extent and severity of the disease.

Only three drugs are FDA-approved for the treatment of lupus: Prednisone Aspirin Hydroxychloroquine

However, none of these drugs are the current standard of care. In everyday practice, numerous other drugs are commonly used. Researchers are conducting numerous clinical studies and drug investigations. Genetic research in lupus is progressing very rapidly, and hopefully new drugs will be approved in the future. There are also different drugs available to treat some of the conditions associated with lupus. a. Treating Mild Systemic Lupus Erythematosus:

Less intensive treatments may be effective for symptoms of mild lupus. They include: Creams and sunblocks for rashes Nonsteroidal anti-inflammatory drugs for fever, arthritis, and headache Antimalarial drugs for pleurisy, mild kidney involvement, and inflammation of the tissue

surrounding the heart b. Treating Severe Systemic Lupus Erythematosus:

More aggressive treatment is needed if there is serious disease progression, as evidenced by: Hemolytic anemia Low platelet count with an accompanying rash (thrombocytopenia purpura) Major involvement in the lungs or heart Significant kidney damage Acute inflammation of the small blood vessels in the extremities or gastrointestinal

tract






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Severe central nervous system symptoms The primary approach to treating severe SLE is to suppress the immune factors, most

often first with corticosteroids and other immunosuppressant drugs. Investigational drugs and procedures are also showing promise.

c. Treating Specific Complications

The major complications of the disease must be treated as separate problems, keeping in mind the specific aspects of SLE. They are discussed elsewhere in this report.

B. DIET AND LUPUS: We receive numerous questions about what sort of diet a lupus patient should

follow and whether there are any foods they should avoid. This article by Dr. David D'Cruz will hopefully answer some of these questions:-

Many patients with lupus are concerned that a strict diet may be necessary to help their condition. Infact our general advice is to have a broad general and nutritious diet with perhaps a slightly increased intake of oily fish such as mackerel, sardines and salmon and perhaps a little less red meat. The only food that should be avoided is alfalfa sprouts as this may cause lupus to flare. It would be sensible to keep within the recommended calorie intake, which is roughly 1,900 calories per day for women and 2,500 calories per day for men. These figures are based on adults with a sedentary lifestyle wishing to maintain their current weight.

The risks of obesity are well known and include a higher risk of heart attacks, cancer and strokes. Lupus patients have a higher risk of cardiovascular problems such as strokes and heart attacks. It is therefore even more important for lupus patients to try and maintain a healthy weight.

Patients on corticosteroids such as prednisolone often gain weight which may be very difficult to shift even on reducing the prednisolone. Steroids are known to upset cholesterol levels and blood sugar levels increasing the risk of diabetes. Furthermore blood pressure may rise both with the steroids and associated weight gain. We have recently conducted a pilot study to test the effects of a standard calorie controlled diet, that is usually recommended from the dieticians department, compared to the low glycaemic index diet that is now very fashionable.

The principle of the low glycaemic index (GI) diet is that certain foods increase the blood sugar very rapidly as these sugar containing foods are easily digested. Thus low GI foods would include proteins such as fish and meat as well as vegetables and certain fruits such as strawberries. High GI foods would include any foods containing refined sugars such as biscuits, many breakfast cereals and sweets. Paradoxically dark chocolate which contains very little sugar may be taken in moderation. By keeping to low GI foods, weight loss can be achieved.

Our results showed that both diets were well tolerated by lupus patients on long term steroid tablets and both groups of patients lost significant amounts of weight ranging from 2 - 4 kg. Very few side effects were reported by the patients. One striking advantage of both diets was that severe tiredness improved significantly with the






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weight loss. One concern of the higher protein intake with the lower GI diet would be that cholesterol and blood pressure levels might be upset. However this was not the case and cholesterol levels remained the same as did blood pressure.

The low GI diet represents a significant advance over the Atkins diet since the GI diet does not prohibit foods such as carbohydrates as with the Atkins diet. For patients on steroids who are finding it difficult to shift the weight gain it would seem reasonable to consider a low GI diet. We are in the process of applying for a grant to broaden our diet study for a longer period of time as this pilot study was only 6 weeks long.

In summary there are considerable benefits to losing weight in lupus - not least being the considerable improvements in tiredness that are such a major problem in patients with lupus. Keeping to a healthy weight will also minimise the risk to cardiovascular health that is increasingly important in lupus patients.






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D. LYME DISEASE:

Lyme disease is a bacterial infection spread by the bite of an infected insect known as a deer tick. The first signs are usually fever and a red rash on the skin where the bite occurred. Joint problems may follow, but the disease usually can be overcome with medication. It is a special concern for people who spend time outdoors in certain regions of the world.






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6.4 LIVING WITH ARTHRITIS: Severe arthritis can limit the ability to walk, dress, or bathe easily. There are a growing

number of devices that are sold to help people with arthritis have an easier time with simple tasks. Such things as easy-to-open bottles, handles on poles to reach high objects, and electric scooters can help people with severe arthritis to live independently.

Although doctors do not yet know how to prevent arthritis, there are many things people can do to reduce its impact, including: Maintaining a healthy weight Exercising to maintain joint flexibility and muscle strength Exercising carefully, especially in contact sports like football Wearing well-cushioned sneakers when walking or running on hard surfaces Getting adequate rest Following the doctor's instructions about pain medications Learning relaxation techniques to reduce flare-ups in times of stress

With a fuller understanding of arthritis, its limitations, and its treatments, people with arthritis can lead full and happy lives.

6.4.1 "RHEUMATISM"

Rheumatism is a non-medical word that many people use to refer to many different forms of arthritis, including rheumatoid arthritis. Older men and women sometimes talk about "having a touch of rheumatism" when their joints ache, especially on cold, rainy days.






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7.0 BACK DISORDERS:

Back disorders can limit a persons ability to sit, stand, walk, bend or carry objects. They include, but are not limited to, degenerative disk disease, scoliosis and herniated disks.

Sites of low back pain. Pain anywhere along the spine (A) can be caused by osteoarthritis. Pain along one or the other side of the spine may be (B) a kidney infection. Trauma to back muscles, joints, or disks (C) causes low back pain. Damage to the

coccyx (D) can occur during a fall. Sciatica (E) can cause pain to run from the back and buttocks area down a leg.






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7.1 RECOMMENDATIONS FOR TREATMENT OF LOWER BACK PAIN:

The initial assessment of patients with low back problems focuses on detecting indications of potentially serious disease, termed "red flags" (i.e., fever or major trauma).

