Susan O sullivan Raymond Siegelman National Phy

302 because it will reflect less acoustic energy than a metal container. D. Precautions b. Place part in water. 1. Acute inflammation; breast implants; open epiphyses c. Place sound head in water keeping it I.Ir-l N and healing fractures. from skin surface and at right angle to body part. d. Move sound head slowly a in direct contact. If E. Contraindications applying stationary technique, reduce intensity 1. Impaired circulation; impaired cognitive function; or use pulsed US. impaired sensation; thrombophlebitis; joint e. Turn up intensity to desired level. cement; plastic components; over vital areas such f. Periodically wipe off any air bubble that may as brain, ear, eye, heart, cervical ganglia; carotid form on sound head or body part during treat- sinuses; reproductive organs; spinal cord; over car- ment. diac pacemakers or pregnant uterus. 3. Indirect contact. (fluid-filled bag), thin walled bag such as a balloon, condom, or surgical glove F. Procedures applied over irregular bony surface. Not widely 1. Direct contact (transducer/skin interface): used, but may be an alternative to immersion tech- Description: moving sound head in contact with nique. relatively flat body surface. a. Place bag around side of sound head squeezing a. Apply generous amount of coupling medium out fluid until all air is removed and sound (gel/cream) to skin. head is immersed in water. b. US requires a homogenous medium (mineral b. Apply coupling agent to skin and place bag oil, water, commercial gel) for effective sound over treatment area. wave transmission and act as a lubricating agent. c. Move sound head slowly within bag maintaining c. Select sound head size (ERA one half the size a right angle between ound head and treatment of the treatment area). Place sound head at area. Do not slide bag on skin. right angle to skin surface. d. Increase intensity to desired level. d. Move sound bead slowly (approx. 1.57sec) in G. Phonophoresis overlapping circles or longitudinal strokes 1. Description: the use of ultrasound to drive medica- maintaining sound head to body surface angle. tions through the skin into the deeper tissues. e. Each motion covering one-half of previous cir- Local analgesics (lidocaine) and anti-inflammatory cle or stroke. drugs (dexamethasone, salicylates) are often used. f. Do not cover an area greater than two to three 2. Method of application is irnilar to direct contact times the size of the effective radiating area technique, except medicinal agent is used as or i (ERA) per five minutes of treatment. To cover part of coupling medium. an area greater than twice the ERA, apply US a. Treatment intensity: 1-3 w/cm2• in two or more sections. b. Treatment time: 5-10 minute . g. While sound head is moving and in firm con- c. Low intensities and longer time more effective tact, turn up intensity to desired level. in introducing medication into skin. h. Treatment intensity: 0.5-2.5 w/cm2 depending 3. Goals and indications. on treatment goal. Lower intensities for acute a. Pain modulation; decrease inflammation in sub- conditions or thin tissue (wrist joint) and for acute and chronic musculoskeletal conditions. chronic conditions or thick tissue (low back) higher intensities should be considered. IV. Mechanical Spinal Traction (Intermittent i. Periosteal pain occurring during treatment may Traction) be due to high intensity, momentary slowing or cessation of moving head. If this occurs, stop A. Description treatment and readjust US intensity or add 1. A distraction force applied to the spine in a man- more coupling agent. ner as to separate or attempt to separate articular J. Treatment time: 3-10 minutes, depending on surfaces between vertebral bodies and elongate size of area, intensity, condition and frequency. spinal structures. Many types of spinal traction are 2. Indirect contact (water immersion), use with irreg- presently used, such a po itional, gravity-assist- ular body parts. a. Fill container with water high enough to cover treatment area. A plastic container is preferred

ed, inversion, continuous, and static traction. This Therapeutic Modalities 303 discussion will focus on intermittent traction since a presentation of the other types are beyond the achieve this angle. scope of this chapter. (4) Some target area specificity may be B. Principles of Traction I. Proper positioning to decrease excessive lordosis achieved by varying the angle of neck. of the neck or low back to effectively allow the Approximately 0°_5° of cervical flexion to traction force to be transmitted through the longi- increase intervertebral space at C l-C5; up tudinal axis of the vertebral bodies. to 25°-30° for C5-C7; 0° for disc dysfunction. 2. Traction to the lumbar disc region. Facet joint separation may require 15 degrees a. A force greater than that needed to overcome of neck extension. (5) The traction force should be applied to the the friction (coefficient of friction: 0.5) of the occipital region and not on the chin. If the legs and pelvis would be needed. patient expresses discomfort in the tem- b. Generally one-half of the body weight is poromandibular joint area, the treatment sufficient. should stop and the head halter readjusted 3. Traction to the neck. to ensure the force is properly applied. a. Exceed the weight of the head multiplied by c. Cervical sliding device. the coefficient of friction. (1) The head is placed on padded headrest which b. A pull of about 7% (10-15 lbs.) of the body positions the neck in 20°-30° of flexion. weight is usually adequate. This will provide a (2) Adjustable neck yoke is tightened to firmly gentle pull to relax muscles with no force on grip just below the mastoid process. the spinal structures. (3) A head strap is secured across the forehead. C. Goals and Indications (4) The device is then attached to spreader bar. I. Decrease joint stiffness (hypomobility);decrease d. Traction force is determined by treatment goals meniscoid blocking muscle spasm; degenerative and patient tolerance. disk; disk protrusion; joint disease; modulate (1) Acute phase. discogenic pain; modulate subacute or chronic (a) Disk protrusion, elongation of soft tis- joint pain; reduce nerve root impingement. D. Precautions sue, muscle spasm about 10-15 pounds I. Acute inflammation aggravated by traction; acute or 7-10% of body weight. strains and sprains; claustrophobia; hiatus hernia; (b) Joint distraction about 20-30 pounds. joint instability; osteoporosis; pregnancy; TMJ e. Treatment time. problems with halter use. (1) Five to ten minutes for acute conditions and E. Contraindications disk protrusion, 15-30 minutes for other 1. Impaired cognitive function; rheumatoid arthritis; conditions. spinal tumors; spinal infections; spondylolisthesis; f. Duty cycle. vascular compromise; very old or young patients. (1) Usually 1: 1 except joint distraction best at 3:1. F. Procedure (Intermittent Traction) 2. Lumbar traction. I. Cervical traction. a. A split table is usually used to minimize friction a. Can be seated or supine. Supine position is between the body and the table. generally preferred. b. Supine position with pillow under the knee or b. Cervical halter. small bench under lower leg. The prone position (1) The head halter is placed under the occiput may be preferable in the case of a posterior her- niated lumbar disc. Some target area specificity and the mandible. may be achieved by varying the angle of pull (2) The head halter is attached to the traction (i.e., to increase intervertebral space at L5-S 1 approximately 45°-60° of hip flexion or at L3-L4 cord directly or to the traction unit through up to 75°-90°). the spreader bar. c. Apply the pelvic harness so that the top edge is (3) The slack is removed from the traction above the iliac crest. cord. The neck should be maintained in d. Attach the thoracic harness so that the inferior 20°-30° of flexion. A pillow may be used to margin is slightly below lower ribs. e. Secure the harness around the pelvis and attach

304 D. Precautions 1. Impaired sensation; malignancy; uncontrolled it to the traction rope or spreader bar. hypertension; obstructed lymph or venous return. f. Thoracic harness provides countertraction to E. Contraindications the pull on the pelvis. 1. Acute inflammation; acute DVT; acute pulmonary g. Treatment force. edema; diminished sensation; cancer; edema with cardiac or renal impairment; impaired cognition; (1) Acute phase 25-45 pounds. infection in treatment area; obstructed lymph (2) Disk protrusion, spasm; elongation of soft channels; very old or young patients. tissues 25% of body weight. F. Procedure (3) Joint distraction 50 pounds or 50% of body 1. Check patient's blood pre ure. 2. Place patient in comfortable position with limb weight. elevated approximately 45° and abducted 20°-70°. h. Treatment time: 5-10 minutes for herniated 3. Apply stockinet over extremity. Be sure all wrinkles are removed. di c, 10-30 minutes for other conditions. 4. Place the appliance over the extremity and attach I. Hold/relax time is determined by goal of treat- the rubber tube to both the appliance and the com- pression unit. ment and patient's tolerance. 5. Set the inflation and deflation ratio to approximately 3:1. Generally, for edema reduction 45-90 seconds V. Intermittent Mechanical Compression on/15-30 seconds off. To shape re idual limb, a 4: 1 ratio is often used. A. Description: pneumatic device that applies external 6. Thrn the power on and slowly increa e the pressure pressure to an extremity through an inflatable appli- to the desired level. ance (sleeve). a. The patient's blood pre ure determines the set- 1. Appliances are designed in a variety of sizes and ting of the device. Some manufacturers recom- lengths to fit either the upper or lower extremity mend that the setting never exceed the patient' (ankle, ankle and lower leg or full extremity). diastolic blood pressure. Other advi e that the 2. The device is attached to an inflatable pneumatic pressure can fall between the diastolic and sys- sleeve by rubber tubing. tolic pressure since the pre sure is on for only a 3. The compression units and appliances are short period of time. designed to inflate a single compartment to b. Numbness, tingling, pul e, or pain should not produce uniform, circumferential pressure on the be felt by the patient during the treatment. extremity or multiple compartments applying 7. At the end of the treatment, turn off the unit, pressure in a sequential manner. Pressure is remove the appliance and tockinet. Inspect skin. greater in the distal compartments and lesser in 8. Usually an elastic bandage or compre sion stocking the proximal compartments. is placed on the extremity to retain the reduction 4. Cold can be applied simultaneously with intermit- before a dependent position i allowed. tent compression in which a coolant (50°-77°F) is 9. Treatment time. pumped through an inflatable sleeve. a. The duration may vary depending on the patient's tolerance. Minimum daily treatment B. Physiological Effects times for lymphedema: 2 hours to 2-three hour 1. External pressure on the extremity increases the sessions; traumatic edema: 2 hour; venous pressure in the interstitial fluids forcing the fluids ulcers: 2.5 hours/3x/week to two hour periods; to move into the lymphatic and venous return sys- residual limb reduction: 1 hour to 3 hour ses- tems, thus reducing the fluid volume in the sions totaling 4 hours. Some conditions may extremity. In addition to mechanical compression, warrant shorter treatment time initially. some conditions may require the daily use of com- 10. Indications: chronic edema lymphedema (e.g., pression stockings to counteract the effect of grav- postmastectomy), stasi ulcer, traumatic edema, ity on the vascular and lymphs systems in the venous insufficiency, amputation. lower extremities. C. Goals and Indications 1. Amputation; arterial insufficiency; decrease chron- ic edema; postmastectomy lymphedema; stasis ulcer; venous insufficiency. Manual massage/ drainage techniques have supplanted use of mechanical compression in many instances.

II. Contraindications: acute inflammation, acute deep Therapeutic Modalities 305 venou thrombosis, arterial insufficiency, acute pulmonary edema, cancer, diminished skin sensa- VII. Tilt Table tion, kidney or cardiac insufficiency, hypertension, cognitive dysfunction, obstructed lymph channels, A. Description: mechanical or electrical table designed infection in area to be treated, very young and frail to elevate patient from horizontal (0°) to vertical (90°) elderly patient . position in a controlled incremental manner. VI. Continuous Passive Motion (CPM) B. Physiological Effects of Tilt Table I. Stimulate postural reflexes to counteract orthostatic A. Description hypotension. 1. Uninterrupted passive motion of a joint through a 2. Facilitate postural drainage. controlled range of motion. A mechanical device 3. Gradual loading of one or both lower extremities. provide continuous movement for extended peri- 4. Begin active head or trunk control. ods of time. 5. Provide positioning for stretch of hip flexors, knee flexors, ankle plantar flexors. B. Physiological Effects of CPM I. Accelerate rate of inter-articular cartilage regener- C. Indications ation, tendon and ligament healing. I. Prolonged bed rest; immobilization; spinal cord 2. Decrease edema and joint effusion. injury, traumatic brain injury; artho tatic hypoten- 3. Minimize contractures. sion; spasticity. 4. Decrea e postoperative pain. 5. Increase synovial fluid lubrication at the joint. D. Procedure 6. Improve circulation. 1. Patient is placed in supine position. 7. Prevent adhesions. 2. Abdominal binder, long elastic stockings, or tensor 8. Improve nutrition to articular cartilage and periar- bandaging to counteract orthostatic hypotension ticular tissue . (venous pooling) may be used. 9. Increa e joint range of motion. 3. Patient secured to table by straps. Knee Gust prox- imal to patella), hip (over pelvis) and trunk (over C. Goals and Indications chest just under the axilla). 1. Po t-immobilization fracture, tendon or ligament 4. Table gradually raised to given angle. Incremental repair; total knee or hip replacement. rise to 30°, 45°, 60°, 80° or 85°, or as tolerated. Po ition can be maintained for as long as 30 to 60 D. Precautions minutes. 1. Intracompartmental hematoma from anticoagulant 5. Vital signs (blood pre sure, heart rate, re piratory u e. rate) need to be monitored to a ess the patient's tolerance to treatment. Cyanotic lip or finger nail E. Contraindications beds may indicate compromised circulation. 1. Increases in pain, edema or inflammation follow- 6. Treatment time. ing treatment. a. Initially, the duration of treatment depends on the patient's tolerance; but, should not exceed F. Procedure (Post-Operative Knee) 45 minutes once or twice daily. I. CPM applied immediately postoperatively with carriages appropriately measured and adjusted. VIII. Massage 2. Rate of motion set at one to four minute cycles. 3. If applied at the knee ROM may be 20°-40° of knee A. Description flexion initially and increased 5°_10°, as tolerated, I. Mechanical manipulation of soft tissue by the until optimal range is reached. Usually a goal of hands. Electrical, mechanical or hydraulic meth- 110-120 degrees is acceptable. ods will not be discussed. Other alternate forms of 4. Treatment time: as little as one hour sessions, three massage such as acupressure, shiat u, or reflexol- time a day up to 24 continuous hours. Patient's ogy are beyond the scope of this section. limb may be removed periodically for active or active assistive exerci e or ADL activities. B. Physiological Effects 5. Duration of treatment: one to three weeks or until 1. Increased venous and lymphatic flow. therapeutic goals are attained. 2. Stretching and loosening of adhesions. 3. Edema reduction. 4. Sedation.

306 move from one area to another and between other strokes. Superficial strokes make no attempt to 5. Muscle relaxation. move deep tissue. Some passive muscle stretching 6. Modulate pain. is performed with deep stroking. 2. Kneading: milking effect of kneading aids in loos- e. Description of Selected Techniques ening adhesions and increa ing venous return. Technique can be done with one or both hands, 1. Stroking (effleurage): gliding movements of hands fingers or using the thumb and first finger. Wring over surface of skin. Superficial stroking: light and lift tissues to break down adhesions. Direction contact. Deep stroking: heavy pressure. of strokes may vary depending on body structure; however, to increase venous return, the strokes 2. Kneading (petrissage): grasping and lifting of tissues. should move from distal to proximal along the Similar to kneading bread. extremity. 3. Friction: heavy compression over soft tissues will 3. Friction: compression of tissue using small circular stretch scars and loosen adhesions. Ball of fingers or long stroking movements, usually with the palmar or thumb should move in small circular or stroking surface of hand or fingers. Pressure may be light manner, pressing superficial tissues over deep (superficial) initially, progressing to heavy (deep) structures. Pressure gradually increases to the moving superficial tissues over deeper tissues. patient's tolerance as technique moves up and down or around the targeted tructures. Pressure 4. Tapping (tapotement): rapid striking with palmar never abruptly released. Cro -fiber friction consists surface of hand and/or fingers, cupped hand (clap- of deep strokes acros the muscle fiber rather than ping, percussion) or ulnar edge of hand and fingers along longitudinal axis of the fiber . (hacking) in an alternating manner. 4. Tapotement: used when stimulation is desired treatment effect. 5. Vibration: shaking of tissue using short, rapid 5. Cupping: applied to the che t to mobilize bronchial quivering motion with hands in contact with the secretions (postural drainage). body part. 6. Vibration: often used in conjunction with cupping for postural drainage to 100 en adherent secretions. D. Procedure 1. Stroking: usually tnltIates and ends treatment. Hand is molded over body part and movement is usually distal to proximal. Stroking is used to +35mV ·70mV RMP Stimulus Time (msec) A +++++++ A K+ . <.. < Na Time(msec) B Figure 10-1: A. Changes in transmembrane potential B and B. Changes in membrane permeability of sodium Figure 10-2: A. Propagation of action potential in and potassium during an action potential. unmyelinated axon and B. myelinated axon.

E. General Considerations in the Application of Therapeutic Modalities 307 Massage 1. Place patient in comfortable relaxed position with cell membrane due to the higher concentration treatment part in gravity eliminated position or of K+ and anions on the inside of the cell relative position in which gravity will assist in venous flow. to the concentration of Na+ on the outside. 2. Body part exposed and well supported with no c. A negative charge is produced within the cell clothing restricting circulation. and a positive charge develops on the outside 3. Begin with superficial stokes. May move to deep of the cell as the positively charged K+ diffuses stroking. from the cell. 4. Deep stroking may be followed by kneading. May d. RMP is -60 mV to -90 illV for excitable cells. alternate between stroking and kneading. e. RMP is maintained by an active sodium-potas- 5. Stroking or kneading should follow friction massage. sium pump that takes in K+ and extrudes Na+. 6. Massage should begin in the proximal segment of 2. Action potential (Figure 10.2) the extremity, move distally and return to proximal a. A stimulus (e.g., electrical) causes the cell mem- region. All stroking movements are directed distal brane to becomes more permeable to Na+ ions. to proximal, especially for edema. b. An action potential (AP) is generated when the 7. Complete treatment with stroking, moving from influx of Na+ causes a reduction in RMP which deep to superficial stroking. occurs slowly at first. Reduction in the RMP is called depolarization. F. Contraindications c. When transmembrane potential reaches a critical 1. Acute inflammation in area, acute febrile condi- threshold level (approximately -55 mY), the tion, severe atherosclerosis, severe varicose veins, voltage-sensitive Na+ and K+ channels open phlebitis, areas of recent surgery, throm- widely. Permeability to Na+ increases rapidly, bophlebitis, cardiac arrhythmia, malignancy, whereas the permeability to K+ increases slowly. hypersensitivity, severe rheumatoid arthritis, hem- d. During depolarization, transmembrane potential orrhage in area, edema secondary to kidney dys- might rise as high as +35 mV. A positive charge function, heart failure, and venous insufficiency. is generated inside the cell and a negative charge outside is produced, as a result of the flow of ions. IX. Basic Concepts of Nerve and Muscle e. The K+ channels are fully open about the time Physiology the Na+ are closed and K+ rushes rapidly out of the cell, making the transmembrane potential A. Properties of ElectricaUy Excitable Cell (Figure 10-1) progressively more negative. This process is 1. Resting membrane potential (RMP). repolarization. a. The cell membrane is more permeable to potas- sium (K+) as compared to sodium (Na+) and MONOPHASIC negatively charged proteins (anions). b. An electrical potential is generated across the BlPHASIC 50 Partially Denervated Denervated Symmetrical Asymmetrical POLVPHASIC Chronaxie Rheobase RussianCum:nl Interfcn:ntiaICum:nt .03 '0 30 100 Time(ms) Time (ms) Figure 10-3: Strength-duration curves for nonnally innervated, Figure 10-4: Basic waveform characteristics. partially denervated, and competely denervated muscle.

308 vated muscle is greater than 1 ms. 3. Very short pulse durations «0.05 msec) with low f. The K+ channels remain open long enough to repolarize the membrane (10-20 mV below intensities can depolarize sensory nerves. Longer RMP). This is called hyperpolarization. pulse durations (<1 msec) are required to stimulate motor nerves. Long pulse durations (>10 msec) g. The K+ channels close and passive diffusion of with high intensities are needed to elicit a response the ions rapidly returns the RMP to its initial from a denervated muscle. level. 4. Nerve conduction velocity and EMG have ren- dered Strength-Duration testing virtually obsolete. 3. Propagation of the action potential (Figure 10.2). D. Motor Point a. Opening of the Na+ and K+ channels and voltage 1. An area of greatest excitability on the kin surface changes that produce an AP at one segment of in which a small amount of current generates a the membrane triggers successive depolarization muscle response. in adjacent regions of the nerve, muscle or 2. In innervated muscle, the motor point is located at membranes. or near where the motor nerve enters the muscle, b. AP movement occurs along the surface of the usually over the muscle belly. nerve or muscle cell. 3. In denervated muscle, the area of greatest c. Movement of the AP along an unmyelinated excitability is located over the muscle distally nerve is generated via sequential depolarization toward the insertion. (eddy currents) along neighboring sites in the E. Types of Muscle Contraction nerve membrane. Speed of conduction in small 1. A low frequency pulse (1-10 pulses/sec) produces diameter fibers is slow due to the greater inter- a brief muscle twitch or muscle contraction with nal resistance in the small fibers. each stimulus. d. In myelinated nerve fibers, saltatory conduction 2. Increasing the number of stimuli (frequency) pro- occurs at discrete junctures (nodes of Ranvier) gressively fuses the individual muscle twitches to in the myelin sheath which surrounds the nerve. a point where the individual twitches are not dis- e. Na+ and K+ ion exchange and current flow is cernible. A tetanic contraction re ults. concentrated at these points. The impulse 3. An asynchronous or worm-like (vermicular) muscle jumps from node to node, conducting nerve response is noted in denervated muscle. impulses at greater rates compared to smaller, F. Basic Concepts of Electricity unmyelinated nerve fibers. 1. Electrical current is the movement of electrons through a conducting medium. B. Electrical Action of Muscle and Nerve 2. Amperage is the rate of flow of electrons. 1. Characteristics of electrical stimulation necessary 3. Voltage is the force that drives electrons through to initiate excitable cell depolarization. the conductive medium. a. Amplitude or intensity of the stimulus must be 4. Resistance is the property of a medium which great enough to cause the membrane potential to opposes the flow of electrons. A substance having be lowered sufficiently to reach threshold levels. a high resistance (such as rubber) is an insulator b. Duration of the individual stimulus must be and a substance having a low resistance (metal) is long enough to produce depolarization of the a conductor. cell membrane. A duration of 1 ms or less is 5. Ohm's Law expresses the relationship between sufficient to stimulate nerve cell membrane, but amperage, voltage and resistance. The current is is too short to stimulate muscle cell membrane. directly proportional to the voltage and inversely c. Rate of rise of the current to the peak intensity proportional to the resistance. The inverse of must be rapid enough to prevent accommoda- resistance is called conductance. tion, which is the rapid adjustment of the mem- brane to stimuli to prevent depolarization. XI. Electrical Stimulation Square wave delivers instantaneous rise. A. Characteristics C. Strength-Duration Curve (Figure 10-3) 1. Wave forms (Figure 10-4). 1. Rheobase is the intensity of the current, having a a. Monophasic (direct or galvanic current): a uni- long duration stimulus, required to produce a min- imum muscle contraction. 2. Chronaxie is the pulse duration of the stimulus at twice the rheobase intensity. Chronaxie of a dener-

directional flow of charged particles. A current Therapeutic Modalities 309 flow in one direction for a finite period of time is a phase (upward or downward deflection b. Decrease pain to encourage joint motion. from and return to baseline). It has either a pos- c. Decrease in edema if significant impediment to itive or negative charge. b. Bipha ic wave (alternating current): a bidirec- motion. tional flow of charged particle . This type of 4. Muscle re-education (training muscles to respond wave form is illustrated as one-half of the cycle above the baseline and the second phase below appropriately to volitional effort). the ba eline. One complete cycle (two phases) a. Act as active assistive exercise. equal a ingle pulse. It has a zero net charge if b. Provide proprioceptive feedback. symmetrical. c. Assist in coordinated muscle movement. c. Polypha ic wave: biphasic current modified to 5. Disuse atrophy (muscle weakness). produce three or more phases in a single pulse. a. Used as an adjunct to volitional movement. This waveform in medium frequency may be 6. Soft tissue repair (wound healing). Russian or Interferential current. a. Pulsed currents (monophasic, biphasic, polypha- B. Current Modulation a. Continuous mode: uninterrupted flow of current. sic) with interrupted modulations. Improved b. Interrupted mode: intermittent cessation of cur- circulation via the muscle pump to improve rent flow for one second or more. tissue nutrition and hasten metabolic waste c. Surge mode: a gradual increase and decrease in disposal. the current intensity over a finite period of b. Monophasic currents (low volt continuous time. modulations, high volt pulsed currents). d. Ramped mode: a time period with a gradual (1) Electrical potential theory. Restoration of rise of the current intensity which is maintained at a elected level for a given period of time fol- electrical charges in wound area. lowed by a gradual or abrupt decline in intensi- (2) Bactericidal effect. Disruption of DNA, ty. RNA synthesis or cell transport system of e. Goals and Indications microorganisms. (3) Biochemical effects. Increased ATP con- 1. Pain modulation. centration, amino acid uptake, increased a. Activation of gate mechanisms (Gate Theory). protein and DNA synthesi . b. Initiation of descending inhibition mechanisms (4) Galvanotaxic effect. Attraction of tissue (endogenous opiate production). repair cells via electrode polarity. (a) Inflammation pha e: macrophages 2. Decrease muscle spasm. a. Muscle fatigue: tetanic contraction sustained (positive); mast cells (negative); neu- for everal minutes via continuous modulation. trophils (positive or negative). b. Muscle pump: interrupted or surge modulation (b) Proliferation phase: fibroblasts (posi- producing rhythmic contraction and relaxation tive). of the muscle to increase circulation. (c) Wound contraction phase: alternating c. Muscle pump and heat: combination of electrical positive/negative. stimulation and ultrasound to increase tissue (d) Epithelialization phase: epithelial cells temperature and produce muscle pumping at (positive). the same time. c. Both low intensity continuous non-pulsed low volt direct current and high volt pulsed current 3. Impaired range of motion (increase in or mainte- can be applied for wound healing. Though the nance of joint mobility). current characteristics (continuous vs. pulse) a. Mechanical stretching of connective tissue and differ, the treatment protocols are similar (low muscles associated with a joint. Used when amplitude current for 30-60 minutes). mu cle strength is deficient or neuromuscular 7. Edema reduction. dysfunction (e.g., spasticity) prevents adequate a. Muscle pump. Increase lymph and venous flow. joint movement. b. Electrical field phenomenon. Effect of electrical charge on interstitial proteins increase lymph and venous flow. 8. Spasticity (ES to reduce hypertonicity). a. Fatigue of the agonist.

310 starting position before turning on the modality. g. Electrode selection. b. Reciprocal inhibition (stimulate antagonist! inhibit agonist). (I) Electrode size. (a) Two electrodes (leads) are required to 9. Denervated muscle. complete the current circuit. One elec- a. Controversy exists relative to the use of electrical trode is generally called the active stimulation for denervated muscle. Previous (stimulating) electrode and is often animal and clinical studies indicated that den- placed on the motor point; the second, ervated muscle can be stimulated by monophasic larger electrode, is called the dispersive or biphasic currents with a long pulse duration, electrode. producing a vermicular contraction. The goal (b) Current density (the amount of current of stimulation was to retard the effects of disuse that is dispersed under the electrode) is atrophy and shorten recovery time. relative to the electrode size. A given b. Recent animal studies suggest that electrical current intensity passing through the stimulation may be deleterious to denervated smaller active electrode produces high muscle by: current density and thus a strong stim- (I) Interfering with regeneration of neuromus- ulus while the same current is per- cular junction and subsequent reinnervation. ceived as less inten e under the larger (2) Traumatizing hypersensitive denervated dispersive electrode because of the muscle. lesser current density. c. The financial cost and prolonged treatment (c) Electrode size should be relative to the time required until reinnervation occurs are size of the treatment ite. Large elec- additional factors to consider when contem- trodes in a small treatment area (i.e., plating using electrical stimulation on dener- forearm) could result in current over- vated muscles. flowing to surrounding muscles pro- ducing undesired effects. C. Contraindications (d) Conversely, small electrodes applied to I. Electrical stimulation should not be placed over: a large muscle (i.e., quadriceps) could a. Healing fractures. result in high current density under the b. Areas of active bleeding. electrodes making electrical stimulation c. Malignancies or phlebitis in treatment area. uncomfortable to the patient. d. Superficial metal implants. e. Pharyngeal or laryngeal muscles. h. The active electrode is usually placed over the f. Electrical stimulation should not be applied to treatment site (motor point), 0 as to produce a patients with demand-type pacemaker, myocar- stimulation effect. The di per ive electrode dial disease. may be placed on the treatment site or at a 2. Use precaution in applying electrical stimulation remote site (see electrode placement). to areas of impaired sensation and severe edema. 3. Do not use any electrical modality if there is evi- i. Electrode preparation. dence of broken or frayed wires or if the unit is not (I) Metal plate/sponge: remove sponge from connected to a ground fault circuit interrupter (see water, remove excess water. hydrotherapy section). (2) Carbonized rubber: place mall amount of gel in center of electrode. Spread gel to cover D. General Guidelines for Electrical Stimulation entire surface. Procedures (3) Pregelled electrode: remove protective cover I. General muscle stimulation procedure. and place a mall amount of gel (metal a. Explain procedure and effects to patient. mesh/foil electrode) or water (Karaya elec- b. Place patient in comfortable position with trode) on electrode. treatment area properly exposed. c. Support body part to be treated. J. Electrode placement. d. A sess skin condition and sensation. (I) Unipolar/monopolar placement: one single e. Reduce skin resistance, if necessary (hot pack, electrode or multiple (bifurcated) active alcohol rub, gentle abrasion). electrodes placed over treatment area. f. Check to see that all controls are in proper

Usually larger-sized dispersive electrode Therapeutic Modalities 311 (inactive) placed ipsilaterally away from treatment area. (muscle pump), ROM. (2) Bipolar placement: equal sized active and a. Slowly increase intensity until a muscular dispersive electrodes on same muscle group or in same treatment area. Smaller response is observed. bifurcated treatment electrodes may be used b. 10 to 25 muscle contractions may be sufficient to better conform to small treatment areas. (3) The space between the active and dispersive to obtain treatment goal. electrodes should be at least the diameter of c. Duty cycle. the active electrode. The distance between the electrodes should be as far as is practica- (1) Interrupted/ramped modulation of current ble. The greater the space between electrodes allows the muscle to recover between stim- the lesser the current density in the interven- ulation periods. ing superficial tissue, thus minimizing the risk of skin irritation, and burns. If deep pen- (2) It has been shown that stimulation on to off etration causes contraction of undesired mus- ratios of 1:3 or more minimize the fatigue cles, move the electrodes closer together. effects of electrical stimulation. k. Inspect the patient's skin. Vigilant skin inspection and skin care is very important with long-term 3. Muscle spasm (fatigue). u e of electrical stimulation. This is especially a. Procedure as above for innervated muscle. important during home use of transcutaneous Current applied in continuous mode. electrical timulation and other electrical stim- ulation modalities. Long-term repetitive stimu- 4. Muscle re-education. lation and electrode placement and removal can a. Parameters and procedure similar to muscle irritate the skin and initiate skin breakdown. strengthening techniques. 1. Secure electrodes to body part. b. Stimulation for multiple sets of singular or m. Set appropriate frequency, waveform and mod- multiple muscle repetitions. ulation rate. c. Treatment sessions of 10-30 minutes depending n. Adjust intensity to achieve the optimal treatment on patient's mental and physical tolerance. effect. o. At end of treatment, slowly decrease intensity XII. Iontophoresis to zero before lifting the active electrode from skin. Turn all controls to beginning position. A. Description 2. Muscle strengthening, muscle spasm or edema 1. The application of a continuous direct current to transport medicinal agents through the skin or mucous membrane for therapeutic purposes. B. Physics 1. Like charges repel like charges. 2. Unlike charges attract unlike charges. C. Electrochemical Effects Related to Iontophoresis 1. Dissolved acids, bases, salts, or alkaloids in an aqueous solution dissociate into positively or neg- atively charged substances (ions) when electrical TABLE 10-7 -INDICATIONS FORTHE USE OF IONTOPHORESIS AND IONS COMMONLY USED INDICATIONS ION POLARITY SOURCE Analgesia Lidocaine, Xylocaine Positive Lidocaine, Xylocaine Salicylate Negative Sodium salicylate Calcium deposits Acetate Negative Acetic acid Dermal ulcers Zinc Positive Zinc oxide Edema reduction Hyaluronidase Positive Wyadase Fungal infections Copper Positive Copper sulfate Hyperhidrosis Water Positive/Negative Tap Water Muscle spasm Calcium Positive Calcium chloride Magnesium Positive Magnesium sulfate Musculoskeletal Dexamethasone Negative inflammatory conditions Hydrocortisone Positive

312 apparatus automatically adjusts parameters. 8. Ob erve treatment area every 3-5 minutes. Report current flows through a substance. 2. Polar effects. any adverse reactions. 9. Turn intensity down slowly to zero at completion a. Positive ions move toward the negative pole (cathode) where a secondary alkaline reaction of treatment. Some units have an automatic cut-off. (NaOH) occurs. G. Indications (Table 10-7) H. Contraindications b. Negative ions move toward the positive pole (anode) where an acid is produced (HCI). 1. Refer to general rules for electrical stimulation. 2. Impaired skin sen ation. D. Ion Transfer 3. Allergy or sen itivity to therapeutic agent or direct 1. The number of ions transferred through the skin is directly related to the: current. a. Duration of the treatment. 4. Denuded area or recent scars. b. Current density. 5. Cuts, bruises or broken skin. c. Concentration of the ions in the solution. 6. Metal in or near treatment area. E. Electrical Stimulation Characteristics oflontophoresis XIII. Transcutaneous Electrical Nerve Stim- 1. Wave form: monophasic. ulation (TENS) 2. Modulation: continuous. A. Description F. Procedure 1. Transcutaneous electrical nerve stimulation is 1. Clean and inspect skin. designed to provide afferent stimulation for pain 2. Position patient and support treatment area. management. 3. Place appropriate size active electrode on treat- ment area. Active electrode same polarity as the B. Physiological Effects medicinal ion. To reduce the alkaline effect on the 1. Pain modulation through activation of central inhi- skin, the negative electrode should be twice as bition of pain transmission (Gate Control Theory). large as the positive regardless of which is the a. Large diameter A-Beta fibers (Figure 10-5) acti- active electrode. vate inhibitory interneurons (substantia gelati- 4. Dispersive electrode placed at either proximal or nosa) located in the dorsal horn (primarily lam- distal distant site about 4-6 inches away. ina II and ill) of the spinal cord, producing 5. The space between the active and dispersive electrodes should be at least the diameter of the ~ .RapbeNucleus active electrode. However, commercial electrode ueductaiGray + sets have a fixed distance that limits the spacing between electrodes. Matter 6. Determine dose. Dosage is product of time and current intensity. Safe limit for active electrode: + anode, 1.0 mA/cm2, cathode, 0.5 mA/cm2• Duration is 10-40 minutes. 7. Turn intensity up slowly to selected level unless Dorsolateral Tract Ascending Tract a 9 A·.... + Toocb Reoepor .I Enkephalin Interneuron 0 @ 0 ~Free Nerve Endiog -------'---<+( C5Free Nerve Endina 6. Inhibitory lDtemeuroo A-Delta. C-Fibc.r •X Figure 10:6: Schematic of descending inhibition mechanisms. A·Delta,C·Piber Figure 10-5: Schematic of gate control theory (Melzack and Wall).

Therapeutic Modalities 313 inhibition of smaller A-Delta and C-Fibers a. Amplitude: comfortable tingling sensation, (pain fibers). paresthesia. No muscle response. b. Pre ynaptic inhibition of the T-cells closes the \"gate\" and modulates pain. The gating mecha- b. Pulse rate 50-80 pps. nism also includes release of enkephalins c. Pulse duration 50-1 00 ~sec. which combine with opiate receptors to d. Duration of treatment: 20-60 min. depre s release of substance P from the A-delta e. Duration of pain relief: temporary. and C-fibers. 2. Acupuncture-like (strong low rate) TENS can be 2. Pain modulation through de cending pathways applied during the chronic pha e of pain. generating endogenous opiate (Figure 10-6). Analgesia produced through tirnulation-evoked a. Noxious stimuli generate endorphin production production of endogenous opiates. Onset of pain from the pituitary gland and other CNS areas. relief may be as long as 20 to 40 minutes. Duration b. Endogenous opiate-rich nuclei, periaqueductal of relief may be long-lasting (an hour or more). gray matter (pAG), in the midbrain and thalamus a. Amplitude: strong, but comfortable rhythmic are also activated by strong stimuli. c. Neurotransmitters from the PAG facilitate the muscle twitches. cells of the nucleus raphe magnus (NRM), and b. Pulse rate: 1-5 pps. reticularis gigantocellularis (RGC). c. Pulse duration: 150-300 Jlsec. d. Efferents from these nuclei travel through the d. Duration of treatment: 30-40 min. dorsal lateral funiculus to terminate on the e. Duration of pain relief: long lasting. enkephalinergic intemeurons in the spinal cord 3. Brief intense TENS: this mode is used to provide to presynaptically inhibit the release of sub- rapid onset, but short-term pain relief during painful tance P from the A-Delta and C-Fibers. procedures (wound debridement, deep friction mas- C. Electrical Stimulation Characteristics sage, joint mobilization or passive stretching). I. Wave form: typically, asymmetrical biphasic with a. Amplitude: to patient's tolerance. a zero net direct current component. Other variations b. Pulse rate: 80-150 pps. including pul ed monophasic current have been used. c. Pulse duration: 50-250 Jlsec. 2. Modulation: continuous or burst. d. Duration of treatment: 15 min. D. Procedures e. Duration of pain relief: temporary (30 minutes- 1. Conventional (high rate) TENS: this most com- mon mode of TENS can be applied during the hour). acute or chronic phase of pain. Modulation of pain 4. Burst mode (pulse trains) TENS: combines char- via inhibition of pain fibers by large-diameter fiber activation (gate mechanism). Onset of pain relief acteristics of both high and low rate TENS. is relatively fast and duration of relief is relatively Stimulation of endogenous opiates, but current is short. r A A f\\ A A A A f\\ A A A A f\\ 1000 vvv vvv UV v v v I Carrier frequency ji \"'\" 2.500 pps Figure I 0-7: Capacitive skin resistance decreases as Burst Interbunt 10ms current frequency increases. 10 ms interVal 10ms Figure 10-8: Russian current. Time-modulated polypha- sic waveform

314 the parameters of the above TENS modes for the pur- pose of preventing neural or perceptual adaptation more tolerable to patient than low rate TENS. due to constant electrical timulation. Frequencies, Onset of analgesia similar to low rate TENS. intensities or pulse durations can be altered by ten or a. Amplitude: comfortable, intermittent paresthesia. more percent one or two time per econd. b. Pulse rate: 50-100 pps delivered in packets or E. Electrode Placement 1. Several options should be considered. bursts of 1-4 pps. Acupuncture site, dermatome distribution of c. Pulse duration: 50-200 Jlsec. involved nerve, over painful site, proximal or dis- d. Duration of treatment: 20-30 min. tal to pain site, segmentally related myotomes, or e. Duration of pain relief: long lasting (hours). trigger points. 5. Hyperstimulation (point stimulation) TENS: use F. Goals and Indications of a small probe to locate and noxiously stimulate 1. Acute and chronic pain modulation. acupuncture or trigger points. Multiple sites may G. Contraindications be stimulated per treatment. Onset of pain relief is 1. Patient with demand-type pacemaker or over chest similar to acupuncture-like TENS. of patient with cardiac disease. a. Amplitude: strong, to patient's tolerance. 2. TENS not applied over eyes, laryngeal or pharyngeal b. Pulse rate 1-5 pps. muscles, head and neck of patient following cerebral c. Pulse duration 150-300 Jlsec. vascular accident, or with epilepsy. d. Duration of treatment: 15 to 30 second incre- 3. TENS not applied to mucosal membranes. ments. XIV. High Voltage Pulsed Galvanic e. Duration of pain relief: long lasting. Stimulation 6. Modulation mode TENS: a method of modulating A. Description: high voltage pulsed current (HYPe). Circuit 1: 3,000 Hz ·····7\\· \"11\"..... /\\ Ti l\\ ./\\. 1\\\" f\\'\" Typically, monophasic twin-peaked pulses of short duration. r/\\ 1\\ f'i v vVv Circuil2: 3,100 Hz AB 1\\ f\\ /\\ 1\\ f\\ ...'[\\\".... ,'1\\.. fI'\" vv \\,) .. ,.. \\,) .. Circuit t ... Circuit 2 f\\ <;j ~1 - - - - - - 1 ~ Superimposed .~I------i u f\\ f\\ f\\ v (\\u v \\,) \\,) v v vV v v C Beat Frequency (100Hz) Figure 10-9: Interferential current. Amplitude modulat- Figure 10-10: Static interference field depicting the area ed polyphasic waveform. of maximum stimulation (circle) and the direction of maximal stimulation (arrows).