In the absence of red flags, imaging and other tests are not recommended in the first 4 to 6 weeks of low back symptoms as they almost never result in a meaningful change in clinical management. Nonprescription medication or an appropriately selected nonsteroidal anti-inflammatory drug (NSAID), appropriate adjustment of physical activity if needed, and the use of thermal modalities such as heat and/or cryotherapies can safely relieve discomfort.

In the absence of red flags, primary care and occupational physicians or other health care professionals can effectively manage low back problems conservatively.

At the first visit, the physician should assure the patient that low back pain (LBP) is normal, has an excellent prognosis and, in most cases, is not debilitating on a long-term basis. Patients with elevated fear avoidance beliefs may require additional instructions and interventions to be reassured of this prognosis. Theoretically, this reassurance has the potential to avoid increasing the probability of the patient developing chronic pain syndrome.

To avoid undue back irritation and debilitation from inactivity, some activity or job modification may be helpful in the acute period. However, bed rest is not recommended for essentially all LBP and radiculopathy patients other than those with unstable fractures or cauda equina syndrome with pending neurological catastrophe. Maintaining ordinary activity, as tolerated, leads to the most rapid recovery.

All patients should be encouraged to return to work as soon as possible as evidence suggests this leads to the best outcomes. This process may be facilitated with modified duty particularly if job demands exceed patient capabilities. Full-duty work is a reasonable option for patients with low physical job demands and the ability to control such demands (e.g., alternate their posture) as well as for those with less severe presentations.

Aerobic exercise has the best evidence of efficacy among the exercise regimens, whether for acute, subacute, or chronic LBP patients.

Non-specific stretching is not recommended as it is not helpful for treatment of LBP. However, specific types of stretching exercises appear helpful (e.g., directional and slump stretching). Strengthening exercises, including lumbar stabilization exercises, are recommended, but not until the acute period of LBP has subsided.

There is evidence of efficacy for manipulation for treatment of non-specific LBP, particularly for those patients who test positive for the Clinical Prediction Rule.

Many invasive and noninvasive therapies are intended to cure or manage LBP, but no strong evidence exists that they accomplish this as successfully as therapies that focus on restoring functional ability without focusing on pain. In those cases, the traditional medical model of "curing" the patient does not work well. Furthermore, patients should be aware that returning to normal activities most often aids functional recovery.

Patients should be encouraged to accept responsibility for managing their recovery rather than expecting the provider to provide an easy "cure." This process will promote using activity rather than pain as a guide, and it will make the treatment goal of return to occupational and non-occupational activities more obvious.

If symptoms persist without improvement, further evaluation is recommended. Within the first 3 months of low back symptoms, only patients with evidence of severe spinal disease or

severe debilitating symptoms and physiologic evidence of specific nerve root compromise confirmed by appropriate imaging studies, can be expected to potentially benefit from surgery.






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Quality evidence exists indicating that patient outcomes are not adversely affected by delaying surgery for weeks or a few months and continued conservative care is encouraged in patients with stable or improving deficits who desire to avoid surgery. However, patients with severe or progressive deficits that are not improving at 4 to 6 weeks may benefit from earlier surgical intervention.

Nonphysical factors (such as psychiatric, psychosocial, workplace, or socioeconomic problems) should be investigated and addressed in cases of delayed recovery or delayed return to work.

Physicians can greatly improve patient response to back symptoms by providing assurance, encouraging activity, and emphasizing that more than 90% of LBP complaints resolve without any specific therapies. While patients may be looking for a clear-cut diagnosis for their LBP, the risk to them of a suggested "cure" for this assumed diagnosis, resulting in failed expectations, may be worse than their symptoms.

Physicians should be aware that "abnormal" findings on x-rays, magnetic resonance images, and other diagnostic tests are so common they are normal by age 40. Bulging discs continue to increase after age 40, and by age 60 will be encountered in 80% of patients. This requires that a skilled physician conduct a careful history and physical examination in order to correlate historical, clinical, and imaging findings prior to assigning the finding on imaging to a patient's complaints. It is recommended that physicians unable to make those correlations, and thus properly educate patients about these complex issues, should defer ordering imaging studies to a qualified consultant in musculoskeletal disorders. Without proper education on prevalence, treatment, and prognosis, patients may become fixated on "fixing" their abnormality (which may in fact be a completely normal condition) and thus iatrogenically increase their risk of developing chronic pain.

Significant abnormalities in hip range-of-motion may increase the probability of back disorders. Summary Tables: Recommendations and Evidence The following summary tables contain the recommendations of the Evidence-based Practice Spine Panel. These recommendations are based on critically appraised higher quality research evidence or, when higher quality evidence was unavailable or inconsistent, on expert consensus observing the First Principles of Clinical Logic as required in the American College of Occupational and Environmental Medicine (ACOEM) Methodology. Table 1 is a summary of the recommendations by treatment (i.e., medications). Table 2 is a summary by low back disorder. The reader is cautioned to utilize the more detailed indications, specific appropriate diagnoses, temporal sequencing, preceding testing or conservative treatment, and contraindications that are elaborated in more detail for each test or treatment in the body of this Guideline when using these recommendations in clinical practice or medical management. These recommendations are not simple "yes/no" criteria. Recommendations are made under the following categories:

Strongly Recommended, "A" Level Moderately Recommended, "B" Level Recommended, "C" Level Insufficient – Recommended (Consensus-based), "I" Level Insufficient – No Recommendation (Consensus-based), "I" Level Insufficient – Not Recommended (Consensus-based), "I" Level Not Recommended, "C" Level Moderately Not Recommended, "B" Level Strongly Not Recommended, "A" Level






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Table 1: Summary of Recommendations for Evaluating and Managing Low Back Disorders

Treatment with Evidence Rating/ Recommendation Level Clinical

Measure Recommended No Recommendation Not Recommended

Diagnostic Testing

X-rays for acute low back pain (LBP) with red flags for fractures or systemic illness, subacute not improving, or chronic LBP as an option to rule out other conditions (I)

Functional capacity evaluations for subacute or chronic stable LBP or post-operative recovery (I)

Routine x-rays for acute, nonspecific LBP (C)

Flexion and extension views for evaluation of symptomatic spondylolisthesis (I)

MRI for acute radicular pain syndromes in first 6 weeks, regardless of signs of neurological impingement, unless severe and not trending towards improvement (C)

Magnetic resonance imaging (MRI) for acute LBP during first 6 weeks if red flags (I)