B. Physics Therapeutic Modalities 315 1. Skin offer high resistance (impedance) to the flow of low voltage current. E. Goals and Indications 2. Pas age of HVPC decreases skin resistance due 1. Inflammation phase: free from necrosis and exu- to the current flowing toward the skin capacitors dates. Promote granulation. (little energy loss) rather than the skin resistors. 2. Proliferation phase: reduce wound size including Thermal effects are negligible (little resistance to depth, diameter and tunneling. current). 3. Epithelialization phase: timulate epidermal pro- liferation and capillary growth. C. Electrical Stimulation Characteristics of High Voltage Pulsed Current F. Contraindications: see general contraindications for 1. Wave form: paired monophasic with instantaneous electrical stimulation. ri e and exponential fall of current. 2. Modulation: continuous, surged or interrupted. X~ Concept of Medium Frequency Currents in Electrical Stimulation D. Procedure 1. Muscle stimulation protocol: refer to general A. Description: electrical stimulating frequencies in the application procedure. range of 2,000 to 5,000 pps that are modulated to pro- 2. Wound healing concept. duce physiologically applied frequencies. Tills concept a. Intact skin surface negative with respect to is utilized in the Russian (time-modulated) and the deeper epidermal layers. interferential (amplitude-modulated) electrical stimu- b. Injury to skin develops positive potentials ini- lation techniques. tially and negative potentials during healing process. B. Physics Related to Medium Frequency c. Absent or insufficient positive potentials retard 1. A decrease in the capacitive skin impedance of the tissue regeneration. skin is noted relative to the increase in current fre- d. Addition of positive potentials, initially through quency (Figure 10-7). anode, may promote or accelerate healing. 2. Electrical stimulation frequency categories: 3. Wound healing parameters. a. Low frequency: 1-1,000 pps. a. Amplitude: comfortable tingling sensation, b. Medium frequency: 1,000-10,000 pps. paresthesia, no muscle response. c. High frequency: >10,000 pps. b. Pulse rate: 50-200 pps. c. Pul e duration: 20-100 flsec. XVI. Russian Current d. Duration of treatment: 20-60 min. 4. Wound healing procedures. A. Description: a 2,500 Hz sine wave (carrier frequency), a. Inspect wound area. which is interrupted for ten milliseconds at ten millisec- b. Position patient and support treatment area. ond intervals, producing fifty, ten-millisecond bursts per c. Clean and debride wound site. Pack with sterile second. Tills type of time interval interruption produces saline soaked gauze. time-modulated current (Figure 10-8). Also known as d. Both high volt pulsed current and low intensity medium frequency, burst alternating current. continuous low volt direct current can be used for wound healing. Though the current charac- B. Electrical Stimulation Characteristics of Russian teristics differ, the treatment parameters are sim- Current ilar in current intensity and treatment duration. 1. Wave form: biphasic sinusoidal. e. Place active electrode over gauze. 2. Modulation: continuous pulsatile current with f. For bactericidal effect, active electrode should burst modulation. have negative polarity. For culture-free wound, active electrode should be positive. C. Method of Application: Muscle Strengthening g. Turn the intensity up slowly to selected level. Protocol h. At conclusion of treatment, turn intensity down 1. Amplitude: tetanic muscle contraction. slowly to zero. 2. Pulse Rate: 50-70 pps. 3. Pulse duration: 150-200 fl ec. 4. Ramp 1-5 seconds based on patient's tolerance. 5. Duty cycle: 1:5. 6. Current applied to provide stimulation during the following volitional activities:

316 to provide a greater area of stimulation as com- pared to static interferential fields. a. Isometric exercise at several points through c. Full field scanning produces a imilar effect as ROM. dynamic interferential fields by bursting the current over the two circuits. b. Slow isokinetic exercise; e.g., 5°-100 /sec. 5. When applying IFC to a small area (two elec- c. Short arc joint movement when ROM is trodes), the interference occurs in the ES unit and is delivered as a pre-modulated current through restricted. one circuit. D. Muscle Spasm Protocol C. Electrical Stimulation Characteristics 1. Wave form: sinusoidal (amplitude-modulated). 1. Muscle fatigue using continuous isometric con- 2. Modulation: continuous (pain); interrupted (muscle traction for several minutes to tolerance. exercise). D. Procedure 2. If muscle pumping is goal, duty cycle is 1: 1. 1. Electrode placement (pad or suction cup electrodes). 3. If ROM is goal, duty cycle is 2:5. a. Bipolar (premodulated IFC). Active and disper- E. Contraindications: see general contraindications. sive electrodes placed over or around small area. b. Quadripolar (IFC). Two sets of electrodes placed XVII. Interferential Current (IFC) diagonally to one another over large area. 2. Treatment parameters. A. Description a. Pain protocol. 1. This current is characterized by the crossing oftwo (1) Similar to high or low rate TENS sinusoidal waves having similar amplitudes, but b. Muscle strengthening protocol. different carrier frequencies which interfere with (1) Similar to low or medium frequency elec- one another to generate an amplitude modulated beat frequency. The consequent beat frequency is trical stimulation. the net difference between the two superimposed E. Goals and Indications frequencies. 1. Modulate pain: increase muscle strength or ROM. B. Physics Related to IFC F. Contraindications: see general contraindications. 1. Constructive interference: when the two waves are in phase, the sum of the superimposed wave is XVIII. Functional Electrical Stimulation (FES) large (Figure 10-9 A). 2. Destructive interference. The sum of the two waves A. Description is zero when the waves are 180° out of phase 1. Functional electrical stimulation encompasses a (Figure 10-9 B). wide range of stimulator units and techniques for 3. Beat frequency (amplitude modulated). Resultant disuse atrophy, impaired ROM, muscle spasm, frequency produced by the two frequencies going muscle re-education and spasticity management. into and out of phase (Figure 10-9 C). FES is also called neuromuscular stimulation a. Constant. Both carrier frequencies are fixed. (NMES) and functional neuromuscular stimula- Beat frequency is net difference between both tion. This section will describe FES as an alterna- frequencies. tive or supplement to the use of orthotic devices. b. Variable. One carrier frequency is fixed and the other varies in frequency generating a variable B. Shoulder Subluxation or sweep frequency. Sweep used to minimize 1. Patients with CVA may initially exhibit weakness accommodation. or flaccid paralysis of the muscles supporting the 4. IFC produces a cloverleaf-like pattern as the elec- glenohumeral joint, especially the supraspinatus trical stimulating effect is at a 45° angle to the flow and posterior deltoid. of current in the two circuits as interference occurs 2. The force of gravity acting on the unsupported upper at the targeted area of the body (Figure 10-10). extremity tends to stretch the ligamentous structures a. Static interferential fields are generated when surrounding the glenohumeral joint resulting in four electrodes (two circuits) are used and the severe pain and decreased upper extremity function. cloverleaf pattern is produced. 3. Electrical stimulation characteristics of FES. b. Dynamic (scan) interferential fields occur a. Wave form: asymmetrical biphasic quare. when the interferential fields are rotated 45° due to the vectoring effect of rhythmically unbalancing the IFC to change the position of the stimulation areas. This effect is purported

b. Modulation: interrupted. Therapeutic Modalities 317 4. Procedure. active muscles. The signals are detected, amplified a. Electrode placement: bipolar. Electrodes on and converted into audiovi ual signals that are supraspinatus and posterior deltoid. used to reinforce voluntary control. B. Principles of EMG Biofeedback b. Treatment parameters. 1. Motor unit: the functional unit of the neuromuscular (I) Amplitude: tetanic muscle contraction to system, consisting of the anterior hom cell, its axon, patient's tolerance. the neuromuscular junction, and all the muscle (2) Pulse rate 12-25 pps. fibers innervated by the axon. Motor unit potentials (3) Duration of treatment: 15-30 minutes. (MUP) are measured in microvolts (/lV). The signals Three times daily up to 6-7 hours. On/off generated by the MUP, which contain both positive ratio: 1:3 (2 sec: 6 sec) progressing to 12:1 and negative phases, are also called a compound (24 sec: 2 sec). action potentials (CAP) since the sensors pick up signals from multiple motor units. C. Dorsiflexion Assist in Gait Training 2. The signal is processed through amplification, rec- 1. Patient with hemiplegia sometimes exhibit para- tification (positive and negative components of the lyzed dorsiflexor and evertor muscles. signal are made unidirectional), and integration 2. FES controls foot drop, and facilitates dorsiflexors (area under curve is computed). The integrated sig- and evertors during swing phase. nal provides readings in microvolt-seconds (/lV/s) 3. Electrical stimulation characteristics. and is displayed as the EMG biofeedback signal. a. Wave form: asymmetric biphasic square. 3. The EMG biofeedback signals, in conjunction b. Pul e duration: 20-250 /lsec. with the patient's voluntary effort, are used to either c. Modulation: interrupted by foot switch. increase or decrease muscle activity to achieve a 4. Procedure. functional goal. a. Electrode placement: bipolar. Peroneal (fibu- C. Recording Electrodes lar) nerve near head of fibula or anterior tibialis 1. Surface electrodes. muscle. a. Global detection: signals from more than one b. Treatment parameters. (1) Amplitude: tetanic muscle contraction suf- muscle. ficient to decrease plantar flexion. b. Detection from mostly superficial muscles. (2) Pulse rate 30-300 pps. c. Advantages: easy to apply, acceptable to (3) Treatment mode: heel switch contains pres- ure- ensitive contact which stops stimulation patient/client. during stance pha e and activates stimulation d. Disadvantages: detection from mostly superfi- during wing phase. Hand switch also allows therapist to control stimulation during gait. cial muscles and frequently from more than one muscle group. D. Other Gait-Assisted Protocol Considerations 2. Types of surface electrodes/sensors. 1. Placement of electrodes on appropriate muscles to a. Metal electrodes (silver-silver chloride): cupped control muscles during push-off (plantar flexors, shaped to accommodate conducting gel. late swing phase (hamstrings), quadriceps and/or b. Disposable electrodes: pregelled center with gluteals (stance phase). surrounding adhesive backing. 2. Electrical stimulation characteristics: similar to c. Carbonized rubber electrodes (re-useable): dorsiflexion protocol. flexible to conform to body part. 3. Method of application: similar to dorsiflexion pro- 3. Needle electrodes/sensors. tocol except for electrode placement. a. Local detection: signals from specific muscle or muscle group. XIX. Electromyographic Biofeedback (EMG b. Detection of deep muscles. Biofeedback) c. Used for EMG diagnosis or research. Rarely used for EMG biofeedback. A. Description d. Advantages: detection of specific muscles. 1. Electronic instrument used to measure motor unit e. Disadvantages: requires skill to apply, less action potentials (MUAP) that are generated by acceptable to patient/client.

318 f. Treatment sessions may be from 5-10 minutes to 30 minutes or more depending on patient tol- D. Electrode Application erance. 1. Electrode selection: select small electrodes (0.02 cm) for specific muscles (hand, forearm, face); g. At end of session, clean patient's skin and large electrodes (1.0 cm) for large muscles or mus- electrodes. cle groups. 2. Electrode placement. 6. Technique for decreasing muscle activity (muscle a. Bipolar technique: two active (positive and relaxation). negative) and a single reference (ground) elec- a. Begin with electrodes closely spaced and trode. The reference electrode may be placed biofeedback instrument sensitivity low to min- between or adjacent to active electrodes. This imize cross talk. arrangement minimizes or eliminates extrane- b. Instruct patient to relax to try and lower audio- ous electrical activity (noise or cross talk). visual signal. Apply relaxation techniques b. Active electrodes placed on or near motor point (deep-breathing, imagery) if necessary. of targeted muscle or muscle group. c. Progress from low to high sensitivity as patient c. Generally active electrodes placed approxi- gains ability to relax muscle and perform func- mately 1 to 5 cm apart and parallel to muscle tional activities. fibers. Reference electrode placed near treat- d. Treatment sessions may be from 5-10 minutes ment site. to 30 minutes or more depending on patient d. Active electrodes placed close together: mini- tolerance. mizes cross talk, yield small signals, more precise e. At end of session, clean patient's skin and signal. electrodes. e. Active electrodes placed further apart: yield large signals, detection from more than one F. Criteria for Patient Selection for Biofeedback muscle. Training 1. Good vision, hearing, and communication abilities. E. Procedure 2. Good comprehension of simple commands, con- 1. Begin treatments in quiet setting, if possible. centration. 2. Clean treatment site with alcohol (slight abrasion, 3. Good motor planning skills. if necessary) to remove dirt and oils from skin to 4. No profound sensory or proprioceptive loss. reduce skin impedance. 3. Apply conductive gel, if needed. 4. Secure the electrodes. 5. Protocol for increasing muscle activity (motor recruitment). a. For weak muscles, begin with electrodes widely spaced and biofeedback instrument sensitivity high, to increase detection. (1) For a single weak muscle, begin with elec- trodes close together if a more precise signal is desired. b. Instruct patient to try and contract muscle (iso- metrically for 6-10 sec.) to produce an audio- visual signal. c. As patient's motor recruitment ability improves, decrease the sensitivity, making it harder to produce an audio-visual signal. d. Use facilitation techniques (tapping, cross facilitation, vibration) to encourage motor unit recruitment, if necessary. e. Progress from simple to more complex/function- al movements as patient gains motor control.

CHAPTER II FUNCTIONALTRAINING, EQUIPMENT & DEVICES Susan B. O'Sullivan and Gerard Dybel I. Gait 3. Midstance: the point at which full body weight is taken by the reference or support limb. A. Phases of the Gait Cycle: Traditional tenninology Midstance (RLA): the contralateral limb leaves the appears fir t and refers to points in time in the gait ground; body weight is taken and advanced over cycle; Rancho Los Amigos (RLA) terminology follows and ahead of the support limb; a period of single and refers to lengths of time in the gait cycle; as both limb support. are in clinical use, readers should be familiar with both. Muscle activation patterns: hip, knee, and ankle I. Heel strike: the point when the heel of the refer- extensors are active throughout stance to oppose ence or support limb contacts the ground at the antigravity forces and stabilize the limb; hip extensors beginning of stance phase. control forward motion of the trunk; hip abductors Initial contact (RLA): the instant that the foot of stabilize the pelvis during unilateral stance. the lead extremity strikes the ground. Muscle activation patterns (Figure 11-1): knee 4. Heel off: occurs after midstance as the heel of the extensors (quadriceps) are active at heel strike reference or support limb leaves the ground. through early stance to control small amount of Terminal stance (RLA): the last period of single knee flexion for shock absorption; ankle dorsiflex- limb support that begins with heel rise and contin- ors (anterior tibialis, ext. hallucis longus, ext. dig- ues until the contralateral leg contacts the ground. itorum longus) decelerate the foot, slowing the Muscle activation patterns: peak activity of plan- plantarflexion from heel strike to foot flat. tarflexors occurs just after heel off to push off and 2. Foot flat: the point when the sole of the foot of the generate forward propulsion of the body. reference or support limb makes contact with the ground; occurs immediately after heel strike. 5. Toe off: the last portion of stance following heel Loading response (RLA): the first period of dou- off when only the toe of the reference or support ble support immediately after initial contact until limb is in contact with the ground. the contralateral leg leaves the ground. Preswing (RLA): the second period of double sup- Muscle activation patterns: gastrocnemius-soleus port from initial contact of the contralateral limb to muscle are active from foot flat through mid- lift off of the support limb. tance to eccentrically control forward tibial Muscle activation patterns: hip and knee extensors advancement. (hamstrings and quadriceps) may contribute to for- ward propulsion with a brief burst of activity.

320 - - - - + .. - - - - - WALKING CYCLE SWING PHASE - STANCE PHASE - SWING PHASE 5 Idealized summary curves representing phasic action of major muscle groups in level walking at 90 steps/min. 1, pretibial group; 2, calf muscles; 3, quadriceps; 4, hamstrings; 5, abductors; 6, adductors; 7, gluteus maximus; 8, erector spinae. Figure I I-I: Actions of Major Muscle Groups During Gait. From Smith. L,Weiss, E. Lehmkuhl, D: Brunnstrom's Clinical Kinesiology. 5th edit.. Philadelphia, FA Davis Co, 1996, p. 426, with permission. 6. Acceleration: the first portion of the swing phase preparation for heel strike. from toe off of the reference limb until midswing. Terminal swing (RLA): the portion of the swing Initial swing (RLA): the first portion of the swing phase from a vertical tibial position of the refer- phase from toe off of the reference limb until max- ence extremity to just prior to initial contact. imum knee flexion of the same extremity. Muscle activation patterns: hamstrings act during Muscle activation patterns: forward acceleration late swing to decelerate the limb in preparation for of the limb during early swing is achieved through heelstrike; quadriceps and ankle dorsiflexors the brief action of quadriceps; by midswing the become active in late swing to prepare for heel- quadriceps is silent and pendular motion is in strike. effect; hip flexors (iliopsoas) aid in forward limb 9. Pelvic motion. propulsion. a. The pelvis moves forward and backward 7. Midswing: the mid portion of the swing phase (transverse pelvic rotation). when the reference extremity moves directly (1) Forward rotation occurs on the side of the below the body. Midswing (RLA): the portion of the swing phase unsupported or swing extremity; mean from maximum knee flexion of the reference rotation is about 4 degrees. extremity to a vertical tibial position. (2) Weight bearing or stance extremity rotates Muscle activation patterns: foot clearance is 4 degrees (a total of 8 degrees). achieved by contraction of the hip, knee flexors b. The pelvi moves up and down on the unsup- and ankle dorsiflexors. ported or swing side (lateral pelvic tilt): approximately 5 degrees; controlled by hip 8. Deceleration: the end portion of the swing phase abductor muscles. when the reference extremity is slowing down in (1) The high point is at midstance.