Standing or weight-bearing MRI for any back or radicular pain syndrome or condition (I)

MRI for subacute or chronic radicular pain syndromes lasting at least 4 to 6 weeks (B)

Computerized tomography (CT) for acute, subacute, chronic non-specific LBP, or radicular pain syndromes (I)

MRI as an option for select chronic LBP (I)

Electrodiagnostic study for acute, subacute or chronic LBP patients who do not have significant leg pain or numbness (C)

Computerized tomography (CT) for acute or subacute radicular pain syndrome that has failed to improve within 4 to 6 weeks (C)

Routine bone scanning for LBP (I)

Myelography, including CT myelography, for uncommon specific situations (I)

Single proton emission computed tomography (SPECT) for acute, subacute, or chronic LBP, or radicular pain syndromes or other LBP-related conditions (I)

Electrodiagnostic studies, which must include needle electromyography (EMG) where CT or MRI is equivocal and there are ongoing pain complaints (C)

Diagnostic ultrasound (I)

Fluoroscopy for acute, subacute, or chronic LBP (I)






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Videofluoroscopy for acute, subacute, or chronic LBP (I) Discography for acute, subacute, or chronic LBP or radicular pain syndromes (B)

MRI discography (C)

Myeloscopy for acute, subacute, or chronic LBP, or spinal stenosis, radicular pain syndromes, or post-surgical back pain problems (I)

Surface electromyography (I)

Thermography for acute, subacute, or chronic LBP or radicular pain (I)

Functional capacity evaluations for acute LBP, acute or subacute radicular pain syndromes, or post-surgical back pain within first 12 weeks of postoperative period (I)

NSAIDs for acute LBP (A)

Gabapentin for chronic radicular pain syndromes (I)

Selective serotonin reuptake inhibitors (e.g., paroxetine, bupropion, trazodone) for chronic LBP (A)

NSAIDs for subacute, chronic, or post-operative LBP (B)

Thiocolchicoside for acute, subacute, or chronic LBP (I) Antidepressants for acute or subacute LBP (I)

NSAIDs for radicular pain syndromes including sciatica (C)

Creams and ointments for acute, subacute, chronic LBP (I)

Topiramate for neuropathic pain, including peripheral neuropathy (I)

Cytoprotective medications for patients with contraindications for NSAIDs (C)

Camphora molmol, Maleluca alternifolia, Angelica sinensis, Aloe vera, Thymus officinalis, Menthe piperita, Arnica Montana, Curcuma longa, Tanacetum parthenium, Zingiber officinalis (I)

Oral and intravenous (IV) colchicine for acute, subacute, or chronic LBP (I)

Acetaminophen for LBP with or without radicular symptoms if contraindications for NSAIDs (C)

Gabapentin for chronic non-neuropathic pain or LBP (C)

Discuss risks/benefits of NSAID

Routine use of opioids for acute, subacute, or






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therapy with patients with known or multiple risk factors for cardiovascular disease (I)

chronic LBP (C)

Acetaminophen or aspirin as 1st-line therapy for patients with known or multiple risk factors for cardiovascular disease (A)

Skeletal muscle relaxants for mild to moderate acute LBP or chronic use in subacute or chronic LBP (other than acute exacerbations) (I)

Norepinephrine reuptake inhibitors for chronic LBP (A) Glucocorticosteroids for acute LBP (B)

Norepinephrine reuptake inhibitors for radicular pain (C)

Glucocorticosteroids for subacute or chronic LBP, mild to moderate radiculopathy (I)

Topiramate for limited use in select chronic LBP as 4th- or 5th-line agent (C)

Tumor necrosis factor-alpha inhibitors for radicular pain syndromes (C)

Carbamazepine for chronic radicular or neuropathic pain as a 4th- or 5th-line agent (I) Gabapentin for perioperative pain management (A)

Tumor necrosis factor-alpha inhibitors for acute, subacute, or chronic LBP (I)

Gabapentin for severe neurogenic claudication with limited walking distance (C)

Vitamins for acute, subacute, or chronic LBP, or post-operative LBP or radiculopathy (I)

Limited use (2 to 3 weeks) of opioids with longer periods for more invasive procedures (C) Willow bark (salix) (I) Skeletal muscle relaxants as 2nd-line treatment in moderate to severe acute LBP not adequately controlled by NSAIDs (B) Spiroflor (I) Skeletal muscle relaxants as 2nd- or 3rd-line treatments for acute radicular pain syndromes or acute post-surgical situations (I)

Complementary or alternative treatments or dietary supplements, etc., other than those discussed in chapter (I)

Glucocorticosteroids for acute severe radicular pain syndromes (C)

Harpagoside in carefully selected patients for acute, subacute, or chronic LBP if NSAIDs contraindicated (C)

Capsicum for acute and subacute LBP, or temporary flare-ups of chronic LBP (B)

Orthotics Bed rest for unstable spinal fractures Bed rest for acute LBP (A)






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and Immobilization

(I)

Alteration of sleep posture (I) Bed rest for subacute and chronic LBP (B)

Bed rest for stable spinal fractures (I)

Bed rest for radicular pain syndromes including sciatica (C)

Bed rest for other low back problems (I)

Commercial sleeping products (e.g., pillows) for primary prevention or treatment of acute, subacute, or chronic LBP (I)

Physical Treatment Methods

Shoe lifts for chronic or recurrent LBP with leg length discrepancy of >2cm (I)

Shoe insoles for spinal pain patients, including those without prolonged walking requirements (I) Shoe insoles and lifts for acute LBP (I)

Shoe insoles for chronic LBP with prolonged walking requirements (C)

Mattress firmness (I)

Shoe insoles and lifts for subacute or chronic LBP, radicular pain syndromes or other back-related conditions other than leg length discrepancy >2cm (I)

Self-application of low-tech cryotherapies for acute LBP (I)

Other optimal sleeping surfaces (e.g., bedding, water beds, hammocks) (I) Shoe insoles and lifts for primary prevention (C)

Self-application of heat therapy including a heat wrap (C)

Infrared therapy for acute LBP (I)

Routine use of cryotherapies in health care provider offices or home use of a high-tech device for LBP (I)

Massage for time-limited use in subacute and chronic LBP patients without underlying serious pathology and as an adjunct to a conditioning program with both graded aerobic exercise and strengthening exercises (C)

Infrared therapy for home use (I) Lumbar supports (C)

Massage for acute LBP and chronic radicular pain syndromes (I) Ultrasound (I) Lumbar supports for prevention of LBP (C)