(2) The low point is during the period of dou- Functional Training, Equipment & Devices 321 ble support. length, body weight, type of surface, gradient, c. The pelvis moves side to side about 4 centime- and activity (e.g. stair climbing). ters, follows the stance or support limb. c. Increased energy costs occur with age, abnor- mal gait (e.g., disease, muscle weakness or 10. Cadence: the number of steps taken per unit of paralysis, physical disability), or with the use time. of functional devices (e.g., crutches, orthoses, a. Mean cadence is 113 steps/minute. prostheses). b. Increased cadence: shorter step length and B. Common Gait Deviations: Stance Phase decreased duration of period of double support. 1. Trunk and hip. c. Running occurs when the period of double sup- a. Lateral trunk bending: the result of weak gluteus port disappears, typically at a cadence of 180 medius; will see bending to the same side as the steps/minute. weakness (Trendelenburg gait); also seen with pain in the hip. 11. Step. h. Backward trunk lean: the result of weak gluteus a. Step length: the linear distance between point maximus; will also see difficulty going up stairs of foot contact (preferably heel strike) of one or ramps. extremity to the point of heel strike of the c. Forward trunk lean: the result of weak quadri- opposite extremity (in centimeters or meters). ceps (decreases flexor moment at the knee), hip b. Step time: the number of seconds that elapse and knee flexion contractures. during one step. d. Excessive hip flexion: the result of weak hip c. Step width: the distance between feet (e.g., extensors or tight hip and/or knee flexors. base of support); measured in centimeters or e. Limited hip extension: the result of tight or meters from one heel to the same point on the spastic hip flexors. opposite heel. f. Limited hip flexion: the result of weak hip flexors (1) Normal step width ranges between 2.54 or tight extensors. and 12.7 cm (l and 5 inches). g. Abnormal synergistic activity (e.g., stroke): (2) Increases as stability demands rise, e.g., excessive hip adduction combined with hip and wide-based gait in older adults or very knee extension, plantarflexion; scissoring or small children. adducted gait pattern. h. Antalgic gait (painful gait): stance time is 12. Stride. abbreviated on the painful limb resulting in an a. Stride length: the linear distance between two uneven gait pattern; the uninvolved limb has a consecutive contact points of the same extrem- shortened step length since it must bear weight ity (in centimeters or meters). sooner than normal. b. Stride time: the number of seconds that elapse 2. Knee. during one stride (one complete gait cycle). a. Excessive knee flexion: the result of weak quadriceps (the knee wobbles or buckles) or 13. Velocity (walking speed): the rate of motion in any knee flexor contracture. direction, the di tance is divided by the time (in (1) Will also see difficulty going down stairs or centimeters/second or meters/minute). a. Average walking speed is 82 m/min (approxi- ramps. mately 3 miles/hour). (2) Forward trunk bending can compensate for b. Affected by physical characteristics: height, weight, gender. weak quadriceps. c. decreased with age, physical disability, etc. b. Hyperextension: the result of a weak quadri- 14. Acceleration: the rate of change of velocity with ceps, plantar flexion contracture, or extensor respect to time. spasticity (quadriceps and/or plantar flexion). 3. Ankle/foot. 15. Energy cost of walking. a. Toe fIrst: toes contact at heel strike; the result a. Average oxygen rate for comfortable walking of weak dorsiflexors, spastic or tight plan- is 12 ml/kg x min. tarflexors; may also be due to a shortened leg b. Metabolic cost of walking averages 5.5 kcal/ (leg length discrepancy); painful heel; or posi- min on level surfaces; energy costs may vary widely depending on speed of walking, stride

322 f. Abnormal synergIstIC actIVIty (e.g., stroke): excessive hip and knee flexion with abduction. tive support reflex. b. Foot slap: the foot makes floor contact with an 2. Knee. a. Insufficient knee flexion: the result of extensor audible slap; the result of weak dorsiflexors or spasticity, pain/decreased range of motion, or hypotonia; compensated for with steppage gait. weak hamstrings. c. Foot flat: entire foot contacts ground; the result b. Excessive knee flexion: the result of flexor of weak dorsiflexors, limited range of motion; spasticity; flexor withdrawal reflex. immature gait pattern (neonatal). d. Excessive dorsiflexion with uncontrolled for- 3. Ankle/foot. ward motion of the tibia (calcaneus gait): the a. Foot drop (equinus): the result of weak or result of weak plantarflexors. delayed contraction of the dorsiflexors or spastic e. Excessive plantarflexion (equinus gait): heel plantarflexors. does not touch the ground; the result of spas- b. Varus or inverted foot: the result of spastic ticity or contracture of the plantar flexors; will invertors (anterior tibialis), weak peroneals, or see poor eccentric contraction and advance- abnormal synergistic pattern (e.g., stroke). ment of the tibia. c. Equinovarus: the result of spasticity of the pos- f. Supination: excessive lateral contact of foot terior tibialis and/or gastrocnemius/soleus; during stance with varus position of calcaneus. developmental abnormality. May occur at initial contact and correct at foot- flat with weight acceptance or remain through- II. Ambulatory Aids out stance. Possible causes: spastic invertors, weak evertors, pes varus, genu varum. A. Canes: widen the base of support to improve balance; g. Pronation: excessive medial contact of foot provide limited stability and unweighting (can unload during stance with valgu position of calca- forces on involved extremity by about 30%); can be neus. Possible causes: weak invertors, spastici- used to relieve pain, antalgic gait. ty, pes valgus, genu valgum. 1. Cane measurement: 20-30 degrees of elbow flexion h. Toes claw: the result of spastic toe flexors, pos- is desirable; measure from the greater trochanter to sibly a hyperactive plantar grasp reflex. a point 6 inches to the side of the toes. 1. Inadequate push off: the result of weak plantar 2. Types: wood or aluminum (adjustable with push flexors, decreased range of motion, or pain in pin lock). the forefoot. 3. Standard: single contact point with the ground; han- C. Common Gait Deviations: Swing Phase dle and shaft may be standard (J shaped) or offset. 1. Trunk: and hip. 4. Quad cane: four contact points with the ground; a. Insufficient forward pelvic rotation (stiff provides increased stability but slows gait. pelvis, pelvic retraction): the result of weak a. Small-based quad cane (SBQC): useful for abdominal muscles, weak flexor muscles (e.g., stairs. stroke). b. Wide-based quad cane (WBQC): does not fit b. Insufficient hip and knee flexion: the result of on stairs. weak hip and knee flexors; inability to lift the 5. Gait: cane is held in the hand opposite to the leg and move it forward. involved extremity; cane and involved extremity c. Circumduction: the leg swings out to the side are advanced together, followed by the uninvolved (abduction/external rotation followed by extremity. adduction/internal rotation); the result of weak hip and knee flexors. B. Crutches: used to increase the base of support, pro- d. Hip hiking (quadratus lumborum action): a vide moderate degree of tability, relieve weightbear- compensatory respon e for weak hip and knee ing on the lower extremitie . flexors, or extensor spasticity. 1. Crutch measurement: 20-30 degrees of elbow flexion e. Excessive hip and knee flexion (steppage gait): is desirable. a compensatory response to shorten the leg; the a. In the standing position, one can subtract 16 result of weak dorsiflexors (e.g., diabetic neu- inches from the patient's height or measure ropathy of the peroneal nerve). from a point 2 inches below the axilla to a point 6 inches in front and 2 inches lateral to the foot.

b. If the patient is supine, measure from the axil- Functional Training, Equipment & Devices 323 la to a point 6-8 inches lateral to the heel. D. Gait Patterns c. Forearm crutches: the cuff should cover the 1. Weight bearing status. proximal third of the forearm, about 1-1112 a. Non-weightbearing: no weight bearing is per- inches below the elbow. mitted. b. Partial weightbearing: toes or ball of involved 2. Axillary crutches: wood, or aluminum designs; foot contacts with the floor; allows a limited handgrip height and crutch height adjusted by amount of weight bearing. wing nuts; push button locks with telescoping legs c. Full weight bearing: full weight is permitted on on some aluminum crutches; axillary pads cushion the involved extremity. Weight can be objective- the top of crutch. ly controlled with use of a limb load monitor. a. Provide increased trunk support over forearm 2. Two-point gait: one crutch and opposite extremity crutches. move together followed by the oppo ite crutch and b. May be difficult to use in small areas. extremity; requires use of two assistive devices c. Prolonged leaning on the axillary bar can result (canes or crutches); allows for natural arm and leg in vascular and/or nerve damage (axillary motion during gait, good support and stability artery/radial nerve). from two opposing points of contact. 3. Three-point gait: both crutches and involved leg 3. Forearm (Lofstrand) crutches: have a forearm cuff are advanced together, then uninvolved leg is and a hand grip; provide slightly less stability but advanced forward; requires use of two assistive increased ease of movement; frees hands for use devices (crutches or canes) or a walker; indicated without dropping the crutch (secured by cuff). for use with involvement of one extremity, e.g., lower extremity fracture. 4. Forearm platform crutches: allow weight bearing 4. Four-point gait: a slow gait pattern in which one on the forearm; used for patients who are unable to crutch is advanced forward and placed on the bear weight through their hands, e.g., patients with floor, followed by advancement of the opposite arthritis; platform can also be attached to walkers. leg; then the remaining crutch is advanced forward followed by the oppo ite remaining leg; requires 5. Crutch tips: rubber, about 1.5 inches in diameter; the use of two assistive devices (crutches or provide suction, minimize slippage. canes); provides maximum stability with three points of support while one limb is moving. C. Walkers: widen base of support, provide increased 5. Swing-to gait: both crutches are advanced forward lateral and anterior stability, can reduce weight-bear- together; weight is shifted onto hands for support ing on one or both lower extremities; easy to use; fre- and both legs are then swung forward to meet the quently prescribed for patients with debilitating con- crutches; requires the use of two crutches or a ditions, poor balance, or lower extremity injury when walker; indicated for individuals with limited use use of crutches is precluded, e.g., elderly patients. of both lower extremities and trunk instability. 1. Type of walkers. 6. Swing-through gait: both crutches are advanced a. Folding (collapsible): facilitate mobility in the forward together; weight is shifted onto the hands community, cars. for support and both legs which are swung forward b. Rolling (wheeled): available with either two or beyond the point of crutch placement; requires the four wheels (four wheels require hand brake to use of two crutches; both swing-to and swing- provide added stability in stopping); facilitates through gaits are used for bilateral lower extremi- walking as a continuous movement sequence. ty involvement, and trunk instability, e.g., patient c. Stair climbing walker: has two posterior exten- with paraplegia, spina bifida. Not as safe as swing- sions and additional handgrips off of the rear to gait. legs for use on stairs. 7. Stairs. d. Reciprocal walkers: hinged, allows advance- a. Ascent: the uninvolved leg always goes up ment of one side of walker at a time; used with first, followed by the crutche (or cane) and the reciprocal gait patterns, reciprocating orthoses. involved leg together. e. Hemi walker: modified for use with one hand only. f. Attachments: fold-down seats, carrying baskets. 2. Measuring: same as for cane.

324 the anterior margin of the shoe for ease of application. b. Descent: the crutches (or cane) and involved leg c. Bal (Balmoral) opening: has stitched down go down first, followed by the uninvolved leg. vamps, not suitable for orthotic wear. 2. Foot orthoses (Fa): may be attached to the interi- c. Mnemonic devices to teach patient: \"The good or of the shoe (e.g., an inserted pad) or exterior to go to heaven, the bad go to hell.\" \"Up with the the shoe (e.g., Thomas heel). good, down with the bad.\" a. Soft inserts (i.e. viscoelastic pIa tic or rubber pads or relief cut-outs) reduce areas of high E. Guarding: protecting the patient from falling; loading, restrict forces, and protect painful or requires the use of a gait belt for initial training for sensitive areas of the feet. most patients. (1) Metatar al pad: located posterior to 1. Level surfaces: stand slightly behind and to one side, typically on the more involved side. metatar al heads; takes pre sure off the 2. Stairs: therapist is positioned below the patient. metatarsal heads and onto the metatarsal a. Ascent: stand behind and slightly to the shafts; allows more push off in weak or involved side. inflexible feet. b. Descent: stand in front and slightly to the (2) Cushion heel: cushion and absorbs forces involved side. at heel contact; used to relieve strain on 3. Sit-to-stand transfers: stand to one side and slight- plantar fascia in plantar fasciitis. ly behind the patient; increased levels of assistance (3) Heel-spur pad. may require therapist to stand in front of patient. b. Longitudinal arch supports: prevent depression of the subtalar joint and correct for pe planus m. Orthotics (flat foot); flat foot can be flexible or rigid. (1) UCBL (University of California Bio- A. General Concepts mechanics Laboratory) insert: a semirigid 1. Orthosis is a device used to: plastic molded insert to correct for flexible a. Correct malalignment and prevent deformity. pes planus. b. Restrict or assist motion. (2) Scaphoid pad: used to support the longitu- c. Transfer load to improve function. dinal arch. d. Reduce pain. (3) Thomas heel: a heel wedge with an extend- 2. Splint: a temporary device that may serve the same ed anterior medial border used to support functions; materials generally not as durable, able the longitudinal arch and correct for flexi- to withstand prolonged use. ble pes valgu (pronated foot). 3. Three-point pressure principle: forms the mechanical c. Posting. basis for orthotic correction; a single force is placed (1) Rearfoot posting: alters the position of the at the area of deformity or angulation; two addition- subtalar joint (STJ), or rearfoot, from heel- al counterforces act in the opposing direction. strike to footflat. Must be dynamic, control 4. Alignment: correct alignment permits effective but not eliminate STJ motion. function. (a) Varus post (medial wedge): limits or a. Minimizes movement between limb and orthoses (pistoning). controls eversion of the calcaneus and b. Minimizes compression on pressure sensitive internal rotation of the tibia after heel- tissues. strike. Reduces calcaneal eversion dur- ing running. B. Lower-Limb Orthoses: Componentsrrerminology (b) Valgus post (lateral wedge): controls 1. Shoes: the foundation for an orthosis; shoes can the calcaneus and ubtalar joint that are reduce areas of concentrated pressure on pressure excessively inverted and supinated at sensitive feet. heelstrike. a. Traditional leather orthopedic shoes or athletic (2) Forefoot posting: supports the forefoot. sneakers can be worn with orthoses; attach- (a) Medial wedge prescribed for forefoot ments can be external (to the outer part of a varus. leather shoe's sole) or internal (a molded shoe insert). b. Blucher opening: has vamps (the flaps contain- ing the lace stays) that open wide apart from

(b) Lateral wedge prescribed for forefoot Functional Training, Equipment & Devices 325 valgus. determines the limits of ankle plantar (3) Contraindicated in the insensitive foot. flexion. In an AFO, if the stop is set to d. Heel lifts (or heel platform). allow slight plantar flexion (approxi- mately 5°), knee extension results; can (I) Accommodates for leg length discrepancy; be used to control for an unstable knee can be placed inside the shoe (up to Y13 that buckles; if the stop is set to allow inch) or attached to the outer sole. too much plantar flexion, recurvatum or knee hyperextension could result. (2) Accommodates for limitation in ankle joint (d) Solid AFO: limits all foot and ankle dorsiflexion. motion. (4) Dorsiflexion assistance. e. Rocker bar: located proximal to metatarsal (a) Spring assist (Klenzak housing): dou- heads; improves weight shift onto metatarsals. ble upright metal AFO with a single anterior channel for a spring assist to f. Rocker bottom: builds up the sole over the aid dorsiflexion. metatar al heads and improves push off in (b) Posterior leaf spring (PLS): a plastic weak or inflexible feet. May also be used with AFO that inserts into the shoe; widely insensitive feet. used to prevent drop foot. (5) Varus or valgus correction straps (T straps): 3. Ankle-Foot Orthoses, (AFOs): consist of a shoe control for varus or valgus forces at the attachment, ankle control, uprights and a proximal ankle. Medial strap buckles around the lat- leg band. eral upright and corrects for valgus; lateral a. Shoe attachments. strap buckles around the medial upright (1) Foot plate: a molded plastic shoe insert; and corrects for varus. allows application of the brace before c. Uprights and attachments (bands or shells). insertion into the shoe, ease of changing (I) Conventional AFOs have metal uprights shoes of same heel height. (aluminum, carbon graphite, or steel) and a (2) Stirrup: a metal attachment riveted to the hinged ankle joint allowing plantarflexion sole of the shoe; split stirrups allow for and dorsiflexion. Provides maximum sup- shoe interchange; solid stirrups are fixed port; if the patient's condition is changing permanently to the shoe and provide for (e.g., peripheral edema), conventional maximum stability. metal AFOs may be easier to alter to b. Ankle controls. accommodate changes than molded AFO's. (I) Free motion: provides mediolateral stabili- (a) Double metal uprights extend upwards ty while allowing free motion in dorsiflex- from the ankle on both sides of the leg ion and plantar flexion. and attach to a calf band. (2) Solid Ankle: allows no movement; indicat- (b) Conventional AFO, calf band (metal ed with severe pain or instability. with leather lining or plastic); provides (3) Limited motion: allows motion to be for proximal stabilization on leg; anteri- restricted in one or both directions. or opening and buckle or Velcro closure. (a) Bichannel adjustable ankle lock (2) Molded AFOs are made of molded plastic (BiCAAL): an ankle joint with the and are lighter in weight and cosmetically anterior and posterior channels that can more appealing; contraindicated for indi- be fit with pins to reduce motion or viduals with changing leg volume. springs to assist motion. (a) Posterior leaf spring (PLS):has a flexi- (b) Anterior stop (dorsiflexion stop): ble, narrow posterior shell; functions determines the limits of ankle dorsi- as dorsiflexion assist; holds foot at 90 flexion. In an AFO, if the stop is set to degree angle during swing; displaced allow slight dorsiflexion (approximate- during stance; provides no medial-lat- ly 5°), knee flexion results; can be used eral stability. to control for knee hyperextension; if the stop is set to allow too much dorsi- flexion, knee buckling could result. (c) Posterior stop (plantar flexion stop):