Transcutaneous electrical Neuroreflexothera Magnets (I)






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neurostimulation (TENS) (single or dual channel) for select use in chronic LBP or chronic radicular pain syndrome as an adjunct for more efficacious treatments (C)

py for acute or subacute LBP or radicular pain syndromes (I)

Manipulation or mobilization for select acute LBP based on Clinical Prediction Rule (B)

Interferential therapy for acute LBP with or without radicular pain (I) Diathermy for any LBP-related condition (C)

Manipulation or mobilization for acute or subacute LBP without Clinical Prediction Rule (C) Infrared therapy for subacute and chronic LBP (I) Acupuncture for select use in chronic LBP as a limited course during which time there are clear objective and functional goals (C) Low-level laser therapy (I) Neuroreflexotherapy for moderate to severe chronic LBP in patients who have failed management with NSAIDs, progressive aerobic exercise program or other exercises, and manipulation (C) Shoe insoles for spinal pain patients, including those without prolonged walking requirements (I) Mechanical devices for administering massage (C)

Mattress firmness (I) Traction for acute, subacute, or chronic LBP or radicular pain syndromes (C)

Other optimal sleeping surfaces (e.g., bedding, water beds, hammocks) (I)

Decompression through traction and spinal decompressive devices for acute, subacute, chronic LBP or radicular pain syndromes (I)

Infrared therapy for acute LBP (I)

Interferential therapy for subacute or chronic LBP, chronic radicular pain syndromes, or other back-related conditions (C)

Infrared therapy for home use (I) TENS for acute or subacute LBP or acute radicular pain syndromes (I)

Ultrasound (I)

Percutaneous electrical nerve stimulation (PENS) for acute or subacute LBP, radicular pain syndromes (I)

Neuroreflexotherapy for acute or subacute LBP or radicular pain syndromes (I) PENS for chronic non-radicular LBP (I)

Interferential therapy for acute LBP w

Microcurrent electrical stimulation for acute, subacute, or chronic LBP or radicular pain syndrome (I)






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H-wave stimulation for acute, subacute, or chronic LBP or radicular pain syndromes (I) Taping or kinesiotaping for acute, subacute, or chronic LBP, radicular pain syndromes or other back-related conditions (I) Myofascial release for acute, subacute, or chronic LBP, or radicular pain syndromes or other back-related conditions (I) High-voltage galvanic for acute, subacute, or chronic LBP, or radicular pain syndromes or other back-related conditions (I) Iontophoresis for acute, subacute, or chronic LBP, or radicular pain syndromes or other back-related conditions (I)

Regular or routine manipulation or mobilization (several times a month for years) (I)

Manipulation for radicular pain syndromes with acute neurological deficits (I)

Adjustments/manipulation of neck/cervical spine, or areas outside lumbopelvic region (I) Manipulation under anesthesia (MUA) and medication-assisted spinal manipulation (MASM) for acute, subacute, or chronic LBP (I) Acupuncture for acute or subacute LBP, radicular pain syndromes or conditions other than chronic LBP (I)

Reflexology for chronic LBP (C)

Reflexology for acute, or subacute LBP, or other spinal conditions (I)

Activity and Exercise

Aerobic exercise for acute, subacute, or chronic LBP (A)

Yoga for acute or subacute LBP (I) Aggressive stretching exercises (I)

Aerobic exercise for post-operative patients (I) Stretching exercises for preventing LBP (C) Slump stretch-related exercise or directional preference stretching exercises for acute, subacute, or chronic LBP (C)

Strengthening of abdominal muscles for treatment or prevention of LBP (I)

Strengthening exercises (after instituting aerobic exercises) for acute, subacute, or chronic LBP, post-operative LBP patients (C)

Lumbar extension machines for acute, subacute, or chronic LBP, or any radicular pain syndrome (I)






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Inclusion of Fear Avoidance Belief Training (FABT) during course of rehabilitation (I)

Aquatic therapy for all acute LBP and all other subacute and chronic LBP not meeting referral criteria (I)

Yoga for select highly motivated chronic LBP patients (C)

Trial of aquatic therapy for subacute or chronic LBP if patient meets referral criteria for supervised exercise therapy and has co-morbidities that preclude participation in weight-bearing physical activity (I)

Injections Epidural glucocorticosteroid injections as option for acute or subacute radicular pain syndromes lasting at least 3 weeks after treating with NSAIDs and without evidence of trending towards spontaneous resolution (I)

Diagnostic facet joint injections for chronic LBP (I)

Epidural glucocorticosteroid injections for acute, subacute, or chronic LBP in the absence of radicular signs and symptoms (C)

Epidural glucocorticosteroid injections as 2nd-line treatment of acute spinal stenosis flare-ups (I)

Botulinum injections for acute, subacute, or chronic LBP, or radicular pain syndromes or other low back problems (I) Intradiscal steroids for acute LBP (I)

Trigger and/or tender point injections as 2nd or 3rd option for subacute or chronic LBP that is not resolving (C)

Intradiscal steroids for subacute or chronic LBP (B)

Sacroiliac joint corticosteroid injections as option for patients with specific known cause of sacroiliitis (C)

Trigger and/or tender point injections for acute LBP (I)

Diagnostic facet joint injections for acute or subacute LBP or radicular pain syndromes (I)

Therapeutic facet joint injections for acute, subacute, chronic LBP or radicular pain syndrome (B)

Facet joint hyaluronic acid injections (I)

Sacroiliac joint injections for acute LBP, including LBP thought to be sacroiliac joint related (I)






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Prolotherapy injections for acute, subacute, chronic LBP or radicular pain syndrome (C)

Radiofrequency lesioning of dorsal root ganglia for chronic sciatica (B) Radiofrequency neurotomy, neurotomy, or facet rhizotomy for any spinal condition (C)

Intradiscal electrothermal annuloplasty (IDET) for acute, subacute, or chronic LBP or any other back-related disorder (I) Percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) for acute, subacute, or chronic LBP, including discogenic LBP (A) Surgical Considerations Lumbar discectomy for radiculopathy due to ongoing nerve root compression with continued significant pain and functional limitation after 4 to 6 weeks and appropriate conservative treatment (B) Decompressive surgery for symptomatic spinal stenosis (neurogenic claudication) that is intractable to conservative management (B)

Lumbar fusion for isthmic spondylolisthesis (C)

Lumbar fusion for degenerative spondylolisthesis (C)