326 a spring-loaded posterior projecti< (lever or ring) that allows the patient (b) Modified AFO: has a wider posterior unlock the knee by pulling up or hool shell with trimlines just posterior to ing the pawl on the back of a chair ar malleoli; foot plate includes more of pushing it up; adds bulk and m, medial and lateral borders of foot; pro- unlock inadvertently with posteric vides more medial-lateral stability knee pressure. (control of calcaneal and forefoot (3) Knee stability. inversion and eversion). (a) Sagittal stability achieved by bands c straps used to provide a posterior: (c) Solid ankle AFO: has widest posterior directed force. shell with trimlines extending forward • Anterior band or strap (knee cap to malleoli; controls (prevents) dorsi- flexion, plantarflexion, inversion and attaches by four buckles to met eversion. uprights; may restrict sittin: increases difficulty in putting c (d) Spiral AFO: a molded plastic AFO that KAFO. winds (spirals) around the calf; pro- • Anterior bands: pretibial or supral vides limited control of motion in all atellar or both. planes. (b) Frontal plane controls: for control ( genu varum or genu valgum; may t (e) Hinged plastic AFOs are available. achieved by the addition of. (3) Specialized AFOs. • Posterior plastic shell. • Older braces utilize valgum (media (a) Patellar-tendon-bearing brim: allows or varum (lateral) correction stra~ for weight distribution on the patellar which buckle around the opposil shelf similar to patellar-tendon-bearing metal upright: less effective as cor prosthetic socket; reduces weight bear- trois than plastic shell. ing forces through the foot. b. Thigh bands. (1) Proximal thigh band. (b) Tone-reducing orthosis: molded plastic (2) Quadrilateral or ischial weight bearin AFO that applies constant pressure to brim: reduces weight bearing through tb spastic or hypertonic muscles (plan- limb. tarflexors and invertors); snug fit is (a) Patten bottom: a distal attachment adde essential to achieve the benefits of to keep the foot off the floor; provide reciprocal inhibition. 100% unweighting of the limb; a lift i required on the opposite leg, e.g., use 4. Knee-Ankle-Foot Orthosis, KAFO: consists of a with Legg-Perthes disease. shoe attachment, ankle control, uprights, knee c. Specialized KAFOs. control, and bands or shells for the calf and thigh. (1) Craig-Scott KAFO: commonly used appli a. Knee controls. ance for individual with paraplegia; con (1) Hinge joint: provides mediolateral and sists of shoe attachments with reinforce hyperextension control while allowing for foot plates, BiCAAL ankle joints set i flexion and extension. slight dorsiflexion, pretibial band, pa\\\\ (a) Offset: the hinge is placed posterior to knee locks with bail release, and singl the weight bearing line (trochanter- thigh bands. knee-ankle, TKA line); assists exten- (2) Oregon orthotic system: a combination 0 sion, stabilizes knee during early stance; plastic and metal components allows fo patients may have difficulty on ramps triplanar control in three planes of motie where knee may flex inadvertently. (sagittal, frontal, and transverse). (2) Locks. (3) Fracture braces: a KAFO device with a cal (a) Drop ring lock: ring drops over joint when knee is in full extension to pro- vide maximum stability; a retention button may be added to hold the ring lock up, permit gait training with the knee unlocked. (b) Pawl lock with bail release: the pawl is

or thigh shell that encompasses the fracture Functional Training, Equipment & Devices 327 site and provides support. (4) Functional electrical stimulation (FES) pression. orthosi : orthotic use and functional ambu- (6) Can be used in other areas of the body such lation is facilitated by the addition of elec- trical stimulation to specific muscles; the as elbow, thigh and so on. pattern and sequence of muscle activation 6. Hip-Knee-Ankle Orthoses, HKAFOs: contain a by portable stimulators is controlled by an externally worn miniaturized computer hip joint and pelvic band added to a KAFO. pack; requires full passive range of motion a. Hip joint: typically a metal hinge joint. good functional endurance; in limited use with individuals with paraplegia, drop foot; (1) Controls for abduction, adduction, rotation. also scoliosis. (2) Controls for hip flexion when locked, typi- d. Standing frames. (I) Standing frames: allows for standing with- cally with a drop ring lock; a locked hip out crutch support; may be stationary or restricts gait pattern to either a swing-to or attached to a wheeled mobility base. swing-through. (2) Parapodium: allows for standing without b. Pelvic attachments: a leather covered, metal crutch support; also allows for ease in sit- pelvic band; attaches the HKAFO to the pelvis ting with the addition of hip and knee joints between the greater trochanter and iliac crest; that can be unlocked, e.g., used with chil- adds to difficulty in donning and doffing; adds dren with myelodysplasia. weight and increases overall energy expendi- 5. Specialized knee orthoses (KO). ture during ambulation. a. Articulated knee orthoses: control knee motion 7. Specialized THKAFOs: contains a trunk band and provide added stability. added to a HKAFO. (I) Post-surgery KO protects repaired liga- a. Reciprocating gait orthosis (RGO): utilizes ments from overload. plastic molded solid ankle orthoses with locked (2) Functional KO is worn long-term in lieu of knees, plastic thigh shells, a hip joint with surgery or during selected activities (sports pelvic and trunk bands; the hips are connected competitions). by steel cables which allow for a reciprocal gait (3) Examples include Lenox Hill, Pro-AM, pattern (either four point or two point); when Can-Am, Don Joy. the patient leans on the supporting hip, it forces b. Swedish knee cage: provides mild control for it into extension while the opposite leg is excessive hyperextension of the knee. pushed into flexion; allows limb advancement. c. Patellar stabilizing braces. 8. Specialized lower limb devices. (I) Improve patellar tracking; maintain align- a. Denis Browne splint: a bar that connects two ment. shoes which can swivel; used for correction of (2) Lateral buttress (often made of felt) or strap club foot or pes equinovarus in young children. po itions patella medially. b. Frejka pillow: keeps hips abducted; used for (3) A central patellar cutout may help position- hip dysplasia or other conditions with tight ing and minimizes compression. adductors in young children. d. Neoprene sleeves. c. Toronto hip abduction orthosis: abducts the (I) Nylon-coated rubber material. hip; used in treatment of Legg-Calve-Perthes (2) Provide compre sion, protection and pro- disease. prioceptive feedback. C. Spinal (trunk) Orthoses: ComponentsITerminology (3) Provide little stabilization unless metal or 1. Corset: provides abdominal compression, increases plastic hinges are added. intra-abdominal pressures; assists respiration in indi- (4) Retains body heat which may increase viduals with spinal cord injury; relieves pain in low- local circulation. back disorders; sacroiliac support, e.g., pregnancy. (5) A central cutout minimizes patellar com- 2. Lumbosacral orthoses (LSO): control or limit lum- bosacral motions. a. Lumbosacral Flexion, Extension, Lateral con- trol orthoses, LS FEL (Knight spinal): includes pelvic and thoracic bands to anchor the ortho- sis with two posterior uprights, two lateral uprights and an anterior corset.

328 racic or lower coliosis curves of 40 degrees or less; also used to treat spondylolisthesis and b. Plastic lumbosacral jacket: provides maximum conditions of severe trunk weakness, e.g., mus- support by spreading the forces over a larger cular dystrophy. area; more cosmetic but hotter. D. Upper-Limb Orthoses: Componentslferminology 1. Functional considerations: most UL orthoses are 3. Thoracolumbosacral orthoses (TLSO): control or directed toward creating usable prehension, func- limit thoracic and lumbosacral motions. tional hand position. a. Thoracolumbosacral Flexion, Extension con- 2. Passive (static) positioning devices: generally trol orthosis, TLS FE (Taylor brace): includes made out of a variety of low-temperature plastics, components of a LS FEL with the addition of i.e., Orthoplast, Hexalite. axillary shoulder straps to limit upper trunk a. Resting splint (cock-up splint): an anterior or flexion. palmar splint that position the wrist and hand b. Plastic thoracolumbosacral jacket: provides in a functional position. maximum support and control of all motions; (1) Wrist can be held in neutral or in 12 to 20 used in individuals recovering from spinal cord injury; Allows for early mobilization out-of- degrees wrist extension. bed and functional training. (2) Fingers supported, all phalanges lightly c. Jewett (TLSO): limits flexion, but encourages hyperextension (lordosis); used for compres- flexed, with thumb in partial opposition sion fractures of the spine. and abduction. (3) Used for patients with rheumatoid arthritis, 4. Cervical orthoses (CO): control or limit cervical fractures of carpal bones, Colies - fracture, motion. carpal tunnel syndrome, stroke with paral- a. Soft collar: provides minimal levels of control ysis, etc. of cervical motions, e.g., cervical pain, b. Dorsal wrist splint: frees the palm for feeling whiplash. and grasping by the use of grips that curve b. Four-poster orthosis: has two plates (occipital around over the second and fifth metacarpal and thoracic) with two anterior and two poste- heads; allows for the attachment of dorsal rior posts to stabilize the head; used for moder- devices (i.e. rubber bands) to make it a dynamic ate levels of control in individuals with cervical device. fracture/spinal cord injury. c. Airplane splint: positions the patient's arm out c. Halo orthosis: attaches to the skull by screws, to the side at about 90 degrees of abduction, the four uprights connect from the halo to a tho- elbow is flexed to 90 degrees; the weight of the racic band or plastic jacket; provides maximal outstretched arm is borne on a padded lateral control for individuals with cervical trunk bar and iliac cre t band; a trap holds the fracture/spinal cord injury; allows for early device across the trunk; used to immobilize the mobilization out-of-bed and functional training. shoulder following fracture or injury when d. Minerva orthosis: a rigid plastic appliance that strapping to the chest is not desirable, or with provides maximum control of cervical burns. motions; uses a forehead band without screws. 3. Dynamic devices. a. Wrist-driven prehension orthosis (flexor hinge 5. Specialized trunk orthoses. orthosis): assists the patient in using wrist a. Milwaukee orthosis: a cervical, thoracic, lum- extensors to approximate the thumb and fore- bosacral orthosis (CTLSO) used to control sco- fingers (grip) in the absence of active finger liosis; it has a molded plastic pelvic jacket and flexion, e.g., facilitate tenodesis grasp in the one anterior and two posterior uprights extend- patient with quadriplegia. ed to a superior neck or chest ring; pads and b. Motor driven flexor hinge ortho is: complex straps are used to apply pressure to areas of control systems that allow for gra p; not gener- convexity of spinal curves; bulky, less cosmet- ally in widespread use. ic; may be used for all kyphotic and scoliotic E. Physical Therapy Intervention: a physical therapist curves of 40 degrees or less. functions as a member of an orthotic clinic team that b. Boston orthosis (TLSO): a low profile, molded plastic orthosis for scoliosis; more cosmetic, can be worn under clothing; used for rnid-tho-

includes the physician, orthotist, and therapists. Functional Training, Equipment & Devices 329 1. A essment. • Ankle joint: at tip of malleolus. a. Preorthotic assessment and prescription evaluate: • Plastic shells or metal uprights, (1) Joint mobility. (2) Sensation. thigh and calf bands: conform to (3) Strength and motor function. contours of limb. (4) Functional level. • No undue tissue pressure or restric- (5) P ychological tatus. tion of function. (3) Dynamic assessment. b. Orthotic pre cription. (a) Fit and function during ADLs, func- (1) Consider the patient's abilities and needs. tional mobility skills, e.g., sit-to-stand. (a) Level of impairments, functional limi- (b) Fit and function during gait. tations, disability. 2. Orthotic training. (b) Status: consider if the patient's condi- a. Instruct the patient in procedures for orthotic tion is permanent or changing. maintenance: routine skin inspection and care. (2) Consider level of function, current lifestyle. b. Ensure orthotic acceptance. (a) Consider if the patient is going to be a (1) Patient should clearly understand func- community ambulator versus a house- tions, limitations of an orthosis. hold ambulator. (2) Can use support groups to assist. (b) Consider recreational and work-related c. Teach proper application (donning-doffing) of needs. the orthosis. (3) Consider overall weight of orthotic d. Teach proper use of the orthosis. devices, energy capabilities of patient. (1) Balance training. Some individuals quickly abandon their (2) Gait training. orthoses in favor of wheelchairs because of (3) Functional activities training. the high energy demands of ambulating e. Reassess fit, function, and construction of the with orthoses, e.g., patients with high levels orthosis at periodic intervals; assess habitual of paraplegia. use of the orthosis. (4) Consider manual dexterity, mental capacity 3. Selected orthotic gait deviations. of the individual. The donning and use of a. Lateral trunk bending: patient leans toward the devices may be too difficult or complicated orthotic side during stance. Possible causes: for some individuals. KAFO medial upright too high; insufficient (5) Consider the pressure tolerance of the skin shoe lift; hip pain, weak or tight abductors on and tissues. the orthotic side; short leg; poor balance. (6) Consider use of a temporary orthosis to b. Circumduction: during swing, leg swings out assess likelihood of functional independ- to the side in an arc. Possible causes: locked ence, reduce costs, e.g., patients with high knee; excessive plantar flexion (inadequate levels of paraplegia. stop, plantar flexion contractures); weak hip flexors or dorsiflexors. All of these could also c. Orthotic asse sment check-out. cause vaulting (rising up on the sound limb to (1) Ensure proper fit and function; construc- advance the orthotic limb forward). tion of the ortho i . c. Anterior trunk bending: patient leans forward (2) Static assessment. during stance. Possible causes: inadequate (a) Check alignments for lower limb knee lock; weak quadriceps; hip or knee flex- orthoses: In midstance, foot should be ion contracture. flat on floor. d. Posterior trunk bending: patient leans backward • Orthotic hip joint: 0.8 cm anterior during stance. Possible cases: inadequate hip and superior to greater trochanter. lock; weak gluteus maximus; knee ankylosis. • Medial knee joint: about 2 cm above e. Hyperextended knee: excessive extension during joint space, vertically midway stance. Possible causes: inadequate plantar flex- between medial joint space and ion stop; inadequate knee lock; poor fit of calf adductor tubercle. band (too deep); weak quadriceps; loose knee

330 Foam underwrap or stockinette may be used. 4. Lubricated pads should be placed over areas of ligaments or extensor spasticity; pes equinus. f. Knee instability: excessive knee flexion during potential blister formation from friction. e.g., heel and lace-area pads on the foot. stance. Possible causes: inadequate dorsiflex- 5. Occlusive dressings hould be applied over wounds ion stop; inadequate knee lock; knee and/or hip or skin conditions to be covered by the tape. flexion contracture; weak quadriceps or insuf- 6. Skin adherent such as benzoin should be applied to ficient knee lock; knee pain. increase adhesion of the tape and aid in toughen- g. Foot slap: foot hits the ground during early ing the skin to decrease irritation. stance. Possible causes: inadequate dorsiflexor C. Application assist; inadequate plantarflexor stop; weak dor- I. If the part has not been previously injured it should siflexors. be taped in a neutral position. h. Toes first: on toes posture during stance. 2. Injured ligaments should be held in a shortened Possible causes: inadequate dorsiflexor assist; position. inadequate plantarflexor stop; inadequate heel a. Lateral or inversion ankle sprains should be lift; heel pain, extensor spasticity; pes equinus; short leg. taped in an everted position. I. Flat foot: contact with entire foot. Possible b. Tape should follow body contours and be causes: inadequate longitudinal arch support; pes planus. applied primarily from medial to lateral in the j. Pronation: excessive medial foot contact dur- case of an inversion sprain. ing stance, valgus position of calcaneus. 3. Tape should be applied with even pressure with Possible causes: transverse plane malalign- overlap of previous tape strip by one-half. ment; weak invertors; pes valgus; spasticity; 4. Circular strapping should be applied very cautious- genu valgum. ly becau e of potential circulatory compromise. k. Supination: excessive lateral foot contact dur- 5. Avoid crease and folds. ing stance, varus po ition of the calcaneus. 6. If tape is too tight, adjust by removing or modify- Possible causes: transverse plane malalign- ing strips or reapply. ment; weak evertors; pes varus; genu varum. D. Complications 1. Excessive stance width: patient stands or walks I. Allergic reactions to the tape. with a wide base of support. Possible causes: 2. Skin irritation. KAFO height of medial upright too high; 3. Reduced circulation. HKAFO hip joint aligned in excessive abduc- 4. If the tape is too tight it might compromise the tion; knee is locked; abduction contracture; ability of the athlete, performing artist, patient, poor balance; sound limb is too short. client, etc. to perform the skill intended. 5. Tape may lose its effectiveness in an hour or so IV. Adhesive Taping and may need to be reapplied. A. Purposes V. Prosthetics I. Limit range of motion of specific joints. 2. Support injured body segment. A. General Concepts 3. Secure protective devices such as felt, foam, gel or I. Prosthesis: a replacement of a body part with an plastic padding, ortboplast or plastazote. artificial device; an artificial limb. 4. Keep dressings and bandages in place and secure. 2. Levels of amputation. 5. Preventive support for a joint that is at risk. a. Transmetatarsal amputation: partial foot ampu- 6. Realign position and reduce pain, e.g., McConnell tation. treatment for patellofemoral pain. b. Ankle disarticulation (Syme's): amputation 7. May enhance proprioception. through the ankle joint; heel pad is preserved and attached to distal end of tibia for weight B. Preparation bearing. 1. Part to be taped should be properly positioned and c. Transtibial amputation: below-knee (BK) supported. amputation; ideally 20-50% of the tibial length 2. Select appropriate type and width of tape. is spared; short transtibial is less than 20% of 3. Body hair hould be shaved, skin should be clean.

tibial length. Functional Training, Equipment & Devices 331 d. Knee disarticulation: amputation through the (4) Socks. knee joint, femur is intact. (a) Used in every suspension system e. Transfemoral amputation: above-knee (AK) except suction. (b) Provide a soft interface between the amputation; ideally 35-60% of the femoral residual limb and the socket; minimize length is spared; short transfemoral is less than shear forces between socket and skin. 35% of femoral length. (c) Changing sock thickness or adding f. Hip disarticulation: amputation of entire lower more socks can assist in accommodat- limb, pelvis is preserved. ing to changes in volume of residual g. Hemipelvectomy: amputation of entire lower limb, prevent pistoning. limb, lower half of the pelvis is resected. (d) Excessive thickness of socks (greater h. Hemicorporectomy: amputation of both lower than 15 ply) can alter fit and weight limbs and pelvis below L4,L5 level. bearing of the socket. I. Transradial amputation: below-elbow (BE) amputation. b. Terminal device (TD). J. Elbow disarticulation: amputation through the (1) Functions to provide an interface between elbow joint. the amputee's prosthesis with the external k. Tran humeral amputation: above-elbow (AE) environment. amputation. (2) Lower limb prosthesis: TD is a foot. 1. Shoulder disarticulation: amputation through (3) Upper limb prosthesis: TD is a hook or the shoulder joint. hand. 3. Components: all prosthetic devices contain a sock- et and terminal device with varying components in B. Lower-Limb Prosthetic Devices (LLPs) between. 1. Partial-foot prosthesis. a. Sockets are custom-molded to the residual a. Plastic foot replacement: restores foot length, limb; total contact is desired with the load dis- protects amputated stump. tributed to all the tissues, assists in circulation, h. Function may be assisted by the addition of a and provides maximal sensory feedback. rocker bottom or plastic calf shell. (I) Functions to: 2. Trans-tibial (below-knee) prosthesis. a. Foot-ankle assembly. (a) Contain the residual tissues. (1) Functions to: (b) Provide a means to suspend the pros- (a) Absorb shock at heel strike. (b) Plantarflex in early stance, permit thetic limb. metatarsophalangeal hyperextension in (c) Transfer forces from the prosthesis to late stance. (c) Cosmetic replacement of foot. the residual limb. (2) SACH foot: (solid ankle cushion heel). (2) Selective loading: pressure tolerant areas (a) The most commonly prescribed foot; non-articulated, contains an energy are built up to increase loading (i.e., build- absorbing cushion heel and internal ups for tendon-bearing areas) while pres- wooden keel that limits sagittal plane sure sensitive areas are relieved to decrease motion primarily to plantarl1exion. loading (i.e., reliefs for bony prominences, (b) Permits a very small amount of medio- nerves, tendons). lateral (frontal plane) and transverse (3) Types. plane motion. (a) A ocket made of hard plastic, with a (c) Assists in hyperextension of knee (knee stability) during stance. soft polyethylene foam liner is the (3) SAFE foot (solid-ankle flexible): a flexible most common type; removable liners non-articulated foot (similar to SACH); aid in ease of prosthetic donning and permits more non-sagittal plane motions; adjustment. prescribed for more active individuals. (b) Flexible sockets: are made of soft, pli- (4) Flex-foot: a leaf-spring shank (not a foot) able thermoplastic material within a rigid frame; used for most AK sockets because of better suspension.