For 3rd lumbar discectomy on same disc, spine fusion at time of discectomy is an option (I) Vertebroplasty and kyphoplasty for select patients (I) Percutaneous discectomy (nucleoplasty), laser discectomy, and disc coblation therapy for any back or radicular pain syndrome (B)

Discectomy for acute, subacute, or chronic LBP without radiculopathy (B)

Lumbar fusion for spinal stenosis unless concomitant instability or deformity proven (C) Lumbar fusion for radiculopathy from disc herniation or chronic LBP after lumbar discectomy (C)

Lumbar fusion for chronic non-specific LBP (B)

Artificial disc replacement for chronic non-specific LBP or other spinal pain syndrome (I)

Sacroiliac joint fusion surgery and other sacroiliac






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joint surgical procedures for any LBP condition (I) Spinal cord stimulators for acute, subacute, or chronic LBP, or radicular pain syndromes or failed back surgery syndrome (I)

Adhesiolysis for acute, subacute, or chronic LBP, or spinal stenosis, or radicular pain syndromes (I)

Rehabilitation/ Behavioral/ Education

Chronic pain management or functional restoration program for chronic pain management (I) Back school for acute LBP (I) Chronic pain management or functional restoration program for subacute LBP (I)

Back school and education for prevention of LBP (C)

Work conditioning and work hardening programs for chronic LBP (C) Cognitive behavioral therapy for acute LBP (I)

Work conditioning and work hardening programs for subacute LBP (I)

Chronic pain management or functional restoration program for acute spinal disorders (I)

Participatory ergonomic programs for highly select subacute and chronic LBP (C)

Work conditioning and work hardening programs for acute LBP (I)

Biofeedback for select chronic LBP as component of an interdisciplinary approach (I)

Biofeedback for acute or subacute LBP (I)

Multidisciplinary rehabilitation programs with focus on cognitive behavioral, occupational, and activity-based approaches combined with aerobic exercise and other conditioning exercise for chronic LBP (C)

Multidisciplinary rehabilitation program with primary focus on LBP interventions (I)

Multidisciplinary rehabilitation program with participatory ergonomics team for subacute or chronic LBP with lost-time injuries (C)

Smoking cessation and weight loss programs to prevent LBP (I)

FABT for acute, subacute, or chronic LBP (B) Back school and education for select chronic LBP and chronic radicular pain syndromes (B)

Cognitive behavioral therapy as component of interdisciplinary program f h i LBP d b LBP






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for chronic LBP and subacute LBP when combined with other indicated therapies with parameters described in "Rehabilitation for Delayed Recovery" section (C)

Table 2: Summary of Recommendations by Low Back Disorders Low Back Disorder

Treatment with Evidence Rating/Recommendation Level

Recommended No Recommendation Not Recommended Acute Low Back Pain

NSAIDs (A) Thiocolchicoside (I) Antidepressants (I)

Cytoprotective medications particularly if contraindications for NSAIDs (C)

Creams and ointments (I)

Anti-epileptic agents including carbamazepine (I)

Acetaminophen if contraindications for NSAIDs (C) Camphora molmol,

Maleluca alternifolia, Angelica sinensis, Aloe vera, Thymus officinalis, Menthe piperita, Arnica Montana, Curcuma longa, Tanacetum parthenium, Zingiber officinalis (I)

Oral and IV colchicine (I)

Discuss risks/benefits of NSAID therapy with patients with known or multiple risk factors for cardiovascular disease (I)

Mattress firmness (I) Routine use of opioids (C)



Skeletal muscle relaxants for mild to moderate acute LBP pain (I)

Limited use (2 to 3 weeks) of opioids with longer periods for more invasive procedures (C)

Infrared therapy (I) Glucocorticosteroids (B)

Skeletal muscle relaxants as 2nd-line treatment in Infrared therapy for Tumor necrosis factor-alpha inhibitors






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select cases of moderate to severe acute LBP (B) home use (I) (I) Harpagoside in carefully selected patients if NSAIDs contraindicated (C)

Interferential therapy–with or without radicular pain (I)

Vitamins (I)

Capsicum (B) Ultrasound (I) Willow bark (salix) (I) Alteration of sleep posture (I) Neuroreflexotherapy (I) Spiroflor (I) Self-application of low-tech cryotherapies (I) Yoga (I) Complementary or alternative

treatments or dietary supplements, etc., other than those discussed in chapter (I)


Botulinum injections (I) Bed rest (A)

Massage (I) Commercial sleeping products for

primary prevention or treatment (I) Manipulation or mobilization for select patients based on Clinical Prediction Rule (B)

Shoe insoles and lifts (I)

Manipulation or mobilization for LBP without Clinical Prediction Rule (C)

Reflexology (I)

Aerobic exercise (A) Lumbar supports (C) Slump stretch-related exercise or directional preference stretching exercises (C)

Magnets (I)

Strengthening exercises after aerobic exercises instituted (C)

Routine use of cryotherapies in health care provider offices or home use of high-tech device (I)

Fear Avoidance Belief Training (FABT) (B) Diathermy (C) Inclusion of FABT during course of rehabilitation (I) Low-level laser therapy (I) Mechanical devices for administering

massage (C)






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Traction (C) and spinal decompressive devices (I) TENS (I) PENS (I) (I) H-wave stimulation (I) Taping and kinesiotaping (I) Myofascial release (I) High-voltage galvanic (I) Iontophoresis (I) Adjustments/manipulation of

neck/cervical spine or areas outside lumbopelvic region (I)

Manipulation under anesthesia (MUA)

and medication-assisted spinal manipulation (MASM) (I)

Acupuncture (I) Strengthening of abdominal muscles (I) Aggressive stretching (I) Aquatic therapy (I) Lumbar extension machines (I) Epidural glucocorticosteroid injections

in absence of radicular signs and symptoms (C)

Intradiscal steroids (I) Trigger and/or tender point injections (I) Diagnostic facet joint injections (I) Therapeutic facet joint injections (B) Facet joint hyaluronic acid injections (I) Sacroiliac joint injections (I) Prolotherapy injections (C) Radiofrequency neurotomy, neurotomy,

or facet rhizotomy (C) IDET (I) PIRFT particularly including discogenic

LBP (A) Spinal cord stimulators (I)






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Discectomy for acute LBP without radiculopathy treatment (B)

Adhesiolysis (I) Back school (I) Cognitive behavioral therapy (I) Chronic pain management or functional

restoration program (I) Work conditioning and work hardening

programs (I) Biofeedback (I)