332 and removal; more cosmetic (no buckles or straps); provides increased mediolateral used with an endoskeletal prosthesis; the stability. long band of carbon fiber originates direct- (3) Supracondylar/Suprapatellar (SC/SP): sim- ly from the shank; stores energy in early ilar to SC but with a high anterior wall; stance for later use during push-off; pre- assists in uspension of short residual scribed for more active individuals. limbs. (5) Single axis foot: an articulated foot with (4) Thigh corset suspension: a hinged joint the lower shank; motion is controlled by with metal uprights attached to a thigh anterior and posterior rubber bumpers that corset; provides larger surface for weight limit dorsiflexion and plantarfiexion; more bearing; prescribed for individuals with stable (permits only sagittal plane motion); sensitive skin on the residual limb; the knee may be prescribed for individuals with joint allows for knee control (locks); pi - bilateral transfemoral amputations. toning may be a problem. b. Shank. 3. Transfemoral (above-knee) prosthesis. (1) Functions to: a. Knee unit. (a) Provide leg length and shape. (1) Axis. (b) Connects and transmits weight from (a) Single axis: permits knee motions to socket to foot. occur around a fixed axis; knee flexion (2) Exoskeletal: conventional components, is needed during late stance and swing, and during sitting and kneeling. usually made of wood with a plastic lami- (b) Polycentric systems (multiple axis): nated finish; colored for cosmesis; durable. changing axis of motion allows for (3) Endoskeletal: contains a central metal adjustments to the center of knee rota- shank (aluminum, titanium and other high- tion; more stable than single axis strength alloys) covered by soft foam and joints; complex, not widely used. external stocking; offers improved cosme- (2) Friction devices: control knee motions, sis; modular components allows for provide resistance to pendular motion at increa ed ease of prosthetic adjustment. the knee. c. Socket. (a) Constant friction: continuous resistance (1) PTB socket (patellar tendon bearing): a is provided by a clamp acting on the total contact socket that allows for moderate knee mechani m; friction device can be loading over the area of the patellar tendon. easily adjusted by crews; usually pre- (2) Pressure sensitive areas of the transtibial scribed for older individuals who do residual limb include: not vary their gait speeds greatly. (a) Anterior tibia. (b) Variable friction: resistance can be reg- (b) Anterior tibial crest. ulated to the demands of the gait cycle; (c) Fibular head and neck. at early swing, high resistance is need- (d) Peroneal nerve. ed to prevent exce ive heel rise; dur- (3) Pressure tolerant areas of the typical trans- ing midswing when the leg swings for- tibial residual limb include: ward, friction demands are minimal; at (a) Patellar tendon. late swing, friction is increa ed to pre- (b) Medial tibial plateau. vent terminal swing impact. (c) Tibial and fibular shafts. (c) Hydraulic knee units (fluid controlled) (d) Distal end (rarely, may be sensitive). or pneumatic knee units (air con- d. Suspension. trolled): adjusts resi tance dynamically (1) Supracondylar leather cuff suspension: to the individual' walking speed; pre- buckles over the femoral condyles; widely scribed for younger, more active indi- used, easily adjusted. viduals; heavier, more complicated; (2) Supracondylar socket suspension (SC): increased maintenance, cost. medial and lateral walls of the socket extend up and over the femoral condyles; a removable medial wedge assists in donning

(3) Knee stabilization in extension achieved by Functional Training, Equipment & Devices 333 (a) Prosthetic alignment: the knee center is aligned posterior to the trochanter- (3) Pressure tolerant areas of the typical trans- knee- ankle (TKA) line; a knee aligned femoral residuallirnb. further posterior will be very stable (a) Ischial tuberosity. (will not flex easily); may be pre- (b) Gluteals. scribed for short residual limbs; an (c) Lateral sides of residuallirnb. unstable knee may occur if the knee (d) Distal end (rarely, may be sensitive). falls anterior to the TKA line. (b) Manual lock: prescribed for individu- c. Suspension. als who require a constantly locked (1) Suction suspension: suction is employed to knee, e.g., weakness of hip extensors; maximize contact and suspension; air is difficulty with clearance of the leg dur- pumped out through a one-way air release ing swing can be controlled by short- valve located at the socket's bottom; suc- ening the total prosthetic limb length tion suspension can be total or partial (indi- about I cm. vidual wears a sock). (c) Friction brake: a device that increases (2) Strap suspension: adjustable, readily friction at midstance to prevent knee accommodates to volume changes. flexion, but permits smooth knee Disadvantage: pistoning when it is the sole motion through the rest of the gait type of suspension. cycle. (a) Silesian bandage: a strap that anchors (d) Extension aid: an external elastic strap the TKA prosthesis by reaching around or internal coiled spring that assists in the pelvis (below iliac crest); controls terminal knee extension during late rotatory motions. wing. (3) Hinge suspension: hinged hip joint attached to a metal/leather pelvic band b. Socket. anchored around the pelvis. (1) Quadrilateral socket: most commonly pre- (a) Adds controls for medialllateral tability cribed AK socket; quadrilateral in shape. of hip (rotation, abduction/adduction). (a) Contains a broad horizontal posterior (b) Reduces Trendelenburg gait deviation. shelf for seating of the ischial tuberosity (c) Disadvantages: adds extra weight and and gluteals. bulk. (b) The medial wall is the same height as the posterior wall while the anterior 4. Knee disarticulation prosthesis. and lateral walls are 2\\12-3 inches higher. a. Functional, allows weight bearing on the distal (c) A posterior directed force is provided end of the femur. by the anterior and lateral walls to b. Problems with cosmesis, added thigh length ensure proper seating. with the knee joint attached, especially notice- (d) Scarpa's bulge: an area built up on the able in sitting. anterior wall to distribute forces across c. Lower shank is shortened to balance leg length the femoral triangle. in standing. (e) Reliefs are provided for the adductor longus tendon, hamstring tendons and 5. Hip disarticulation prosthesis. sciatic nerve, gluteus maximus and a. Socket is molded to accommodate the pelvis; rectus femoris. weight bearing occurs on ischial seat, iliac (2) Pre ure ensitive areas of the typical trans- crests. femoral re idual limb. b. Endoskeletal components frequently used, (a) Distolateral end of the femur. decreases weight of prosthesis. (b) Pubic symphysi . c. Stability achieved with hip extension aid; poste- (c) Perineal area. rior placement of knee joint with anterior place- ment of the hip joint to the weight bearing line. 6. Immediate Post-operative Prosthesis (rigid dressing). a. Plaster of Paris socket is fabricated in the oper- ating room with the capability to attach a foot and pylon.

334 (a) Circumference measurements: check for edema. b. Advantages. (1) Allows early, limited weight-bearing (b) Length: bone, oft tissue length. ambulation within days of surgery. (c) Shape: should be cylindrical or coni- (2) Limits postoperative sequelae: edema, postoperative pain. cal; check for abnormalities, i.e., bul- (3) Enhances wound healing. bous end, dog ears, adductor roll. (4) Allows for earlier fit of permanent prosthesis. (3) Check vascular tatu of ound limb, resid- uallimb: pul e , color, temperature, troph- c. Limitations. ic changes, pain/intermittent claudication. (1) Requires skilled application and close (4) ROM: active and passive; examine for con- monitoring. tractures that might interfere with prosthet- (2) Does not allow for daily wound inspection; ic prescription, e.g., hip and knee flexion contraindicated for older patients with car- contractures. diovasular compromise and increased risk (5) Sensation. for wounds. (a) Proprioception, visual, vestibular func- tion, contributions to balance; loss of C. Upper-Limb Prosthetic Devices (ULPs) proprioception in the amputated limb 1. Below-elbow (BE) prosthesis: contains a terminal will necessitate a compensatory shift to device (TD), wrist and forearm socket, harness the other senses for balance control. system. (b) Phantom limb sensation: a feeling of 2. Above-elbow (AE) prosthesis: in addition, con- pressure or pare thesia as if corning tains an elbow, and arm socket. from the amputated limb. Sensations 3. Conventional system: power for voluntary opening are normal, not painful; may last for of the TD (hook or hand) is transmitted by a cable the lifetime of the individual. from a figure-of-eight shoulder harness to the TD; (c) Phantom pain: an intense burning or rubber bands are used for closure and prehensile cramping pain; disabling, frequently trength; forearm rotation is done by manual interferes with rehabilitation. prepositioning of the TD. (6) Strength: strength of residuallirnb as toler- a. BE prosthesis: bilateral scapular abduction or ated; strength of the sound limb, trunk, ipsilateral flexion of the humerus are used to upper extremities needed for function. pull on the cable and force opening of the (7) Functional status. hook. (a) Functional mobility skills: bed mobili- b. AE prosthesis (dual control system): the same ty, transfers, wheelchair use. motions can be used to flex the elbow in the AE (b) Activities of daily living: basic, instru- prosthesis; when the elbow locks (by scapular mental (use of telephone, shopping, depression and humeral extension), the forces etc.). are then transmitted to operate the TD. (8) Cardiopulmonary function, endurance. 4. Externally powered system: microswitches (EMG (a) The shorter the amputation limb, the myoelectric devices) are activated by the same greater the energy demands, i.e., oxy- motions as conventional power systems; small gen consumption is increased 65% electric motors (battery powered) are activated to over normal walking in the patient with operate the TD. transfemoral amputation; similar to a. Improves ease of function, prehensile strength. fast walking in normal for the patient b. Adds weight, increased maintenance, cost. with transtibial amputation. (b) Functional capacity further limited by: D. Physical Therapy Intervention: ideally the physical concomitant di eases (e.g., cardiovas- therapist functions as a member of the prosthetic clinic cular disea e, diabete ), individual fit- team that includes physician, prostheti t, and therapists ness level, pain. 1. Preprosthetic management. (9) Neurologic factors. a. Preprescription examination. (a) Cognitive function. (1) Skin: inspect incision for healing; scar tis- sue; other lesions. (2) Residual limb.

(b) Check for neuropathy. Functional Training, Equipment & Devices 335 (c) Check for neuroma: an abnormal (b) Transfemoral: flexion, abduction, growth of nerve cells occurring in the external rotation of hip; counteract re idual limb after amputation. with regularly scheduled time in (lO)P ychosocial factors: motivation, adjust- prone-lying time. ment and acceptance, availability of sup- port systems. (7) Flexibility exercises. b. Preprosthetic training: goals and interventions. (a) Full AROM and PROM, active stretch- (1) Ideally begins pre-operatively and contin- ing especially in hip and knee exten- ues post-operatively. sion. (2) Facilitate psychological acceptance. (b) Flexibility of sound limb and trunk. (3) Post-operative dressings: applied to the residual limb; helps to limit edema, accel- (8) Strengthening: utilize a general strengthen- erate healing, reduce post-operative pain, ing exercise program with special emphasis shape the residual limb. on: (a) Elastic wraps: flexible, soft bandaging, (a) Hip extensors: especially for the inexpensive; requires frequent reappli- patient with transfemoral amputation. cation, with pressure greatest distal to (b) Knee extensors: the patient with trans- proximal; if wraps are allowed to tibial amputation. loosen, may have problems with (c) Hip abductors: for stance phase pelvic edema control; avoid circular wrapping stability. which produces a tourniquet effect. (d) Dynamic exercises: utilize gravity and (b) Stump shrinkers: flexible, soft, inex- body weight to provide resistance dur- pensive, readily available in different ing functional mat activities. sizes. (c) Semirigid dressings: Unna paste dress- (9) Functional mobility training. ing (zinc oxide, gelatin, glycerin and (a) Sit-to-stand transitions, transfers, calamine); applied in the operating standing. room. (b) Wheelchair independence. (d) Rigid dressings: plaster of Paris dress- (c) Hopping on the sound limb; mobility ing; applied in the operating room; a in the seated position, i.e. scooting for component of immediate postoperative patients with bilateral transfemoral fitting; allows for edema reduction and amputation. early ambulation with a temporary (d) Early walking with crutches or walker; prosthesis (pylon and foot). Good for consider early ambulation with a tem- patients who are young, and who are porary prosthesis. good candidates for a permanent pros- thesis. (l O)Bilaterallower extremity amputation. (4) Desensitizing activities: pressure, rubbing, (a) Wheelchair training important. Will be stroking, bandaging of the residual limb. primary means of locomotion. (5) Hygiene: inspection and care of the resid- (b) Prolonged wheelchair time increases uallimb. likelihood of hip and knee flexion con- (6) Positioning for prevention of contracture; tractures; prone positioning program is position to avoid include: important. (a) Transtibial: prolonged flexion and (c) Energy expenditure during prosthetic external rotation at the hip, knee flex- ambulation is increased dramatically; a ion; counteract with use of a posterior trial period with temporary prostheses board to keep knee straight while in can be used to evaluate ambulation wheelchair; regularly scheduled time potential with permanent prostheses; in prone-lying. especially useful with the elderly. (d) Bilateral transfemoral amputation: ambulation usually requires walker; loss of lower-extremity proprioception increase balance difficultie ; loss of knee extensor function will result in

336 smooth weight transfer from sound limb to prosthetic limb, continuous significant later difficulties with stair movement sequence. climbing, curbs, stepping. (b) Biofeedback training: limb load (e) Bilateral transfemoral amputation: devices to facilitate prosthetic weight patients can be fitted with shortened acceptance. prostheses (stubbies) consisting of a (c) Training with use of least assistive socket and foot component (modified device; parallel bars may interfere with rocker feet) with no knee joints; learning and independent ambulation increases ease of use and function; gen- in some patients. erally poor acceptance due to cosmesis. (5) Functional activities training: including 2. Prosthetic management. transfers, stairs, curbs, ramps, down and up a. Prosthetic check-out. from floor, recreational activities, etc. (1) Prosthesis: delivered as ordered, proper (6) Regular inspection and maintenance of the functioning; inspect both on and off the prosthesis. patient. (7) Hygiene: care of stump socks, interior of (2) Static assessment. the socket. (a) Alignment and comfort in standing, (8) Facilitate prosthetic acceptance. sitting. 3. Selected prosthetic gait deviations. (b) Leg length discrepancy: pelvis level. a. Transfemoral amputation. (c) Fit and suspension: pistoning when (1) Circumduction: the prosthesis swings out pelvis is lifted. to the side in an arc. Possible causes: a long (3) Dynamic assessment. prosthesis, locked knee, small or loose (a) Sit-to-stand transitions. socket, inadequate suspension, foot plantar (b) Gait: smooth, safe gait, absence of gait flexed; abduction contracture, poor knee deviations; gait speeds normally control. decrease to reduce high levels of energy (2) Abducted gait: prosthesis is laterally dis- expenditure. placed to the side. Possible causes: crotch (c) Stairs and inclines. or medial wall discomfort, long prosthesis, (4) Inspection of the residual limb with the low lateral wall or malalignment; tight hip prosthesis off. abductors. (a) Proper loading: transient redness is to (3) Vaulting: the patient rises up on the sound be expected in pressure tolerant areas limb to swing the prosthesis through. after prosthetic use. Possible causes: prosthesis too long, inade- (b) No redness should be seen in pressure quate suspension, socket too small, pros- sensitive areas. thetic foot set in too much plantarflexion, b. Prosthetic training: goals and interventions. too little knee flexion. (1) Donning and doffing of the prosthesis: (4) Lateral trunk bending during stance: the training specific to type of socket and type trunk bends toward the prosthetic side. of suspension. Possible causes: low lateral wall, short (2) Strengthening, flexibility exercises. prosthesis, high medial wall; weak abduc- (a) Emphasis on hip extension and knee tors, abductor contracture, hip pain, short extension (transtibial) with the pros- amputation limb. thesis on. (5) Forward flexion during stance: the trunk (3) Balance and coordination. bends forward. Possible causes: unstable (a) Symmetrical stance and weight bear- knee unit, short ambulatory aids; hip flex- ing on prosthetic limb. ion contracture. (b) Weight shifting to limits of stability. (6) Lumbar lordosis during stance: exaggera- (c) Dynamic balance control, e.g., step- tion of the lumbar curve. Possible causes: ping activities. insufficient support from anterior or poste- (4) Gait training. (a) Conventional training: focus on

rior walls, painful ischial weight bearing; Functional Training, Equipment & Devices 337 hip flexion contracture, weak hip extensors or abdominals. bumper is too soft resulting in excess dorsi- (7) High heel rise: during early swing the heel flexion of the foot; prosthetic foot keel too rises excessively. Possible causes: inade- short; knee flexion contracture. quate knee friction, too little tension in the (6) Delayed knee flexion during late stance: extension aid. patient feels as if they were walking \"up (8) Terminal swing impact: the prosthesis hill\". Possible causes: socket is set too far comes to a sudden stop as the knee extends back or lacks sufficient flexion; dorsiflex- during late swing. Possible causes: insuffi- ion bumper is too stiff causing excess plan- cient knee friction or too much tension in tar flexion; prosthetic foot keel too long. the extension aid; patient fears that the knee will buckle, forceful hip flexion. VI. Wheelchairs (9) Swing phase whips: at toe-off, the heel moves either medially or laterally. Possible A. Components causes: socket is rotated, knee bolt is rotat- 1. Postural support system. ed, foot is malaligned. (1) Sling seat: standard on wheelchairs. Hips (lO)Foot rotation at heel strike: as the heel con- tend to slide forward, thighs tend to adduct tacts the ground, the foot rotates laterally, and internally rotate. Reinforces poor sometimes with vibratory motion. Possible pelvic position (posterior pelvic tilt). causes: foot is malaligned, stiff heel cush- (2) Insert or contour seats: creates a stable, ion or plantar flexion bumper. firm sitting surface, wood or plastic padded (11)Foot slap: excessive plantar flexion at heel with foam. strike. Possible cause: heel cushion or plan- (a) Improves pelvic position (neutral tar flexion bumper is too soft. pelvic position). (12)Uneven tep length: patient favors sound (b) Reduces the tendency for the patient to limb and limits weight bearing time on the slide forward or sit with a posterior prosthetic limb. Possible causes: socket pelvic tilt (sacral sitting). discomfort or poor alignment; hip flexion (3) Seat cushions: distribute weight bearing contracture or hip instability. pressures. Assists in preventing decubitus b. Transtibial amputation. ulcers in patients with decreased sensation, (1) Excessive knee flexion during stance. prolongs wheelchair sitting times. Possible causes: socket may be aligned too (a) Pressure-relieving contoured foam far forward or tilted anteriorly; plantar flex- cushion: uses dense, layered foam. ion bumper is too hard limiting plantar Accommodates moderate to severe flexion, high heel shoe; knee flexion con- postural deformity. Easy for caregivers tracture or weak quadriceps. to reposition patients, low maintenance. (2) Inadequate knee flexion during stance. May interfere with slide transfers. Possible causes: socket may be aligned too (b) Pressure-relieving fluid/gel or combina- far back or tilted posteriorly; plantar flex- tion cushion (fluid/gel plus foam). Can ion bumper or heel cushion too soft; low be custom-molded. Accommodates heel shoe; anterodistal discomfort, weak moderate to severe postural deformity. quadriceps. Easy for caregivers to reposition (3) Lateral thrust at midstance. Possible caus- patients. Requires some maintenance, es: foot is inset too much. heavier, more expensive. (4) Medial thrust at midstance. Possible caus- (c) Pressure-relieving air cushion. Accom- es: foot is outset too much. modates moderate to severe postural (5) Drop off or premature knee flexion in late deformity. Lightweight, improved pres- stance. Possible causes: socket is set too far sure distribution. Expensive, base may forward or excessively flexed; dorsiflexion be unstable for some patients. Requires continuous maintenance. (4) Adds to measurements to determine back height.

338 (1) Fixed or folding. (a) Folding facilitates mobility in the com- (5) Pressure relief push-ups are required typi- munity, ease of storage. cally every 15-20 minutes. (b) Rigid frame facilitates stroke efficiency; increases distance per stroke. b. Back: support to the mid-scapular region is provided by most standard sling back wheel- (2) Available in heavy-duty, standard, light- chairs. weight, active-duty lightweight, ultra-light (1) Lower: back height may increase functional weight construction. mobility, i.e., sports chairs; may also (a) In general the lighter the weight of the increase back strain. frame, the greater the ease of use. (2) High back height may be necessary for (b) Level of expected activity and environ- patients with poor trunk stability or with ment should be taken into account extensor spasms. when deciding on frame construction. (3) Insert or contour backs: improve trunk extension and overall upright alignment. b. Wheels, handrims. (4) Lateral trunk supports: improve trunk (1) Casters: the small front wheels, typically 8 alignment for patients with scoliosis, poor inches in diameter; caster locks can be stability. added to facilitate wheelchair stability dur- ing transfers. c. Armrests. (2) Drive wheels: the large rear wheels used (1) Full-length or desk length; desk length for propulsion; outer rim allows for hand facilitates use, proximity to a desk or table. grip and propulsion. (2) Fixed height or adjustable height; (a) Projections may be attached to the rims adjustable height arm rests can be raised to (vertical, oblique, or horizontal) to facil- facilitate sit-to-stand transfers. itate propulsion in patients with poor (3) Removable armrests: facilitate transfers. handgrip, e.g., quadriplegia; horizontal (4) Wraparound (space saver) armrests: reduce or oblique projections widen the chair the overall width of the chair by 1Y2 inches. and may limit maneuvering in the home. (5) Upper extremity support surface (trays or (b) Friction rims/leather gloves: increase troughs) can be secured to the armrests; handgrip friction, ease of propulsion in provides additional postural assistance for patients with poor handgrip. patients with decreased use of upper (c) Construction of drive wheels: standard extremities. spokes or spokeless wheels. d. Leg rests. c. Tires. (1) Fixed. (1) Standard hard rubber tires: durable, low (2) Swing-away, detachable: facilitates ease in maintenance. transfers, front approach to wheelchair (2) Pneumatic (air-filled) tires: provide a when ambulating. smoother ride, increased shock absorption; (3) Elevating: indicated for LE edema control, require more maintenance. postural support; contraindicated for patients with knee flexor (hamstring) d. Brakes. hypertonicity or tightness. (1) Most brakes consist of a lever system with a cam. e. Foot rests. (2) Brakes must be engaged for all transfers in (1) Footp1ates: provide a resting base for feet, and out of chair. feet are neutral with knees flexed to 90 (3) Extensions may be added to increase ease degrees; footplates can be raised or in both locking and unlocking, e.g., for removed to facilitate transfers. upper extremity weakness, arthritis. (2) Heel loops: help maintain foot position, prevent posterior sliding of the foot. e. Additional attachments. (3) Straps (ankle, calf): can be added to stabi- (1) Seat belts (pelvic positioner): belt should lize the feet on the foot plates. grasp over the pelvis at a 45 degree angle to the seat. 2. Wheeled mobility base. a. Frame.