Subacute Low Back Pain

NSAIDs (B) Thiocolchicoside (I) Antidepressants (I)

Cytoprotective medications particularly if contraindications for NSAIDs (C)



Acetaminophen if contraindications for NSAIDs (C)

Camphora molmol, Maleluca alternifolia, Angelica sinensis, Aloe vera, Thymus officinalis, Menthe piperita, Arnica Montana, Curcuma longa, Tanacetum parthenium, Zingiber officinalis (I)



Mattress firmness (I) Gabapentin (I)

Harpagoside in carefully selected patients if NSAIDs contraindicated (C)

Infrared therapy for home use (I)

Routine use of opioids (C)






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Capsicum (B) Ultrasound (I) Skeletal muscle relaxants (I) Alteration of sleep posture (I) Neuroreflexotherapy

(I) Glucocorticosteroids (I)

Self-application of low-tech cryotherapies (I) Yoga (I) Tumor necrosis factor-alpha inhibitors (I)


Botulinum injections (I)

Vitamins (I)

Massage for time limited use in subacute LBP patients without underlying serious pathology and as an adjunct to a conditioning program that has both graded aerobic exercise and strengthening exercises (C)

Willow bark (salix) (I)

Manipulation or mobilization for LBP without Clinical Prediction Rule (C)

Spiroflor (I)

Aerobic exercise (A) Bed rest (B) Slump stretch-related exercise or directional preference stretching exercises (C)

Commercial sleeping products for primary prevention or treatment (I)


Shoe insoles and lifts except if leg length discrepancy >2cm (I)

Trial of aquatic therapy if patient meets referral criteria for supervised exercise therapy and has co-morbidities that preclude participation in weight-bearing physical activity (I)


Trigger and/or tender point injections as 2nd or 3rd option for subacute LBP that is not resolving (C)

Decompression through traction and spinal decompressive devices (I)

Chronic pain management or functional restoration program (I)

Reflexology (I)

Work conditioning and work hardening programs (I)

Lumbar supports (C)

Participatory ergonomic programs for highly select subacute LBP (C)

Magnets (I)

Multidisciplinary rehabilitation Mechanical devices






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program with a participatory ergonomics team for subacute LBP with lost-time injuries (C)

for administration of massage (C)

Inclusion of FABT during course of rehabilitation (I)

Adjustments/manipulation of neck/cervical spine or areas outside lumbopelvic region (I)

FABT (B) Low-level laser therapy (I) Cognitive behavioral therapy as component of interdisciplinary program (C)

Infrared therapy (I)

Diathermy (C) Traction (C) Interferential therapy (C)

TENS (I) PENS (I) Microcurrent electrical stimulation

(I) H-wave stimulation (I) Taping and kinesiotaping (I) Myofascial release (I) High-voltage galvanic (I) Iontophoresis (I) MUA and MASM (I) Acupuncture (I) Strengthening of abdominal

muscles (I) Aggressive stretching (I) Aquatic therapy for all other

subacute LBP (I) Lumbar extension machines (I) Epidural glucocorticosteroid

injections in absence of radicular signs and symptoms (C)

Intradiscal steroids (B) Diagnostic facet joint injections (I) Therapeutic facet joint injections

(B)


Prolotherapy injections (C) Radiofrequency neurotomy,






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neurotomy, facet rhizotomy (C) IDET (I) PIRFT particularly including

discogenic LBP (A) Spinal cord stimulators (I) Discectomy for subacute LBP

without radiculopathy treatment (B) Adhesiolysis (I) Biofeedback (I)

Chronic Low Back Pain

NSAIDs (B) Thiocolchicoside (I) Selective serotonin reuptake inhibitors (e.g., paroxetine, bupropion, trazodone) (A)

Cytoprotective medications if contraindications for NSAIDs (C)



Acetaminophen if contraindications for NSAIDs (C) Camphora molmol,

Maleluca alternifolia, Angelica sinensis, Aloe vera, Thymus officinalis, Menthe piperita, Arnica Montana, Curcuma longa, Tanacetum parthenium, Zingiber officinalis (I)



Mattress firmness (I) Gabapentin (C)

Acetaminophen or aspirin as the 1st-line therapy for patients with known or multiple risk factors for cardiovascular disease (A)


Routine use of opioids (C)






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Norepinephrine reuptake inhibitors (A) Infrared therapy for

home use (I) Skeletal muscle relaxants (I)

Opioid trial – both function and pain must improve to continue (I)

Ultrasound (I) Systemic glucocorticosteroids (I)

Topiramate for limited use as 4th- or 5th-line agent (C)

Diagnostic facet joint injections (I)

Tumor necrosis factor-alpha inhibitors (I)

Harpagoside in carefully selected patients if NSAIDs contraindicated (C)

Botulinum injections (I) Vitamins (I)

Capsicum for temporary flare-ups (B) Willow bark (salix) (I) Alteration of sleep posture (I) Spiroflor (I) Neuroreflexotherapy for moderate to severe chronic LBP in patients who have failed management with NSAIDs, progressive aerobic exercise program or other exercise and manipulation (C)


Shoe insoles if prolonged walking requirements (C)

Bed rest (B)

Shoe lifts for chronic or recurrent LBP patients with leg length discrepancy of >2cm (I)

Commercial sleeping products for primary prevention or treatment (I)

Self-application of low-tech cryotherapies (I)

Reflexology (C)


Shoe insoles and lifts for chronic LBP other than for lg length discrepancy >2cm (I)

Massage for time limited use in chronic LBP patients without underlying serious pathology and as an adjunct to a conditioning program that has both graded aerobic exercise and strengthening exercises (C)

Lumbar supports (C)

TENS for chronic LBP as an adjunct Magnets (I)






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for more efficacious treatments (C) Acupuncture for select use as a limited course during which there are clear objective and functional goals (C)


Aerobic exercise (A) Diathermy (C) Slump stretch-related exercise or directional preference stretching exercises (C)

Infrared therapy (I)


Low-level laser therapy (I)


Mechanical devices for administering massage (C)

Yoga for select highly motivated patients (C) Traction (C)

Trial of aquatic therapy if referral criteria met for supervised exercise therapy and co-morbidities that preclude participation in weight-bearing physical activity (I)


Trigger and/or tender point injections as 2nd or 3rd option for chronic LBP that is not resolving (C)

Interferential therapy (C)

Chronic pain management and functional restoration program (I)

PENS for chronic nonradicular LBP (I)

Work conditioning and work hardening programs (C)

Microcurrent electrical stimulation (I)

Participatory ergonomic programs for highly select chronic LBP (C)

H-wave stimulation (I)

Biofeedback for select chronic LBP as component of an interdisciplinary approach (I)

Taping and kinesiotaping (I)

Multidisciplinary rehabilitation programs with focus on cognitive behavioral, occupational, and activity-based approaches combined with aerobic exercise and other conditioning exercise (C)

Myofascial release (I)

Multidisciplinary rehabilitation program with a participatory ergonomics team for chronic LBP with lost-time injuries (C)

High-voltage galvanic (I)






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FABT (B) Iontophoresis (I) Back school and education (B) Regular or routine manipulation or

mobilization (several times a month for years) (I)

Cognitive behavioral therapy as component of interdisciplinary program (C)


MUA and MASM (I) Aggressive stretching exercises (I) Strengthening of abdominal muscles (I)

Aquatic therapy for all other chronic LBP (I)

Lumbar extension machines (I)

Epidural glucocorticosteroid injections in absence of radicular signs and symptoms (C)

Intradiscal steroids (B) Therapeutic facet joint injections (B) Facet joint hyaluronic acid injections (I) Prolotherapy injections (C) Radiofrequency neurotomy, neurotomy,

facet rhizotomy (C) IDET (I) PIRFT particularly including discogenic

LBP (A) Lumbar fusion for chronic LBP after

lumbar discectomy (C) Lumbar fusion for chronic nonspecific

LBP (B) Artificial disc replacement for chronic

nonspecific LBP (I) Spinal cord stimulators (I) Sacroiliac joint fusion surgery and other

sacroiliac joint surgical procedures (I)






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Percutaneous discectomy (nucleoplasty), laser discectomy, and disc coblation therapy (B)

Discectomy for chronic LBP without radiculopathy treatment (B)

Adhesiolysis (I) Post-operative Low Back Pain

NSAIDs (B) Camphora molmol, Maleluca alternifolia, Angelica sinensis, Aloe vera, Thymus officinalis, Menthe piperita, Arnica Montana, Curcuma longa, Tanacetum parthenium, Zingiber officinalis (I)

Vitamins (I)


Shoe insoles (I) Willow bark (salix) (I)


Mattress firmness (I) Spiroflor (I)





Infrared therapy for home use (I)

Bed rest (I)

Gabapentin for perioperative pain management (A)

Ultrasound (I) Reflexology (I)

Limited use (2 to 3 weeks) of opioids with longer periods for more invasive procedures (C)

Botulinum injections (I) Lumbar supports (C)

Skeletal muscle relaxants as 2nd- or 3rd-line agents for acute post-surgical situations (I)

Magnets (I)

Alteration of sleep posture (I) Routine use of cryotherapies in health care provider offices or home use of high-tech device (I)

Aerobic exercise (I) Diathermy (C)






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Stretching exercises to regain normal range of motion (I)





Myofascial release (I) (I) Iontophoresis (I) Adjustments/manipulation of

neck/cervical spine or areas outside lumbopelvic region (I)

Acupuncture (I) Aggressive stretching (I) Strengthening of abdominal

muscles (I) Radiofrequency neurotomy,

neurotomy, facet rhizotomy (C) IDET (I) Spinal cord stimulators for failed

back surgery syndrome (I)

Radicular Pain Syndromes

NSAIDs (C) Camphora molmol, Maleluca

alternifolia, Angelica sinensis, Aloe vera, Thymus officinalis, Menthe piperita, Arnica Montana, Curcuma longa, Tanacetum parthenium, Zingiber officinalis (I)

Glucocorticosteroids for mild to moderate radiculopathy (I)


Tumor necrosis factor-a inhibitors (C)








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Spiroflor (I)


Shoe insoles (I) Vitamins (I)

Norepinephrine reuptake inhibitors (e.g., tricyclic anti-depressants) (C)

Mattress firmness (I) Complementary or alternative treatments or dietary supplements, etc., other than those discussed in chapter (I)

Opioid trial – both function and pain must improve to continue (I)


Bed rest (C)

Carbamazepine as 4th- or 5th-line treatment (I)

Reflexology (I)

Skeletal muscle relaxants as 2nd- or 3rd-line agents for acute radicular pain (I)

Infrared therapy for home use (I) Shoe insoles and lifts except if leg length discrepancy >2 cm (I)

Glucocorticosteroids for acute, severe radicular pain syndromes (C)

Ultrasound (I) Lumbar supports (C)

Alteration of sleep posture (I) Neuroreflexotherapy (I) Magnets (I)

Massage for chronic radicular pain syndromes (I)

Botulinum injections (I) Routine use of cryotherapies in health care provider offices or home use of high-tech device (I)

TENS for chronic radicular pain syndrome as an adjunct for more efficacious treatments (C)

Lumbar extension machines (I)






117/124

Epidural glucocorticosteroid injections for acute or subacute radicular pain syndromes lasting at least 3 weeks after treatment with NSAIDs and without evidence of trending towards spontaneous resolution (I)

Diathermy (C)


Back school and education for chronic radicular pain syndromes (B)


Lumbar discectomy for patients with radiculopathy due to ongoing nerve root compression who continue to have significant pain and functional limitation after 4 to 6 weeks and appropriate conservative treatment (B)

Traction (C)


Interferential therapy for chronic radicular pain (C)

For 3rd lumbar discectomy on same disc, spine fusion at time of discectomy is an option (I)

TENS for acute radicular pain (I)

PENS (I)

Microcurrent electrical stimulation (I)

H-wave stimulation (I)







118/124

Myofascial release (I)

High-voltage galvanic (I)

Iontophoresis (I)

Manipulation for radicular pain syndromes with acute neurological deficits (I)


Acupuncture (I)

Diagnostic facet joint injections (I)

Therapeutic facet joint injections (B)


Prolotherapy injections (C)

Radiofrequency neurotomy, neurotomy, facet rhizotomy (C)

IDET (I)

Lumbar fusion for radiculopathy from disc herniation (C)






119/124

Percutaneous discectomy (nucleoplasty), laser discectomy, and disc coblation therapy (B)

Spinal cord stimulators (I)

Artificial disc replacement (I)

Sacroiliac joint fusion surgery and other sacroiliac joint surgical procedures (I)