(2) Seat positioners: can add lateral positioners Functional Training, Equipment & Devices 339 at hip and knee or medial positioner at knee (adductor pommel) to maintain alignment tions whose center of gravity is now located of the lower extremities, control for spastic- more posterior when seated in the wheelchair. ity; a seat wedge or a tilt-in-space seat can f. Powered wheelchairs: utilize a power source be used for extensor spasms or thrusting. (battery) to propel the wheelchair; prescribed for patients who are not capable of self-propul- (3) Seat back positioners: can add lateral trunk sion or who have very low endurance. positioners to maintain alignment, control (1) Microprocessors allow the control of the for scoliosis. wheelchair to be adapted to various con- (4) Anti-tipping device: a posterior extension trols, i.e., joystick, head controls. attached to the lower horizontal supports, (2) Proportional drives: changes in pressure on prevent tipping backward in the chair; also the control result in directly corresponding limits going up curbs or over door sills. changes in speeds. (3) Microswitching systems: speed is preset, (5) Hill-holder device: a mechanical brake that controls turn system on and off, i.e., puff-n- allows the chair to go forward, but auto- sip tubes for individuals with quadriplegia. matically brakes when the chair goes in g. Sports wheelchairs: variable; generally include reverse; useful for patients who are not able lightweight, solid frames, low seats, low backs, to ascend a long ramp or hill without a rest. seats that accommodate a tucked position, leg straps, slanted drive wheels, small push rims. 3. Specialized wheelchairs. B. Wheelchair Measurements a. Reclining back: indicated for patients who are 1. General concepts. unable to independently maintain upright sit- a. Overall the size of the wheelchair must be pro- ting position. portional to the size of the patient and take into (1) Reclining wheelchairs include an extended account the demands of expected use and the back and typically elevating legrests; head environment in which the chair will be used. and trunk supports may also be added. b. Assessments should be taken with the patient (2) Electric reclining back helps to redistribute on a firm surface (sitting or supine). weight bearing if patient cannot do active 2. There are six key measurements to fit someone for push-ups or pressure relief maneuvers. a wheelchair. b. Tilt-in-space: entire seat and back may be a. Seat width. tipped backwards (normal seat to back angle is (1) Measure on the patient: width of the hips at maintained); indicated for patients with exten- the widest part. or spasms that may throw the patient out of (2) Chair measure: add 2 inches to the patient's the chair, or for pressure relief. measure. c. One-arm drive: the drive mechanisms are locat- (3) Potential problems. ed on one wheel, usually with two outer rims (a) Excessive width of the wheelchair will (or by push lever); the patient propels the wheelchair by pushing on both rims (or lever result in added difficulties in reaching with one hand); difficult for some patients to the drive wheels and propelling the use, e.g., patients with left hemiplegia, cogni- chair. tive/perceptual impairments. (b) Wheelchair width should accommo- d. Hemiplegic chair (Hemi chair): a chair that is date width of doorways; can use a nar- designed to be low to the ground, allowing rowing device, requires coordination to propul ion with the non-involved upper and turn the cranking device. lower extremities. (c) A wheelchair that is too narrow will e. Amputee chair: wheelchair is modified by result in pressure/discomfort on the lat- placing the drive wheels posterior to the verti- eral pelvis and thighs; lateral space cal back supports (approximately 2 inches should allow for changes in the thick- backward); increases the length of the base of ness of clothing. support and posterior stability; prescribed for b. Seat depth. patients with bilateral lower extremity amputa- (1) Measure on the patient: posterior buttock to

340 (2) If the patient is going to use a seat cushion, the height of the cushion must be added to the posterior aspect of the lower leg in the the patient measurement. popliteal fossa. (2) Chair measure: subtract 2-3 inches from (3) Potential problems. the patient measure. (a) Added back height may increase diffi- (3) Potential problems. culties in getting the chair into a car or (a) Seat depth that is too short fails to sup- van. (b) Added back height may also prevent port the thigh adequately. the patient from hooking onto the push (b) Seat depth that is too long may com- handle for stabilization and weight relief, e.g., the patient with quadriple- promise posterior knee circulation or gia. result in a kyphotic posture, posterior tilting of pelvis, and sacral sitting. 3. Standard dimensions (in inches): c. Leg length/seat to footplate length. (1) Measure on the patient: from the bottom of a. Chair Style Seat Seat Seat the shoe (customary footwear) to just under Width Depth Height the thigh in the popliteal fossa; when a seat cushion is used, the height must be sub- Adult 18\" 16\" 20\" tracted from the patient's measurement. Narrow adult 16\" 16\" 20\" (2) Potential problems. Slim adult 14\" 16\" 20\" (a) Excessive leg length will encourage Hemi/low seat 17.5\" sacral sitting and sliding forward in the Junior 16\" 16\" 18.5\" chair. Child 14\" 11.5\" 18.75\" (b) Length that is too short will create Tiny tot 12\" lIS' 19.5\" uneven weight distribution on thigh and excessive weight on the ischial seat. b. Custom made wheelchairs add significantly to d. Seat height. the cost of a wheelchair; whenever possible, (1) No patient measure. patients should be matched to standardized (2) Chair measure: minimum clearance chairs. between the floor and the footplate is 2 inches, measured from the lowest point on C. Wheelchair Training: many first time users require the bottom of the footplate. instruction in use and care of the wheelchair. (3) Add 2 inches to the patient leg length meas- 1. Instruct in good sitting posture and pressure relief. ure. a. Instruct in use of wheelchair cushion: care and e. Arm rest height (hanging elbow height). maintenance, schedule of use (whenever sit- (1) Measure on the patient: from the seat plat- ting); limitations of cushion. form to just under the elbow held at 90 b. Instruct in periodic pressure reliefs: arm push- degrees with the shoulder in neutral posi- ups; weight shifts - leaning to one side, then tion. other. (2) Chair measure: add 1 inch to the patient's 2. Wheelchair propulsion. hanging elbow measure. a. Instruct in manual wheelchair propulsion. (3) Potential problems. (1) Both arms on drive (push) wheels, one arm (a) Armrests that are too high will cause on drive wheel/one foot pulls diagonally shoulder elevation. across floor under chair (e.g., the patient (b) Armrests that are too low will encour- with hemiplegia), or one arm (one-arm age leaning forward. drive, both outer rims located on one side). f. Back height: height will vary depending upon (2) Propulsion: forward/backward, flat sur- the amount of support the patient needs. faces, uneven surfaces. (1) Measure on the patient: from the seat plat- (3) Turning: pushing harder with one hand than form to the lower angle of the scapula, other; sharp turning: pull one wheel back- mid-scapula, top of shoulder, depending on ward while pushing other wheel forward. the degree of support desired.

(4) Negotiation of obstacles. Functional Training, Equipment & Devices 341 b. Power chair training: focus on driving skill and wheelchair inside car by pulling wheelchair afety; in truct in use of switches (on/off, behind the car seat, or to use a wheelchair lift tum ), joystick; maneuverability, safe stop- (van equipped). ping. 3. Wheelchair management VII. Transfer Training a. Instruct in use of wheel locks (brakes), foot supports (foot plate, legrest), elevating legrests, A. Dependent Transfers: minimal or no active partic- armrests. ipation by patient. b. Instruct in routine maintenance of wheelchair; 1. Dependent lift transfer (football transfer). normal cleaning and maintenance, power chair a. Wheelchair is positioned parallel to surface. (battery) maintenance. b. Patient is flexed forward at hips in tucked posi- 4. Community mobility. tion with hips and knees flexed. a. Ramp. c. Therapist locks patient's tucked knees between (1) Ascending: forward lean of head and trunk, legs; places one hand under buttocks and one hand on transfer belt. use shorter strokes; move hands quickly for d. Patient is rocked forward and lifted using a propulsion. backward weight shift with therapist in a semi- (2) Descending ramps: grip handrims loosely, squat position. control chair's descent; or descend in e. Therapist then pivots using small steps and wheelie position (steep ramp). gently lowers patient to support surface. b. Instruct in how to pop a \"wheelie\" in order to 2. Dependent stand-pivot transfer. Similar to above negotiate curbs; the patient learns how to come but patient's lower extremities are extended and in up onto and balance on the rear wheels with the contact with floor. front ca ters off the ground (e.g., the patient 3. Hydraulic lift transfer. Positioning and widening with paraplegia). of base of device is critical to tability. (1) Practice maintaining balance point in wheelie position (therapist tips chair back B. Assisted Transfers: requires some participation by into position). patient; levels of assistance include stand-by, mini- (2) Practice moving into wheelie position: mal, moderate, or maximal assistance. Includes verbal patient places hands well back on han- cueing or manual assistance for lift, support or bal- OOms; then pulls (moves) them forward ance control. Transfer belts, trapeze bars, overhead abruptly and forcefully. The head and trunk loops can be used to provide additional control. are moved forward to keep from going over 1. Assisted stand-pivot transfer. backward. Use lightweight wheelchair to a. Used for patients who are unable to stand inde- facilitate training. pendently and can bear some weight on lower (3) Balancing in wheelie position: chair tips extremities (e.g., the patient with CVA, incom- further back when wheels are pushed for- plete SCI, hip fracture/replacement). ward; chair tips toward upright when b. Wheelchair is placed parallel to surface (on the wheels are pulled back. patient's sound or stronger side). (4) Practice curb ascent: place the front casters c. Therapist can block out one or both of the up on the curb, the patient then pushes rear patient's knees to provide stability; support can wheel up curb; momentum used to assist. be added by placing both hands on the patient (5) Practice curb descent: descending back- (on both buttocks, both on upper back, or one ward with forward head and trunk lean; on buttock/one on upper back. descending forwards in wheelie position. d. Patient rocks forward and pushes up into stand- c. Practice a cending/descending stairs: in wheel- ing. chair, on buttocks. e. Therapist assists patient with forward weight d. In truct in how to fall safely, return to wheel- shift and standing, pivoting toward chair, and chair. controlled lowering toward the support surface. e. Instruct in how to transfer into a car, place f. Variation: assisted squat-pivot transfer for patients who are unable to stand fully, e.g., with marked weakness both lower extremities.

342 free environment, greatest level of functional independence. 2. Assisted transfer using a transfer (sliding) board. 2. Standard adult wheelchair dimensions for environ- a. Used for the patient with good sitting balance who mental access. can lift most but not all of weight of buttocks, a. Width: 24 to 26 inches from rim to rim. e.g., the patient with complete level C5 SCI. b. Length: 42 to 43 inches. b. Wheelchair is placed parallel to surface. c. Height (push handles to floor): 36 inches. c. Patient moves forward in chair and board is d. Height (armrest to floor): 29 to 30 inches. placed well under buttocks. e. Footrests may extend for very large people. d. Patient performs transfer by doing a series of pushups and lifts along board. =f. 3600 turning space 60 inches by 60 inches. e. Therapist assists in lift (hands on buttocks, on =g. 900 turning space minimum of 36 inches. transfer belt or one on buttock/one on belt). f. Care must be taken not to pinch fingers under h. Minimum clear width for doorways and halls = board or drag/traumatize skin. 32 inches; ideal is 36 inches. g. Feet can remain on foot pedals or be positioned on the floor. 1. High forward reach = maximum of 48 inches h. The patient with complete level C6 SCI can be from floor; low forward reach = a minimum of independent with transfer board on level surfaces. 15 inches from the floor. 3. Push-up transfer (pop-over transfer). j. Side reach = maximum of 24 inches. a. Used for patient with good sitting balance who 3. Home. can lift buttocks clear of sitting surface; can be a progression in transfer training from using a a. Entrance: accessible; stairs with handrail, ramp, transfer board. platform to allow for ease of door opening. b. The patient with complete C7 level SCI can be independent in transfers without a sliding b. Floors: nonskid surface, carpeting securely fas- board. tened; no scatter rugs. c. The patient utilizes head-hips relationship to successfully complete the transfer (movement c. Furniture arrangement: should allow sufficient of head in one direction results in movement of room to maneuver easily, e.g., with wheelchair, the hips in the opposite direction/towards the or ambulating with assistive device. support surface being transferred to). d. Doors: thresholds should be flush or level (no C. Types of Transfers doorsills); standard door width is 32 inches; 1. In and out of bed. outside door swing area requires a minimum of 2. In and out of wheelchair. 18 inches for walkers and 26 inches for wheel- a. Level surfaces. chairs. b. Un-level surfaces: to floor. 3. On and off toilet, tub seat. e. Stairs: uniform riser heights (7 inches high) 4. In and out of car. with a tread depth (a minimum of 11 inches); handrails, recommended height is 32 inches, Y2 D. Training Instructions to 2 inches in diameter; nonslip surface; well 1. Inform patient about the transfer, and expectations lighted; color code with warm colors (reds, for the patient. oranges, yellows) if visual impairments exist. 2. Synchronize actions using commands and counts. 3. Reduce assistance as appropriate. f. Bedroom: furniture arrangement for easy maneuverability; a minimum of 3 feet on side VIII. Environmental Considerations of bed for wheelchair transfers; [Ifm mattress, stable bed, sufficient height to facilitate sit-to- A. Environmental Assessment stand transfers; phone accessibility; appropri- 1. Purpose. ate height for wall switches is 36 to 48 inches; a. Assess degree of safety, function, and comfort outlets a minimum of 18 inches above the of the patient in the home, community, and floorboard. work environments. b. Provide recommendations to ensure a barrier- g. Bathroom: optimal toilet seat height is 17 to 19 inches; tub seat, nonskid tub surface or mat; grab bars securely fastened; optimal height of horizontal grab bars from 33 to 36 inches. h. Kitchen: appropriate height of counter tops, for wheelchair users no higher than 31 inches;

counter depth of at least 24 inches; accessible Functional Training, Equipment & Devices 343 equipment and storage areas. 4. Community/workplace. 2. The ergonomic program should focus on making a. Steps: recommended T-9~, riser height is T-9~. the job fit the person. b. Ramps: recommended ratio of slope to rise is 1:12 (for every inch of vertical rise, 12 inches 3. Engineering controls accomplish this by the design of ramp is required); minimum of 36 inches or modification of the work station, work methods, wide, with nonslip surface; handrail waist high and tools to reduce exposure to awkward postures, for ambulators (34 to 38 inches) and should repetitive motion, and excessive exertion. extend 12 inches beyond the top and bottom of runs; ramp should have level landing at top and C. Personal Protective Equipment (PPE) bottom. I. Can be used to address specific ergonomic stressors. c. Parking (so-called handicapped parking): park- 2. These devices may include: ing space with adjacent 4 foot aisle for wheel- a. Gloves. chair maneuverability; accessible within a b. Protective guards. short distance of buildings; curb cutouts. c. Clothing for protection from the cold or expo- d. Building entrance: accessible; accessible elevator. sure to chemicals. e. Access to public telephones, drinking foun- 3. Braces, splints and back support belts are consid- tains, bathrooms. ered to be part of the medical management pro- f. Ergonomic assessment of immediate work gram and are not PPE. area: appropriate lighting, temperature, seating surface, height and size of work counter. D. Management Model (from APTA [2001] Guide to g. Public transportation: accessible. Physical Therapy Practice, 2nd ed and Occupational Health Physical Therapy Guidelines: Prevention IX. Ergonomics of Work-Related InjurylIllness. Initial BODII-99-25- 71.) A. Definitions 1. Examination. I. Refers to the relationships among the worker. a. Complete history of the client company's 2. The work that is done. injury/illness experience. 3. The tasks and activities inherent in that work. b. Ergonomic tests and measures examine: 4. The environment in which the work is performed. (1) Environment. 5. Ergonomics uses scientific and engineering princi- (2) Site. ples to improve the safety, efficiency, and quality (3) Tools. of movement involved in work. (4) Equipment. 6. Purpose: maintain the health and productivity of (5) Materials. workers at an optimally safe level. (6) Machinery. 7. Model of injury/illness prevention: worker behav- (7) Physical demands. iors attempt to balance the demands of work with (8) Physical stressors. the worker's capacity. Worker behavior in this bal- (9) Environmental conditions. ance is affected by administrative controls. c. Individual worker tests and measures include: 8. Work demands: processes and tools, production (1) Anthropometrics. levels, work schedules. (2) Worker's physical capacity. 9. Worker capacity: objective assessment of worker's (3) Work and health habits. current level of ability to perform the physical 2. Evaluation. demands of a specific identified job. a. Injury or illness data analysis. 10. Administrative controls: changes in the way that b. Work analysis. work in a job is assigned or scheduled to reduce c. Evaluation of worker/workforce safety, behavior, the magnitude, frequency, or duration of exposure and compliance. to ergonomic risk factors. 3. Diagnosis. a. Identification of at-risk employees. B. Hazard Prevention and Control b. Identification of at-risk work processes/work- 1. Preferably controlled by the use of engineering stations. interventions. c. Identification of solutions. 4. Prognosis is related to preventing injury/illness and should include:

344 c. Based on physical work capacity assessment, employers are encouraged to make accommo- a. An estimate of anticipated goals for all inter- dations to normal duty or provide alternative or ventions. transitional duty work. b. An estimate of expected outcomes for all inter- 2. Management of neuromusculoskeletal injury. ventions. a. Diagnosis of the neuromusculoskeletal condi- tion and application of interventions to specific 5. Interventions. systems and tissue affected by the injury. a. Procedural interventions include: b. Determination of safe work activity that will (I) Monitoring at-risk employees and work not compromise medical stability. processes. c. The design of safe, progressive rehabilitation pro- (2) Ergonomics. grams based on the workers' job demands and (3) Education and training. within the functional and medical limitations. (4) Health promotion. d. Minimization of 10 t work time through (5) Retum-to-work case management. aggressive clinical management and promotion (6) Occupational health committee/team of productive work. development. b. Participatory interventions include: 3. Facilitation of timely and appropriate referrals. (I) Team involvement in work assignment. a. Referrals for necessary interventions are facili- (2) Human resources management. tated through constant monitoring of neuro- (3) Labor relations. musculoskeletal signs, symptoms, medical sta- (4) Design and production standards. bility, and progress. b. Injured workers are proce sed through the 6. Outcomes: generating, analyzing, and interpreting employer's health system working interde- data related to injury/illness prevention and pendently with physicians and other health ergonomics. care providers. x. Role of the Physical Therapist in Occu- 4. Minimization of injury/reinjury incident rate. a. The physical therapist's role in minimizing pational Health injury recurrence is in making ergonomic rec- ommendations for: A. Examination of Individuals (I) Work station design. 1. Work-related impairment. (2) Work performance and worker training that 2. Functional limitation. may be specific to the worker's neuromus- 3. Disability. culoskeletal condition. 4. Other health-related conditions which prevent (3) Providing early intervention to workers individuals from performing their occupational with potentially disabling neuromuscu- pursuits in order to determine a diagnosis, progno- loskeletal sign or symptoms. sis, and intervention. (4) Participating on a comprehensive team for the timely dissemination of information B. Integrate Prevention and Wellness Programs in the including: Workplace, Consultation, Screening and Education (a) Physician. (b) Physical therapi t, C. Physical Therapist Management of the Acutely (c) Employer repre entative. Injured Worker (from APTA. Occupational Health (d) Safety management. Physical Therapy Guidelines:Physical Therapist (e) Injured worker. Manage~entof the Acutely Injured Worker. BOD 03- 01-17-56.) D. Phases of Physical Therapy Intervention I. Management of lost time and minimization of dis- I. Admission to a specific phase care is based upon ability. the physical therapy examination, evaluation, a. Optimize work performance and minimize the diagnosis, prognosis of the worker's functional development of work-related occupational dis- and neuromusculo keletal status. ability. b. Effective and timely management of the injured worker is enhanced by participation in some form of productive duty and access to on-site or convenient off-site physical therapy services.