Adhesiolysis (I) Spinal Stenosis Cytoprotective medications if

contraindications for NSAIDs (C) Camphora molmol, Maleluca alternifolia, Angelica sinensis, Aloe vera, Thymus officinalis, Menthe piperita, Arnica Montana, Curcuma longa, Tanacetum parthenium, Zingiber officinalis (I)



Shoe insoles (I) Spiroflor (I)


Mattress firmness (I) Complementary or alternative treatments or dietary supplements, etc., other than those discussed in chapter (I)



Bed rest (I)






120/124

Gabapentin for severe neurogenic claudication with limited walking distance from spinal stenosis (C)

Infrared therapy for home use (I) Shoe insoles and lifts except if leg length discrepancy >2 cm (I)

Opioid trial–both function and pain must improve to continue (I)

Ultrasound (I) Reflexology (I)

Alteration of sleep posture (I) Botulinum injections (I) Shoe insoles and lifts for primary prevention (C)

Epidural glucocorticosteroid injections as 2nd-line treatment of acute flare-ups (I)

Lumbar supports (C)

Decompressive surgery for symptomatic spinal stenosis that is intractable to conservative management (B)

Magnets (I)

Routine use of cryotherapies in health care provider offices or home use of high-tech device (I) Diathermy (C) Low-level laser therapy (I) Mechanical devices for administering massage (C)


Taping and kinesiotaping (I) Myofascial release (I) High voltage galvanic (I) Iontophoresis (I) Adjustments/manipulation of neck/cervical spine or areas outside lumbopelvic region (I)

Acupuncture (I) Radiofrequency neurotomy, neurotomy, facet rhizotomy (C) IDET (I)

Lumbar fusion unless concomitant instability or deformity proven (C)






121/124

Artificial disc replacement (I)

Spinal Fractures Bed rest for unstable spinal fractures (I)


Sacroiliac joint fusion surgery and other sacroiliac joint surgical procedures (I)

Vertebroplasty and kyphoplasty for vertebral body compression fractures among those with chronic or severe pain (I)

Mattress firmness (I) Percutaneous discectomy (nucleoplasty), laser discectomy, and disc coblation therapy (B)

NSAIDs (I) Other optimal sleeping surfaces (e.g., bedding, water beds, hammocks) (I)

Adhesiolysis (I)

Acetaminophen for patients with contraindications for NSAIDs (C)

Infrared therapy for home use (I) Bed rest for stable spinal fractures (I)

Gabapentin for perioperative pain management (A)

Ultrasound (I) Vitamins (I)

Limited use (2 to 3 weeks) of opioids with longer periods for more severe fractures (C)

Neuroreflexotherapy (I) Willow bark (salix) (I)

Skeletal muscle relaxants as 2nd- or 3rd-line agents for more severe pain (I)

Botulinum injections (I) Spiroflor (I)

Alteration of sleep posture (I) Complementary or alternative treatments or dietary supplements, etc., other than those discussed in chapter (I)

Gradual introduction of aerobic exercises during and to facilitate recovery (I)

Reflexology (I)

Strengthening exercises after aerobic exercises instituted and after healed (I)

Lumbar supports (I)


Magnets (I)


Routine use of cryotherapies in health care provider offices or home use of high-tech device (I) Diathermy (I) Low-level laser therapy (I)






122/124

Mechanical devices for administering massage (I)

Interferential therapy (I) Taping and kinesiotaping (I) Myofascial release (I) High-voltage galvanic (I) Iontophoresis (I) Adjustments/manipulation (I) Acupuncture (I) Aggressive stretching (I)

Strengthening of abdominal muscles (I)

Sacroiliitis Sacroiliac joint corticosteroid injections for specific known cause of sacroiliitis (C)

Gabapentin (I) Sacroiliac joint fusion surgery and other sacroiliac joint surgical procedures (I)

NSAIDs (I) Mattress firmness (I) Bed rest for stable spinal fractures (I)

Acetaminophen if contraindications for NSAIDs (I)


Vitamins (I)


Infrared therapy for home use (I) Willow bark (salix) (I)

Alteration of sleep posture (I) Ultrasound (I) Spiroflor (I) Aerobic exercises (I) Neuroreflexotherapy (I) Complementary or

alternative treatments or dietary supplements, etc., other than those discussed in chapter (I)

Strengthening exercises after aerobic exercises instituted (I)

Botulinum injections (I) Reflexology (I)


Lumbar supports (I)


Magnets (I)







123/124

Diathermy (I) Low-level laser therapy (I) Mechanical devices for administering massage (I) Interferential therapy (I) Taping and kinesiotaping (I) Myofascial release (I) High-voltage galvanic (I) Iontophoresis (I)

Adjustments/manipulation (I) Acupuncture (I) Aggressive stretching (I)


Spondylolisthesis Lumbar fusion for isthmic spondylolisthesis (C)

Gabapentin (I) Bed rest (I)

Lumbar fusion for degenerative spondylolisthesis (C)

Mattress firmness (I) Vitamins (I)

NSAIDs (I) Other optimal sleeping surfaces (e.g., bedding, water beds, hammocks) (I)


Acetaminophen if contraindications for NSAIDs (I)

Infrared therapy for home use (I) Spiroflor (I)


Ultrasound (I) Complementary or alternative treatments or dietary supplements, etc., other than those discussed in chapter (I)

Alteration of sleep posture (I) Neuroreflexotherapy (I) Reflexology (I) Aerobic exercises (I) Botulinum injections (I) Lumbar supports (I) Strengthening and stabilization exercises after aerobic exercises instituted (I)

Magnets (I)








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Diathermy (I) Low-level laser therapy (I) Mechanical devices for administration of massage (I)

Interferential therapy (I) Taping and kinesiotaping (I) Myofascial release (I) High-voltage galvanic (I) Iontophoresis (I) Adjustments/manipulation (I) Acupuncture (I) Aggressive stretching (I)


Filename: PTPM010PTM_of_Physical_mobility_impairment-Medical_Journal

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Title: PHYSICAL THERAPY MANAGEMENT OF PHYSICAL MOBILITY IMPAIRMENT RELATED PATIENTS

Subject: Author: Abdulrehman Mulla Keywords: Comments: Creation Date: 4/12/2009 8:52 AM Change Number: 18 Last Saved On: 6/5/2009 2:40 AM Last Saved By: Abdulrehman S. Mulla Total Editing Time: 3,704 Minutes Last Printed On: 6/5/2009 2:40 AM As of Last Complete Printing Number of Pages: 124 Number of Words: 36,477 (approx.) Number of Characters: 207,919 (approx.)

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