2. Progression from one phase to the next is based on Functional Training, Equipment & Devices 345 objective functional tests and measurements. Duration of treatment is influenced by the level of work/activity decisions, disability determination, physical activity required by the job if a reason- or to generate a rehabilitation plan. able accommodation for the job is not available. D. Specific Physical Demand Characteristics a. Acute phase: immediate post trauma, focusing 1. Categories of work demands. on the control and reduction of localized a. Sedentary. inflammation, joint or soft tissue restriction, b. Light. and stabilization and containment of the injury. c. Medium. b. Post-acute phase: involvement of the injured d. Heavy. worker in more active/functional activities. e. Very heavy. Functional training to increase ability to per- 2. Frequency of work demands. form physical tasks related to community and a. Never. work reintegration. b. Occasional. c. Reconditioning phase: more vigorous thera- c. Frequent. peutic exercise emphasizing daily functional d. Constant. and work activities and improved endurance. E. Physical Demands in the Workplace d. Return-to-work phase: this phase is indicated 1. Physical abilities required to perform work tasks for workers who have progressed satisfactorily success full y. through the reconditioning phase but are not 2. Physical demands include: ready to return to work due to physical, func- a. Work postures/positions. tional, behavioral or vocational deficits. An b. Body movements. objective functional capacity evaluation (FCE) c. Forces applied to the worker. may used as a basis for entry into this phase. d. Repetition of the work tasks. F. FCE Protocols XI. Functional Capacity Evaluation (FCE) 1. A standard protocol includes tests and measures consistently applied to all patient'slclient's under- (from APTA. Occupational Health Physical Therapy going a functional capacity evaluation. Guidelines: Evaluating Functional Capacity. BOD 11- 2. A job specific protocol includes tests and meas- 01-07-11.) ures consistently applied to patient/client undergo- ing a functional capacity evaluation with reference A. Purpose to a specific, identified job. 1. Provide an objective measure of a patient's/client's safe functional abilities compared to the physical XU. Work Conditioning and Work Hardening demands of work. Programs (from APTA. Occupational Health B. Uses of the FCE Physical Therapy Guidelines:Work Conditioning and 1. Retum-to-work and job placement decisions. Work Hardening Programs. BOD 03-01-17-58.) 2. Disability evaluation. 3. Determination of work function with non-work A. Definitions related illness and injuries. 1. Work conditioning programs: 4. Determination of function in non-occupational a. Intensive, work-related, goal-oriented condi- settings. tioning programs. 5. Intervention and treatment planning. b. Designed specifically to restore systemic neu- 6. Case management and case closure. romusculoskeletal functions, muscle perform- ance, motor function, range of motion, and car- C. Definition diovascular/pulmonary functions. 1. A detailed examination and evaluation that objec- 2. Work hardening programs. tively measures the patient's/client's current level a. Highly structured, goal-oriented, individual- of function, primarily within the context of the ized intervention programs designed to return demands on competitive employment. the patient/client to work. 2. Measurements of the FCE are compared to the b. Multi-disciplinary in nature, using real and physical demands of a job or other functional simulated work activities designed to restore activities, and are used to make return to physical, behavioral, and vocational functions.

346 3. Psychophysical concepts. a. The maximal acceptable weight of lift defmes B. Program Content what a person can lift repeatedly for an extend- I. Work conditioning. ed period of time without excessive fatigue. a. Requires work conditioning examination and b. The psychophysical approach provides a evaluation. means of estimating the combined effects of b. Utilizes work conditioning and functional biomechanical and physiological stressors on activities related to work. manual lifting. c. Provide multi-hour sessions up to: 4 hours/day, 5 days/week, 8 weeks. XIV. Guidelines for Seated Work d. Addresses physical and functional needs pro- vided by one discipline. A. Definition 2. Work hardening. I. Sitting transfers body weight to supporting areas. a. Requires work hardening examination and a. Seat pan through ischial tuberosities. evaluation. b. Backrest through soft tissues. b. Utilizes real or simulated work activities. c. Armrests through forearms. c. Provided in multi-hour sessions up to: 8 d. Floor. hours/day, 5 days/week, 8.weeks. 2. Sitting posture varies due to the design of the chair d. Addresses physical, functional, behavioral, voca- and the task being performed. tional needs within a multidisciplinary model. a. Lumbar spine posture during sitting. b. Pelvis rotates posteriorly and the lumbar spine XIII. Manual Material Handling Lifting flattens when moving from standing to unsup- ported sitting. Limits c. Knee and hip angles control spinal posture dur- ing sitting due to the insertion of various mus- A. Factors Affecting \"Safe\" Load Lifting. cles on the pelvis and legs. I. Biomechanical concepts factors. 3. Lumbar disc pressure during sitting. a. Greatest biomechanical stressors and the a. Compression forces measured at L3 disc: pres- largest moments during lifting occur in the sures measured with the subject standing are lumbar spine, in particular L5-S 1 disc. about 35% lower than the pressure measured b. Disc compressive forces, shear forces, and tor- when the subject is sitting without support. sional forces are believed to be largely respon- b. Use of a lumbar support decreases lumbar disc sible for vertebral end-plate fractures, disc her- pressure. niations, and nerve root irritation. c. Backward inclination of the backrest from 90 c. The weight of the load and the distance from degrees to 110 degrees results in decreased the load to the base of the spine are significant lumbar disc pressure. contributors to lumbosacral compressive and d. Decreased disc pressure when arm rests were shear forces when using either a squat or used. stooped lifting posture. 4. Chair dimensions for seated work. 2. Physiological concepts. a. Chair height: sufficient to allow the feet to be a. The worker's ability to perform dynamic, placed firmly on the floor or a foot support. repetitive lifting is limited by their maximal b. Knee flexion angle is about 90 degrees with the aerobic capacity. popliteal fold about 2-3 cm above the seat sur- b. Repetitive lifting tasks could exceed the worker's face. If too low, there is excessive knee flexion normal energy capacities, causing decreased and the spine is flexed and the pelvis is poste- strength and increasing their risk of injury. riorly rotated. If too high, the feet do not reach c. Age, gender, and physical conditioning may the floor and there is excessive pressure on the affect a worker's ability to perform repetitive back of the thighs. lifting. c. Chair length/depth: the seat pan should provide d. Lifting from floor to knuckle height requires about 10 cm clearance from the popliteal fossa greater whole-body work while performing lifts above waist height requires greater shoul- der and arm muscle work.

Functional Training, Equipment & Devices 347 to allow for leg movement and avoid pressure on the back of the knees. d. Seat pan slope: a backward slope of 5 degrees is suggested for normal upright sitting. e. Arm re t height: the elbow should be flexed to 90 degrees and the shoulder in neutral position. XV. Upper Extremity Work-Related Musculo- skeletal Disorders (WRMSD) A. WRMSD Definition 1. Disorders of the muscles, tendons, ligarnerts, joint cartilage, blood vessels, or spinal discs. 2. Associated with exposure to known risk factors. a. Excess force. b. Repetition. c. Awkward postures. d. Vibration. e. Temperatures. f. Contact stresses. 3. Possible relationship between onset and severity of WRMSD and performance of highly repetitive of forceful tasks. B. Common Upper Extremity WRMSD 1. Carpal tunnel syndrome. 2. Tendinitis. 3. Tenosynovitis. 4. Ganglion cy t . 5. Bursitis. 6. Myo itis. 7. Synoviti . 8. Fibromyalgia. 9. Osteoarthritis. 10. Raynaud's syndrome. 11. Complex regional pain syndrome (CRPS)/reflex sympathetic dystrophy (RSD).

CHAPTER 12 PROFESSIONAL ROLES & MANAGEME T William Farina I. Institutional Types/Practice Environments fIrst contact with patients. A. Acute Care (short-term hospital) 3. This care often requires inpatient hospitalizatiol 1. Treatment for a short term illness or health problem. 2. Average patient length of stay is less than 30 days. or ambulatory same day surgery such as hemi Usually length of stay is even less than 7 days. 3. Providers may be physicians, physician assistants, repair. nurses, physical therapists, etc. 4. Rapid discharge for next level of care makes the D. Tertiary Care (tertiary health care) physical therapist's role in patient and family edu- cation and in discharge planning increasingly 1. Highly specialized, technologically-based medica important. services, e.g., heart, liver or lung transplants ani B. Primary Care 1. Basic or \"fIrst level\", health care. other major surgical procedures. 2. Provided by primary care physicians (PCP), including family practice physicians, pediatricians, 2. Provided by highly specialized physicians in internists, and sometimes obstetric/gynecologic (OB/GYN) physician specialists. hospital setting. 3. Provided on an outpatient basis. 4. Physical therapists support primary care teams 3. Physical therapists respond to requests for consul through examination, evaluation, diagnosis, prog- nosis, and prevention of musculoskeletal and neu- tation made by other healthcare practitioners. romuscular disorders. 5. Often the PCP is the \"gatekeeper\" to other subspe- E. Subacute Care cialists, including physical therapy. 1. An intermediate level of health care for medical!\" C. Secondary Care (specialized care) 1. \"Second level\" medical services. fragile patients too ill to be cared for at home. . 2. Provided by medical specialists, such as cardiolo- gists, urologists, and dermatologists, not having 2. Provided by medical and nursing services as we] as rehabilitative services (PT, OT, and ST) at higher level than is offered in a skilled nursin facility (SNF) on a regular basis. . 3. Provided within the hospital or skilled nursin facility setting. . F. Transitional Care Unit 1. Hospital-based skilled nursing facility. 2. Care provided by medical, nursing and rehabilita tion services, including physical and occupatiom therapists and speech and language pathologist on a daily basis. 3. Patients are often discharged home, to assisted livin facilities, or skilled nursing facilities.

Professional Roles & Management 349 G. Ambulatory Care (outpatient care) L. Hospice Care I. Includes outpatient preventative, diagnostic and treatment services. I. Care available for dying patients and their family 2. Provided at medical offices, surgery centers or out- patient clinics. at home or in-patient settings. 3. Providers may be physicians, physician assistants, nurse practitioners, physical therapists, or others. 2. Hospice team includes: nurses, social workers, 4. Less costly than in-patient care. Favored by man- aged care plans. chaplains, volunteers, and physicians. Physical 5. Outpatient rehabilitation centers, or physical therapy clinics, outpatient satellites of institutions or privately and occupational therapy serviQes are optional. owned outpatient clinics. 3. Medicare and Medicaid require at least 80 percent H. Skilled Nursing Facility (extended care facility) I. Free standing or part of a hospital. of hospice care be provided at home. 2. Care provided by continuous nursing, rehabilita- tion, and various other health services on a daily 4. Eligibility for reimbursement includes: basis. 3. Medicare defines \"daily\" as 7 days a week of skilled a. Medicare eligibility. nursing and 5 days a week of skilled therapy. 4. Patients are not in an acute phase of illness, but b. Certification by physician of terminal illness. require skilled care on an inpatient basis. 5. SNF's must be certified by Medicare, meeting (Less than or equal to 6 months of life). • qualifications including 24 hour nursing coverage, availability of physical, occupational and speech M. Home Health Care therapy. 1. Health care provided to individuals and their fam- I. Acute Rehabilitation Hospital 1. Facility that provides rehabilitation, social, and ilies in their homes. vocational services to disabled persons to facilitate their return to maximal functional capacity. 2. Provided by a Home Health Agency, which may 2. Rehabilitation involves the coordinated services of medical, rehabilitative, social, educational and be governmental; voluntary or private; non-profit vocational services for training or retraining. or for-profit. J. Chronic Care Facility (long term care facility) 3. Patient eligibility includes: I. Long term care facility providing services to patients for 60 days or longer. a. Home bound or has great difficulty leaving the 2. Medical services provided to patients with perma- home without assistance or an assistive device. nent or residual disability caused by a non- reversible pathological health condition. b. Health risk leaving the home. 3. May require specialized care/rehabilitation. c. Requires skilled care from one of the following K. Custodial Care Facility services: nursing, physical therapy, occupa- I. Patient care that is not medically required but nec- essary for the patient who is unable to care for tional therapy, or speech. him/herself. d. Physician certification. 2. Custodial care may involve medical or non-medical serviees which do not seek a cure. e. Potential for progress. 3. This type of care is usually not covered under f. More than housekeeping deficits. managed care plans. 4. Environmental safety is consideration of physical 4. Daily care is delivered by nonmedical support staff. therapist, e.g., proper lighting, securing scatter rugs, handrails, wheelchair ramps. 5. Supplemental equipment may be necessary, e.g., raised toilet seats, grab bars, long handled utensils, etc., if delivered by a licensed durable medical equipment vendor to the home at the time of dis- charge from the hospital. 6. Adaptive equipment ordered in the home is not reimbursable except for items such as wheelchairs, commodes, hospital beds, etc. 7. Substance abuse should be reported immediately to the physician. 8. Physical abuse should be immediately and directly communicated to the proper authorities; e.g., department of social service should be notified if child abuse is suspected. 9. The laws that mandate reporting of abuse of an elder, disabled individual or minor may vary from state to state. N. School System 1. The physical therapist serves as a consultant to

350 2. Legally mandated regulations are set forth by the Center for Medicare & Medicaid Services, a divi- teachers working with students with disabilities in sion of U.S. Department of Health and Human the classroom. Services. 2. Major goal of physical therapy treatment is the a. Center for Medicare & Medicaid Services (CMS) child's functioning in the school setting. is the federal agency which develops rules and 3. Recommendations are made for adaptive equip- regulations pertaining to federal laws, in particu- ment to facilitate improved posture, head control, lar the Medicare and Medicaid programs. and function, e.g., using a computer, viewing a b. Facilities that participate in Medicare and/or blackboard, improving mobility from class to class. Medicaid programs are monitored regularly for O. Private Practice compliance with CMS guidelines by federal 1. Entrepreneurial physical therapists that work for or and state surveyors. own a free standing independent physical therapy c. Often State Departments of Public Health practice. monitor MedicarelMedicaid compliance of 2. May accept all insurances if they have provider inpatient institutions, and \"fiscal intermedi- numbers. aries\" are contracted to monitor compliance of 3. Settings vary from sports physical therapy and Medicare part B regulations. orthopedic clinics, rehabilitation agencies, occu- d. Facilities that repeatedly fail to meet CMS pational health, etc. guidelines may lose their Medicare and/or 4. Must document every visit, and complete re-eval- Medicaid certification(s) (e.g., \"provider sta- uations at least every 30 days for reimbursement tus\"). purposes. 3. Standards related to safety are set forth and II. The United States Health Care System enforced by the Occupational Safety and Health Administration (OSHA), a division of the U.S. A. Overview Department of Labor. 1. A group of decentralized subsystems serving dif- a. Structural standards and building codes are ferent populations. established and enforced by OSHA to ensure 2. Overwhelmingly private ownership of health care the safety of structures. delivery. b. The safety of employees and consumers is reg- 3. Relatively small federal and state governmental ulated by OSHA standards for handling infec- programs working in conjunction with a large pri- tious materials, and blood products, controlling vate sector, although the government pays for a blood borne pathogens, operating machinery large portion of these private sector services and handling hazardous substances. through Medicare and Medicaid reimbursement. c. Material Safety Data Sheets are mandated by 4. Decentralization results in overlap in some areas OSHA. These sheets give employees informa- and competition in others; therefore, health care is tion about potentially hazardous materials in primarily a business that is market driven, espe- the workplace and how to protect themselves. cially for patients covered by managed care insur- d. The blood borne pathogen standard requires ance. institutions to have processes in place to reduce a. Patients are viewed as consumers due to this the risk of exposure to blood borne pathogens. economic focus. This includes a written safety plan, employee b. Cost containment while maintaining quality of training, and proper disposal practices. service is a delicate balancing act that is not e. Other OSHA standards covers x-ray safety, always achieved. electrical and fire safety, and provide for the 5. Primary care physicians have increased signifi- provision of personal protective equipment cance as the first line for evaluation and interven- (PPE). tion, and the referral source for specialized and/or ancillary services. 4. Individual states develop their own requirements with state agencies enforcing these regulations. B. Health Care Regulations State accreditation to obtain licensure for a health 1. Health care is a highly regulated industry with care facility is mandatory. most regulations mandated by law, at both the state and federal levels.

5. Local or county entities also develop regulations Professional Roles & Management 351 pertaining to health care institutions, (i.e., physical plant safety features such a fire, elevator and boil- Retarded and Other Developmentally Disabled er regulation ). Persons (AC-MRDD) is a voluntary agency that accredits programs or agencies that serve persons C. Voluntary Accreditation with developmental disabilities. 1. Voluntary accreditation and self-imposed compli- 4. Outpatient centers for comprehensive rehabilita- ance with established standards is sought by most tion can be accredited by JCABO, CARF, and/or health care organizations. AC-MRDD. 2. Accreditation is a status awarded for compliance 5. National League for Nursing/American Public with standards and regulations promulgated by the Health Association (NLN/APHA) is a voluntary pecifIc accrediting agency. agency that accredits home health and community 3. Accreditation ensures the public that a health care nursing agencies that offer nursing and other facility i adequately equipped and meets high health services outside hospitals, extended care standards for patient care and has qualifIed profes- facilities and nursing homes. sionals and competent staff. 6. Some accrediting bodies may perform unan- 4. Accreditation affirms the competence of practi- nounced or unscheduled site surveys to ensure tioners and the quality of health care facilities and ongoing compliance. organizations. E. The Accreditation Process 5. Although national accreditation through an 1. Accreditation is initiated by the organization sub- accrediting agency is voluntary; in reality, it is mitting an application for review followed by a mandatory for most third party reimbursement and survey conducted by the accrediting agency. to be eligible for federal government grants and 2. A self-study or self-assessment is conducted to contracts. examine the organization based on the accrediting 6. CMS and many states accept certain national agency's standards. accreditations as meeting their respective require- 3. An on-site review is conducted with an individual ments for participation in the Medicare and reviewer or surveyor, or a team visiting the organ- Medicaid programs and for a license to operate. ization. 4. The accreditation and the re-accreditation process D. Voluntary Accrediting Agencies involve all staff. Tasks include document prepara- 1. Joint Commission on the Accreditation of Health tion, hosting site visit team, and interviews with Care Organizations (JCAHO). accreditors. a. The voluntary agency that accredits health care 5. Once accredited, the organization undergoes peri- facilities according to JCABO established odic review, typically every three years. standards and conditions. 6. Some accrediting bodies may perform unan- b. JCAHO accredits hospitals, skilled nursing nounced or unscheduled site surveys to ensure facilities (SNFs), home health agencies, pre- ongoing compliance. ferred provider organizations (PPOs), rehabilita- tion facilities, health maintenance organizations III. Reimbursementffhird Party Payers for (HMOs), behavioral health including mental Healthcare Services health and chemical dependency facilities, ambulatory clinics, physician's networks, hos- A. Medicare pice care, long term care facilities and others. 1. Administered by federal government Center for 2. Commission on Accreditation of Rehabilitation Medicare & Medicaid Services (CMS), through Facilities (CARF) is the voluntary agency that accredits free-standing rehabilitation facilities and the extension of Title xvrn of the Social Security the rehabilitative programs of larger hospital sys- tems in the areas of behavioral health, employment Act, 1965. (work hardening) and community support services 2. Provides medical coverage and health care services and medical rehabilitation (spinal cord injury, chronic pain). to individuals: 3. Accreditation Council for Services for Mentally a. 65 years or older. b. With permanent kidney failure or other long term disabilities. 3. Social Security Amendment of 1983. a. Established Medicare's prospective payment